Archive for the 'Public Health' Category

Give Thanks

Saturday, November 24th, 2018

 

Map of Total Fertility Rates courtesy of M. Tracy Hunter

At the risk of seeming overly optimistic, I would like to make a list of good things that are happening in the world of family planning and demography. Here goes:

My perception is that people are starting to realize the advantages of having small families. Their motivation is two-fold. Many people are realizing that it is possible to be married and have a good life with just one child, or with no children at all. In the USA and in many other rich countries this is practical because we have old age benefits, but more difficult where these benefits don’t exist so people have to rely on their children. There is another, altruistic reason a few are limiting their fertility. They see that the world is already overpopulated and don’t want to contribute further to the problems we are causing.

There are better, safer and more effective contraceptive methods than 52 years ago when Gail and I got married. The number of women using highly effective methods is rising, and (thanks to some good people running altruistic organizations) some are more affordable. An example is Medicines 360 which makes the Liletta™ IUD available to nonprofit clinics for just $50.

Colorado was chosen several years ago for a 5 year experiment. Women were able to receive LARCs (Long Acting Reversible Contraceptives, such as IUDs and implants) at no cost, even if they didn’t have insurance. The result was phenomenal—the unplanned pregnancy rate in our state dropped dramatically, and so did the abortion rate. I like to think of all the young people who were able to finish high school and go on to college because of this experiment. That experiment is over, but funding has continued thanks to private and state funding.

Emergency Contraceptive pills are now available without a prescription. This medication is so safe that there are essentially no cases of serious harm from taking it. It is not the best solution, because it is used after a failure—failure of a man to respect a woman, failure of a couple to use contraception or failure of a condom. Nevertheless, EC pills have prevented thousands of unplanned pregnancies.

There is also a movement to make birth control pills available without prescription (www.freethepill.org), or with a prescription from a pharmacist. Now a woman can purchase “the pill” over the internet, and in some states (including Colorado and New Mexico) pharmacists can prescribe hormonal contraceptives by following a protocol. Planned Parenthood has been doing something similar for years. A woman can purchase pills there, if all is ok, after answering a health questionnaire and having her blood pressure checked.

Although the need for abortion is decreasing, there are still all-too-many unplanned pregnancies. Access to abortion services is being curtailed in many parts of this country, causing women to have unsafe abortions. This is similar to what happened before Roe v. Wade in the USA, and is common in countries where abortion is illegal. The good news is that mifepristone and misoprostol, the pills used for a medical abortion, are available over the internet.

There are problems with internet-aided abortions. Most of these pills come from India, are expensive, some are of low quality, and they can take weeks to arrive. Unfortunately, medical care by internet has some inherent issues that will be difficult to resolve. It lacks the personal support that is so important when making an important decision. Also, there are two possible complications. Unless a woman has an ultrasound she might not know that the pregnancy is ectopic. These medications won’t cure a tubal pregnancy, which can rupture and cause serious internal bleeding. And the medications aren’t always effective in ending a pregnancy, so follow-up pregnancy tests are important.

Many countries now have Total Fertility Rates (TFRs) below the replacement rate—the number of children needed to replace the two parents. Replacement rate is slightly more than 2 because some kids die before they reach the age of parenting. This means that the countries’ populations will eventually decrease. Don’t be fooled, however—with few exceptions, all countries have increasing populations due to population momentum and increasing longevity. Of the CIA’s list of countries, only 105 have a TFR above 2.1, and 119 are less. The average TFR for the world is 2.4. We are getting closer to slowing population growth, but still adding about 80 million people to the already overcrowded planet each year.

I’ll be attending the International Conference on Family Planning this month and hopefully will have more good news for you soon!

© Richard Grossman MD, 2018

Avoid these Causes of Infertility

Sunday, September 30th, 2018

A solution has been found for overpopulation! Unfortunately, this is not a reason for celebration.

This essay is another in my all-too-long series of bad ways to control population. It joins essays on genocide, the Doctrine of Discovery and gun violence.

Sperm counts are declining around the world. Fortunately, most men still have enough sperm to become fathers when they want, but that might not be the case forever. There are even predictions, if the current trend continues, that the human species will cease to exist! Just how worried should we be about declining sperm counts?

A review article suggests that the average sperm counts in European and other “western” countries has declined markedly. The overall count has declined 50 to 60% from 1973 to 2011. Another study found the same—or worse—is true for Africa. Between 1965 and 2015 they found a decrease of more than 70%! Fortunately, as you remember from biology class, only one pollywog fertilizes an egg. However fertilization requires that a crowd accompany that one lucky sperm.

I look at these studies with some concern about their accuracy. However, it seems that men truly are making fewer sperm. In addition to this decrease, genital abnormalities and testicular cancer have become more common. What is affecting men so badly? Perhaps we can learn something by consulting “man’s best friend”.

Veterinarians have studied the reproduction of a group of guide dogs for decades, and found decreases in sperm quality and increases in genital abnormalities and testicular cancer. The dogs seem to reflect the same problems as men are facing! The question is: what is causing these problems?

The vets did something that most men would object to—testicular biopsies. These little bits of tissue were tested for several chemicals with names such as “PDBE28” “PCB153” and “DHEP”. The chemicals were found in the dog food, and in the biopsy tissue, too, in levels that inhibit fertility.

These chemicals have been developed in the last few decades to promote “better living through chemistry”. They are some of a huge number of organic chemicals that have beneficial uses and have found their way into our homes—and into our bodies.

