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The Last Taboo

There are 7 billion humans on earth, so why can't we talk about population?

"It's okay," Dutta assures me. "It's water from the tube well."

The nearby tube well delivers clean water from an underground aquifer via a hand pump—a fairly recent development in rural West Bengal, where people have traditionally drunk, bathed, and swum alongside their livestock in the ponds of monsoon water, unknowingly afflicting themselves with everything from chronic diarrhea to hookworm to dysentery to typhoid. Halder has only recently begun using water from the tube well—thanks to a pilot program initiated by Freedom From Hunger.

"When we investigated why women default on their microloans," says Marcia Metcalfe, FFH's director of microfinance and health protection, "we discovered the problem was almost always due to a health crisis in the family. Women will abandon their jobs and their loans to care for a sick family member. Investigating further, we learned that many of these illnesses were preventable or easily curable. So we began to design a program to treat those problems."

Two years ago, Halder received a health education course funded by FFH and staffed by Bandhan. Since then, she's trained her family to use tube-well water for drinking, washing the dishes, and rinsing themselves after bathing in the pond. (Although half the tube wells in West Bengal are contaminated with unsafe levels of arsenic—caused by irrigation and the rainwater ponds—Halder's tube well is clean. For others, the answer to clean, safe water lies in different pumping techniques or in deeper wells.) Halder has also used some of her loan money to build a sanitary pit toilet, replacing the ancient rural custom of fertilizing the fields after dark. She's taught the family to wear sandals to the toilet to prevent hookworm infestation—its iron-deficiency anemia is a contributing factor in maternal and child death here—and to wash their hands afterward.

These modest changes have transformed chronic sickness into good health that's rippled far beyond the family's two rooms. Halder explained the basics of sanitation to her own siblings and her three married daughters in distant villages, all of whom changed their own families' ways. Her neighbors noticed the Halders' improved health and followed the lead, and the hygienic revolution rippled outward.

"We even wondered about our cows," says Halder. "They were emaciated from diarrhea. So we gave them tube-well water and now they're healthy, too."

The water in my steel mug at Supta Halder's house is flavored with isabgol, the psyllium seed husks traditionally used as a digestive aid in India—the same ingredient in Metamucil, recognizable by the sweet taste and slightly slimy texture. I smile, silently toasting Supta Halder's achievements with a glass of laxative.

Halder was recently elected sastho sohayika ("health helper") by her fellow Bandhan loan recipients. This is a new role in the village and another FFH health initiative, designed by Dutta and implemented through Bandhan. As a sastho sohayika, Halder has been trained to assess the basic medical needs of her fellow villagers. Government care is available. But the nearest clinic is miles away, and hospitals are even farther.

Trideep Roy, assistant manager for the Bandhan health program in Bagnan, explains that rural villagers rarely know when their condition warrants a trip to the clinic. Furthermore, families will usually pay for medical care only for the man of the family—even though women of childbearing age and beyond, as well as children, tend to need care more frequently.Bandhan microloans have allowed Rehana Bibi and Supta Halder to radically alter their families and communities.Bandhan microloans have allowed Rehana Bibi and Supta Halder to radically alter their families and communities.

Supta Halder is on call around the clock. If a patient needs more than she can provide, she contacts Nabanita Mondal, a Bandhan health care officer, who oversees 30 sastho sohayika and is trained to refer patients to the government system. Halder doesn't earn any money as a sastho sohayika. Instead, she has access to a small pharmacy of common health care products—antacids, aspirin, oral rehydration solution, deworming medication, antibacterial soap, and birth control pills—which she sells to patients for a small profit. These products are available at government health clinics, often for free. But the clinic is far and often unreliable: closed when it's supposed to be open, or plagued by empty shelves. Halder's home visits also allow women to shop in private—like an Avon lady with contraceptives.

Halder says the sastho sohayika position has increased her standing with her family and in the community, although she's aware that if she makes a wrong call the consequences to her reputation, even her well-being, could be serious. Nevertheless, she loves her work. When I ask how these changes of the past five years—the loans, the jobs, the income, the health care expertise—have changed her family life, Halder offers a concise answer, which Dutta translates as "much better." Asked what her husband thinks of all the changes, she smiles and says he's very happy with their new life.

THE UPSTAIRS classroom in Bagnan's Goalberia Primary School is crowded with colors so clashing they harmonize: Chrome yellows, turquoises, fuchsias, fire-engine reds, and iridescent greens adorn the saris and shirts draped on some 50 women and children. The people gathered here are so restless, nervous, and shy, hidden behind such bright fluttery fabrics, that I feel as if I've stepped into a room full of exotic butterflies.

