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The Moment of Lift: How Empowering Women Changes the World

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For the last twenty years, Melinda Gates has been on a mission. Her goal, as co-chair of the Bill & Melinda Gates Foundation, has been to find solutions for people with the most urgent needs, wherever they live. Throughout this journey, one thing has become increasingly clear to her: If you want to lift a society up, invest in women.

In this candid and inspiring book, Gates traces her awakening to the link between women's empowerment and the health of societies. She shows some of the tremendous opportunities that exist right now to “turbo-charge" change. And she provides simple and effective ways each one of us can make a difference.

Convinced that all women should be free to decide whether and when to have children, Gates took her first step onto the global stage to make a stand for family planning. That step launched her into further efforts: to ensure women everywhere have access to every kind of job; to encourage men around the globe to share equally in the burdens of household work; to advocate for paid family leave for everyone; to eliminate gender bias in all its forms.

Throughout, Gates introduces us to her heroes in the movement towards equality, offers startling data, shares moving conversations she's had with women from all over the world—and shows how we can all get involved.
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For Jenn, Rory, and Phoebe

Our deepest fear is that we are powerful beyond measure.



When I was little, space launches were a huge deal in my life. I grew up in Dallas, Texas, in a Catholic family with four kids, a stay-at-home mom, and an aerospace engineer dad who worked on the Apollo program.

On the day of a launch, we’d all pile into the car and drive to the home of one of my dad’s friends—another Apollo engineer—and watch the drama together. I can still feel in my bones the suspense of those countdowns. “Twenty seconds and counting, T minus fifteen seconds, guidance is internal, Twelve, Eleven, Ten, Nine, ignition sequence start, Six, Five, Four, Three, Two, One, Zero. All engines running. Liftoff! We have a liftoff!!!”

Those moments always gave me a thrill—especially that moment of lift when the engines ignite, the earth shakes, and the rocket starts to rise. I recently came across the phrase “moment of lift” in a book by Mark Nepo, one of my favorite spiritual writers. He uses the words to capture a moment of grace. Something was “lifted like a scarf on the wind,” he writes, and his grief went silent and he felt whole.

Mark’s image of lift is filled with wonder. And wonder has two meanings for me. It can mean awe, and it can mean curiosity. I have loads of awe—b; ut just as much curiosity. I want to know how lift happens!

At one time or another, we’ve all been sitting on a plane at the end of a long takeoff run, waiting anxiously for the moment of lift. When the kids were little and we were on a plane ready to take off, I’d say to them “wheels, wheels, wheels,” and the moment the plane got off the ground I’d say “Wings!!” When the kids were a bit older, they would join me, and we all said it together for years. Once every so often, though, we’d say “wheels, wheels, wheels” more times than we expected, and I’d be thinking, Why is it taking so long to get off the ground!?

Why does it sometimes take so long? And why does it sometimes happen so fast? What takes us past the tipping point when the forces pushing us up overpower the forces pulling us down and we’re lifted from the earth and begin to fly?

As I’ve traveled the world for twenty years doing the work of the foundation I cofounded with my husband, Bill, I’ve wondered:

How can we summon a moment of lift for human beings—and especially for women? Because when you lift up women, you lift up humanity.

And how can we create a moment of lift in human hearts so that we all want to lift up women? Because sometimes all that’s needed to lift women up is to stop pulling them down.

In my travels, I’ve learned about hundreds of millions of women who want to decide for themselves whether and when to have children, but they can’t. They have no access to contraceptives. And there are many other rights and privileges that women and girls are denied: The right to decide whether and when and whom to marry. The right to go to school. Earn an income. Work outside the home. Walk outside the home. Spend their own money. Shape their budget. Start a business. Get a loan. Own property. Divorce a husband. See a doctor. Run for office. Ride a bike. Drive a car. Go to college. Study computers. Find investors. All these rights are denied to women in some parts of the world. Sometimes these rights are denied under law, but even when they’re allowed by law, they’re still often denied by cultural bias against women.

My journey as a public advocate began with family planning. Later I started to speak up about other issues as well. But I quickly realized—because I was quickly told—that it wasn’t enough to speak up for family planning, or even for each of the issues I’ve just named. I had to speak up for women. And I soon saw that if we are going to take our place as equals with men, it won’t come from winning our rights one by one or step by step; we’ll win our rights in waves as we become empowered.

These are lessons I’ve learned from the extraordinary people I want you to meet. Some will make your heart break. Others will make your heart soar. These heroes have built schools, saved lives, ended wars, empowered girls, and changed cultures. I think they’ll inspire you. They’ve inspired me.

They’ve shown me the difference it makes when women are lifted up, and I want everyone to see it. They’ve shown me what people can do to make an impact, and I want everyone to know it. That is why I wrote this book: to share the stories of people who have given focus and urgency to my life. I want us to see the ways we can help each other flourish. The engines are igniting; the earth is shaking; we are rising. More than at any time in the past, we have the knowledge and energy and moral insight to crack the patterns of history. We need the help of every advocate now. Women and men. No one should be left out. Everyone should be brought in. Our call is to lift women up—and when we come together in this cause, we are the lift.


The Lift of a Great Idea

Let me start with some background. I attended Ursuline Academy, an all-girls Catholic high school in Dallas. In my senior year, I took a campus tour of Duke University and was awed by its computer science department. That decided it for me. I enrolled at Duke and graduated five years later with a bachelor’s degree in computer science and a master’s in business. Then I got a job offer from IBM, where I had worked for several summers, but I turned it down to take a job at a smallish software company called Microsoft. I spent nine years there in various positions, eventually becoming general manager of information products. Today I work in philanthropy, spending most of my time searching for ways to improve people’s lives—and often worrying about the people I will fail if I don’t get it right. I’m also the wife of Bill Gates. We got married on New Year’s Day in 1994. We have three children.

That’s the background. Now let me tell you a longer story—about my path to women’s empowerment and how, as I’ve worked to empower others, others have empowered me.

* * *

In the fall of 1995, after Bill and I had been married nearly two years and were about to leave on a trip to China, I discovered I was pregnant. This China trip was a huge deal for us. Bill rarely took time off from Microsoft, and we were going with other couples as well. I didn’t want to mess up the trip, so I considered not telling Bill I was pregnant until we came back. For a day and a half, I thought, I’ll just save the news. Then I realized, No, I’ve got to tell him because what if something goes wrong? And, more basically, I’ve got to tell him because it’s his baby, too.

When I sat Bill down for the baby talk one morning before work, he had two reactions. He was thrilled about the baby, and then he said, “You considered not telling me? Are you kidding?”

It hadn’t taken me long to come up with my first bad parenting idea.

We went to China and had a fantastic trip. My pregnancy didn’t affect things except for one moment when we were in an old museum in Western China and the curator opened an ancient mummy case; the smell sent me hurtling outside to avoid a rush of morning sickness—which I learned can come at any time of day! One of my girlfriends who saw me race out said to herself, “Melinda’s pregnant.”

On the way home from China, Bill and I split off from the group to get some time alone. During one of our talks, I shocked Bill when I said, “Look, I’m not going to keep working after I have this baby. I’m not going back.” He was stunned. “What do you mean, you’re not going back?” And I said, “We’re lucky enough not to need my income. So this is about how we want to raise a family. You’re not going to downshift at work, and I don’t see how I can put in the hours I need to do a great job at work and raise a family at the same time.”

I’m offering you a candid account of this exchange with Bill to make an important point at the very start: When I first confronted the questions and challenges of being a working woman and a mother, I had some growing up to do. My personal model back then—and I don’t think it was a very conscious model—was that when couples had children, men worked and women stayed home. Frankly, I think it’s great if women want to stay home. But it should be a choice, not something we do because we think we have no choice. I don’t regret my decision. I’d make it again. At the time, though, I just assumed that’s what women do.

In fact, the first time I was asked if I was a feminist, I didn’t know what to say because I didn’t think of myself as a feminist. I’m not sure I knew then what a feminist was. That was when our daughter Jenn was a little less than a year old.

Twenty-two years later, I am an ardent feminist. To me, it’s very simple. Being a feminist means believing that every woman should be able to use her voice and pursue her potential, and that women and men should all work together to take down the barriers and end the biases that still hold women back.

This isn’t something I could have said with total conviction even ten years ago. It came to me only after many years of listening to women—often women in extreme hardship whose stories taught me what leads to inequity and how human beings flourish.

But those insights came to me later. Back in 1996, I was seeing everything through the lens of the gender roles I knew, and I told Bill, “I’m not going back.”

This threw Bill for a loop. Me being at Microsoft was a huge part of our life together. Bill cofounded the company in 1975. I joined Microsoft in 1987, the only woman in the first class of MBAs. We met shortly afterward, at a company event. I was on a trip to New York for Microsoft, and my roommate (we doubled up back then to save money) told me to come to a dinner I hadn’t known about. I showed up late, and all the tables were filled except one, which still had two empty chairs side by side. I sat in one of them. A few minutes later, Bill arrived and sat in the other.

We talked over dinner that evening, and I sensed that he was interested, but I didn’t hear from him for a while. Then one Saturday afternoon we ran into each other in the company parking lot. He struck up a conversation and asked me out for two weeks from Friday. I laughed and said, “That’s not spontaneous enough for me. Ask me out closer to the date,” and I gave him my number. Two hours later, he called me at home and invited me out for that evening. “Is this spontaneous enough for you?” he asked.

We found we had a lot in common. We both love puzzles, and we both love to compete. So we had puzzle contests and played math games. I think he got intrigued when I beat him at a math game and won the first time we played Clue, the board game where you figure out who did the murder in what room with what weapon. He urged me to read The Great Gatsby, his favorite novel, and I already had, twice. Maybe that’s when he knew he’d met his match. His romantic match, he would say. I knew I’d met my match when I saw his music collection—lots of Frank Sinatra and Dionne Warwick. When we got engaged, someone asked Bill, “How does Melinda make you feel?” and he answered, “Amazingly, she makes me feel like getting married.”

