The hidden gem of the Cairo Consensus: helping
to end population growth with entertainment media
William
N. Ryerson
William
N. Ryerson is President of Population Media Center (PMC)
(www.populationmedia.org), an organization that strives to improve the health
and wellbeing of people around the world through the use of
entertainment-education strategies. He also serves as Chair and CEO of the
Population Institute in Washington, DC (www.populationinstitute.org). In
developing countries, PMC creates long-running serialized dramas on radio and
television, in which characters evolve into role models for the audience on
various social and health issues.
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DOI: 10.3197/jps.2018.2.2.51
Licensing: This article is Open Access (CC BY 4.0).
How to Cite:
Ryerson, W.N. 2016. 'The Hidden Gem of the Cairo Consensus: Helping to End Population Growth with Entertainment Media'. The Journal of Population and Sustainability 2(2): 51–61.
https://doi.org/10.3197/jps.2018.2.2.51
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In
1994, the Programme of Action of the International Conference on Population and
Development was adopted. The Programme conveys anthropocentric sensibilities
when discussing the idea of sustainable development. Moreover, the Programme
has largely been interpreted in such a way that it fails to hold the goal of
ending population growth at the same level of esteem as the goal of ensuring
reproductive health and rights. Despite some unfavorable outcomes, the
Programme’s orientation around gender equality is to be celebrated. In section
11.23, the Programme highlights a key tactic to help achieve gender equality:
effective use of the entertainment media, including radio and television soap
operas and drama. Since 1998, Population Media Center has successfully used
mission-driven entertainment to confront the most powerful drivers of ongoing
rapid population growth: the social norms, attitudes and behaviors related to
the status of women in various societies around the world; misinformation about
contraception and cultural barriers to its use (such as male opposition); and
perceived norms with regard to ideal family size.
Nearly
a quarter century ago, in September, 1994, the Programme of Action of the
International Conference on Population and Development (UNFPA, 1994) was
adopted. The occasion was heralded as a watershed moment in how UN Member
States, non-governmental organizations, and donors would approach questions of
fertility and human population growth. The lengthy document, referred to
informally as the “Cairo Consensus”, still serves as the philosophical
guide-star for most international development efforts related to reproductive
health and family planning, whether funded publically or privately.
One
way to accurately summarize this consensus is that every individual adult on
the planet is thought to have the basic right to decide, freely and
responsibly, the number and spacing of their children and to have the
information, education, and means to do so (see Principle 8). Moreover, the
fundamental pathways to achieving this level of reproductive autonomy are
working to establish bona fide “gender equality and equity and the empowerment
of women, the elimination of all kinds of violence against women, and ensuring
women’s ability to control their own fertility” (see Principle 4).
While
the ethical desirability of these pathways is strong and enduring, from a global
sustainability perspective, the Programme of Action is not without serious
weakness. For example, while recognizing the interdependence of global
population, international development and environmental outcomes, the document
nonetheless promulgates a decidedly anthropocentric worldview, using
phraseology such as, “Human beings are at the centre of concerns for
sustainable development”, and “People are the most important and valuable
resource of any nation”. Such statements unwisely conceive that humans are at
the center of all material and ethical concerns (Crist & Kopnina, 2014).
Pleasingly,
recent initiatives and actions housed within the United Nations (UN) have begun
constructing a “non-anthropocentric paradigm in which the fundamental basis for
right and wrong action concerning the environment is grounded not solely in
human concerns” (UN Harmony with Nature, 2018a). Perhaps in the not too distant
future, the UN’s Commission on Population and Development can reconsider the
Program of Action’s troubling anthropocentric bent in light of a new
jurisprudence quickly developing around the rights of nature (UN Harmony with
Nature, 2018b) — not to mention many years’ worth of experiences and learning
that have taken place in the fields of population and development since Cairo.
Another
important criticism of the Cairo Consensus is that it has resulted in a
collective failure, in the minds of most development and philanthropic
professionals, to hold the goal of ending population growth at the same level of esteem as
the goals of ensuring reproductive health and rights (MAHB, 2014). Indeed,
history shows that some reproductive health and rights activists hoped to
influence the drafting of the Programme of Action so that it would discredit
population concerns altogether (Petchesky, 1995). Fortunately, this agenda has
and always will remain impossible to realize: human population dynamics are
existentially fundamental to both civilization and the natural world. Any
efforts to diminish the central importance of human population dynamics to
natural history, and humanity’s place within that history, are doomed to fail.
