Karl Hofmann, president and CEO of Population Services International, gives his morning lecture Wednesday in the Amphitheater.
In 1985, Karl Hofmann was a young vice consul serving at the U.S. Embassy in Rwanda; there, one of his many responsibilities was to manage the Ambassador’s Self-Help Fund, a program designed to disperse small grants to local communities for things like a new roof on a school building, or dig a well. These grants often had transformative impacts.
“A small grant of $5,000 to $10,000 could transform the trajectory of a community,” he said. But, he followed up, a fair question to ask is “What became of any of those small grant investments in remote communities in a place like Rwanda?”
“Did they serve as the basis for genuine, locally led development,” he said, “or did they fall into disuse when the donor money dried up or ran out?”
That is the “age-old challenge of development work,” Hofmann told his Chautauqua audience Wednesday morning in the Amphitheater, delivering his installment of the Chautauqua Lecture Series’ Week Four theme of “Eight Billion and Counting: The Future of Humankind in a Crowded World.” The answer to that question, said Hofmann, now president and CEO of Population Services International, is that it depends. Hofmann shared his experiences managing international health plans and his insights on the challenges and impacts of development work, with a particular focus on family planning in the developing world and demographic trends — PSI’s bread and butter, along with a focus on other issues like malaria, HIV/AIDS and child survival.
The nature of development work is rapidly shifting, Hofmann said. It also carries greater weight than he thinks it should.
“In many places — in most places — remittances and private flows dwarf official development systems,” he said, and in places like the United States, there’s assumptions made about foreign aid and development that are “a little bit disconnected from reality.” Contrary to popular belief, all non-defense international affairs spending, including contributions to multilateral organizations and various aid programs, constitutes less than 1% of the U.S. federal budget.
“But within that 1% comes the U.S.’ leading role in something that we call international family planning assistance,” he said. “The U.S. has been the leading, bilateral family-planning donor for decades, throughout different administrations.”
Early in his career, Hofmann was surprised to learn about the U.S. Agency for International Development procurement of millions of condoms during the Reagan administration — highlighting America’s longstanding commitment to providing contraception through foreign assistance programs, despite political fluctuations.
But the need for contraceptives has grown with the global population; the U.S. contribution to those needs has remained flat, he said.
Family planning assistance is more than just contraceptives — it’s strengthening local healthcare systems, training personnel, and using new technologies. All of that work “can make a big difference in the reproductive health and fertility of women in the Global South,” Hofmann said, and frankly, the COVID-19 pandemic accelerated some of that innovation. He cited Pfizer’s Cyanapress, a self-injectable, long-acting reversible contraceptive that addresses access challenges in remote areas, as an example.
“Pfizer developed this technology, the Gates Foundation made an advanced-market commitment to buy it, and Gates and other donors — like the Children’s Investment Fund Foundation engaged organizations like PSI and others to help roll out this technology in places of high, unmet contraceptive need,” he said.
Family planning and reproductive health are “strong drivers of broader social and economic development,” Hofmann said. “There’s no place on earth that has achieved transformative, breakthrough growth in the modern era that hasn’t embraced family-planning as a part of their policy agenda. It’s a quintessential best bet in development.”
He pointed to Bangladesh and Iran — countries that have seen two of the most rapid declines in fertility in the modern era — as examples.
Family planning shouldn’t be as controversial as it is, Hofmann said. In the United States, he has never seen a bureaucrat “rewarded for running toward these issues. I can assure you, from my own decades in government, that work on population or family-planning was not considered — ironically — sexy, and not considered to be good for one’s career.”
But the work is important, even foundational. It’s more than family planning, he said. It’s about human rights, autonomy, agency and freedom.
“The most alarming kind of freedom for some, apparently, is the ability of women to control their fertility,” Hofmann said. In his adult lifetime, the “story of population and fertility has been ‘up, up, up,’” and it carried with it dire predictions. The story of our children’s lifetimes, he said, will be “down, down, down.”
In 75 years, he said, there will be half as many Chinese people in the world as there are now. In 75 years, half of all Japanese will be over 65 years old. By the end of the century, Niger will have a larger population than Russia. Hofmann pointed to what’s called a “youth bulge” in Niger, and asked what such a trend could mean for a country.
“‘Demographic dividend’ is a hopeful term, and rightly so,” he said, “because large youth cohorts are potential energy and sources of innovation for any society, if they are given a chance to be educated, to find meaningful employment, to be able to plan the families they desire. The demographic dividend is no guarantee — it depends on the wise choices and sometimes the good luck of the relevant governing authorities.”
A youth bulge can be a dividend, or a curse, depending on the policies.
“The trade-off between long-term development priorities such as education, job training, workforce development, private sector development, long-term development priorities — the trade-off between those and short-term humanitarian emergencies,” like in Israel, Palestine and Ukraine, is “growing more acute,” Hofmann said.
Demographic trends are long, slow, and then “seemingly overwhelming,” he added. The United Nations, when it offers population projections, breaks numbers down into “classic U.N. speak” of “half a child.” Not practical, Hofmann said, but that’s the difference in quality of life for women across the globe.
“Even though fertility is declining practically everywhere, the long-term effects of continued relatively high fertility can really have dramatic impacts over time,” he said.
The climate-population connection was another critical area Hofmann explored. He argued for integrating reproductive health with climate mitigation efforts, emphasizing that meeting the unmet need for family planning could have significant long-term benefits for planetary health.
“For a long time, neither the reproductive health nor the climate communities really wanted to connect with one another, because both parties felt like the other had lots of unwelcome baggage,” he said. “It’s too easy for this climate population conversation to devolve into a sort of ‘We need less of them to make it easier for us’ kind of conversation. The reality is much more complicated, of course.”
There’s no need to “fixate” on what was in the past called population control — it doesn’t work, Hofmann said, and is “grossly unethical and isn’t even necessary.” Instead, he urged his audience to think about “meeting unmet needs.”
Two years ago, the medical journal The Lancet published findings that 160 million women globally, who wanted access to contraception to limit their number of children, didn’t have access to it.
“Spacing and limiting is good for the health of the mother, and maternal mortality. It’s good for the survival rate of other siblings. It’s good for families to be able to thrive, and for communities and nations and, ultimately, for all of us to lead healthier lives,” Hofmann said. “But 160 million women at least have an unmet need for modern contraception right now. This is what I would call a classic market failure. Demand is not being met by supply.”
Why? Again, no one runs toward these issues, he said. Steady funding means declining funding, and there’s plenty of stigma and societal pressure around these issues.
“In our own country, comprehensive sexual education is a lightning rod,” Hofmann said. “The ability of women to control their fertility is apparently only slightly less dangerous than the literacy of a girl.”
But meeting these unmet needs would have the same impact as ending all illegal deforestation in the world, he said. He pointed back to the climate-population conversation, and hoped that “surely there’s a place for climate mitigation efforts that start with meeting unmet needs for family planning anywhere.”
In the United States, Hofmann said, the CDC has estimated that there are 19 million women with an unmet need for modern contraception, and the (high) per capita emissions of the average American makes contraception a prudent investment for both reproductive health and climate action.
“In the lower resourced parts of the world, in many parts of the Global South, meeting unmet needs has a small impact now on emissions because per capita emissions are very low,” Hofmann said, “but we’ve seen the long-term impact of these trends over time and future emissions accelerated by rising rates of urbanization and industrialization makes meeting unmet needs now a very compelling long-term investment in planetary health.”
In closing, he asked: “Is demography destiny?” Again, it depends. Demographic trends are “long-horizon,” and “people assume that these trends are immutable. But for all those, our actions and the actions of many, many others matter.”
