Winston Churchill famously said that “there is no finer investment for any community than putting milk into babies”—but perhaps he was wrong. Perhaps the baby might be the eighth child of an exhausted mother who began having children in her teens, or the baby might grow up to become a mother as a teenager and die in childbirth or from an unsafe abortion. Lois Quam, author of the recently published Who Runs the World: Unlocking the Talent and Inventiveness of Women Everywhere, might disagree with Churchill and make a case for investing in women and girls. There is strong evidence that such investment will “bolster good governance, economic growth, community health, and peace and stability.”
We live in an age of “polycrisis”—climate change, environmental destruction, war and impending greater wars, poverty, gross inequality, hunger, and forced migration. A polycrisis, argues Quam, needs a “multifix” and the best one will be to set free the talent, energy, and new ideas of women—half of humanity, who at the moment are largely constrained by lack of education and opportunity, and reproductive burdens.
Quam pursues the mission of unlocking the talent of girls and women through her role as the chief executive of Pathfinder International, which works to “build lasting and trusted local partnerships to strengthen health systems, forging resilient pathways to sexual and reproductive health and rights for all.”
About 800 women die every day in childbirth, and 95% of those deaths occur in low and middle income countries. Half of all pregnancies worldwide are unplanned, and 275 million women use unsafe contraception. Almost half (45%) of the world’s roughly 70 million abortions are unsafe. Adolescent girls and women aged 15-19 have around 20 million pregnancies a year, of which half are unintended. More than half (55%) of those unintended pregnancies end in abortions, many of which are unsafe. Girls aged 10-14 are also becoming pregnant.
Pathfinder recognises that it cannot help from the outside. It starts work at the most local level of the health system. In this way the most vulnerable can be reached. Pamela Onduso, the Kenya leader of Pathfinder, says, “The core insight is this: pathfinding means understanding and respecting the cultures and norms of the community we serve, coupled with strategic partnerships with public, private, faith based, and ecumenical stakeholders to achieve sustainable development. That’s how our country programmes work.”
Although its core mission is improving the reproductive health of women, Pathfinder recognises how problems and responses are interconnected and so also works on matters like climate change and health system strengthening. Tabinda Sarosh, Pathfinder’s president in South Asia, the Middle East, and North Africa, says, “One of the reasons that, at times, our work has not achieved its full impact is the way we have been organised. Reproductive healthcare provided in isolation does not reflect a woman’s journey. If a woman is struggling to bring food to the table or has a child who is sick, she’s going to deprioritise her own health and wellbeing.” She describes how “climate change is like an underlying, constant restriction of resources affecting nutritional status, access to education, access to health services, and the ability of systems to be responsive and reach people. It is in the DNA of Pathfinder to take a systems strengthening approach. We have for many years increased the envelope size for systems strengthening to include climate change.”
Before joining Pathfinder, Quam worked on health reform in both her US home state of Minnesota and nationally, spent years in business, and became the head of global health in the Obama administration. She decided in that role that she wanted a programme to reduce maternal mortality and asked government agencies what could be achieved. When told that a reduction of 8% was possible, she thought that inadequate and, remembering her time in business, asked for a plan to reduce deaths by 50%—to be delivered in three days. The team she appointed identified three delays in women getting the help they needed: not having a plan for when things went wrong; lack of transport to a facility; and delay in receiving care when they arrived. The plan tackled each of these delays, and, although it did not reduce overall deaths by 50%, it reduced them by 44% in Zambia and 42% in Uganda. The plan is now being used in Cross River State in Nigeria.
One of the aspects of reproductive health that makes it different from, for example, trying to reduce deaths from malaria or tuberculosis, is the need to combat organisations that oppose safe abortion, family planning, and even the education of girls, or women joining the workforce. Some of these organisations, particularly American evangelical movements, are extremely well funded. Pathfinder also has to cope with changing policies on funding safe abortion as power changes in the US.
Since joining Pathfinder, Quam has reformed the organisation, doing what to my mind feels right but is evoking opposition. Pathfinder was founded by Clarence Gamble, a doctor and an heir to Proctor and Gamble. Like many of his contemporaries promoting the use of contraception in the 20s, Gamble was a eugenicist who believed that “healthy white people should have children and that black and brown people should not.” Pathfinder has now acknowledged its unsavoury beginnings and donated Gamble’s papers to Harvard Medical School for anybody to study. Global reproductive health programmes have to be very clear that their work is based on human rights and the necessity of fully informed consent—not only because of eugenicists, but also because anxiety about the “population explosion” in the 1970s and 80s led to forced sterilisations and China’s one child policy.
Exploring Pathfinder’s past caused discomfort, but still more discomfort was caused by shifting power from the US to the countries where Pathfinder works. The headquarters of most large development organisations continues to be based in the US or Europe, and, as a longstanding joke puts it, “development funding builds capacity for sure—in the Washington, DC, and Boston suburbs.” Quam and her colleagues have worked to change this, and she now runs Pathfinder alongside presidents based in and from Asia and Africa. The benefit became apparent when Burkina Faso experienced a coup: Quam had no experience of managing the consequences (although I can’t help observing that the US came close), whereas the local leaders did have such experience. In 2020, 6% of global roles were in the countries where Pathfinder works, but by 2023 it was 37%. There is further to go, but inevitably there are losers in any change—Quam writes that shifting power and jobs outside the US is not for the thin skinned.
Quam ends her book quoting an Australian aboriginal expression: “If you have come here to help me you’re wasting your time, but if you’ve come because your liberation is bound up with mine, then let’s work together.” Amen.
Footnotes
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RS is a longstanding friend of Lois Quam, who was on The BMJ editorial board when he was editor in chief. RS subsequently worked with and for LQ and became director of the UnitedHealth/National, Heart, Lung, and Blood Centres of Excellence programme in low and middle income countries, which LQ helped to found. RS is now an unpaid member of the president’s advisory council of Pathfinder International.