Ashley Judd with a group of women and children in India
Photo: Courtesy of
After years spent working with international health organization PSI and the HIV education group YouthAIDS, Ashley Judd could be considered as much a humanitarian activist as a glamorous actress. Here, she interviews Pulitzer Prize–winning New York Times columnist and author Nicholas Kristof about the global impact of his book (co-written with his wife, Sheryl WuDunn) Half the Sky.
Ashley Judd: You've drawn global attention to the unique needs and challenges of women in the developing world. Is the battle to bring attention to this issue being won or lost? And how do you feel about your contribution, both through your columns and the extraordinary book, Half the Sky, you and your wife, Sheryl, have written?

Nicholas Kristof: Oh, the battle is definitely being won. There's no question that "international women's issues" are going from a fringe concern and a "soft" issue to a serious topic in the spotlight. Partly that's because women's rights are increasingly recognized not only as a justice issue but also as a way to fight poverty and reduce civil conflict. When you have American generals in Afghanistan trying to get more girls in school because they recognize that that's an effective strategy to undercut the Taliban, you know things have changed. And the Council on Foreign Relations used to be the place to discuss missile shields and Middle East politics, while now it is also discussing maternal mortality and human trafficking.

At The New York Times, I was delighted to see an article about maternal deaths as the lead story on the front page in May. We in the news media traditionally haven't been great at covering these issues, and the lead story traditionally was reserved for some ponderous pronouncement by a president or prime minister. So to see dead mothers being treated with equal seriousness was a welcome surprise and reflects the way these issues are rising on the agenda.

The tide was already coming in, but I hope that Half the Sky helped it gain a bit of momentum. One of the greatest challenges is how to reach beyond the choir, and I think the book clubs that have chosen Half the Sky and the universities that chose it for a college-wide read have helped expose the ideas in it to people who were outside that choir. One of the most exciting things for Sheryl and me has also been the number of readers who have started giving to clubs or aid organizations to try to make a difference.

AJ: Maternal mortality has been thought to be an unmovable problem, yet a recent study by The Lancet shows that several countries have made progress in its reduction. What, in your view, are the contributing factors?

NK: The study by The Lancet underscored just how much we don't know. It's quite remarkable that we don't have a grasp on how many women die from pregnancy complications each year. Is it 350,000 or 550,000? The data just aren't good enough to be sure, partly because no one counts dead mothers in many poor countries. I must say that I often see statistics in United Nations studies and elsewhere that claim a degree of precision that I find absurd.

For example, there's an often-cited statistic that one-quarter of young women aged 15 to 19 in the developing world are married (outside China). But in truth, in many poor countries, kids have very little idea how old they are and don't have birth certificates, so any age-related statistic is a wild guess.

In terms of reducing maternal mortality, my sense is that the big effort to train traditional birth attendants was pretty much a failure. It probably reduced neonatal mortality but didn't obviously save mothers' lives. But rural health systems have been improved, infrastructure has improved, vehicles and cell phones have become more common, and all these make it easier to rush a woman to a hospital when she's in obstructed labor. More broadly, I think some countries are now taking maternal health more seriously, and that perspective is trickling down to the villages.

AJ: Much of the funding for development targets specific health or social areas without addressing overlapping issues or systemic failure. But there's a trend now to address issues more holistically. Have you seen integrated development projects that work?

NK: The old stove-piping clearly didn't work very well. It was maddening that all the HIV funding meant that a woman could be treated for HIV but wasn't helped when she suffered from pregnancy complications. On the other hand, the drawback of the integrated approach is that it's expensive and it's hard to know what is cost-effective when you try a bunch of interventions simultaneously. I'm a huge believer in rigorous testing in randomized experiments, with careful measurement before and after. Monitoring and evaluation has traditionally been a weak area for nongovernmental organizations [NGOs], and humanitarians should be every bit as careful as for-profit businesses in ensuring that they get the most bang possible for the buck.

AJ: What are the benefits of working through the private sector in developing countries to improve women's health and overall well-being?

NK: Look, the private sector is incredibly good at distribution. If we could get condoms and bed nets into every village that serves beer, we'd save vast numbers of lives. The NGO world used to have a bit of disdain for business, but it's shedding that, and I think it is an important step forward. The private sector and NGO sectors can accomplish a huge amount if they work together.

