Archive for the 'Population' Category

Look Where We Need Family Planning the Most

Thursday, April 27th, 2017

“As we crawled through the city, we encountered a crowded slum area. The temperature was well over 100, and the air was a haze of dust and smoke. The streets seemed alive with people. People eating, people washing, people sleeping. People visiting, arguing, and screaming. People thrusting their hands through the taxi window, begging. People defecating and urinating. People clinging to buses. People herding animals. People, people, people, people.”   Ann and Paul Ehrlich in Population Bomb, 1968

Impact = Population x Affluence (consumption) x Technology

                                                Ehrlich and Holdren, 1971

 

Close your eyes for a moment and conjure up an image of overpopulation. Did you picture hundreds of people hanging off a train in India? or dark-skinned crowds in a street in a poor country?

Yes, family planning is important in those scenarios. Voluntary access to modern contraception is important for humanitarian reasons in the global south. You probably know the litany of its benefits: decreased maternal mortality, healthier children, economic savings, progress in standard of living and education, local environmental protection.

However, the need for effective, universal access to family planning and to safe, legal abortion is much more important in rich countries in the global north. This is because of the issue of consumption.

What! you might be asking. The average woman in many African countries has 5 or more children. Niger tops the list; the total fertility rate there is over 7! Surely the population explosion there must be causing problems. Yes, Niger is one of the lowest ranked countries in the UN’s Human Development Index. Repeated drought has caused famine; population pressure and overgrazing cause environmental degradation.

Let’s compare two countries in the Western Hemisphere—the USA and Haiti. They are, respectively, one of the richest and one of the poorest in the world. The carbon footprint of an average person in the USA is about 20 tons of CO2 per year, while that of a Haitian is 0.2 tons—one hundredth of ours! Thus it would take a hundred Haitians to equal the climate damage done by one of us.

Another way to compare the impact of a single person in the two countries is with Ecological Footprint. The ratio between the two countries is 16 to 1. Thus 16 kids of a really large Haitian family would have the same impact of a single-child family in the USA. I have to admit that there are several problems with this comparison: it doesn’t include the two parents, the average Haitian family size is just a little over 3 so I doubt that there are many as large as 16. The legacy of a large family grows over generations. In Niger, if each generation has 7 children, the number of grandchildren would be 49!

The two measures of impact are different. The carbon footprint is global, since carbon emissions into the atmosphere spread over the whole planet. The Ecological Footprint includes carbon emissions, but it also includes effects that are localized, such as damage to the local environment. In any case, the impact of a person in the USA is much greater than one in Haiti or Niger, and it is spread over the planet.

There is good news! The unintended pregnancy rate (this includes mistimed and unwanted pregnancies) has dropped significantly in the USA. Whereas this rate has hovered at about 50% for years, the latest information is that it has dropped to 45%. The news is especially good for young women, when an unintended pregnancy can be devastating. This decrease is due to increasing use of effective contraception. It is very concerning that the new administration threatens women’s reproductive health and may make contraception and abortion services either unaffordable or totally unavailable.© Richard Grossman MD, 2017

Let Her Decide

Monday, February 27th, 2017

          “Father slapped his hand on the table. ‘If Sarah was a boy, she would be the greatest jurist in South Carolina!’” This quote is from Sue Monk Kidd’s popular novel, The Invention of Wings. It is inspired by Sarah and Angelina Grimké, whose family were slaveholders in the first half of the 19th century. These sisters moved from South Carolina to Philadelphia where they joined the abolition movement and the Religious Society of Friends. They were condemned because Quakers didn’t allow women to lecture in public at that time. Speaking as a Quaker, I am pleased that one of our religion’s current core beliefs is equality, including equal status of men and women.

In Nobel Prize winner Orhan Pamuk’s A Strangeness in My Mind, one of the characters waited tables at the Bounty Restaurant in Istanbul, Turkey. A reflection of the status of women in 1984 is that the owner’s idea of success “…was for a woman to come in with a group of men and be able to have a pleasant evening… without being subjected to innuendo and arguments all night, and to enjoy herself enough to come again, though in all the Bounty Restaurant’s checkered history, this had sadly never happened.”

The status of women in many countries is terrible, as it was in the early history of the USA. Fortunately women’s status is slowly improving globally, but there have been setbacks. Some of the worst have to do with access to reproductive health. While the science of birth control and abortion has improved, restrictions have made it more difficult and more expensive for women to receive the services they desire.

First came the Helms Amendment in 1973, the year that abortion was legalized in the USA. Appended to the Foreign Assistance Act, this amendment prevents federal money from being used abroad to provide abortions or even information about abortion.

The Helms Amendment kills women. It is estimated that 11,000 women die annually because they do not have access to safe abortions. Each year there are 20 million unsafe abortions world wide, mainly in poorer countries, that kill 47,000 women. Remember that the abortion rate is paradoxically higher where it is illegal! Sadly, many of these women are mothers of large families. Many lives could be saved if the USA would encourage safe abortion services.

Passed 3 years later, the Hyde Amendment prohibits federal Medicaid funding for abortions in the USA. There are three exceptions to this, fortunately—for cases of rape or incest, or if the pregnancy presents a risk to the woman’s life. Some states use non-federal funds to pay for abortions; New Mexico does, but Colorado does not. Both of these amendments regrettably target the poorest of women, especially women in rural areas with limited access to health care.