Bill and I also shared a belief in the power and importance of software. We knew that writing software for personal computers would give individuals the computing power that institutions had, and democratizing computing would change the world. That’s why we were so excited to be at Microsoft every day—going 120 miles an hour building software.

But our conversations about the baby made it clear that the days of our both working at Microsoft were ending—that even after the children were older, I would likely never go back there. I had wrestled with the idea before I was pregnant, talking with female friends and colleagues about it, but once Jenn was on the way, I had made up my mind. He didn’t try to talk me out of it. He just kept asking, “Really?!”

As Jenn’s birth approached, Bill started asking me, “Then what are you going to do?” I loved working so much that he couldn’t imagine me giving up that part of my life. He was expecting me to get started on something new as soon as we had Jenn.

He wasn’t wrong. I was soon searching for the right creative outlet, and the cause I was most passionate about when I left Microsoft was how you get girls and women involved in technology, because technology had done so much for me in high school, college, and beyond.

My teachers at Ursuline taught us the values of social justice and pushed us hard academically—but the school hadn’t conquered the gender biases that were dominant then and prominent today. To give you a picture: There was a Catholic boys high school nearby, Jesuit Dallas, and we were considered brother-sister schools. We girls went to Jesuit to take calculus and physics, and the boys came to Ursuline to take typing.

Before I started my senior year, my math teacher, Mrs. Bauer, saw Apple II+ computers at a mathematics conference in Austin, returned to our school, and said, “We need to get these for the girls.” The principal, Sister Rachel, asked, “What are we going to do with them if nobody knows how to use them?” Mrs. Bauer replied, “If you buy them, I’ll learn how to teach them.” So the school reached deep into the budget and made its first purchase of personal computers—five of them for the whole school of six hundred girls, and one thermal printer.

Mrs. Bauer spent her own time and money to drive to North Texas State University to study computer science at night so she could teach us in the morning. She ended up with a master’s degree, and we had a blast. We created programs to solve math problems, converted numbers to different bases, and created primitive animated graphics. In one project, I programmed a square smiley face that moved around the screen in time to the Disney song “It’s a Small World.” It was rudimentary—computers couldn’t do much with graphics back then—but I didn’t know it was rudimentary. I was proud of it!

That’s how I learned that I loved computers—through luck and the devotion of a great teacher who said, “We need to get these for the girls.” She was the first advocate for women in tech I ever knew, and the coming years would show me how many more we need. College for me was coding with guys. My entering MBA class at Microsoft was all guys. When I went to Microsoft for my hiring interviews, all but one of the managers were guys. That didn’t feel right to me.

I wanted women to get their share of these opportunities, and that became the focus of the first philanthropic work I got involved in—not long after Jenn was born. I thought the obvious way to get girls exposed to computers was to work with people in the local school district to help bring computers into public schools. I got deeply involved in several schools, getting them computerized. But the more I got into it, the more it became clear that it would be hugely expensive to try to expand access to computers by wiring every school in the country.

Bill believes passionately that technology should be for everyone, and at that time Microsoft was working on a small-scale project to give people access to the internet by donating computers to libraries. When Microsoft completed the project, they scheduled a meeting to present the results to Bill, and he said to me, “Hey, you should come learn about this. This is something we both might be interested in.” After we heard the numbers, Bill and I said to each other, “Wow, maybe we should do this nationwide. What do you think?”

Our foundation was just a small endowment and an idea back then. We believed that all lives had equal value, but we saw that the world didn’t act that way, that poverty and disease afflicted some places far more than others. We wanted to create a foundation to fight those inequities, but we didn’t have anyone to lead it. I couldn’t run it, because I wasn’t going to go back to a full work schedule while I had little kids. At that time, though, Patty Stonesifer, the top woman executive at Microsoft and someone Bill and I both respected and admired, was leaving her job, and we had the temerity to approach her at her farewell party and ask her if she would run this project. She said yes and became the first foundation employee, working for free in a tiny office above a pizza parlor.

That’s how we got started in philanthropy. I had the time to get involved when I was still at home with Jenn because we didn’t have our son, Rory, until Jenn was 3 years old.

I realize in looking back that I faced a life-forming question in those early years: “Do you want to have a career or do you want to be a stay-at-home mom?” And my answer was “Yes!” First career, then stay-at-home mom, then a mix of the two, then back to career. I had an opportunity to have two careers and the family of my dreams—because we were in the fortunate position of not needing my income. There was also another reason whose full significance wouldn’t become clear to me for years: I had the benefit of a small pill that allowed me to time and space my pregnancies.

It’s a bit ironic, I think, that when Bill and I later began searching for ways to make a difference, I never drew a clear connection between our efforts to support the poorest people in the world and the contraceptives I was using to make the most of our family life. Family planning became part of our early giving, but we had a narrow understanding of its value, and I had no idea it was the cause that would bring me into public life.

Obviously, though, I understood the value of contraceptives for my own family. It’s no accident that I didn’t get pregnant until I had worked nearly a decade at Microsoft and Bill and I were ready to have children. It’s no accident that Rory was born three years after Jenn, and our daughter Phoebe was born three years after Rory. It was my decision and Bill’s to do it this way. Of course, there was luck involved, too. I was fortunate to be able to get pregnant when I wanted to. But I also had the ability to not get pregnant when I didn’t want to. And that allowed us to have the life and family we wanted.

Searching for a Huge Missed Idea

Bill and I formally set up the Bill & Melinda Gates Foundation in 2000. It was a merger of the Gates Learning Foundation and the William H. Gates Foundation. We named the foundation for both of us because I was going to have a big role in running it—more than Bill at the time, because he was still fully engaged at Microsoft and would be for the next eight years. At that point, we had two kids—Jenn was 4 and had started nursery school, and Rory was just 1—but I was excited to take on more work. I made it clear, however, that I wanted to work behind the scenes. I wanted to study the issues, take learning trips, and talk strategy—but for a long time I chose not to take a public role at the foundation. I saw what it was like for Bill to be out in the world and be well known, and that wasn’t appealing to me. More important, though, I didn’t want to spend more time away from the kids; I wanted to give them as normal an upbringing as possible. That was hugely important to me, and I knew that if I gave up my own privacy, it would be harder to protect the children’s privacy. (When the kids started in school, we enrolled them with my family name, French, so they would have some anonymity.) Finally, I wanted to stay out of the public work because I’m a perfectionist. I’ve always felt I need to have an answer for every question, and I didn’t feel I knew enough at that point to be a public voice for the foundation. So I made it clear I wouldn’t make speeches or give interviews. That was Bill’s job, at least at the start.

From the beginning, we were looking for problems that governments and markets weren’t addressing or solutions they weren’t trying. We wanted to discover the huge missed ideas that would allow a small investment to spark massive improvement. Our education began during our trip to Africa in 1993, the year before we were married. We hadn’t established a foundation at that point, and we didn’t have any idea how to invest money to improve people’s lives.

But we saw scenes that stayed with us. I remember driving outside one of the towns and seeing a mother who was carrying a baby in her belly, another baby on her back, and a pile of sticks on her head. She had clearly been walking a long distance with no shoes, while the men I saw were wearing flip-flops and smoking cigarettes with no sticks on their heads or kids at their sides. As we drove on, I saw more women carrying heavy burdens, and I wanted to understand more about their lives.

After we returned from Africa, Bill and I hosted a small dinner at our home for Nan Keohane, then president of Duke University. I almost never hosted that kind of event back then, but I was glad I did. One researcher at the dinner told us about the huge number of children in poor countries who were dying from diarrhea and how oral rehydration salts could save their lives. Sometime after that, a colleague suggested we read World Development Report 1993. It showed that a huge number of deaths could be prevented with low-cost interventions, but the interventions weren’t getting to people. Nobody felt it was their assignment. Then Bill and I read a heartbreaking article by Nicholas Kristof in The New York Times about diarrhea causing millions of childhood deaths in developing countries. Everything we heard and read had the same theme: Children in poor countries were dying from conditions that no kids died from in the United States.

Sometimes new facts and insights don’t register until you hear them from several sources, and then everything starts coming together. As we kept reading about children who were dying whose lives could be saved, Bill and I began to think, Maybe we can do something about this.

The most bewildering thing to us was how little attention this got. In his speeches, Bill used the example of a plane crash. If a plane crashes, three hundred people die, and it’s tragic for the families, and there’s an article in every newspaper. But on the same day, thirty thousand children die, and that’s tragic for the families, and there’s no article in any newspaper. We didn’t know about these children’s deaths because they were happening in poor countries, and what’s happening in poor countries doesn’t get much attention in rich countries. That was the biggest shock to my conscience: Millions of children were dying because they were poor, and we weren’t hearing about it because they were poor. That’s when the work in global health started for us. We began to see how we could make an impact.

Saving children’s lives was the goal that launched our global work, and our first big investment came in vaccines. We were horrified to learn that vaccines developed in the United States would take fifteen to twenty years to reach poor children in the developing world, and diseases that were killing kids in the developing world were not on the agenda of vaccine researchers back here. It was the first time we saw clearly what happens when there’s no market incentive to serve poor children. Millions of kids die.

That was a crucial lesson for us, so we joined governments and other organizations to set up GAVI, the Vaccine Alliance, to use market mechanisms to help get vaccines to every child in the world. Another lesson we kept learning is that the problems of poverty and disease are always connected to each other. There are no isolated problems.

* * *

On one of my early trips for the foundation, I went to Malawi and was deeply moved to see so many mothers standing in long lines in the heat to get shots for their kids. When I talked to the women, they’d tell me the long distances they’d walked. Many had come ten or fifteen miles. They’d brought their food for the day. They’d had to bring not only the child who was getting vaccinated but their other children as well. It was a hard day for women whose whole lives were already hard. But it was a trip we were trying to make easier and shorter, and a trip we were urging more mothers to take.