On
the other hand, while the Programme of Action’s various weaknesses are real,
and important to guard against, its strengths are also numerous. One little
known strength, which at first glance may strike the casual observer as
esoteric, comes in the realm of entertainment media. On this score, the
drafters of the Programme wisely highlighted a key strategy for any who are
concerned with unsustainable population size and growth. In section 11.23 of
the Programme of Action, it is noted that “Governments, non-governmental
organizations and the private sector should make greater and more effective use
of the entertainment media, including radio and television soap operas and
drama, folk theatre and other traditional media to encourage public discussion
of important but sometimes sensitive topics related to the implementation of
the present Programme of Action”.
Indeed,
for the past two decades, Population Media Center (PMC) has produced
entertainment programming to promote social and cultural change directly
related to population dynamics – while improving the lives of millions of
people around the world.
While
dramatic radio and television shows may seem far-removed from a serious
response to humanity’s well-documented global overshoot, when such programming
is based on social and behavior change communications theory, results can be
both substantial and cost-effective. More importantly, such programming can be
customized to confront the most powerful drivers of ongoing rapid population
growth: the social norms, attitudes and behaviors related to the status of
women in various societies around the world; misinformation about contraception
and cultural barriers to their use (such as male opposition); and perceived
norms with regard to ideal family size.
Certainly,
the Programme of Action did well to focus attention on gender inequality.
Arguably, rampant and severe gender inequality – deeply rooted in social norms
– does serve as the most fundamental and powerful driver of humanity’s already
oversized total population and ongoing growth. For example, when a female’s
personal autonomy is socially constrained or totally absent – from lack of
education, lack of opportunity, or outright oppression – family size decisions
are often controlled by husbands or in-laws (Agha, 2010), and families end up
being larger than if women could truly decide for themselves how many children
to have and when.
Of
course, gender equality cannot be achieved without the backing of legal
conventions. Far too many governments have failed to guarantee women equality
in basic legal and human rights, in access to or control of resources, in
employment or earnings, or in political participation. Men continue to occupy
most positions of political and legal authority. Globally, only about 22% of
parliamentarians are women. Laws against domestic violence are often not
enforced on behalf of women.
However,
at a fundamental level, all forms of gender inequality and discrimination are
rooted in the socially constructed belief that girls and women are somehow
inferior to boys and men. Until broad based normative change around the social
status of women is achieved, it will remain impossible for the majority of the
world’s women to responsibly decide the number and spacing of their children.
Their low social status precludes the conditions necessary to do so. Certainly,
the ability to obtain both contraceptive supplies and services, and the full
range of supporting information women need to manage childbearing will continue
to be compromised in oppressive social situations (Campbell, Prata and Potts,
2013).
Another
example of how addressing social norms is key to slowing down and stopping population
growth is the concept of “unmet need” for contraception. This condition is
defined as when women are fecund and sexually active and report not wanting any
more children within the next two years – but are not using any method of
contraception.
It is
well known that there are 214 million women in the developing world who meet
the definition of having such an “unmet need” (Guttmacher Institute, 2017). A
persistent current of commentary from some family planning advocates and other
development experts — and the popular media discourses following their lead —
attribute unmet need to a “lack of access” to contraception.
However,
Population Media Center’s analyses of Demographic and Health Survey reports
from nearly 100 countries over the last two decades have consistently described
a different reality: women with unmet need for contraception rarely cite cost,
convenience or a “lack of access” as the reason they are not using
contraception. In many countries, lack of access and cost are cited by less
than 5% of the respondents. Rather, the primary barriers to use of family
planning are large desired family size, fear of health effects (including
misinformation about safety and effectiveness of contraceptives), and various
forms of opposition, based on religion, fatalism, or patriarchal social norms.
Increasingly,
new analyses are pointing to similar conclusions. In June 2016, for example,
Guttmacher Institute researchers scrupulously analyzed a decade of data related
to reasons for non-use in 52 developing countries (Sedgh, Ashford, and Hussain,
2016). They found non-users who actually “lack access” comprise 5% of the
reasons for non-use. Meanwhile, based on the authors’ reporting, fear of health
effects and personal or spousal opposition to contraception account for 49% of
non-use. In other words, non-use related to informational and socio-cultural
barriers out-numbers non-use related to a lack of access by a factor 10.
