Reduce Barriers to Family Planning

December 24th, 2017

There’s no good news about male contraceptives yet, but there is much progress in the field of family planning for women. This column will touch on some of the high points.

Perhaps the best news is that, globally, more women who want to avoid pregnancy are using an effective contraceptive method. The number who weren’t using modern contraception was estimated to be 225 millionin 2014but is 214 million now. The decrease is partly due to huge efforts from Family Planning 2020 to make better family planning available in developing countries. With local support as well as funding from rich countries and foundations, FP2020 has provided over 30million women with effective contraception.

The goal of FP2020 is to reach 120 million previously unserved women with effective family planning by the year 2020. In many places couples only had access to one or two methods, such as condoms or tubal ligation. FP2020’s strategy includes avoiding coercion and offering a choice of several methods.

Please remember that it is not just developing countries that wrestle with unintended fertility. In 2008 in the USA 51% of pregnancies were unintended. There is good news here, too; it is now just 45%. This decrease, and the significant decrease in abortions, is thought to be due to Long Acting Reversible Contraception—LARCs. These methods include IUDs, implants and the 3-month shot. One in 7 women in the USA is now using these most reliable types of birth control.

LARCs have two shortcomings, however. In general they are expensive—but remember that dollar-for-dollar, contraception saves more than any other health intervention!

The other problem with LARCs is convenience, since most require a health care professional. An exception is the 3-month shot, “Depo” or DMPA. This has been in use for birth control for almost 50 years, but requires a clinic visit 4 times a year.

Sayana Press® is an innovative solution that is accepted very well. It is a small plastic bubble filled with the medication and a short attached needle. The woman just punctures her skin, squeezes the bulb and she is protected against pregnancy for 90 days.

Malawi, a small East African country with large families, compared women who went to the clinic to get their shots with women who injected the medicine themselves. They found that women who were given the first shot at the clinic then took home 3 Sayana Presses® were much more likely to use the medication for a full year.

Birth control pills are available without prescription in many countries, and the USA will be following suit if Daniel Grossman has any say. Grossman and I may be distantly related, and we are very close in our belief that “the pill” is amazingly safe and there should be minimal barriers to its access. Grossman has started the “Free the Pill” campaign. This would follow the way Emergency Contraceptive (EC) pills have gone over the counter; now sells EC pills!

Another physician named Grossman—Jessica—heads up Medicines 360. This organization has as its mission “…to expand access to medicines for women regardless of their socioeconomic status, insurance coverage, or geographic location.” Their first product is a big success! Liletta® is an IUD that releases a hormone over 4 years, is safe and very effective, and decreases menstrual bleeding and cramping. It is primarily sold to clinics and is significantly less expensive than similar IUDs.Recently there is good news about all IUDs; they reduce the risk of a woman getting cervical cancer.

When Trump reinstated and expanded the Global Gag Rule, the Dutch started “SheDecides” to replace essential funding for reproductive health. More countries, foundations and individuals have stepped up to pledge $200 million! This amazing organization’s goal is to make it possible for “…girls and women to decide freely and for themselves about their sexual lives, including whether, when, with whom and how many children they have.”

Most couples in the USA use contraception at some time in their lives, even if their religion opposes birth control. In much of the global south, however, this is not the case. There the Roman Catholic hierarchy turns most women away from birth control. This might change, however. The Pontifical Gregorian University in Rome will be holding a series of talks on the 50th anniversary of Humanae Vitae, according to the National Catholic Register.

Despite political forces in this country that are trying to erect barriers around access to family planning, there is a lot of good news about contraception for women.

© Richard Grossman MD, 2017

Heed this Warning

November 25th, 2017

In 1992 the Union of Concerned Scientists published the “World Scientists’ Warning to Humanity”. Twenty-five years later it has just been updated.

Most of the Nobel Prize winners then alive and 1575 senior scientists signed the original warning. It started with the words: “Human beings and the natural world are on a collision course. Human activities inflict harsh and often irreversible damage on the environment and on critical resources. If not checked, many of our current practices put at serious risk the future that we wish for human society and the plant and animal kingdoms, and may so alter the living world that it will be unable to sustain life in the manner that we know.”