I remember seeing a young mother with small kids and asking her, “Are you taking these beautiful children to get their shots?”

She answered, “What about my shot? Why do I have to walk twenty kilometers in this heat to get my shot?” She wasn’t talking about a vaccination. She was talking about Depo-Provera, a long-acting birth control injection that could keep her from getting pregnant.

She already had more children than she could feed. She was afraid of having even more. But the prospect of spending a day walking with her children to a far-off clinic where her shot might not be in stock was deeply frustrating to her. She was just one of the many mothers I met during my early trips who switched the topic of our conversation from children’s vaccines to family planning.

I remember traveling to a village in Niger and visiting a mother named Sadi Seyni whose six children were competing for her attention as we talked. She said the same thing I heard from so many mothers: “It wouldn’t be fair for me to have another child. I can’t afford to feed the ones I have now!”

In a large and very poor neighborhood of Nairobi named Korogocho I met Mary, a young mother who sold backpacks made from scraps of blue jean fabric. She invited me into her home, where she was sewing and watching her two small children. She used contraceptives because, she said, “Life is tough.” I asked if her husband supported her decision. She said, “He knows life is tough, too.”

Increasingly on my trips, no matter what their purpose, I began to hear and see the need for contraceptives. I visited communities where every mother had lost a child and everyone knew a mother who had died in childbirth. I met more mothers who were desperate not to get pregnant because they couldn’t take care of the kids they already had. I began to understand why, even though I wasn’t there to talk about contraceptives, women kept bringing them up anyway.

The women were experiencing in their lives what I was reading in the data.

In 2012, in the world’s sixty-nine poorest countries, 260 million women were using contraceptives. Over 200 million more women in these nations wanted to use contraceptives—and couldn’t get them. That meant millions of women in the developing world were getting pregnant too early, too late, and too often for their bodies to handle. When women in developing countries space their births by at least three years, each baby is almost twice as likely to survive their first year—and 35 percent more likely to see their fifth birthday. That’s justification enough to expand access to contraceptives, but child survival is just one reason.

One of the longest-running public health studies dates from the 1970s, when half of the families in a number of villages in Bangladesh were given contraceptives and the other half were not. Twenty years later, the mothers who took contraceptives were healthier. Their children were better nourished. Their families had more wealth. The women had higher wages. Their sons and daughters had more schooling.

The reasons are simple: When the women were able to time and space their pregnancies, they were more likely to advance their education, earn an income, raise healthy children, and have the time and money to give each child the food, care, and education needed to thrive. When children reach their potential, they don’t end up poor. This is how families and countries get out of poverty. In fact, no country in the last fifty years has emerged from poverty without expanding access to contraceptives.

We made contraception part of the early giving of our foundation, but our investment was not proportional to the benefits. It took us years to learn that contraceptives are the greatest life-saving, poverty-ending, women-empowering innovation ever created. When we saw the full power of family planning, we knew that contraceptives had to be a higher priority for us.

It wasn’t just a matter of writing bigger checks, either. We needed to fund new contraceptives that would have fewer side effects, last longer, and cost less, and that a woman could get in her own village or take by herself in her home. We needed a worldwide effort that included governments, global agencies, and drug companies working with local partners to deliver family planning to women where they lived. We needed a lot more voices speaking up for women who weren’t being heard. By that time I had met many impressive people who had been working in the family planning movement for decades. I talked to as many as I could and asked them how our foundation could help, what I could do to amplify their voices.

Everyone I approached seemed to become awkwardly silent, as if the answer was obvious and I didn’t see it. Finally, a few people told me, “The best way for you to support the public advocates is to become one. You need to join us.”

That wasn’t the answer I was looking for.

I am a private person—in certain ways, a bit shy. I was the girl in school who raised her hand to speak in class while other kids bellowed their answers from the back row. I like to work offstage. I want to study the data, go see the work, meet people, develop a strategy, and solve problems. By then, I was accustomed to making speeches and giving interviews. But suddenly friends, colleagues, and activists were pressing me to become a public advocate for family planning, and that alarmed me.

I thought, Wow, am I going to step publicly into something as political as family planning, with my church and many conservatives so opposed to it? When Patty Stonesifer was our foundation’s CEO, she warned me, “Melinda, if the foundation ever steps into this space in a big way, you’re going to be at the center of the controversy because you’re Catholic. The questions will all be coming to you.”

I knew this would be a huge shift for me. But it was clear the world had to do more on family planning. Despite decades of efforts by passionate advocates, progress had largely stalled. Family planning had fallen off as a global health priority. This was partly because it had become so politicized in the United States, and also because the AIDS epidemic and vaccine campaigns had drawn funding and attention away from contraceptives globally. (It is true that the AIDS epidemic did lead to widespread efforts to distribute condoms, but for reasons I’ll explain later, condoms were not a helpful contraceptive tool for many women.)

I knew that my becoming an advocate for family planning would expose me to criticism I wasn’t used to and would take time and energy from other foundation activities. But I began to feel that if anything was worth those costs, it was this. I felt it in a visceral, personal way. Family planning was indispensable to our ability to have a family. It allowed me to work and have the time to take care of each child. It was simple, cheap, safe, and powerful—no woman I knew went without it, but hundreds of millions of women around the world wanted it and couldn’t get it. This unequal access was simply unjust. I couldn’t look the other way as women and children were dying for want of a widely available tool that could save their lives.

I also considered my duty to my children. I had a chance to stand up for women who didn’t have a voice. If I turned it down, what values was I role modeling for my kids? Would I want them to turn down difficult tasks in the future and then tell me that they were following my example?

And my own mother had a powerful influence on my choice, though she might not have known it. She always said to me as I was growing up, “If you don’t set your own agenda, somebody else will.” If I didn’t fill my schedule with things I felt were important, other people would fill my schedule with things they felt were important.

Finally, I have always carried in my head images of the women I’ve met, and I keep photographs of the ones who have moved me the most. What was the point of their opening their hearts and telling me about their lives if I wasn’t going to help them when I had the chance?

That clinched it for me. I decided to face my fears and speak out publicly for family planning.

I accepted an invitation from the UK government to cosponsor a family planning summit in London with as many heads of state, experts, and activists as we could attract. We decided we would double our foundation’s commitment to family planning and make it a priority. We wanted to revive the global commitment that all women worldwide must have access to contraceptives, so that we can decide for ourselves whether and when to have a child.

But I still had to figure out what my role would be and what the foundation needed to do. It wouldn’t be enough just to convene a global summit, talk about contraceptives, sign a declaration, and go home. We had to set goals and form a strategy.

We joined the UK government in a sprint to hold the summit in London in July of 2012, two weeks before everyone’s attention turned to the opening of the London Olympics at the end of the month.

The approach of the summit triggered a wave of media stories that highlighted the life-saving value of family planning. The British medical journal The Lancet published a study funded by the UK government and our foundation showing that access to contraception would cut the number of mothers who die in childbirth by a third. A report by Save the Children said a million teenage girls die or are injured in childbirth every year, which makes pregnancy the number one cause of death for teen girls. These findings and others helped set a tone of urgency for the conference.

There was a big crowd at the summit, including many heads of state. The speeches went well, and I was pleased with that. But I knew the test of success would be who stepped up and how much money we raised. What if national leaders didn’t support the initiative? What if governments didn’t increase their funding? Those worries had been giving me a sick feeling for months—not very different from the fear of throwing a party where no one shows up, but in this case, the media would show up to report on the failure.

I won’t say that I shouldn’t have worried. My worries make me work harder. But the funding and support were greater than my highest hopes. The United Kingdom doubled its commitment to family planning. The presidents of Tanzania, Rwanda, Uganda, and Burkina Faso and the vice president of Malawi were present at the conference and played a key role in raising the $2 billion committed by developing countries. That included Senegal, which doubled its commitment, and Kenya, which increased its national budget for family planning by a third. Together we pledged to make contraceptives available to 120 million more women by the end of the decade in a movement we called FP 2020. It was by far the largest sum of money ever pledged to support access to contraceptives.

Just the Beginning

After the conference, my best friend from high school, Mary Lehman, who had traveled with me to London, joined me for dinner with some influential women who also attended the conference. We were all having a glass of wine and enjoying a sense of satisfaction, and I was personally relieved to be done. After many months of planning and worrying, I felt I could finally relax.

That’s when these women all said to me, “Melinda, don’t you see? Family planning is just the first step for women! We have to move on to a much bigger agenda!!”

I was the only one at the table naïve enough to be surprised—and I was overwhelmed. I didn’t want to hear it. Talking to Mary in the car after dinner, I said over and over, “Mary, they’ve got to be kidding.” I was near tears and kept thinking, No way. I’m already doing my part and it’s more than I can handle, and there is already a ton of work ahead on family planning alone to meet the goals we just declared—never mind a wider women’s agenda.

The call for “more” was especially hard to hear after an emotional visit I’d had a few days earlier in Senegal. I was sitting in a small hut with a group of women talking about female genital cutting. They had all been cut themselves. Many had held their daughters down to be cut. As they were telling me about it, my colleague Molly Melching, who’s worked in Senegal for decades and was acting as my translator that day, said, “Melinda, some of this I’m not going to translate for you because I don’t think you could take it.” (At some point I have to summon the guts to ask her what she was holding back.)

Those women told me that they had all turned against the practice. When they were younger, they were afraid if they didn’t have their daughters cut, the girls could never be married. When their daughters hemorrhaged to death, they believed it was evil spirits. But they had come to see these views as lies and had banned cutting in their village.

They believed they were telling me a story of progress, and they were. But to understand in what sense it was progress required an understanding of how cruel and widespread this practice still was. They were telling me how far they had come, and were also revealing to me how awful things still were for girls in their country. The story was horrifying to me—and I just shut down. I saw the effort as hopeless and endless, beyond my stamina and resources, and I said to myself, “I quit.”