The
largest constituency of non-users of contraception in the world are those who
are simply not seeking to avoid pregnancy. Statistics from the developing
world, for example, show that of 1.6 billion women of reproductive age living
in these regions, only about half (885 million women) want to avoid a pregnancy
at all (Guttmacher Institute, 2017). Evidence suggests social norms related to
high-desired family size are major drivers of this type of non-use, especially
in West Africa, where “ideal number of children” often exceeds actual fertility
rate.
Here,
a glance at some examples of country specific data from USAID’s Demographic and
Health Surveys (DHS) is helpful (see – https://dhsprogram.com/Where-We-Work/Country-List.cfm).
In 2012, the ideal number of children for women in Niger was 9.5 – for men, it
was 10.9, while fertility was 7.6. Notably, but unsurprisingly, 47% of women in
Niger expressed an intention to never use contraception in the future (DHS,
2012). Similarly, in 2014, the ideal number of children for women in Senegal
was 5.6 – for men, the ideal number was 7.5, while fertility rate was 5.0. Over
60% of women in Senegal expressed an intention to never use contraception in
the future (DHS, 2014).
Changing
these troubling dynamics will require helping people understand the personal
benefits in health and welfare for them and their children of fewer, spaced
births and delayed childbearing. It will require a major shift in societal
attitudes and knowledge. It involves role modeling small family norms and
making them popular and ending child marriage.
The
good news is that progress on these issues is not impossible; even the most damaging,
deeply-rooted social norms can be changed. However, social norms are, by
definition, deeply entrenched. Patient and determined approaches to change are
necessary. Direct messaging, talking points, and “quick fix” interventions that
are contrary to dominant social norms are usually insufficient to create change
and may even be counter-productive.
Meanwhile,
high-quality entertainment is in demand nearly everywhere on the planet.
Likewise, as the vast majority of people on Earth have access to some form of
broadcast media (whether radio, TV, internet or other), the delivery of
entertainment via mass media outlets can reach large audiences cost-efficiently
and reliably. Decades of work has shown that education can be combined with
entertainment, attracting enthusiastic audiences and informing, empowering, and
motivating normative change. One powerful intervention in the quest to end
population growth, therefore, involves broadcasting entertainment-education
serial dramas. These powerful, emotionally compelling entertainment products
can catalyze normative change around the status of women, perceptions of the
safety and efficacy of contraception (and cultural barriers to their use, such
as male opposition), and perceived norms with regard to ideal family size.
The
unique entertainment strategy deployed by PMC is constructed from multiple
scientifically validated communication, psychosocial, and psychological
theories. Bandura’s (1977, 1986) Social Learning and Social Cognitive Theories
play a fundamental role in PMC’s creative process. According to these theories,
much of human behavior is learned through observation of role models, whether
in person or through the media. Meanwhile, sufficient time is necessary for
observational learners to engage in a “mediating process” – to incrementally
reflect upon an observed behavior and its consequences and in turn develop
sufficient self-efficacy to enact the new behavior.
PMC’s
entertainment products always honor and advance the hallmarks of great episodic
story-telling, such as captivating characters, cliffhangers,
multiple/interwoven storylines, and unexpected plot twists. The shows are
delivered in long-running episodic format, usually broadcasting for a duration
of 1 to 3 years. The programs are socially relevant, with fictional settings
accurately reflecting the existing world of the audience. Production and
writing teams, sourced from the country where the show will air, embed three
character types into the story: positive, negative, and transitional. The positive
and negative characters represent the extremes of behavior on one or more
particular issues as practiced in the audience’s own community, while also
serving as positive and negative role models for the transitional characters.
The
methodology portrays the transitional character moving through a sequence of
experiences. First the transitional character encounters a situation that
requires or forces a decision on their part (e.g., “Life cannot continue as
before”). At this point, both the positive and negative characters —
purposefully designed to exhibit polarized and opposing values — make attempts
to influence the transitional character’s decision so that the decision
coincides with their own outlook and worldview. The transitional character then
makes a decision, wholly and completely of his or her own accord. The
transitional character experiences a reward or punishment based on whether her
or his decision was good (aligned with the positive character) or bad (aligned
with the negative character).
