 Yes, we had a name change of our school, so we're now at the Harvard T.H. Chan School of Public Health, where in every bathroom it says that hand washing is the cornerstone of public health, so I'm staring at this the whole time thinking hand washing is the cornerstone of public health. I'm not going to be talking about hand washing today, another very important public health issue. Today, I'm going to be talking about the fertility response to crises, and it's a little bit of an unusual topic, and there's not a lot of literature on it, but that's one that I've been exploring through a range of projects, and the researchers channeled towards a hypothesis that I'm building that the positive fertility response to crises may be one of the underlying drivers of sustained high fertility in Africa. So that is that following a crisis, fertility goes up, and with many crises in Africa, this fertility response is reinforced, and fertility rates remain high. So this is sort of where I'm heading with it. It's not complete today, but sort of heading there in general. So today I'm going to take you through that small but very important literature, and then highlight a case of the fertility response to crises with an empirical analysis that I'm working on, looking at how the age at first birth for girls exposed to armed conflict is actually very low compared to those who are not exposed to armed conflict. So in analyzing anything to do with fertility, it's natural for us to turn to demography to understand these fertility dynamics. In a review paper compiled by Ken Hill, a demographer and one of my former esteemed colleagues, he analyzes the fertility response to crises and draws on the Davis and Blake 1956 model of the proximate determinants of fertility. Ken's review paper states that changes in the proximate determinants of fertility are necessary and sufficient for fertility change, so that any effect on the crises must work through one of these variables. But what are these variables? What are these proximate determinants? In the simplified version, it's age of marriage, contraceptive use, and breastfeeding. So and demographers will examine how the crisis affects these proximate determinants, how the crisis affects age of marriage, how the crisis affects contraceptive use, how the crisis affects breastfeeding. The Davis and Blake model is a little bit more broad, and for example to get to the point of a live birth and thus the fertility outcome, the crisis could interrupt the fertility outcome in a number of points in that journey. So the crisis could affect exposure to intercourse, for example coercive sex, increasing the likelihood of conception. A crisis could affect contraceptive non-use as supply chains are cut, increasing the likelihood of conception. Or the crisis could affect stillbirths due to nutritional deficiency, and in that case it would reduce the births. However, for me and for others it's the story behind these proximate determinants, the story behind age of marriage, the story behind contraceptive use, the story behind breastfeeding, and how we get there that's the journey to understand that deeper side of that fertility response to the crisis. Indeed, in the discussion in Ken's review article, he explores possible channels where the crisis affects these proximate determinants of fertility, citing a possible hypothesis that refugees may marry earlier because of lack of alternative, a lack of attractive alternatives, an early marriage leading to early childbearing and increasing the total fertility rate. So he brushes on it but doesn't really explore it very deeply. There are a few others who study the demography of disasters and the fertility response to disasters in particular, and then demographers who do all take these proximate determinants approach. War in Angola, they look at delayed marriage separation, impaired fecundity, tsunami in Indonesia, looking at increases in miscarriage, and health infrastructure that was damaged and thus the access to contraceptive use, and war in Eritrea, again delayed marriage and spousal separation. So in Ken's article and these three examples in the Palestine example, fertility is going up or down depending on which channel that you look at. But it's all contemporaneous analysis. Disaster strikes what happens to fertility in the next two to five years. This demographic framework is a framework, but it doesn't give us this deep meaning behind the fertility change. It's just a channel of how the crisis affects exposure to intercourse through marriage or coercion, separation, contraceptive use or non-use as supply chains are cut or programs are implemented, and breastfeeding practices that may change either through nutritional problems or if there's lack of feeding alternatives, then maybe people stick with breastfeeding. Okay, that's demographers. Economists like me, we also like to analyze fertility behavior. So notice that I say fertility behavior and not fertility rate like I would as a demographer. Economics is about decision making and economists studying fertility are interested in how people go about making decisions to have a child. It's the decision making process that goes behind the proximate determinants of fertility. So while demographers like Bongarts and economists like Pritchett don't see eye to eye, we've had a bit of time to contemplate since this boxing match that they had in the early 1990s, and we can say that economists are interested in behavior change that leads to changes in the proximate determinants that then leads to changes in fertility. Economists really like an exogenous shock, and see how this exogenous shock changes the decision making over fundamental life events like investment, work and having children, and we've seen that in a Barrow Becker framework. We use mathematical models, I have a preference for the overlapping generations model, to understand how this process of a crisis can affect preferences for children, the cost of raising them, and also effects on income and prices, as my former colleague Javier Baez did when looking at hurricanes in Colombia. I too have done this analysis using the economics approach and modeling children as insurance. I looked at the fertility response to three high mortality earthquakes. You might know some of them if you're interested in crises. The Izmit Turkey earthquake in 1999, 17,000 people were killed. Gujarat, India, 2001, 20,000 people were killed. Kashmir, Pakistan, 2005, 90,000 people were killed. So in that paper that I find that there's an increase in fertility and increase in childbearing following the earthquake, that's more than the