I suspect most of us, at one time or another, say “I quit.” And we often find that “quitting” is just a painful step on the way to a deeper commitment. But I was still stuck in my private “I quit” from Senegal when the women at the table in London told me how much more had to be done. So I said my second “I quit” to myself in one week. I looked into the abyss between what needed to be done and what I was able to do and I just said “No!”

Even though I said it only to myself, I meant it. But later, when I began to drop my defenses, I realized that my “No!” was only a moment of rebellion before my surrender. I had to accept that the wounds of those girls in Senegal and the needs of women around the world were beyond anything I could heal. I had to accept that my job is to do my part, let my heart break for all the women we can’t help, and stay optimistic.

Over time, I came to “Yes,” and that allowed me to see what the women in London were telling me. Family planning was a first step, but that first step wasn’t only gaining access to contraceptives; it was a step toward empowerment. Family planning means more than getting the right to decide whether and when to have children; it is the key to breaking through all kinds of barriers that have held women back for so long.

My Huge Missed Idea: Invest in Women

Some years ago in India, I visited women’s self-help groups and realized that I was seeing women empower each other. I was seeing women lifting each other up. And I saw that it all begins when women start talking to each other.

Over the years, the foundation has funded women’s self-help groups with a number of different aims: to prevent the spread of HIV, to help women farmers buy better seeds, to help women get loans. There’s a whole range of reasons to form groups. But no matter what the original focus, when women get information, tools, funding, and a sense of our power, women lift off and take the group where they want it to go.

In India, I met with women farmers in a self-help group who had purchased new seeds and were planting more crops and getting better yields on their farms—and they told me about it in the most personal ways. “Melinda, I used to live in a separate room in the house. I wasn’t even allowed to be in the house with my mother-in-law. I had a room off the back, and I didn’t have any soap. So I washed with ashes. But now I have money, so I can buy soap. And my sari is clean, and my mother-in-law respects me more. So she lets me in the house now. And I have more money now, and I bought my son a bike.”

You want to talk about being respected by your mother-in-law? Buy your son a bike.

Why does this win respect? Not because of a local custom. It’s universal. The mother-in-law respects the daughter-in-law because her income has improved the life of the family. When we women can use our talent and energy, we begin to speak in our own voices for our own values, and that makes everybody’s life better.

As women gain rights, families flourish, and so do societies. That connection is built on a simple truth: Whenever you include a group that’s been excluded, you benefit everyone. And when you’re working globally to include women and girls, who are half of every population, you’re working to benefit all members of every community. Gender equity lifts everyone.

From high rates of education, employment, and economic growth to low rates of teen births, domestic violence, and crime—the inclusion and elevation of women correlate with the signs of a healthy society. Women’s rights and society’s health and wealth rise together. Countries that are dominated by men suffer not only because they don’t use the talent of their women but because they are run by men who have a need to exclude. Until they change their leadership or the views of their leaders, those countries will not flourish.

Understanding this link between women’s empowerment and the wealth and health of societies is crucial for humanity. As much as any insight we’ve gained in our work over the past twenty years, this was our huge missed idea. My huge missed idea. If you want to lift up humanity, empower women. It is the most comprehensive, pervasive, high-leverage investment you can make in human beings.

I wish I could tell you the moment this insight came to me. I can’t. It was like a slow-rising sun, gradually dawning on me—part of an awakening shared and accelerated by others, all of us coming to the same understanding and building momentum for change in the world.

One of my best friends, Killian Noe, has founded an organization called Recovery Café that serves people suffering from homelessness, addiction, and mental health challenges, and helps them build lives they’re excited about living. Killian inspires me to explore things more deeply, and she has a question she’s made famous among her friends: “What do you know now in a deeper way than you knew it before?” I love this question because it honors how we learn and grow. Wisdom isn’t about accumulating more facts; it’s about understanding big truths in a deeper way. Year by year, with the support and insight of friends and partners and people who have gone before me, I see more clearly that the primary causes of poverty and illness are the cultural, financial, and legal restrictions that block what women can do—and think they can do—for themselves and their children.

That’s how women and girls became for me a point of leverage and a place to intervene across the range of barriers that keep people poor. The issues that make up the chapters in this book all have a gender focus: maternal and newborn health, family planning, women’s and girls’ education, unpaid work, child marriage, women in agriculture, women in the workplace. Each of these issues is shaped by barriers that block women’s progress. When these barriers are broken, opportunities open up that not only lift women out of poverty, but can elevate women to equality with men in every culture and every level of society. No other single change can do more to improve the state of the world.

The correlation is as nearly perfect as any you will find in the world of data. If you search for poverty, you will find women who don’t have power. If you explore prosperity, you will find women who do have power and use it.

When women can decide whether and when to have children; when women can decide whether and when and whom to marry; when women have access to healthcare, do only our fair share of unpaid labor, get the education we want, make the financial decisions we need, are treated with respect at work, enjoy the same rights as men, and rise up with the help of other women and men who train us in leadership and sponsor us for high positions—then women flourish … and our families and communities flourish with us.

We can look at each of these issues as a wall or a door. I think I already know which way we see it. In the hearts and minds of empowered women today, “every wall is a door.”

Let’s break down the walls and walk through the doors together.


Empowering Mothers

Maternal and Newborn Health

In 2016 on a trip to Europe, I made a special visit to Sweden to say good-bye to one of my heroes.

Hans Rosling, who died in 2017, was a trailblazing professor of international health who became famous for teaching experts facts they should already know. He became well known for his unforgettable TED Talks (more than 25 million views and counting); for his book Factfulness, written with his son and daughter-in-law, which shows us that the world is better than we think it is; and for their Gapminder Foundation, whose original work with data and graphics has helped people see the world as it is. For me personally, Hans was a wise mentor whose stories helped me see poverty through the eyes of the poor.

I want to tell you a story Hans shared with me that helped me see the impact of extreme poverty—and how empowering women can play the central role in ending it.

First, though, I should let you know that Hans Rosling was less taken with me than I was with him, at least at the start. In 2007, before we knew each other, he came to an event where I was going to speak. He was skeptical, he later told me. He was thinking, American billionaires giving away money will mess everything up! (He wasn’t wrong to be worried. More on that later.)

I won him over, he said, because in my remarks I didn’t talk about sitting back in Seattle reading data and developing theories. Instead, I tried to share what I’d learned from the midwives, nurses, and mothers I had met during my trips to Africa and South Asia. I told stories about women farmers who left their fields to walk for miles to a health clinic and endured a long, hot wait in line only to be told that contraceptives were out of stock. I talked about midwives who said their pay was low, their training slight, and they had no ambulances. I purposely didn’t go into these visits with fixed views; I tried to go with curiosity and a desire to learn. So did Hans, it turns out, and he started much earlier than I did and with greater intensity.

When Hans was a young doctor, he and his wife, Agneta—who was a distinguished healthcare professional in her own right—moved to Mozambique, where Hans practiced medicine in a poor region far from the capital. He was one of two doctors responsible for 300,000 people. They were all his patients, in his view, even if he never saw them—and usually he didn’t. His district had 15,000 births a year and more than 3,000 childhood deaths. Every day in his district, ten children died. Hans treated diarrhea, malaria, cholera, pneumonia, and problem births. When there are two doctors for 300,000 people, you treat everything.

This experience shaped who he was and defined what he taught me. After we met, Hans and I never attended the same event without getting time with each other, even if it was only a few minutes in the hallway between sessions. In our visits—some long, some short—he became my teacher. Hans not only helped me learn about extreme poverty; he helped me look back and better understand what I had already seen. “Extreme poverty produces diseases,” he said. “Evil forces hide there. It’s where Ebola starts. It’s where Boko Haram hides girls.” It took me a long time to learn what he knew, even when I had the advantage of learning it from him.

Nearly 750 million people are living in extreme poverty now, down from 1.85 billion people in 1990. According to the policymakers, people in extreme poverty are those living on the equivalent of $1.90 a day. But those numbers don’t capture the desperation of their lives. What extreme poverty really means is that no matter how hard you work, you’re trapped. You can’t get out. Your efforts barely matter. You’ve been left behind by those who could lift you up. That’s what Hans helped me understand.

Over the course of our friendship, he would always say, “Melinda, you have to be about the people on the margins.” So we tried together to see life through the eyes of the people we hoped to serve. I told him about my first foundation trip and how I came away with so much respect for the people I saw because I knew their daily reality would ruin me.

I had visited the slum of a large city, and what shocked me was not little kids coming up to the car and begging. I expected that. It was seeing little kids fending for themselves. It shouldn’t have surprised me; it’s the obvious consequence of poor mothers having no choice but to go off to work. It’s a matter of survival in the city. But whom do they leave the baby with? I saw children walking around with infants. I saw a 5-year-old running with his friends in the street, carrying a baby who was still in the wobbly-headed stage. I saw kids playing near electrical wires on a rooftop and running near sewage that was streaming down the edge of the street. I saw children playing near pots of boiling water where vendors were cooking the food they were selling. The danger was part of the kids’ day and part of their reality. It couldn’t be changed by a mother making a better choice—the mothers had no better choice to make. They had to work, and they were doing the best anyone could do in that situation to take care of their kids. I had so much regard for them, for their ability to keep on doing what they had to do to feed their children. I talked many times with Hans about what I saw, and I think it prompted him to tell me what he saw. The story Hans shared with me a few months before he died was, he told me, the one that he thought best captured the essence of poverty.

When Hans was a doctor in Mozambique in the early 1980s, there was a cholera epidemic in the district where he worked. Each day he would go out with his small staff in his health service jeep to find the people with cholera rather than wait for them to come to him.

One day they drove into a remote village at sunset. There were about fifty houses there, all made of mud blocks. The people had cassava fields and some cashew nut trees but no donkeys, cows, or horses—and no transportation to get their produce to market.