As audience
members listen or watch the transitional characters experience this sequence of
events, spread over successive episodes, their emotional ties and
identification with the transitional characters sparks an emotive,
psychological desire to adopt similar values and actions in their real life.
Simultaneously, as they follow the transitional characters successfully
navigating the challenge of repeated decision making and the resulting
consequences, the audience gains a vicarious experience of self-efficacy on the
process of implementing change.
A
good example of PMC’s transformational entertainment is the condensed story of
Ngendo, a character in PMC’s 208-episode radio serial drama, Agashi. This hit program aired from January 2014 to January 2016 in
the country of Burundi, which has an annual population growth rate of over 3%.
This program reached more than two million people and cost a mere $0.74 US per
loyal listener.
Ngendo‘s
story
Ngendo
is a 30-year-old farmer (and is also a transitional character in this fiction).
He and his wife, Tengenge, have already had 3 children in 4 short years. They
are quite poor in a financial sense. Unfortunately, Ngendo’s mother (who is a
negative character) insists the couple should have as many children as
possible.
Early
in the story, Tengenge (who is a positive role model for the audience) begs
Ngendo to allow her to use family planning. Ngendo refuses and, as a
consequence, Tengenge gets pregnant again. This time, it is announced that she
will have triplets. Tengenge becomes very weak and requires frequent visits to
the health center – which consumes the family’s already tight budget. With
three children and triplets, the family can’t afford food and Ngendo is forced
to steal. He is caught and seriously wounded during his capture.
During
his night in the hospital, his brother (who serves as a positive character)
convinces Ngendo about the benefits of family planning. When he returns home,
Ngendo surprises Tengenge by saying that they should use contraceptives. With
his brother’s help, Ngendo finally stands up to his mother and refuses to have
another child. Shocked by this “betrayal”, his mother tries to poison Tengenge.
When she is caught in the act, the villagers chase her, vowing to burn her
alive for trying to murder her daughter-in-law. She is driven out of the
village and never seen again.
Agashi aired two new episodes per week on seven
radio stations in Burundi with national coverage. At one point, over 80% of
Burundians, aged 15-49, were listening to the show. As measured by an end-line
survey, after controlling for other variables (such as income, education, and
place of residence), Agashi listeners were: 2 times more likely than
non-listeners to say they know a place to obtain a method of family planning;
2.3 times more likely than non-listeners to report that their partner/spouse is
open to the discussion of family planning; and 1.8 times more likely than
non-listeners to say that they generally approve of family planning for
limiting the number of children.
At clinics
in Burundi during the broadcast, 20% of new reproductive health clients cited Agashi by
name when they were asked what inspired the visit to the clinic. Similarly, in
Sierra Leone, 50% of new reproductive health clients cited PMC’s program Saliwansai as
the source of information that brought them to the clinic.
It is
worth pointing out that the transitional character in this story was a
fictional Burundian man – not a woman. In Burundi, the ideal number of children
is over 4 for men, and the percentage of currently married men aged 15-49 who
want to have another child either sooner or later is over 60%. Moreover, over
20% of married women in Burundi do not make decisions about their own health
care — rather the husband does. Clearly, if gender equality is to be fully
realized in Burundi, changing the attitudes and behaviors of men will be
instrumental. Likewise, to ease socio-cultural barriers inhibiting the use of
contraception – such as mother-in-law opposition – there will need to be a critical
mass of empowered individuals who are motivated to adopt behaviors that
contradict age old norms.
Finally,
there may be no more important aspect to the goal of ending human population
growth than helping people around the world understand the health benefits for
them and their children of fewer, spaced births (Johns Hopkins Bloomberg School
of Public Health, 2016). This is especially true in East, Central, and West
Africa where the average number of children per woman still ranges between five
and six– and the number of children per man is likely even higher (Schoumaker,
2017). Whether, and how quickly, fertility rates decline in these regions over
the next few decades will be the major factor in determining the peak of world
population (Madsen, 2015).
As we
look towards the quickly approaching 25th anniversary of the Programme of Action of
the International Conference on Population and Development, we can find comfort
in recognizing the power ensconced in section 11.23. After all, theory driven
entertainment media are particularly well suited to tackle the most acute needs
in global family planning programs and related efforts to end population
growth: interventions that can challenge and spark change in long-established
and widely practiced social norms around gender equality, contraceptive uptake,
and ideal family size.
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