Categories
Population

Pray for Ukraine

The map above, from Wikipedia, shows the extent of the Russian invasion as of 3/15/22

“We believe that widespread, effective and voluntary use of medically sound and individually acceptable birth control is an essential factor in any humane design to raise world living standards and achieve international peace.”

            I read these words in Scientific American in 1960. It was close enough to World War II that I knew about the quest for the Germans for “lebensraum”, so it made intuitive sense. 

            Hitler was envious of the people who left Europe and settled the Americas. Immigrants were treated to unspoiled forests and fertile land, unlike what they had left behind in Europe. Those settlers used murder, disease and starvation to rid the land of the indigenous people who were already there. We descendants benefitted hugely from the Americas’ resources.

            As part of the “Masterplan for the East”, Hitler and the Nazis invaded what is now Poland, Ukraine and other countries. This genocidal plot was to get rid the of the inhabitants of the rich land to the east and replace them with Germans. Fortunately, however, the Nazis were fighting on other fronts and the masterplan was only partially accomplished. Starvation, outright murder and disease were the Nazi tools of extermination.  

            The Russians took over after WW II, using similar techniques of annihilation. Stalin was just as cruel as the Nazis, and perhaps even more successful in killing. Although millions died, it was more than just luck that some survived. Survivors used whatever means they could to eke out a living. In 2008 my wife and I visited western Ukraine and met a distant family member who had been an OB-GYN in a town similar in size to Durango. (I have changed the family’s names.) Dimitri Kovalenko’s mother and grandmother planted plum trees during Stalin’s reign of terror, and sold prunes to pay Dimitri’s medical school tuition. After graduation, Dimitri was able to build two homes, one for his mother and the other where he raised his family. 

            When we visited, Dimitri’s wife, Iryna, was still working parttime as a pediatrician. Their two daughters, Kira and Natasha, were both in the same town. Kira, also a physician, lived in the house that Dimitri had built for his mother, a short walk away. Natasha had recently moved from Kherson, a large city to the south, to be with her elderly parents.

            Kira’s husband, also a gynecologist, gave me a tour of the local hospital. The hospital was similar in many ways to what I was used to, but with some major differences. I remember a patient’s room as being drab, with no TV, and the equipment was similar to what we had in the USA 30 years earlier.

            I have stayed in touch with this family. Dimitri’s health continued to deteriorate; he died 3 years ago. Iryna retired to help take care of him—she is now in her 80s. When the Russian invasion started, Kira and Natasha decided to leave Ukraine any way they could. Sasha wanted to stay in her home, understanding well the horrors she that might face. Fortunately, she has neighbors who will help take care of her.

            The two younger women left Ukraine with only a small bag each, not knowing what the future held for them. They made their way to Moldova, then to Rumania and are now in Germany. They are safe there, living in the home of some kind strangers. Fortunately, they have had our help and the help of a friend who speaks German. I imagine that most of the Ukrainian refugees have no one who can translate for them, nor much money, nor friends in the USA to assist them.

            US media talk about the millions of refugees from Ukraine. For me it is much more personal, knowing Dimitri’s family. 

            Many wars are over resources. Putin may want to take over the Ukraine’s rich agriculture and natural resources, including uranium, or it is possible that he is trying to reconstitute the Russian empire. What is clear is that Putin is a megalomaniac, and cannot be trusted. I don’t know if overpopulation is playing a part in the invasion of Ukraine, but in general, more people lead to more conflict.

© Richard Grossman MD, 2022

Categories
Contraception Hope Public Health

Discover a Success Story in Africa

Smoking hut in northern Ghana

            Last month I wrote about the 5 countries I have enjoyed visiting in Africa, including citing their amazingly low per capita GDP. Although most of the population growth over the next decades is predicted to occur on that continent, I see some rays of hope.

            There are two places in the world where studies have been done on ways to increase voluntary family planning, along with other important medical research. One is Matlab, Bangladesh and the other is Navrongo, northern Ghana. I had never heard of the Navrongo studies until shortly before visiting there! 

            Both Matlab and Navrongo have shown that community health workers can improve health significantly. In addition to family planning, the Ghanaian studies studied several successful interventions, including vitamin supplementation and mosquito nets treated with an insect repellant. Their family planning research showed that it is possible to increase contraceptive use and slow population growth even in an impoverished, poorly educated population. This is especially important research since Navrongo is close to the Sahel, and the people there are similar to Sahelians in their preference for large families.

            In 1995, the beginning of the Navrongo studies, the average woman had about 5 children. Fifteen years later, in 2010, that number had dropped to a bit over 4, both in the Navrongo control group and in the country as a whole. One of the interventions decreased the fertility further, to 3.7; a significant reduction.  Now, a decade later, the fertility rate for the whole country is 3.7 children per woman. That group was ten years ahead of the rest of the country! This group combined specially trained community health nurses (as opposed to stationing them at a clinic or hospital) and “zurugelu”.

            “Zurugelu” means “togetherness for the common good”, and was male-centered in the past. For a better explanation, I asked one of the investigators who had worked in Navrongo what “zurugelu” meant. Here is Dr. James Phillips’ reply:

“The zurugelu approach is a social engagement strategy that involves merging the organizational system of primary health care provision with the traditional system of social organization and governance.  When gender problems were evident, we attempted to turn patriarchy on end by working with women’s social groups in ways that were traditionally dominated by men.  Social events, termed “durbars”, were traditionally male events that were led by traditional male social leaders.   To build women’s autonomy and roles, we worked with leaders to eventually have women’s convened and women’s led durbars.  We also had gender outreach activities for responding to the needs of women.   As such, the “zurugelu” approach was a gender development strategy.”

(A “durbar” is a meeting of men with their chiefs.)

            It is interesting that neither community health nurses nor zurugelu alone had much effect on fertility. Even though the nurses educated women about family planning and supplied the necessary materials, fertility did not decrease significantly in the regions where they were introduced but didn’t have zurugelu. Nor did zurugelu alone have much effect by itself. It took both working together for the fertility to come down.

            The need for both nurses and zurugelu is a very important observation. The statement has been made frequently that worldwide over 200 million women want to limit their fertility but don’t have access to modern contraception. Since the nurses provided that access, we know that access alone isn’t enough—at least in this group of people. Apparently tradition and paternalism were significant barriers to using contraception. It took zurugelu to change attitudes before people made the most of what family planning was available.

            What difference did zurugelu make? This traditionally male function opened the eyes of men to the needs of women. Furthermore, the Navrongo programs strengthen the roles of women. 

            Now, back to my visit in Ghana. It was dusk as we were driving from Navrongo back to Nalerigu. We passed a straw hut with smoke emerging from its roof.

            “Is it on fire?” I asked.

            “No”, my host replied. “She’s just cooking the evening meal.”

            Although there is much beauty in northern Ghana, and everyone I met was friendly and warm, my impression is that life is difficult. Now that child mortality is a fourth of what it was 50 years ago, people will benefit from smaller families as well as more education.

© Richard Grossman MD, 2022