As Hans’s team arrived, a crowd peered inside his jeep and began saying, “Doutor Comprido, Doutor Comprido,” which in Portuguese means “Doctor Tall, Doctor Tall.” That’s how Hans was known—never “Doctor Rosling” or “Doctor Hans,” just “Doctor Tall.” Most of the villagers had never seen him before, but they had heard of him. Now Doctor Tall had come to their village, and as he got out of the car, he asked the village leaders, “Fala português?” Do you speak Portuguese? “Poco, poco,” they answered. A little. “Bem vindo, Doutor Comprido.” Welcome, Doctor Tall.

So Hans asked, “How do you know me?”

“Oh, you are very well known in this village.”

“But I’ve never been here before.”

“No, you’ve never been here. That’s why we are so happy you’ve come. We are very happy.” Others joined in: “He is welcome, he is welcome, Doctor Tall.”

More and more people gathered, joining the crowd softly. Soon there were fifty people around, smiling and looking at Doctor Tall.

“But there are very few people from this village who come to my hospital,” Hans said.

“No, we very seldom go to hospital.”

“So how come you know me?”

“Oh, you are respected. You are so respected.”

“I am respected? But I’ve never been here.”

“No, you’ve never been here. And yes, very few go to your hospital, but one woman came to your hospital, and you treated her. So you are very respected.”

“Ah! One woman from this village?”

“Yes, one of our women.”

“Why did she come?”

“Problem with childbirth.”

“So she came to be treated?”

“Yes, and you are so respected because you treated her.”

Hans started feeling a bit of pride, and asked, “Can I see her?”

“No,” everyone said. “No, you cannot see her.”

“Why not? Where is she?”

“She’s dead.”

“Oh, I’m sorry. She died?”

“Yes, she died when you treated her.”

“You said this woman had a problem giving birth?”


“And who took her to the hospital?”

“Her brothers.”

“And she came to the hospital?”


“And I treated her?”


“And then she died?”

“Yes, she died on the table where you treated her.”

Hans began to get nervous. Did they think he’d blundered? Were they about to unleash their grief on him? He glanced to see if his driver was in the car so he could make a getaway. He saw it was impossible to run so he began to talk slowly and softly.

“So, what illness did the woman have? I don’t remember her.”

“Oh, you must remember her, you must remember her, because the arm of the child came out. The midwife tried to drag the child out by the arm, but it was impossible.”

(This, Hans explained to me, is called an arm presentation. It blocks the chance of getting the child out because of the position of the baby’s head.)

At that point, Hans remembered everything. The child was dead when they arrived. He had to remove the child to save the life of the mother. A C-section was never an option; Hans didn’t have the setting for surgery. So he attempted a fetotomy (bringing out the dead infant in pieces), and the uterus ruptured and the mother bled to death on the operating table. Hans couldn’t stop it.

“Yes, it was very sad,” Hans said. “Very sad. I tried to save her by cutting off the baby’s arm.”

“Yes, you cut off the arm.”

“Yes, I cut off the arm. I tried to take the body out in pieces.”

“Yes, you tried to take it out in pieces. That’s what you told the brothers.”

“I’m very, very sorry that she died.”

“Yes, so are we. We are very sorry, she was a good woman,” they said.

Hans exchanged courtesies with them, and when there wasn’t much else to say, he asked—because he is curious and courageous—“But how can I be respected when I didn’t save the woman’s life?”

“Oh, we knew it was difficult. We know that most women who have the arm coming out will die. We knew that it was difficult.”

“But why did you respect me?”

“Because of what you did afterward.”

“What was that?”

“You went out of the room into your yard. You stopped the vaccination car from leaving. You ran to catch up with it, you made the car come back, you took out boxes from the car, and you arranged for the woman from our village to be wrapped in a white sheet. You provided the sheet, and you even provided a small sheet for the pieces of the baby. Then you arranged for the woman’s body to be put into that jeep, and you made one of your staff get out so there would be room for the brothers to go with her. So after that tragedy, she was back home the same day while the sun was still shining. We had the funeral that evening, and her whole family, everyone was here. We never expected anyone to show such respect for us poor farmers here in the forest. You are deeply respected for what you do. Thank you very much. You will always be in our memory.”

Hans paused here in the story and told me, “I wasn’t the one who did that. It was Mama Rosa.”

Mama Rosa was a Catholic nun who worked with Hans. She had told him, “Before you do a fetotomy, get permission from the family. Don’t cut a baby before you have their permission. Afterward, they will ask you only for one thing, to get the parts of the child. And you will say, ‘Yes, you will get the parts, and you will be given the cloth for the child.’ That’s the way. They don’t want anybody else to have parts of their baby. They want to see all the pieces.”

So Hans explained, “When this woman died, I was sobbing, and Mama Rosa put her arm around me and said, ‘This woman was from a very remote village. We must take her home. Otherwise no one will come to the hospital from that village for the next decade.’

“‘But how can we take her?’

“‘Run out and stop the vaccine car,’ Mama Rosa told me. ‘Run out and stop the vaccine car.’”

And Hans did it. “Mama Rosa knew what people’s realities were,” he said. “I never would have known to do that. Often in life, it’s the older males who get credit for the work that young people and women do. It isn’t right, but that’s how it works.”

That was Hans’s deepest witness of extreme poverty. It wasn’t living on a dollar a day. It was taking days to get to the hospital when you’re dying. It was respecting a doctor not for saving a life but for returning a dead body to the village.

If this mother had lived in a prosperous community and not on the margins among farmers in a remote forest in Mozambique, she never would have lost her baby. She never would have lost her life.

This is the meaning of poverty I’ve come to see in my work, and I see it also in Hans’s story: Poverty is not being able to protect your family. Poverty is not being able to save your children when mothers with more money could. And because the strongest instinct of a mother is to protect her children, poverty is the most disempowering force on earth.

It follows that if you want to attack poverty and if you want to empower women, you can do both with one approach: Help mothers protect their children. That is how Bill and I began our philanthropic work. We didn’t put it in those words at the time. It just struck us as the most unjust thing in the world for children to die because their parents are poor.

In late 1999, in our first global initiative, we joined with countries and organizations to save the lives of children under 5. A huge part of the campaign was expanding worldwide coverage for a basic package of vaccines, which had helped cut the number of childhood deaths in half since 1990, from 12 million a year to 6 million.

Unfortunately, the survival rate of newborns—babies in the first twenty-eight days of life—has not improved at the same pace. Of all the deaths of children under 5, nearly half come in the first month. And of all the deaths in the first month, the greatest number come on the first day. These babies are born to the poorest of the poor—many in places far beyond the reach of hospitals. How can you save millions of babies when their families are spread out in remote areas and follow centuries of tradition when it comes to childbirth?

We didn’t know. But if we wanted to do the most good, we had to go where there’s the most harm—so we explored ways to save the lives of mothers and newborn babies. The most common factor in maternal and infant death is the lack of skilled providers. Forty million women a year give birth without assistance. We found that the best response—at least the best response we have the know-how to deliver now—is to train and deploy more skilled healthcare providers to be present for mothers at birth and in the hours and days after.

In 2003, we funded the work of Vishwajeet Kumar, a medical doctor with advanced training from Johns Hopkins who was launching a life-saving program in a village called Shivgarh in Uttar Pradesh, one of India’s poorest states.

In the midst of this project, Vishwajeet married a woman named Aarti Singh. Aarti was an expert in bioinformatics—and began applying her expertise to designing and evaluating programs for mothers and newborns. She became an indispensable member of the organization, which was named Saksham, or “empowerment,” by the people in the village.

Vishwajeet and the Saksham team had studied births in poor rural parts of India and saw that there were many common practices that were high risk for the baby. They believed that many newborn deaths could be prevented with practices that cost little or nothing and could be done by the community: immediate breastfeeding, keeping the baby warm, cutting the cord with sterilized tools. It was just a matter of changing behavior. With grants from USAID and Save the Children and our foundation—and by teaching safe newborn practices to community health workers—Saksham cut newborn mortality in half in eighteen months.

At the time of my 2010 visit to Shivgarh, there were still 3 million newborn deaths in the world every year. Nearly 10 percent of those deaths occurred in Uttar Pradesh, which has been called the global epicenter of newborn and maternal deaths. If you wanted to bring down the number of newborn deaths, Uttar Pradesh was an important place to work.

On the first day of my trip, I met with about a hundred people from the village to talk about newborn care. It was a large crowd, with mothers seated at the front and men toward the back. But it felt intimate. We were sitting on rugs laid out under the shade of a large tree, packed in tightly to make sure no one was left out in the blistering sun. After the meeting, we were greeted by a family with a little boy about 6 years old. Seconds later, Gary Darmstadt, who was our foundation’s head of maternal and newborn health at the time, whispered to me, “That was him; that was the baby!” I looked back and saw the 6-year-old boy and said, “What baby? That’s not a baby.” “That’s the one Ruchi saved,” he said. “Oh my gosh!” I said. “That’s the baby you told me about!?”

That 6-year-old boy had become lore. He was born in the first month of the Saksham program when the community health workers had just been trained, community skepticism was high, and everyone was watching. The baby, whom I had just seen as a healthy 6-year-old, was born in the middle of the night. The mother, in her first pregnancy, was exhausted and fainted during childbirth.

As soon as the sun came up, the recently trained community health worker was notified of the birth and came immediately. Her name was Ruchi. She was about 20 years old and came from a high-caste Indian family. When she arrived, she found the mother still unconscious and the baby cold. Ruchi asked what was going on, and none of the family members in the room said a thing. They were all terrified.

Ruchi stoked the fire to warm the room, then got blankets and wrapped the baby. She took the baby’s temperature—because she was trained to know that hypothermia can kill babies or be a sign of infection. The infant was extremely cold, about 94 degrees. So Ruchi tried the conventional things she’d done in the past, and nothing worked. The baby was turning blue. He was listless, and Ruchi realized that he would die unless she did something right away.

