Archive for October 12th, 2013

Puerto Rico

Saturday, October 12th, 2013

This story started 30 years ago when we lived in Puerto Rico. Actually, the real beginning was 15 years before that, in Nicaragua.

We returned to Puerto Rico this spring after a three-decade absence. The island seemed even better than when we lived there. There was less trash, people were friendlier and now toll roads bypass overcrowded arteries.

Of course, Puerto Rico is not a separate country, but a commonwealth of the USA. Fortunately Puerto Rico keeps independent statistics, and one of them was a real surprise.

Flash back to 1968. My best experience in medical school was in the little Nicaraguan town of Puerto Cabezas, on the Caribbean coast. I learned a huge amount from the one physician, Ned Wallace, at the Moravian hospital there.

Gail (then my wife of only two years) and I lived in a tiny cabin with another medical student couple, a short walk to the hospital—and to the Caribbean Ocean. We adopted Noxa (“hello” in Miskito), a sociable green parrot.

We traveled by dugout canoe to provide the first medical care some villagers had ever received. Our wives passed out worm medicine and gave immunization shots, while we medical students saw patients in the four languages of the area—Miskito, Spanish, Creole and English. It was not the best medical care, but our patients were appreciative.

Ned was an excellent role model—he could do just about anything! I realized that living and practicing medicine in the tropics had personal advantages, in addition to helping people. At that time I resolved that, if we ever had kids, they should grow up knowing that the entire world was not like the USA, and that everyone didn’t speak English. Fortunately, Gail agreed.

In 1983 we moved our family from Durango to the little hill town of Castañer in central Puerto Rico. I practiced medicine and our two sons, in 3rd and 6th grades, learned Spanish by immersion. It was an enlightening experience in a different culture.

I was frustrated in Castañer by the number of women who wanted to limit their fertility, but lacked the money. Typically women married young and had 3, 4 or more closely spaced children. When I asked older women what birth control they used, the answer was often “my husband takes care of me” (withdrawal) or “I’ve been operated” (tubal ligation). Birth control pills and IUDs, effective temporary means of contraception, were just too expensive in this impoverished area.

Before returning to Puerto Rico this year I consulted the World Population Data Sheet ( for some demographic information. To my surprise the TFR (Total Fertility Rate—the number of children a woman has during her lifetime) was low. For a society to neither grow nor shrink, the TFR has to be about 2.1–one child to replace teach parent, plus a fraction for children who die before adulthood. Puerto Rico’s TFR is 1.6 now, far below replacement! However, it will take several decades for the population to stabilize.

What brought about this change In Puerto Rico? Did people recognize that the island is limited in size, that it has approached its carrying capacity? Is it that there is less adherence to religious doctrine?

Nobody seems to know exactly what happened. As far as I can make out, however, marriage is later and more couples choose to be childless. More women are employed, a common reason people choose smaller families.  The main change seems to be that contraception and tubal ligation (still very popular) are available with governmental aid, helping people achieve their reproductive and economic goals. Legal abortion is less common now that contraception is easier to obtain.

Puerto Ricans live in a beautiful green place of sun and ocean, but they have low incomes by our standards—only a third of the average income on the mainland. Thanks to government support, now people are able to receive the family planning services they desire. Puerto Rico has joined half of the world’s countries where women have sufficient access to family planning so that their populations will eventually stop growing. Where does the USA fit in? our TFR, at 1.9, is slightly below replacement.

Our return to Puerto Rico was lots of fun. We visited with friends and enjoyed the sun and ocean. Teaching our granddaughters to body surf was special for me. I also learned that even a poor area, if it has the will to help women control their fertility, can achieve zero population growth along with an improved economy.

© Richard Grossman MD, 2013

Join Me in Celebrating my 70th Birthday

Saturday, October 12th, 2013

I’ve lived more than half my life here in La Plata County and have reached a milestone. This month I turned 70. My only sibling, Clara, died too young at age 71, although our parents both lived to over 85. This is a good time for me to take stock.
Writing this column for the Herald has been a real pleasure. I have had reason to research all sorts of subjects and to pretend that I’m an expert in them all. Thanks to the Herald for giving me a way to exercise my mind—and hopefully stave off dementia!
It has been my great privilege to have been a part of so many people’s lives as a physician in our community. One of my greatest pleasures is to re-meet folks I have helped into this world. An unrealized goal was to deliver three generations of babies. It has been wonderful, however, to help deliver the sons and daughters of people I first met as newborns.
One of my reasons for becoming a physician and then specializing in obstetrics and gynecology was concern about human population. The world’s population has tripled since my birth, and that of the USA has more than doubled. Because of economic development and our higher standard of living, human use of resources has been multiplied many times. My original reason for concern about overpopulation has to do with my wanting to work for peace. High population density, and thus competition for resources, is a common reason for war. I am still working to minimize this cause of armed conflict. However, now there are many other reasons for concern about population, including extinction of species and climate change. I have been accused of performing abortions only to slow population growth; this is not so! There are strong individual reasons, too—almost as many as there are women with unplanned pregnancies.
Abortion is seldom mentioned in the media except with an associated dark cloud. I am proud to be a physician who performs safe, legal abortions in a caring atmosphere. Whenever I think of retiring from being an abortion provider I remember the quiet teen who sat up after her abortion and said: “Thank you doctor. You gave me back my future.”
I have a conundrum. Sometimes people comment on my quirky sense of humor, but it has not been exercised much when writing these columns. Perhaps the subjects I write about are just too serious for me to find ways to joke about them. I need help: if you can think of jokes about the future of the planet—climate change, extinction of species and overpopulation—please write me.
I also have a bucket list—a list of things I would like to do while I still am able. One big item on the list is to continue exploring the world and our immediate surroundings. We still backpack, but the distances we hike before making camp are getting shorter. Fortunately our dog, Tyrone, helps carry stuff.
Obstetrics has one unique disease that kills women and babies. Physicians have never figured out what causes preeclampsia (also called toxemia of pregnancy or Pregnancy Induced Hypertension); my bucket list includes researching its physiology. About 30 years ago I came up with a hypothesis—that PIH is the woman’s body’s way of compensating for the baby’s obstructing blood flow to the lower half of her body. I never got around to testing this theory, but I hope to do start that study soon.
One of my successes has been to learn enough Spanish to be able to function medically in that language. This has been a help to the many immigrants (and their wives) who do much of the low-paying labor in our area. Recently I have volunteered at the La Plata Community Clinic where Spanish is valuable. It seems strange, after limiting my practice to just women for so long, to also care for men, but they are rewarding. This clinic deserves our community’s support.
I am fortunate that my life is still exciting. Gail and I just celebrated our 47th wedding anniversary. We still enjoy each other’s company, and she has been a wonderful support. I feel very lucky that we found each other.
It has been a great pleasure to be a part of the Durango community, and that of the Herald. Thank you all—including those of you who disagree with me—for being part of my life. Please join me in celebrating my transition to geezerhood!

© Richard Grossman MD, 2013

Creative Commons Attribution 3.0 United States
This work is licensed under a Creative Commons Attribution 3.0 United States.