t would mark the beginning of a beautiful friendship. Nearly 20 years ago, the United Kingdom's Medical Research Council (MRC) tropical disease unit began setting up a rural surveillance system in The Gambia to assess new approaches to preventing malaria in children. Once its work on bednets and prophylactic treatments had begun, demographer Allan Hill persuaded the Council that much wider public health questions could be answered using their follow-up methods and suddenly found himself in a cooperative relationship that would last almost two decades. After working with MRC researchers on the first major trial of impregnated bednets on malaria morbidity and mortality in an area south of the Gambia River, Hill turned his attention to the 40 rural villages on its North Bank near Farafenni. Here, the MRC and the Gambian government had established a major field station in a region chosen for its remoteness and absence of a broad range of health interventions. Hill, then teaching at the London School of Hygiene and Tropical Medicine, would go on to participate in a series of studies to help stem the region's high child mortality rates and to understand why high fertility remains characteristic of its rural population.

Today, Hill's home base may be the Harvard School of Public Health, where he is Andelot Professor of Demography in the Department of Population and International Health--but he is still a familiar face in Farafenni and its surrounding villages. Hill has worked out of the MRC field station for about two decades on research emphasizing population trends and reproductive health issues. Recently, he and a team of graduate students from the School have been heavily engaged in a series of studies examining the reproductive lives of families in these isolated communities. Their sometimes-surprising findings have been aimed at informing organizations trying to develop family planning policies in West Africa. "One of Dr. Hill's greatest contributions has been to get the demography of fertility on the MRC agenda," notes Amy Ratcliffe, S.M.'96, S.D.'00, a former student of Hill's, who now works for the Council and personifies the collaborative nature of the station's work.

The font of collaborative research at the station also reflects the evolution of the population studies field as a whole. "The old style of demography that looked at family planning as a way of achieving lower fertility rates is outmoded," says Hill. "It's a much softer agenda now, in terms of rights and gender issues. Instead of saying 'we are convinced that slower population growth is good for your welfare,' we are saying people should be able to choose the number of children they have."

The region where Hill and his students work to clarify this new agenda lies on the north side of the Gambia River, in a tiny North African nation bordered on the north, east, and south by Senegal and on the west by the Atlantic. There, polygamous Muslim families live in small villages of less than 1,500 residents. Cut off from the country's more developed south bank region, subsistence farmers live simply, raising cattle and growing rice, millet, and peanuts. Electricity and running water are scarce. Bad roads, poverty, and lack of transportation prevent villagers from routinely seeking services in larger, more developed communities. This part of The Gambia naturally lends itself to the study of malaria, trachoma, reproductive morbidity, fertility and infertility, maternal and child mortality, and a host of other public health issues, and consequently the Harvard team has worked alongside many other MRC researchers at the busy field station over the years.

For the past decade, Hill's research contingent has scrutinized the inhabitants' reproductive health patterns, looking, for instance, at links between primary health and infant mortality, the acceptance of birth control devices, and attitudes about family size. One of its most recent studies provides a powerful example of how population research is shifting. Traditionally, researchers examining customs and attitudes about childbirth and reproduction gathered all their information from women. After all, women give birth and take the lead, if not the only, role in caring for children. But lately population scientists have begun to realize that this approach has left them with a gender gap in their knowledge about reproductive health. Men may not give birth or even contribute much to childcare in many cultures--but they do play an important role in decisions about when to have children and how large their families should be.

Therefore, when most researchers set out with clipboard in hand these days, they gather information from both partners. In joint work with her former professor, Ratcliffe adopted such an approach when surveying village residents about their attitudes on family size. Together, she and Hill found that men and women have very different fertility preferences and experiences. For example, the men wanted an average of 15 children, while the women said they would like to give birth to around seven--a disparity that is possible in this polygamous society. They also discovered that men started their families later than women, had more children, and continued procreating as they aged. "Our findings demonstrate the need for studies that include both men and women from the outset," they wrote in the Bulletin of the World Health Organization. "With a view to reducing fertility and improving reproductive health in West Africa and elsewhere, it is essential to understand personal interest in high fertility as well as the means available to both partners for achieving it."

Several of Hill's other collaborative studies have produced equally surprising results. Case in point is the Harvard Birth Intervals Project. Working with Northwestern University anthropologist Caroline Bledsoe, Hill surveyed Gambian women and found they were using birth control to a counterintuitive end--to ensure they have more children, not fewer. The researchers discovered that these women were employing the technique of birth spacing--using either traditional or modern contraceptive methods--not to limit family size, but actually increase it by improving their odds of delivering healthy babies. The approach stems from the Gambian belief that women are endowed with a limited capacity for giving birth and that each pregnancy expends some of that potential, particularly if they occur in rapid succession. Spacing births provided an effective way for the women to conserve their childbearing capacity and ensure that each pregnancy had a positive outcome. The results helped explain why women who had experienced a miscarriage or stillbirth still frequently sought out modern birth control. While it would seem logical from the Western perspective of time-restricted reproductive capacity for women to conceive quickly following a failed pregnancy, Gambian women instead place a greater premium on health over age limits for ensuring fertility and regard a delayed pregnancy as a way to recover physically and emotionally from the trauma of a non-live birth.

Bledsoe notes that their work not only challenged the Western assumption that women use birth control to limit family size but also showed how contraceptives are used effectively to subvert the intentions of family planners. "Population planners see the length of birth intervals as determinants of high fertility and advocate creating longer spaces in order to reduce fertility," she says. "The Gambian project found, however, that in a society in which high fertility is so valued yet health conditions are so difficult, getting pregnant, bringing the pregnancy to term, and giving birth to healthy babies are not accidents of nature, as population planners have assumed, but skillful achievements." Their unexpected findings will be discussed in Bledsoe's upcoming book Contingent Lives: Fertility, Time and Aging in West Africa. Adds Dr. Gijs Walraven, the director of MRC's Reproductive Health Program, "This work strengthened the idea that these women see continuing fertility and motherhood as their main source of security."

Another Hill graduate student, Margaret Luck, S.M.'92, S.D.'97, has conducted a study that promises to have an immediate impact on the lives of Gambian women. Comparing the success of different contraceptive programs in the villages west of Farafenni, she found that women were receptive to birth control education delivered by trained female volunteers from their own extended families. "Based on these results," says Luck, "we recommended that family planning programs should take advantage of existing rural social networks to inform potential family planning users about contraceptive methods."

Hill, his students, and MRC scientists plan to build further on their accomplishments. Upcoming studies, led by Walraven, will examine the effectiveness of several reproductive health intervention programs, including prevention of postpartum hemorrhage in home births, intermittent malaria treatment in pregnancy to reduce anemia in mothers and low birthweight babies, and a postpartum package with special attention to anemia, infection, depression, family planning, and breastfeeding. And in a gesture of reciprocity, many scientists at the MRC field station have and will continue to provide services to the population. How long this mutually beneficial arrangement can go on is up for debate, according to Hill. "We've got to be careful not to overstudy the population," he asserts. But as long as their health and welfare benefit, Hill intends to learn as much from the Gambian people as possible. Notes Bledsoe, "Allan is someone whose sustained interest in a particular developing country population--a rarity in the social sciences--continues to open the way for work that has been fruitful not only to him and his students and collaborators, but also for the people with whom he's worked in The Gambia."

Tinker Ready