One of the life-saving practices Ruchi had learned was skin-to-skin care: holding a baby against the mother’s skin to transfer warmth from the mom to the newborn. The technique prevents hypothermia. It promotes breastfeeding. It protects from infection. It is one of the most powerful interventions we know of for saving babies.

Ruchi asked the baby’s aunt to give the infant skin-to-skin care, but the aunt refused. She was afraid that the evil spirit she thought was gripping the baby would take her over as well.

Ruchi then faced a choice: Would she give the baby skin-to-skin care herself? The decision wasn’t easy; doing something so intimate with a low-caste infant could bring ridicule from her own relatives. And this was a foreign practice in the community. If it didn’t go well, the family could blame her for the death of the baby.

But when she saw the baby getting colder, she opened up her sari and placed the newborn against her bare skin, with the baby’s head nestled between her breasts and a cloth covering both her head and the baby’s for modesty and warmth. Ruchi held the baby that way for a couple of minutes. His skin color appeared to be changing back to pink. She took out her thermometer and tested the baby’s temperature. A little better. She held the baby a few minutes more and took his temperature again. A little bit higher. Every woman there leaned in and watched as the baby’s temperature rose. A few minutes later, the baby started to move; then he came alive; then he started to cry. The baby was fine. He wasn’t infected. He was just a healthy baby who needed to be warmed and hugged.

When the mother regained consciousness, Ruchi told her what had happened and guided her in skin-to-skin care, then helped her initiate breastfeeding. Ruchi stayed another hour or so, watching the mother and baby in skin-to-skin position, and then she left the home.

This story spread like lightning through the nearby villages. Overnight, women went from saying “We’re not sure about this practice” to “I want to do this for my baby.” It was a turning point in the project. You don’t get behavior change unless a new practice is transparent, works well, and gets people talking—and Ruchi’s revival of this one-day-old baby had everybody talking. This was a practice all women could do. Mothers became seen as life-savers. It was immensely empowering and transformative.

Their Cup Is Not Empty

I learned a lot from my trip to Shivgarh, and the most striking lesson for me—and what made it a departure from a lot of our prior work—is that it wasn’t about technological advances. Our emphasis at the foundation has always been on scientific research to develop life-saving breakthroughs like vaccines. We call this product development, and it continues to be our main contribution. But Vishwajeet and Aarti’s program for mothers and newborns showed me how much can be achieved by sharing simple practices that are widely known throughout the world. This taught me in a profound way that you have to understand human needs in order to effectively deliver services and solutions to people. Delivery systems matter.

What do I mean by a “delivery system”? Getting tools to people who need them in ways that encourage people to use them—that is a delivery system. It is crucial, and it is often complex. It can require getting around barriers of poverty, distance, ignorance, doubt, stigma, and religious and gender bias. It means listening to people, learning what they want, what they’re doing, what they believe, and what barriers they face. It means paying attention to how people live their lives. That’s what you need to do if you have a life-saving tool or technique you want to deliver to people.

Before launching the program, Saksham hired a local team of top students who spent six months working with the community to understand their existing practices and beliefs around childbirth. Vishwajeet told me, “Their cup is not empty; you can’t just pour your ideas into it. Their cup is already full, so you have to understand what is in their cup.” If you don’t understand the meaning and beliefs behind a community’s practices, you won’t present your idea in the context of their values and concerns, and people won’t hear you.

Historically, the mothers in the community would go to the Brahmin, a member of the priestly caste, and ask when to start breastfeeding, and he would say, “You can’t let down milk for three days, so you should start after three days.” False information is disempowering. Mothers would heed the advice of the Brahmin, and for the first three days of the newborn’s life, they would give the baby water—which was often polluted. Vishwajeet and Aarti’s team had prepared for this moment. They gently questioned traditional practices by pointing to patterns in nature that were part of the villagers’ way of life. They cited the example of a calf and its mother. “When we try to milk a cow and it doesn’t express milk, we make the calf suckle her to get the milk to let down, so why don’t you try the same and keep the baby against your breast to express milk.”

The villagers still said, “No, this isn’t going to work.” So the local team went to a few people in the community who had courage and influence and tried to persuade them. Team members knew that if they could create a culture of support around a young mother, the mother would be much more likely to try the new practice. When a few mothers tried it and were able to breastfeed right away, they said, “Wait a minute; we didn’t realize we could do this!” Then things took off; the community began to try the other health practices as well.

It’s a delicate thing to initiate change in a traditional culture. It has to be done with the utmost care and respect. Transparency is crucial. Grievances must be heard. Failures must be acknowledged. Local people have to lead. Shared goals have to be emphasized. Messages have to appeal to people’s experience. The practice has to work clearly and quickly, and it’s important to emphasize the science. If love were enough to save a life, no mother would ever bury her baby—we need the science as well. But the way you deliver the science is just as important as the science itself.

Midwife in Every Village

When I returned to the foundation after my trip to Shivgarh, I talked to our staff about delivery and cultural awareness and how crucial they are to saving lives. I said we have to keep working on innovation in products, in science and technology, but we have to work with the same passion on innovation in delivery systems as well. Both are indispensable.

Let me illustrate with an example that is personal to me, and one I haven’t shared before. It’s about my mom’s older sister Myra.

My aunt Myra is very dear to me. I called her “my other mother” when I was growing up. When she used to visit us, she would spend time coloring and playing board games with my sister, Susan, and me. We also went shopping a lot. She was so energetic and upbeat that it didn’t ever figure in my image of Aunt Myra that she didn’t have the use of her legs.

When my mom and Myra were young girls in the 1940s, they were playing at their great-uncle’s house, and afterward he told my grandmother, “Myra was sure being lazy today. She wanted me to carry her home.”

That night Myra woke up screaming in pain. My grandparents took her to the hospital, and a team of doctors figured out she had polio. They wrapped her legs up with gauze, boiled water, and put on hot packs. Doctors thought the heat would help, but it didn’t make any difference. Three or four days later, her legs were paralyzed. She was in the hospital for sixteen months, and my grandparents were allowed to visit her only on Sundays. Meanwhile, none of the kids in the neighborhood would play with my mom anymore. Everyone was terrified of the polio virus.

In the 1940s, the great polio challenge was product development, namely, finding a vaccine. Delivery didn’t matter. There was nothing to deliver. It wasn’t a question of privilege or poverty. The scientific innovation hadn’t happened yet. There was no protection for anyone against polio.

As soon as Jonas Salk developed his polio vaccine in 1953, the passionate effort to protect people from polio shifted from product development to delivery, and in this case, poverty did matter. People in wealthy countries were vaccinated quickly. By the late 1970s, polio had been eliminated in the US, but it continued to plague much of the world, including India, where the vast landscapes and large population made polio especially hard to fight. In 2011, defying most expert predictions, India became polio free. It was one of the greatest accomplishments in global health, and India did it with an army of more than 2 million vaccinators who traversed the entire country to find and vaccinate every child.

In March of 2011, Bill and I met a young mother and her family in a small village in Bihar, one of the most rural states in India. They were migrant workers, desperately poor, and working at a brick kiln. We asked her if her children had been vaccinated for polio, and she went into her hut and returned with an immunization card with the names of her children and the dates they received the vaccine. The vaccinators had not just found her children once. They had done so several times. We were awestruck. That is how India became polio free—through massive, heroic, original, and ingenious delivery.

Meeting people who deliver life-saving support to others is one of the highlights of my work. A few years ago on a trip to Indonesia, I met a woman named Ati Pujiastuti. As a young woman, Ati had enrolled in a government program called Midwife in Every Village that trained 60,000 midwives. She completed the program when she was just 19 years old and was assigned to work in a rural mountain village.

When she arrived in the village, she wasn’t welcome. People were hostile and distrustful of outsiders, especially young women with ideas for how to make things better. Somehow, this young woman had the wisdom of a village elder. She went door-to-door to introduce herself to everyone. She showed up at every community event. She bought the local newspaper and read it aloud to anyone who couldn’t read. When the village got electricity, she scraped up the money to buy a tiny TV and invited everyone to come watch with her.

Still, nobody wanted her services until, by pure accident, a pregnant woman who was visiting the village from Jakarta went into labor and asked Ati to deliver her baby. The birth went well, the villagers began to trust Ati, and soon every family wanted her present when mothers gave birth. She made sure that she was there, every time, even at the risk of her own life. Once she lost her footing while crossing a river and had to cling to a rock until help came. Another time she slipped on a muddy mountain path next to the edge of a cliff. Several times, she was thrown off her motorbike while riding on unpaved roads. Still, she stayed on and kept delivering babies. She knew she was saving lives.

As much as we need women on the ground delivering these services, we also need women in high places with vision and power. One of those women is Dr. Agnes Binagwaho, the former health minister of Rwanda.

In 2014, Agnes and I coauthored a piece in The Lancet. We called attention to the newborn lives that could be saved if the world could remedy one harsh reality: Most women in low-income countries give birth at home without a skilled attendant.

Putting a skilled birth attendant at the side of every mother in labor has been one of the great causes of Agnes’s life.

It’s not a cause anyone would have predicted twenty-five years ago. Agnes was working as a pediatrician in France in 1994 when she began hearing frightening news reports from home. Members of the majority ethnic group, the Hutus, had begun slaughtering minority Tutsis. She followed the horror from afar as almost a million people were murdered in a hundred days. Half of her husband’s family was killed.

Agnes hadn’t lived in Rwanda since she was 3 years old, when her father moved the family to France so he could go to medical school. But after the genocide, she and her husband decided to return to their country and help rebuild.

Returning to Rwanda was a shock, especially for a medical doctor who practiced in Europe. Even before the genocide, Rwanda was one of the worst places in the world to give birth, and the conflict made the situation far worse. Almost all the nation’s health workers had either fled or been killed, and wealthy nations weren’t giving health aid. A week after she arrived, Agnes nearly left. But her heart was breaking for those who couldn’t leave—so she stayed, became the longest-serving health minister in her country’s history, and spent the next two decades helping to build a new health system for Rwanda.