AJ: What role do NGOs like PSI play in helping to empower women?

NK: I'm a huge fan of PSI, partly because you can't begin to chip away at poverty unless you deal with rapid population growth. And you can't empower women when they are obliged to churn out babies nonstop because they don't have access to birth control.

I also think PSI is very good at listening to local people and giving them ownership, which is crucial for any aid program. There are no silver bullets in development, and that includes family planning and health work. But we're getting better at figuring out what works and how to make it happen. And reproductive health is clearly part of the package of solutions.

AJ: You've been outspoken about the need to reduce unsafe abortions, one of the leading preventable killers of women globally, and you have come out as a proponent of expanded availability of medication abortion. Why?

NK: I think medications are going to transform abortions. Surgical abortion involves a measure of risk and is relatively easy for authorities to crack down on. If a woman shows up at a hospital after a botched surgical abortion, she can face legal consequences. But medications such as misoprostol are now available to induce a miscarriage early in pregnancy, and there's nothing to differentiate it from a regular miscarriage. The medications have other standard uses, for ulcers and for postpartum bleeding, so they can't be banned. They're also very cheap. My hunch is that surgical abortions in the first trimester will become much rarer and that abortion will become much harder for governments to control.

AJ: We often struggle to include men in family planning interventions, yet research shows that men significantly influence women's reproductive health decisions. What are the more successful strategies you have seen to engage men in supporting a woman's right to make her own decisions?

NK: We often try things like billboards and slogans to change attitudes, and it's not obvious to me that they work very well. The three things that seem most effective to change men's attitudes toward women—and women's attitudes toward themselves—are education, television and income generation.

Getting more boys in school helps women as well. Television tends to expose conservative rural families to middle class urban norms, where wives can come and go and aren't beaten. Income generation, microsavings and microlending give women more economic weight and more voice in the household.

AJ: One of the inspirational stories you tell in your book is of Edna Adan of Somaliland, who succeeded in raising enough funds to build a maternity hospital in her fragile country. PSI/Somaliland is collaborating with the Somaliland Ministry of Health to prevent and treat postpartum hemorrhage by increasing access to misoprostol and training healthcare providers on its use. PSI is fortunate to partner with the "Edna Maternity Hospital." Where should donor efforts be placed in order to empower women like Edna to save women's lives in their own countries?

NK: Aid efforts usually go farther where there is local leadership and knowledge. As Americans, our efforts are most likely to succeed where we are the Sherpas who assist local heroes like Edna as they climb their summits. For example, Edna is trying to fight female genital mutilation (FGM), and that works because she's a Muslim woman who was herself cut as a child. When you get Americans denouncing FGM, there's sometimes a backlash. So I think that to the extent possible we should aim to support local efforts like Edna's, with everything from accounting and fundraising help to technical support like the postpartum hemorrhage treatments that you describe.

AJ: PSI follows evidence in developing our health interventions. When we look more closely at those we serve, we find the majority are women and girls. Do you think it's more advantageous to have an overarching strategy to address the needs of girls or allow the solutions to come from evidence, research and the country and community levels? 

NK: I'm a believer in step-by-step evidence-based solutions. There's a Chinese expression, "Mozhe shitou, guo he," suggesting that the way you cross a stream is to feel for the stones, step by step—and that's an excellent approach to aid and development. Grand theories woven in New York or Washington rarely work very well, so it's crucial to go and listen and self-correct and build on what works.

AJ: How excited are you about the documentaries being made about the exquisitely resilient women to whom you introduced the world in Half the Sky?

NK: The documentaries are another way to reach beyond the choir to a new audience, and that makes us very excited. The plan is for the documentaries to air on national television in the fall of 2011, along with a traveling museum exhibit and an online game to draw people into these issues. The other thing that is exciting is that Half the Sky is now coming out in many foreign languages, including Arabic, and we hope that it'll have the same impact abroad and will build support for great groups like PSI that are on the front lines.

Read more interviews with visionary leaders in PSI's Impact magazine.

Keep Reading:
Ashley Judd shares the power of change in Africa
The power of microcredit—read an excerpt of Half of the Sky
Change women's lives around the world with $5—or 5 minutes
Anna Kournikova's PSI-sponsored HIV education mission to Russia


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