This is a Muslim community in Bagnan. Many of the women here are recipients of Bandhan loans. As is often the case, the forum coincides with the due date on loan repayments—since this is the day every month these women gather anyway (though all are welcome at the health forum, male or female). The women are eager and attentive, focusing on today's lesson taught by Nabanita Mondal—a pretty young mother wearing stylish eyeglasses and a salwar kameez, the long tunic and pants that constitute the working uniform of modern Indian women. The lecture is the 20th of 24, and the first of a two-part series on HIV/AIDS.

Chairman Chandra Shekhar Ghosh took the hard lessons of his own upbringing to develop a program that serves 2 million women.Bandhan Chairman Chandra Shekhar Ghosh took the hard lessons of his own upbringing to develop a program that serves 2 million women."Who knows about this disease?" Mondal asks. Only five women raise their hands—although one young woman stands to deliver a comprehensive lecture in a confident voice. Soumitra Dutta, translating for me, is impressed by her knowledge and asks where she learned this. At the hospital, she says.

Today's lesson is taught with a single tool, a drop-down poster with five cartoon images, designed for those who are illiterate. The drawings depict an infected man alongside an identical-looking uninfected man, the insides of a human body with a man firing an assault rifle at cells, a gaunt patient in a hospital bed, a naked man and woman in bed, and a composite image of a hypodermic needle, a blood transfusion, and a mother breastfeeding.

These lectures are Dutta's brainchild, designed during a hard year of field testing with FFH and Bandhan resources. The curriculum covers everything from birth control to pre- and postnatal care, breastfeeding, child nutrition, maternal nutrition, and hygiene. He confesses he was worried when he heard that Trideep Roy and Nabanita Mondal would be bringing me to Goalberia to see his program in action, worried the women might be too shy to be responsive. But it's clear these mothers, wives, sisters, and daughters—initially so distracted by my presence, and now focused powerfully on the lesson—are hungry for this education.

Dutta tells me that Bandhan recently opened an office in the extremely poor, densely populated, and predominantly Muslim city of Murshidabad, 120 miles from here, where female literacy is only 36 percent, the fertility rate is around 10, says Dutta, and child labor and malnutrition are rife. The services provided by the FFH/Bandhan symbiosis—the loans, the visits of a sastho sohayika, the health forums—may be the only means for these women to gain any control over their futures.

"Even though oral contraceptives are available for free or nearly free in Indian public health centers," says FFH's Metcalfe, "Bandhan health officers sell to more women in their homes than the government reaches. This is particularly true for Muslim women, whose lives may be more limited than Hindu women, and for whom privacy is an intensely important issue."

"Already it's working," adds Dutta. "And if it can work in Murshidabad, it can work anywhere."


The plunge in Iran's birth rates has been swift, uniform, and voluntary—engineered via a media blitz, access to free birth control, and education for girls.

THE BEST FAMILY plans, the best intentions of any woman, can be waylaid by her government, since politics control fertility with godlike powers. In 2003, the predominantly Catholic Philippines bowed to church demands to support only "natural family planning"—otherwise known as the rhythm method, and grimly referred to as Vatican roulette. (See "Close Your Eyes and Think of Rome.") The Filipino government no longer provides contraceptives for poor Filipinas, and government clinics no longer distribute donated contraceptives, including the wealth of modern birth control once provided by the US Agency for International Development. (Filipina Health Secretary Esperanza Cabral, however, continues defiantly to distribute free condoms to combat rising HIV infection rates.)

Today more than half of all pregnancies in the Philippines are unplanned—10 percent more than a decade ago. In a first-of-its kind study in the Philippines, the Guttmacher Institute calculates that easy access to contraception would reduce those births by 800,000 and abortions by half a million a year. Furthermore, it would deliver a net savings to the government on the order of $16.5 million a year in reduced health costs from unwanted pregnancies, including the brutal medical consequences of illegal back-alley abortions.

In Iran, the fertility pendulum has gone the other way in recent years. From a high of 7.7 in 1966, total fertility fell to 6 during the Shah's reign, spiked to 7 during the Islamic Revolution (when marriage became legal for 12-year-old boys and 9-year-old girls), then plummeted 50 percent between 1988 and 1996, continuing down to 1.7 today. That plunge, known as the "Iranian miracle," was one of the most rapid fertility declines ever recorded.