Under Agnes, the health ministry started a program where each Rwandan village (with about 300 to 450 residents) elects three community health workers—one dedicated solely to maternal health.

These and other changes have been dramatically successful. Since the genocide, Rwanda has made more progress in making birth safer than almost any other nation in the world. Newborn mortality is down by 64 percent. Maternal mortality is down by 77 percent. A generation after Rwanda was considered a lost cause, its health system is studied as a model. Agnes is now working with Dr. Paul Farmer, one of my heroes for bringing healthcare to poor people, first in Haiti and then around the world. Partners in Health, which Paul cofounded, has launched a new health sciences university in Rwanda, the University of Global Health Equity. Agnes is vice-chancellor of the university and is promoting fresh research into what makes delivery work.

What inspires me most about Agnes’s work in Rwanda, Ati’s work in Indonesia, and Vishwajeet and Aarti’s work in India is that they all show how a passionate emphasis on delivering services can ease the effects of poverty. This underscores the value of Hans Rosling’s stories about extreme poverty: When you begin to understand the daily lives of the poor, it does more than give you the desire to help; it can often show you how.

When people are not getting healthcare that most others get, the problem is by definition one of delivery. Medicine, services, and skilled assistance are not reaching them. That’s what it means to be poor. They’re on the margins. They’re not getting the benefit of what human beings know how to do for each other. So we have to invent a way of getting it to them. This is what it means to fight the effects of poverty. It’s unglamorous from a technological standpoint, but deeply satisfying from a human viewpoint—innovation driven by the feeling that science should serve everyone. No one should be excluded.

That is a lesson I have kept close to my heart: Poverty is created by barriers; we have to get around or break down those barriers to deliver solutions. But that’s not all. The more I saw our work in the field, the more I realized that delivery needs to shape strategy. The challenge of delivery reveals the causes of poverty. You learn why people are poor. You don’t have to guess what the barriers are. As soon as you try to deliver help, you run into them.

When a mother can’t get what she needs to protect her children, it’s not just that she’s poor. It’s something more precise. She doesn’t have access to a skilled birth attendant with the latest knowledge and crucial health tools. Why? There could be many reasons. She doesn’t have information. She doesn’t have money. She lives far from town. Her husband is opposed to it. Her mother-in-law doubts it. She doesn’t think she can ask for it. Her culture frowns on it. When you know why a mother can’t get what she needs, you can figure out what to do.

If the barrier is distance, money, knowledge, or stigma, we have to offer tools and information that are closer, cheaper, and less tainted by stigma. To fight poverty, we have to see and study the barriers and figure out if they’re cultural, or social, or economic, or geographic, or political, and then go around them or through them so the poor aren’t cut off from benefits others enjoy.

As soon as we began to spend more time understanding how people live their lives, we saw that so many of the barriers to advancement—and so many of the causes of isolation—can be traced to the limits put on the lives of women.

In societies of deep poverty, women are pushed to the margins. Women are outsiders. That’s not a coincidence. When any community pushes any group out, especially its women, it’s creating a crisis that can only be reversed by bringing the outsiders back in. This is the core remedy for poverty and almost any social ill—including the excluded, going to the margins of society and bringing everybody back in.

Back when I was in elementary school, there were two girls who sat at the back of the class, smart girls, but quiet and a little socially awkward. And there were two other girls, socially confident and popular, who sat toward the front of the class. The popular girls in front picked on the quiet girls in the back. I’m not talking about once a week. It was constant.

They were careful to do it when the teacher couldn’t see or hear—so no one did anything to stop them. And the quiet girls just got quieter. They were afraid to look up and make eye contact because it would bring on more abuse. They suffered terribly, and the pain never went away even after the bullying stopped. Decades later, at a class reunion, one of the popular girls apologized, and one of the girls who was bullied answered, “It’s about time you said something.”

All of us have seen something like this. And we all had a role in it. Either we were bullies, or we were victims, or we saw bullying and didn’t stop it. I was in that last group. I saw everything I just described. And I didn’t stop it because I was afraid that if I spoke up, the bullies would turn on me too. I wish I had known how to find my voice and help the other girls find theirs.

As I grew up, I thought abuse like that would happen less and less. But I was wrong. Adults try to create outsiders, too. In fact, we get better at it. And most of us fall into one of the same three groups: the people who try to create outsiders, the people who are made to feel like outsiders, and the people who stand by and don’t stop it.

Anyone can be made to feel like an outsider. It’s up to the people who have the power to exclude. Often it’s on the basis of race. Depending on a culture’s fears and biases, Jews can be treated as outsiders. Muslims can be treated as outsiders. Christians can be treated as outsiders. The poor are always outsiders. The sick are often outsiders. People with disabilities can be treated as outsiders. Members of the LGBTQ community can be treated as outsiders. Immigrants are almost always outsiders. And in most every society, women can be made to feel like outsiders—even in their own homes.

Overcoming the need to create outsiders is our greatest challenge as human beings. It is the key to ending deep inequality. We stigmatize and send to the margins people who trigger in us the feelings we want to avoid. This is why there are so many old and weak and sick and poor people on the margins of society. We tend to push out the people who have qualities we’re most afraid we will find in ourselves—and sometimes we falsely ascribe qualities we disown to certain groups, then push those groups out as a way of denying those traits in ourselves. This is what drives dominant groups to push different racial and religious groups to the margins.

And we’re often not honest about what’s happening. If we’re on the inside and see someone on the outside, we often say to ourselves, “I’m not in that situation because I’m different.” But that’s just pride talking. We could easily be that person. We have all things inside us. We just don’t like to confess what we have in common with outsiders because it’s too humbling. It suggests that maybe success and failure aren’t entirely fair. And if you know you got the better deal, then you have to be humble, and it hurts to give up your sense of superiority and say, “I’m no better than others.” So instead we invent excuses for our need to exclude. We say it’s about merit or tradition when it’s really just protecting our privilege and our pride.

In Hans’s story, the mother from the forest lost her life because she was an outsider. She lost her baby because she was an outsider. And her family had a warm memory of the doctor who returned their bodies to the village because they were outsiders. They were not used to being treated with respect. That is why they suffered so much death.

Saving lives starts with bringing everyone in. Our societies will be healthiest when they have no outsiders. We should strive for that. We have to keep working to reduce poverty and disease. We have to help outsiders resist the power of people who want to keep them out. But we have to do our inner work as well: We have to wake up to the ways we exclude. We have to open our arms and our hearts to the people we’ve pushed to the margins. It’s not enough to help outsiders fight their way in—the real triumph will come when we no longer push anyone out.


Every Good Thing

Family Planning

A few days after I visited Vishwajeet and Aarti’s program, which trained community health workers who attended home births, I visited a maternal and newborn health program called Sure Start, which encourages mothers to deliver in clinics with trained birth attendants and medical equipment.

When I arrived at the project site, I was invited to watch a group of twenty-five pregnant women playing a quiz game on principles of good health, answering questions about early breastfeeding and first-hour newborn care. Then I met with a women’s group centered on pregnant women and their family members, mainly mothers-in-law and sisters-in-law. I asked the pregnant women if they faced any family resistance for participating in the program. Then I asked the mothers-in-law what changes they’d seen since they’d been pregnant with their own children. One older woman told me that she had given birth to eight children at home, but six had died within a week of delivery. Her daughter-in-law was now pregnant for the first time, and the older woman wanted her to receive the best possible care.

In the afternoon, I was able to visit the home of a mother named Meena who had delivered a baby boy just two weeks before. Meena’s husband worked for daily wages near their home. Their children had all been delivered at home except for the newborn, who was born in a clinic with the support of Sure Start. Meena held her infant in her arms as we talked.

I asked Meena if the program had helped her, and she gave me an enthusiastic yes. She felt delivering in a clinic was safer for her and the baby, and she had started breastfeeding the same day, which made her feel free to bond with her baby immediately, and she loved that. She was very animated, very positive. She clearly felt good about the program, and therefore so did I.

Then I asked her, “Do you want to have any more children?”

She looked as if I’d shouted at her. She cast her eyes down and stayed silent for an awkwardly long time. I was worried that I’d said something rude, or maybe the interpreter had offered a bad translation, because Meena kept staring at the ground. Then she raised her head, looked me in the eyes, and said, “The truth is no, I don’t want to have any more kids. We’re very poor. My husband works hard, but we’re just extremely poor. I don’t know how I’m going to feed this child. I have no hopes for educating him. In fact, I have no hopes for this child’s future at all.”

I was stunned. People tend to tell me the good news, and I often have to ask probing questions to find out the rest. This woman had the courage to tell me the whole painful truth. I didn’t have to ask. And she wasn’t finished.

“The only hope I have for this child’s future,” she said, “is if you’ll take him home with you.” Then she put her hand on the head of the 2-year-old boy at her leg and said, “Please take him, too.”

I was reeling. In a moment, we had gone from a joyous conversation about a healthy birth to a dark confession about a mother’s suffering—suffering so great that the pain of giving her babies away was less than the pain of keeping them.

When a woman shares her grief with me, I see it as a huge honor. I listen intently, offer sympathy, and then try to point out an upside somewhere. But if I had tried in that moment to say something upbeat to Meena, it would have been false and offensive. I asked her a question and she told me the truth; it would have denied her pain to pretend to be positive. And the pain she described was beyond anything I could imagine—she felt the only way to help her children live a good life was to find them another mother.

I told her as gently as I could that I had three children of my own, and that her children loved her and needed her. Then I asked, “Do you know about family planning?” She said, “I do now, but you people didn’t tell me before, and now it’s too late for me.”

This young mother felt like a complete failure, and so did I. We had totally let her down. I was so overwhelmed with emotion, I don’t even recall how we parted or how I said good-bye.