replacement effect of children who died as a consequence of the earthquake. So this indicates that people change their risk assessment of where they lived and guarded against the future loss of family members so that they could achieve their desired family size. Preferences, risks, insurance, markets, prices, this is the way that economists frame things. So like the demographic model brought the understanding of how the crisis impacts on the proximate determinants of fertility, the framework used by economists helps us understand how the crisis affects fertility decision making behavior including the decision of how to have a child. So this all sounds great. Demographers and economists have worked out the framework we can apply to understand the fertility response to crises and I've applied this myself for the three high mortality earthquakes with great academic satisfaction. And then I started talking to people in the field in Burundi and it changed everything. Talk to a regular person in the poorest highest fertility country in the world, Burundi. Burundi's about the country the size of Switzerland. It's landlocked. It's a former Belgian colony just south of Rwanda and it's been in the news recently for its politically motivated unrest and it's been in on and off in civil war and unrest since independence. I met Bernadette while doing qualitative work in Burundi trying to develop a better measure for female empowerment. Completely a separate project. And along with achieving that objective, Bernadette's story opened my mind to a new way of looking at the fertility response to crises. Let's listen to her story. So she's orphaned in civil war. She lived with her sister growing up into her teen years. Her sister marries young and her new brother-in-law doesn't really appreciate Bernadette hanging around. So instead of bouncing house to house relative to relative, Bernadette seeks independence by taking command of her own security. She quickly marries, has a child and jumps into a situation of family and that security that she was looking for. She mobilized herself. She took action and materialized that path to security that she thought best. But time moves on and her life walks on a trajectory just as our own does. The trajectory she wanted was emotional and financial security. She has two more kids. But her actual trajectory is one of domestic violence and abuse from her in-laws. Her husband abandons her. In fact, he gets sent to jail, sent to prison for five years. And she can no longer live with her in-laws as while he's in prison, he designs Bernadette and marries another woman. She then moves to Bujumbura from where she was in the countryside and supports herself and her three children by selling herself in transactional sex. And her children are not always living with her and she separated from them for long periods of time and sends money to them to support them. That's not Bernadette. That's a file photo I bought. But she has three children. So Bernadette's living, coping, surviving and supporting her children in Burundi and I'm back at Harvard reading trying to make sense of all of this. I'm reading about crises. I'm reading about what happens to people after crisis. I'm reading that they suffer post-traumatic stress disorder. I'm reading my colleague Mary Waters' work who talks about post-traumatic growth. I'm reading about resilience. What is resilience? Resilience is the capability of an individual community or nation to rebound from a crisis. Varying degrees of resilience will determine how well the individual adapts and transforms in response to a crisis. Adapts and transforms. Let's go back to Bernadette. In the beginning, she sought ways to cope, to build security, to make a life that she wanted with a family, a husband, children and a home. She deployed her adaptive capacity and she succeeds in that part. But this path was not transformative. The desire to have a husband, have children, create a family to build security for herself across her lifetime was a very well-structured thought for Bernadette. But it did not yield. And instead she was in a cycle of poverty and isolation, now with three children to support that she barely sees. But who else is using family formation and childbearing as a way to build resilience in response to a crisis? I took a closer look at this and examined the behaviour of 2.3 million women in sub-Saharan Africa. I applied the resilience framework and, like in Bernadette's case, I was interested in the age of first birth. I was interested to see if Bernadette's story could be observed at the continental scale. Across the life course, do we observe women who are born into war, exposed at age zero? Do they go on to have their first birth at a younger age? And this young age of first birth is a way for them to build resilience, just the way that Bernadette had done it. I used the demographic and health surveys for sub-Saharan Africa, combined with a dataset on armed conflict events in sub-Saharan Africa, constructed by PREO in Norway. And I wanted to compare women who were exposed to armed conflict at age zero to those women who were not exposed to conflict at age zero. To examine the later life effects of early life exposure to armed conflict, I have to make sure that I handle the repeat events of armed conflict that may occur at various times across the life course for these women in both treatment and control groups. So I turn to others who've done this kind of life course analysis. Others that I've looked at do the intergenerational effects of exposure to natural disasters, the Dutch famine, the 1956 China famine. But these studies focus on in utero biological channel, of exposure to the crises while in utero, and how this affects the health and well-being in later life. The channel's biological and the shock doesn't repeat. This didn't mirror the case of war and what I wanted to analyze where the channel could be psychological to build resilience and the crisis can repeat across the life course. So I turn to the economics literature and look at life course outcomes of early life exposure to recessions and pollution. Exposures where the events can repeat and the channel can include aspects of mental health. So this is what I find. I find that women who were exposed to armed conflict at age zero went on to have their first child seven months younger than the average girl in sub-Saharan Africa who had not been exposed to armed conflict. Seven months younger because she was born into war. Blue line, this is sort of from zero onwards and it's going to measure the age of age at first birth. So this is the group who were not exposed to