After this powerful introduction there are several headings. The heading titled “Population” states what many people (especially economists) are still denying. It starts with: “The earth is finite.”

Later in the “Population” heading you can read: “Pressures resulting from unrestrained population growth put demands on the natural world that can overwhelm any efforts to achieve a sustainable future.” I find it remarkable that those who write about “sustainable development” so often ignore this obvious fact.

This 1992 Warning had 5 points under the title “What We Must Do”. Point #3 states: “We must stabilize population. This will be possible only if all nations recognize that it requires improved social and economic conditions, and the adoption of effective, voluntary family planning.” Unfortunately this was all but ignored. In fact, just 2 years later, at the UN’s International Conference on Population and Development, delegates decided to turn the focus away from population and toward HIV and reproductive rights. This had an unfortunate effect on support for family planning programs.

So much for the past. Not too many people were aware of the 1992 document, and fewer took it to heart. Scientists have updated the Warning on its 25th anniversary in a remarkable fashion. “World Scientists’ Warning to Humanity: A Second Notice” was published last month in BioScience, a well-known journal. Although eight authors appear on the title page, the total number of signatories is huge—15,364 scientists from 184 countries! It is not too late to join this elite crew if, indeed, you are a scientist. Go to to find out more and to endorse the article. Over 3,000 people have done added their names.

The current Warning is not optimistic. Of the 9 issues treated 25 years ago, only one shows improvement. The good news is that ozone-depleting emissions (chlorofluorocarbons) are decreasing. They jeopardize the atmospheric ozone that guards us against dangerous ultraviolet radiation. The other 8 trends are all bad; these include fresh water supplies, total forest area, vertebrate species abundance and ocean dead zones. Need I also mention that the CO2 level is rising and the climate is heating up?

It comes down to two factors—population and consumption. The authors put it this way: “We are jeopardizing our future by not reining in our intense… material consumption and by not perceiving continued rapid population growth as a primary driver behind many ecological and even societal threats.”

Slowing population growth seems much more attainable than decreasing consumption, however. So many people want to manage their fertility but don’t have access to effective contraception—we must expand access to birth control here and abroad.

There is hope. The new Warning points out that pressure on politicians, especially from scientists and concerned citizens, can create change. The authors also cite the importance of changing individual behaviors such as choosing to have small families and to consume less—including moving toward a plant-based diet. They celebrate the decrease in family size throughout most of the world and praise the decrease in world hunger. They use the example of the decrease in chlorofluorocarbons as an example of what can be done when there is political will.

The Warning gives 13 steps to take in order to move in the correct direction to save our life support systems. The 12th is to revise our economy to reduce inequality of wealth and to take into account the externalities that harm our planet. The last proposes a revolutionary idea—to determine what a long-term sustainable human population might be, then to rally support to reach that goal.

Can more than 18,000 scientists make a difference in a positive direction? We have seen how much damage one person, the president of the USA, can do by moving us away from sustainability. It is time for us to heed the far-sighted Warning for our progeny’s sake.

© Richard Grossman MD, 2017

Essay distributed to two large groups of experts

November 14th, 2017

I am happy that an essay I wrote was distributed by the IUSSP (International Union for the Scientific Study of Population). It was then picked up and redistributed to the PERN (Population-Environment Research Network). Through the miracle of digital communications several thousand people have been able to read this–without a single piece of paper being used!

The essay was written in response to one that was published by IUSSP and written by a wonderful person, David Lam. David is optimistic about the future of the planet to support 4 billion more people. I am concerned that we have already caused so much damage and believe that the degradation will worsen unless we slow our population growth rate, and decrease our consumption. Dr. Lam’s essay is available at:

My essay is below, somewhat shortened by excluding information about a wager that Dr. Lam has with another friend, Stan Becker. The complete essay is available at:

The world in which the next 4 billion people will live

I was pleased to read Professor David Lam’s N-IUSSP essay “The world’s next 4 billion people will differ from the previous 4 billion” (Lam 2017). He outlines past, present and projected future population growth. He points out that much of the population growth will occur in Africa, and that a higher proportion will be older, if current trends continue. He also wonders “…whether the world can absorb another 4 billion people.”