Although we may not be aware, when we bring home new furnishings, they are often treated with chemicals such as PDBE28 to decrease the rate at which they burn. These chemicals are also in building materials, vehicles and plastics—they are ubiquitous. They may have saved lives because of their fire retardant properties, but they may also have changed many lives because of their biological effects. Almost all—97%—of people in the USA have detectable levels of this group of chemicals in their blood!

The shape of these artificial molecules is similar to the shape of some hormone molecules. Hormones are chemical messengers that tell distant parts of our bodies what to do. They fit into receptors that receive hormonal molecules and activate cells. The analogy of lock and key is often used because the hormonal molecule is usually specific to certain receptors on certain cells. Because their shape is similar, endocrine disrupting chemicals fit in receptors. The disruptor can either stimulate the cell or, if the “key” gets stuck in the “lock”, the disrupting chemical can block the action of the real hormone.

Switching to women, now. Female fertility is also decreasing. The epidemic of  obesity is affecting fertility, as is some women waiting too long to have children. Their bodies are also sensitive to the effects of endocrine disrupting chemicals. In a study of California women, those with high levels of PCBEs took longer to conceive a pregnancy than women with lower levels. 

There hasn’t been enough written in the press about endocrine disruptors, perhaps because this subject is very complicated. Two facts that stick in my mind are that endocrine disruptors have their strongest effect when they are very, very dilute— because of their combination of stimulating and blocking effects. This means that the usual testing done by the FDA may find little risk because they didn’t dilute the chemical enough—the opposite of the usual when testing for toxicity. Indeed, endocrine disruptors may have an effect when they are equal to a pinch of salt in an Olympic-sized swimming pool!

I plan to write more about endocrine disruptors since they are so pervasive and have so many bad effects. Time will tell if these chemicals will cause a significant decrease in our population. If they do, it will be involuntary—which is tragic.

©Richard Grossman MD 2018

Recognize Family Planning as a Human Right

Tuesday, May 29th, 2018

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Family planning was declared to be a basic human right fifty years ago this month. The right to family planning was included in the International Conference on Human Rights held in Tehran, May 1968.

The concept of universal human rights started after World War II with the United Nations. Its charter included the obligation “…to promote… universal respect for, and observance of, human rights and fundamental freedoms for all without discrimination….” The Tehran conference was held 23 years later to define what those rights are. One of several points states:

“The protection of the family and of the child remains the concern of the international community. Parents have a basic human right to determine freely and responsibly the number and the spacing of their children”

The 84 countries attending this Iranian conference agreed to be bound by the decisions, but the world has changed radically since then. For one thing, there are more than double that number of countries. Furthermore, global population has more than doubled from 3,600,000,000 to 7,500,000,000 people. On the good side, there are more, safer and more effective methods of contraception available. The right to family planning is supported by many programs, including FP2020 which works in many developing countries. Planned Parenthood and the federal Title X (ten) program in the USA are under jeopardy because of a proposed law limiting healthcare providers from mentioning the word “abortion”.

Unfortunately the right to family planning is being limited or taken away in many countries. Funding for many organizations working internationally has been barred by the Global Gag Rule. The GGR prevents the US from funding any foreign agency that provides abortion services anywhere—or even mentions the word “abortion”. Because of the lack of these services women will go without birth control and there will be millions of unplanned pregnancies, and thousands of women will die from complications of pregnancy—and, ironically, there will be more abortions!

The Tehran Proclamation has 9 standards to uphold the human right to family planning. These include non-discrimination, availability of information, accessibility of services and supplies, quality, autonomy of decision making, privacy and confidentiality. I am happy to report my experience has been that these standards are upheld everywhere I have worked,. 

It is difficult to envision a UN conference being held in Iran now—there have been many changes since 1968. The Shah was overthrown in 1979 and the country became an Islamic theocracy, lead by a “Supreme Leader”. A pleasant surprise came about a decade later.

High level government and university experts held a conference in 1988 to discuss Iran’s population, which was increasing rapidly at that time. Attendees agreed “…that the rate of population growth in the Islamic Republic of Iran was high and this would have a negative effect on the welfare of the people. Hence, the participants strongly urged the Government to set up a family planning programme and integrate population factors in policy-making.” (quoted from “A New Direction in Population Policy and Family Planning in the Islamic Republic of Iran”)

The High Judicial Council of Iran decided “family planning does not have any Islamic barrier” so long as abortion was not involved. New laws were passed to promote small families. Couples were required to take birth control classes before they could get a marriage license. Government clinics were set up offering a wide choice of methods, including vasectomy. In addition, the government discouraged childbearing before age 18 and after 35 and recommended that children be spaced 3 or 4 years apart. The family planning program urged couples to have no more than 3 children; government employees lost some of their benefits, such as maternity leave and food coupons, if the family had more than 3 children. 

The TFR (the average number of children that a woman bears in her lifetime) in Iran had been as high as 7.0, had decreased to 5.5 in 1988 and now is less than replacement at 1.8—the same as the USA. It doesn’t mean that population is shrinking—there are millions of children and teens whose reproductive years are still ahead of them—so it will take decades before the population stabilizes.

A dictatorship can use its influence to slow population growth. Although there are many dictators in the world today, I think Iran is the most successful in slowing its growth. That sort of heavy-handed governing wouldn’t work in the USA. Indeed, I believe that people should have the right “…to determine freely and responsibly the number and the spacing of their children.”

© Richard Grossman MD, 2018

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