Iran's demographic reversal was swift, uniform, and voluntary. Women of all childbearing ages in urban and rural parts of the country simply began to have smaller families practically overnight. Demographer Mohammad Jalal Abbasi-Shavazi of the University of Tehran writes that the feat was engineered through a mobilization between government and media: Information was broadcast nationwide about the value of small families, followed up with education about birth control, implemented with free contraceptives. Progressive social measures further primed Iran: increasing public education for girls (today more than 60 percent of Iranian university students are women); a new health care system; access to electricity, safe water, transportation, and communication. Similar fertility reversals have occurred in Costa Rica, Cuba, South Korea, Taiwan, Thailand, Tunisia, and Morocco—as quickly as in China but minus the brutal one-child policy.

The United States, plagued by its own ping-pong policy, has been little help. Beginning with Ronald Reagan in 1984, the "global gag rule," also known as the Mexico City Policy, prohibited US funding of any foreign family planning organizations providing abortions. The gag rule barred the discussion of abortion or any critique of unsafe abortions, even if these medical services were implemented with the group's own money (a ruling that would have been unconstitutional in the US). Bill Clinton rescinded the policy in 1993, but George W. Bush reinstated it in 2001, and before Barack Obama could rescind it again, the flow of aid to developing countries slowed or even stopped, eviscerating health care and severely undermining family planning efforts in at least 26 developing nations, primarily in Africa.

Joanna Nerquaye-Tetteh, former executive director of the Planned Parenthood Association of Ghana, testified before Congress in 2004 on the policy's effects in her country. "The gag rule completely disrupted decades of investment in building up health care services," she said. "We couldn't provide contraceptives and services to nearly 40,000 women who had formerly used our services. We saw within a year a rise in sexually transmitted infections and more women coming to our clinics for post-abortion care as a result of unsafe abortions."

Although it's unclear how many babies were added to the human family as a result of the global gag rule, the UN estimates that at its height in 2005, the unmet demand for contraceptives and family planning drove up fertility rates between 15 and 35 percent in Latin America, the Caribbean, the Arab states, Asia, and Africa—a whole generation of unplanned Bush babies.


IN AN UPSCALE Kolkata suburb, I meet with Chandra Shekhar Ghosh, founder and chairman of Bandhan, a tall man with crooked eyeglasses and a straightforward smile. He speaks quietly of his father, a hardworking Bengali who owned a sweet shop that prospered modestly in good times and was among the first to suffer in bad times. "My mother did not work outside the home and could not help financially when times got tough," he says. "From a young age, I realized the inflexibility of this model in an ever-changing world and vowed to change it."

Sitting in with us is one of his finance managers, Maneeta Rathore, a bubbly young woman who shares the same devotional enthusiasm I saw among the staff in Bandhan's field office in Bagnan, where Trideep Roy, Nabanita Mondal, and the loan officers work and live during the week. Many Bandhan staff members are stationed so far from home that they manage to return to their families only once or twice a month. Nevertheless, Ghosh's people wear an aura of pride and purpose and a happiness not the norm among taciturn Bengalis, the New Yorkers of India.

When Ghosh opened the first Bandhan branch office in 2002 in Bagnan, he slept on the floor for months at a time, Soumitra Dutta tells me. Maneeta Rathore says Ghosh couldn't get a single banker to listen to him back then, and now they're knocking at his door. In only eight years, he has grown his hope for the poor from a single field office in Bagnan to more than a thousand field offices serving more than 2 million female clients in 14 Indian states. Two years ago, Forbes magazine voted Bandhan the No. 2 microfinance institute in the world based on size, efficiency, risk, and return.

Ghosh is not the original microloan pioneer. That credit goes to Bangladeshi Muhammad Yunus, who founded Grameen ("villages") Bank in 1983. His revolutionary model was to loan to the unloanable poor—notably women—who lacked collateral, enabling them to develop their own businesses and free themselves from poverty. This radical innovation won Yunus the Nobel Peace Prize in 2006. Empirical studies now support his intuition of 27 years ago: Women make better loan recipients than men if your aim is to increase family well-being. Compared to men's loans, women's loans double family income and increase child survival twentyfold.

Ghosh is bringing this program into the 21st century by adding the health forums and the sastho sohayika program, as well as an initiative called Targeting the Hard Core Poor, aimed at those who can't meet the requirements for a microloan. "These are the homeless and the downtrodden," he says. "The widows with children who beg for a living and who have no resources and no confidence. Rather than money, we give them an asset, a milk goat or cow or a roadside tea stall. We guide them through about 18 months of business development before they graduate into the microloan program."

At the outset of our meeting, Ghosh makes a point of telling me there is no peace in money, no peace when others suffer, but peace only when everyone shares in it. When I ask if he imagines expanding his help for the poor beyond India, he says yes, but won't reveal where. I suggest he try the US, likewise home to impoverished people unable to procure credit or health care—people whom no one believes in. He blinks, surprised. Then giggles.

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