As a demographer, it is appropriate that Lam should focus on humans. However, I fear that he has largely ignored the environment in which we live when he wrote this essay. I have difficulty accepting his statement: “An important source of optimism about the world’s ability to support an additional 4 billion people is the success in supporting the previous 4 billion.” My concern is that the past 4 billion have degraded natural world upon which we depend, and that this degradation will make the world much less welcoming to the next 4 billion.

A changing world (not always for the better)

I agree that the next 4 billion people will differ from the previous 4 billion as professor Lam explains, but so will the world in which those people live. Dr. Norman Borlaug understood this when he stated, in his Nobel Prize acceptance speech of 1970: “The green revolution has won a temporary success in man’s war against hunger and deprivation; it has given man a breathing space. If fully implemented, the revolution can provide sufficient food for sustenance during the next three decades. But the frightening power of human reproduction must also be curbed; otherwise the success of the green revolution will be ephemeral only. Most people still fail to comprehend the magnitude and menace of the ‘Population Monster’. …Since man is potentially a rational being, however, I am confident that within the next two decades he will recognize the self-destructive course he steers along the road of irresponsible population growth….”

Borlaug’s three decades have passed and we have seen the side effects of the “green revolution”—decreasing soil quality, decreasing forest coverage, increasing pollution (including huge anoxic ocean dead zones), rapid loss of species and, perhaps worst of all, climate change. The “green revolution” has allowed us to feed more people so that, finally, fewer people go to bed hungry. However, more food has made it possible for our human population to grow at a faster rate, despite monumental increases in reproductive health and family planning.

How can we quantify human impact?

The formula popularized by Ehrlich and Holdren (1974) gives an idea of our human impact on the earth: I = P x A x T (I = impact; P = population; A = affluence (or consumption); T = technology). Let’s look at these factors in the opposite order. We are starting to develop technology to decrease our impact, such as solar panels and more efficient vehicles, but the benefit so far from new technology is relatively small. As for the A factor, affluence, I have met very few people who actually wish to decrease their consumption. There is too much social pressure for people to increase their consumption. Furthermore, leading an affluent life is more comfortable so it has become the goal of billions of people.

Slowing population growth, on the other hand, is the “low hanging fruit” to reduce human impact P. An estimated 225 million women worldwide wish to avoid pregnancy but are not using effective contraception (Singh et al. 2014). Moreover, having fewer offspring has been shown to be the most effective way of reducing impact, using greenhouse gas emissions as a measure of impact (Murtaugh & Schlax 2009).

How can we determine to what extent human activities are degrading our planet? The best measure of planetary sustainability is the Ecological Footprint. This shows that humans are already overtaxing the planet. Indeed, it would take 1.6 planets Earth to support our human population sustainably the way we are currently living (Figure 1). Unfortunately, there is only one Earth.Schermata 2017-11-12 alle 15.11.12

This degradation of our life support system will become a grave problem as the next 4 billion people are added. There will be more people to share the resources and more people to contaminate the world with their waste products. The most visible of the latter is the climate change caused by carbon dioxide from our use of fossil fuels, but there are many other examples. Already food production systems are stretched to keep up with the addition of about 80 million people each year. With global warming, the outlook for increases in food production in some African states is poor. Feeding even 9 billion by midcentury will clearly be a major challenge.

We have been fortunate to live in this era, but I fear that the next 4 billion people will live in a world that is very different, and not so enjoyable. Current inhabitants must think more about preserving the earth for future generations.


Ehrlich P.R., Holdren J.P. 1971. Impact of Population Growth. Science 171 (3977): 1212–1217. doi:10.1126/science.171.3977.1212

Lam D. 2011. How the World Survived the Population Bomb: Lessons From 50 Years of Extraordinary Demographic History. Demography, 48(4): 1231-1262.

Lam D. 2017.  The world’s next 4 billion people will differ from the previous 4 billion. (N-IUSSP July 24, 2017)

Murtaugh P.A., Schlax M.G. 2009. Reproduction and the carbon legacies of individuals. Global Environmental Change 19: 14–20.

Singh S., Darroch J.E., Ashford L.S. 2014. Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health. New York: Guttmacher Institute.

Becker S. 2013. Has the World Really Survived the Population Bomb? Demography. 50(6): 2173-2181.


Figure 1Global Footprint Network, 2017.

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