Meena dominated my mind for the rest of the trip. It took me a long time before I could take it all in. Clearly, it was good to help her deliver in a facility, but it wasn’t good enough. We weren’t seeing the whole picture. We had a maternal and newborn health program, and we talked to expecting mothers about their needs in maternal and newborn health. That was the lens we looked through to see the work, but the lenses we should have been looking through were the eyes of Meena.

When I talk to women in low-income countries, I see very little difference in what we women all want for ourselves and our children. We want our kids to be safe, to be healthy, to be happy, to do well in school, to fulfill their potential, to grow up and have families and livelihoods of their own—to love and be loved. And we want to be healthy ourselves and develop our own gifts and share them with the community.

Family planning is important in meeting every one of those needs, no matter where a woman lives. It took a woman with courage to burn this message into me, and her pain became a turning point in my work. When one person tells me a harsh truth, I can be sure that she’s speaking for others who aren’t as bold. It makes me pay better attention, and then I realize that others have been saying the same thing all along, just more softly. I haven’t heard it because I haven’t really been listening.

Shortly after I spoke to Meena, I traveled to Malawi and paid a visit to a health center. The center had a room for vaccinations, a room for sick kids, a room for HIV patients, and a room for family planning. There was a long line of women waiting to visit the family planning room, and I talked to a few of them—asking where they had come from, how many children they had, when they started using contraceptives, what kind of contraceptives they used. My nosiness was matched by the women’s eagerness to talk about their lives. One woman told me that she had come to get her injection but didn’t know if it would be available, and all the other women nodded. They said they would walk ten miles to the health clinic not knowing if the shot would be in stock when they got there, and many times it wasn’t. So they’d be offered some other kind of contraceptive. They might be offered condoms, for example, which clinics tended to have in good supply because of the AIDS epidemic. But condoms are often unhelpful for women trying to avoid pregnancy. Women have told me over and over again, “If I ask my husband to wear a condom, he will beat me up. It’s like I’m accusing him of being unfaithful and getting HIV, or I’m saying that I was unfaithful and got HIV.” So condoms were useless for many women, and yet health clinics would claim they were stocked up on contraceptives when all they had was condoms.

After I heard most of the women tell the same story about walking a long way and not getting the shot, I stepped inside the room and found that, in fact, the clinic did not have the shot everyone had come for. That wasn’t a minor inconvenience for these women. It wasn’t just a matter of driving to the next pharmacy. There was no pharmacy. And they had come miles on foot. And there were no other contraceptives these women could use. I have no idea how many of the women I met that day became pregnant because the health center was out of stock.

An unplanned pregnancy can be devastating for women who can’t afford to feed the children they already have, or who are too old, too young, or too ill to bear children. My visit with Meena opened my eyes to women who didn’t know about contraceptives. My visit to Malawi opened my eyes to women who knew about contraceptives and wanted contraceptives but couldn’t get them.

It hadn’t come as a revelation to me that women want contraceptives. I knew it from my own life, and it was one of the things we supported at the foundation. But after these trips, I began to see it as central, as the first priority for women.

When women can time and space their births, maternal mortality drops, newborn and child mortality drops, the mother and baby are healthier, the parents have more time and energy to care for each child, and families can put more resources toward the nutrition and education of each one. There was no intervention more powerful—and no intervention that had become more neglected.

In 1994, the International Conference on Population and Development in Cairo drew more than 10,000 participants from around the world. It was the largest conference of its kind ever held and a historic early statement on the rights of women and girls. It urged the empowerment of women, set goals for women’s health and education, and declared that access to reproductive health services, including family planning, is a basic human right. But funding for family planning had dropped significantly since Cairo.

That’s a big reason why contraceptives were the number one issue on my mind in 2010 and 2011. And the subject kept coming up everywhere I went. Back in Seattle, in October 2011, Andrew Mitchell, the UK’s secretary of state for international development, was attending a malaria summit hosted by our foundation and approached me with an idea: Would we be interested in hosting another summit the following year, this one on family planning? (This, of course, became the summit I described in chapter 1.)

The idea of an international family planning summit struck me as both scary and exciting, a huge project. I knew that we would have to emphasize setting goals, improving data, and being more strategic. But I also knew that if we were going to set ambitious goals and reach them, we had to meet a much tougher challenge. We had to change the conversation around family planning. It had become impossible to have a sensible, rational, practical conversation about contraceptives because of the tortured history of birth control. Advocates for family planning had to make it clear that we were not talking about population control. We were not talking about coercion. The summit agenda was not about abortion. It was about meeting the contraceptive needs of women and allowing them to choose for themselves whether and when to have children. We had to change the conversation to include the women I was meeting. We needed to bring in their voices—the voices that had been left out.

That’s why, just before the summit, I visited Niger, a patriarchal society with one of the highest poverty rates in the world, an extremely low use of contraceptives, an average of more than seven children per woman, marriage laws that allow men to take several wives, and inheritance laws that give half as much to daughters as to sons and nothing to widows who don’t have children. Niger was, according to Save the Children, “the worst place in the world to be a mother.” I went there to listen to the women and meet those mothers.

I traveled to a small village about an hour and a half northwest of the capital and met with a mother and okra farmer named Sadi Seyni. (I mentioned her in chapter 1, too.) Sadi was married at 19—old for Niger, where nearly 76 percent of all girls under 18 are married. After her first child, Sadi was pregnant again in seven months. She didn’t learn about family planning until after she had her third child and a doctor at her local one-room clinic told her about contraceptives. She then began spacing her births. When I met her, Sadi was 36 years old and had six children.

We talked in Sadi’s home. She sat opposite me on her bed with two children beside her, another snuggling into her lap, another standing behind her on the bed, and two older children sitting nearby. They were all dressed in colorful fabrics, each a different pattern, and Sadi and the older girls wore headscarves; Sadi’s was a solid purple. The sun was pouring in through the windows, only partially blocked by a sheet they’d put up, and Sadi answered my questions with an energy that showed she was glad to be asked.

“When you don’t do family planning,” she said, “everybody in the family suffers. I’d have a baby on my back and another in my belly. My husband had to take on debt to cover the basics, but even that wasn’t enough. It’s complete suffering when you don’t do family planning, and I have lived that.”

I asked her if she wanted another child, and she said, “I don’t plan on having another child until the little one is at least four. If she’s four, she can play with her little brother or sister; she can take him on her back. But now, if I were to bring her a little brother, it would be like punishing her.”

When I asked her how women find out about contraceptives, she said, “The good thing about being a woman here is that we gather a lot and talk. We talk when we meet under a tree to pound our millet. We talk at feasts after a baby is born, and that is where I talk to others about getting a shot and how much easier it is to use than the pill. I tell them you should take it to give yourself and your children a break.”

What mother wouldn’t understand that—giving yourself and your children a break?

The following day I visited the National Center for Reproductive Health in Niamey, the capital. After our tour, five women who were there to get services joined us for conversation. Two young women told us about their lives, and then we heard from an outspoken 42-year-old mother named Adissa. Adissa had been married off at age 14, gave birth to ten children, and lost four. After her tenth pregnancy, she visited the family planning center to get an IUD and has not been pregnant since. That’s caused her husband and sister-in-law to look on her with suspicion and ask why she hasn’t delivered recently. “I’m tired,” she told them.

When I asked Adissa why she decided to get an IUD, she sat and thought for a moment. “When I had two kids, I could eat,” she said. “Now, I cannot.” She receives from her husband the equivalent of a little over a dollar a day to take care of the entire family.

I asked Adissa if she had any advice for the younger women who were there, and she said, “When you can’t take care of your children, you’re just training them to steal.”

A few minutes later we all got up to leave. Adissa walked toward the tray of food that no one had touched, put most of it in her bag, wiped a tear from her eye, and left the room.

As I took in everything I had just heard, I wanted so badly for everyone to hear Adissa. I wanted a conversation led by the women who’d been left out—women who want contraceptives and need them and whose families are suffering because they can’t get them.

The Old Conversation—That Left Women Out

Changing the conversation has been a lot harder than I expected because it’s a very old conversation, grounded in biases that don’t easily go away. The conversation has been in part a response to the work of Margaret Sanger, who has a complex legacy.

In 1916, Sanger opened the first clinic in the United States that offered contraceptives. Ten days later, she was arrested. She posted bail, went back to work, and was arrested again. It was illegal to distribute contraceptives. It was also illegal to prescribe them, to advertise them, or to talk about them.

Sanger was born in 1879 to a mother who would eventually have eighteen pregnancies and care for eleven children before dying of tuberculosis and cervical cancer at the age of 50. Her death encouraged Sanger to become a nurse and work in New York City slums with poor immigrant mothers who had no contraceptives.

In a story she told in her speeches, Sanger was once called to the apartment of a 28-year-old woman who was so desperate to avoid another baby that she had performed a self-induced abortion and nearly died. The woman, realizing how close she’d come to killing herself, asked the doctor how she could prevent another pregnancy. The doctor suggested she tell her husband to sleep on the roof.

Three months later, the woman was pregnant again, and after another attempt at abortion, Sanger was again called to the apartment. This time the woman died just after Sanger arrived. As she told it, that prompted Sanger to quit nursing, swearing that she would “never take another case until I had made it possible for working women in America to have the knowledge to control birth.”

Sanger believed women could achieve social change only if they were able to prevent unwanted pregnancy. She also saw family planning as a free speech issue. She gave public talks. She lobbied politicians. She published columns, pamphlets, and a newspaper about contraceptives—all illegal at the time.

Her arrest in 1916 made her famous, and over the next two decades more than a million women wrote to her in desperation, pleading for help in getting contraceptives. One woman wrote, “I would do anything for my two children to help them go through a decent life. I am constantly living in fear of becoming pregnant again so soon. Mother gave birth to twelve children.”

Another wrote, “I have heart trouble and I would like to be here and raise these four than have more and maybe die.”

A southern farm woman wrote, “I have to carry my babies to the field, and I have seen their little faces blistered by the hot sun.… Husband said he intended making our girls plow, and I don’t want more children to be slaves.”

These women’s letters were published