Nicknamed the “Global Gag Rule”, the Mexico City policy was announced in 1984. Many overseas organizations get their funding from multiple sources, including from the federal government. This Rule prohibits any recipient of federal funds from any counseling or provision of abortion services—even if that funding comes from another source. The Gag Rule is a political football. Started by Reagan, every Democratic president since has rescinded it, but every Republican, including most recently Trump, has reinstated it in even more restrictive form.

138 organizations have signed a statement opposing the Global Gag Rule. What can we as individuals do? Population Connection (formerly “ZPG”) started a campaign supporting Congress’s move to block the Rule permanently. 46 senators have co-sponsored Senate Bill 210, the Global Health, Empowerment and Rights (HER) Act. In the House, a companion bill H.R. 671 has support from 140 Representatives. Go to http://www.populationconnectionaction.org/fight4her/ for more information

A new organization was formed in reaction to the reinstatement of the Global Gag Rule. Lilianne Ploumen, a social activist and minister in the Dutch cabinet, started “She Decides – Global Fundraising Initiative”. The Dutch government announced that it will contribute 10 million Euros to this initiative to help replace the funding the Gag Rule has taken away—and it has been joined by support from 7 other governments. There is more information and the opportunity to donate at: https://www.shedecides.eu.

Here in Colorado some members of our State Legislature have recognized the problems caused by diminished reproductive rights and have written House Resolution 1005. Democrats, including our own Barbara McLachlan, support this resolution. It champions the full range of reproductive health, including abortion. Would that there were more strong advocates nationwide such as we have here in Colorado!

© Richard Grossman, MD 2017

Stay Current on International Family Planning

Thursday, December 29th, 2016

family-planning-sign-in-ethiopia-by-maurice-chedel

 A sign in Ethiopia showing the positive effects of having only 2 children. (Escape from poverty, health, a better housing, a fertile surrounding with trees, a better education) Picture by Maurice Chédel

“All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so.”                         United Nations, 1994

 

Although reproductive rights may be in jeopardy in this country, there is reason for optimism both here and abroad.

India has the world’s second largest population—about a billion and a third people. Thanks to family planning programs, family size there has been decreasing slowly through the years. Unfortunately there have been some bad bumps on the road. For instance, decades ago both men and women were sterilized without really understanding their surgery. The government put pressure on family planners to meet quotas and they, in turn, pressured patients to have surgery. Recently several women died after shoddy surgery in tubal ligation “camps”. It turned out that these unfortunate women wanted family planning, but weren’t given the option of temporary contraceptive methods nor adequately told of the risks of the surgery.

Sterilization, condoms, “the pill” and IUDs have been the mainstays in India, but the government has just added contraceptive injections to the short list of methods available to women without cost. The “Depo” shot has the advantages of lasting 3 months, of being very effective and lacking the serious side effects of contraceptives with estrogen. Therefore women who cannot use “the pill” can use it. Worldwide, “Depo” has been prescribed for birth control for over 40 years.

Although the USA has some of the most stringent rules for approving medications, I find it interesting that some other countries have limited access to birth control that we take for granted. Depo in India is one example, and birth control pills in Japan are another. For years Japanese women were not able to get “the pill” and couples mainly relied on condoms for contraception. The rationale was that condoms prevented the transmission of disease and could prevent problems if there was marital infidelity. It was only in 1999 that this policy was changed.

In many parts of Africa women needed a physical examination and blood tests before they could get a prescription for “the pill”. Few could afford these luxuries, driving up the number of unplanned pregnancies. In much of Latin America, on the other hand, a woman can walk into a “farmacia” and purchase whichever brand she would like.

Emergency contraceptive pills are easily available throughout much of the world. Plan B and other brands are now available in pharmacies in this country without prescription. They have been shown to be amazingly safe, although not as effective as having an IUD inserted. Of course EC should only be used in case of an emergency, such as rape or a broken condom, and it provides no protection against infection.

Price gouging for medications exists outside the USA. In England, for instance, the cost for EC could be more than US$40—while the same medication in France would cost less than US$10. There is an eye-catching British campaign suggesting that a woman in need could save money by taking the bus to Paris to get her pills!

Although millions more women in the USA have access to free family planning thanks to “Obamacare”, unfortunately there are still limitations. Some 20 million women in the USA live in “contraceptive deserts”. These are areas without reasonable access to publically funded clinics that offer the full range of contraceptive methods. Despite this, the teen-pregnancy rate has fallen precipitously in the past 25 years—a big reason for celebration!

Globally there is mixed news from the immense attempt to provide family planning services in some of the most difficult to reach and poorest parts of the world. The Family Planning 2020 campaign is now about halfway through its tenure, which started in 2012 and goes until 2020. Its goal is to reach 120 additional women with family planning services in 8 years. They have reached 30 million new users of contraception, which is an amazing achievement—but short of their interim goal by 20 million. It is incredibly difficult to deliver health services in areas where this campaign is working; I wish them luck.

Speaking of luck, last month I was hit by a car while crossing Main Avenue in a crosswalk. Fortunately I have no serious injury except for a broken ankle. It is also fortunate that I am totally retired from the practice of medicine—but plan to continue writing these columns. Happy Holidays to readers of Population Matters!

© Richard Grossman, 2016

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