armed conflict at age zero and seven months younger. They had their first birth. This is the group who were exposed to armed conflict at age zero. But I'm wanting to analyze this in the resilience channel. So let's go back to what resilience is. Resilience is the capability of an individual community or nation to rebound from a crisis. Varying degrees of resilience will determine how well an individual adapts and transforms to the crisis. Resilience is not a trait that we are born with but one that we can promote. Attachment to parents, education, religion and mastery are key factors that promote resilience. Attachment as a resilience promoting factor is explained in the context of the child gaining support from the parent, the bond to the parent. And this is very well explored in the child development literature and also in the context of children at war. To study the fertility response to crisis within the resilience framework I consider this attachment hypothesis. I hypothesize that fertility increases in response to the crisis as women seek to promote their resilience through attachment. Only this time we're looking at the mother and not the child. The positive fertility response to the crisis implies that women actively seek ways to increase their resilience. The promotion of resilience is not a passive evolution. Women seek ways to promote resilience using the resources that they have. In the child development literature it's easy to follow the attachment to parent, the attachment to parent, the parent promotes resilience as it's ingrained in our human existence to be shielded from the harshness of the world by the known security of the parent's protection. But in my case where the mother chooses to have another child in response to exposure to a crisis then the mother does not get the protection from the child and thus the promotion of resilience through the attachment is not the same as it is for the child in this relationship. For the mother, just as Bernadette thought, in having a child she gains a sense of ownership when all other belongings are stripped away. It gives her a sense of agency as she now identifies as a mother when all other markers of self are devalued. For the woman who seeks to build resilience, just as Bernadette did, it is thought that the child empowers the woman. So let's recall our list of things that promote resilience attachment, education, religion and mastery. So if childbearing through the attachment hypothesis builds resilience then we should see that education nulls the fertility response to crises if the resilience promoting factors are substitutable. And indeed this is what I find. So remember the blue line is our age at first birth and the white is exposed to conflict at age zero. So the first lines I'm going to show you here are the ones going underneath are girls with no education. So when a girl has no education then her age and she's exposed to war at age zero then her age at first birth is actually 10 months younger than those girls who still have no education but are not exposed to war at age zero. Okay let's look at the educated girls though. For girls with completed secondary school we see no difference between those who were born into war and those not. For educated girls childbearing is not used as a resilience promoting factor but those girls without education they rely on childbearing to promote resilience. Bernadette had little education she relied on childbearing it was adaptive but not transformative. For girls with education they do not rely on childbearing or attachment as a resilience promoting factor and education could be adaptive and transformative. But at the national and continental scale we observe that uneducated girls who are born into war are using childbearing as a resilience promoting factor just as Bernadette did. I use the extreme case of war but shocks risks and stresses all of the other crises come in many forms and I've seen this fertility response to natural disasters and now in the case of war. And I've been building towards gathering evidence that speaks to this hypothesis that girls seek to build resilience through early childbearing and high fertility and this may explain the sustained high fertility rates that we observe in sub-Saharan Africa but it's the girls who have few resources the vulnerable who are more likely to use childbearing as a resilience promoting factor. My hypothesis that the positive fertility response to crises may be one of the underlying reasons for sustained high fertility in Africa is getting some traction but it's the vulnerable girls who are falling behind using childbearing as a resilience promoting factor where it's adaptive but not transformative. In Burundi working with Pathfinder International and a really talented group from the University of Burundi I'm conducting field work to ensure access to family planning services by vulnerable girls some vulnerable girls are the target and we want to make sure that we address this heterogeneity and the treatment response so that the vulnerable are not on a trajectory to a poor outcome. For the case of Bernadette and for the low educated in the population-based study I did on armed conflict the vulnerable are those with the positive fertility response to the crises but as we've been talking in the context of resilience and the response this response is adaptive but not transformative. If it's the vulnerable who make the fertility decision in response to a crisis then we'll see this widening inequality and the vulnerable left behind. Thank you. Today I've talked about the fertility response to crises I've told you how demographers approach the issue how economists including me in studying the three high mortality earthquakes approach the fertility decision but then we saw how Bernadette's story opened up the study of the fertility response to crises into a story of resilience a story of how women seek to adapt in the face of a crisis but we must work to help the vulnerable so that the drive to build resilience is adaptive and transformative as we saw in the case of the highly educated girls in the in the armed conflict example. My hypothesis that the positive fertility response to crises may be one of the reasons for sustained high fertility in Africa is getting some evidence but in gathering this evidence it also brings a warning on the human scale that the vulnerable are using this as a tool to build resilience they adapt but it's not transformative and we must work towards resilience promoting factors that are transformative so that women can rise up and be empowered even in the face of large-scale crises. Thank you.