Don’t Control Population this Way

There are many ways to decrease human numbers, and most of them should be shunned. Indeed, some of them are quite horrifying. In this and subsequent columns I’ll write about some of them.

It has been more than 20 years since the Rwandan genocide, but it stands out in my mind as the worst episode of human slaughter in recent history. Estimates of the number of people killed in a terrible 100 day period range from 1/2 million to a million. The population of Rwanda at that time was less than 8 million; a huge proportion of this small country’s people killed each other. In addition, an estimated 2 million were displaced or fled the country.

Genocide is the intentional destruction of a national, ethnic, racial, or religious group. Theories about the causes of genocide include tribalism, autocratic rulers and lack of resources. An article about this genocide, “Remember Rwanda” by James Gasana was published in WorldWatch. Gasana is Rwandan and had held 2 different cabinet positions in that country. In this article he noted that murder was common where people went to bed hungry.

In 1994 Rwanda had an almost entirely agricultural economy and was overpopulated. As the population rose the size of landholdings shrank and the overworked land became less productive. Even if people wanted to limit their fertility, the predominant religion, Roman Catholicism, preached against “artificial” contraception.

That is in the past. With international help and amazing resilience, the Rwandan people have put that terrible part of their history behind them. However, another country appears to be enduring a religiously motivated genocide. The Rohingya people in Myanmar (Burma) are both an ethnic minority and, as Muslims, have different religious beliefs from the Buddhist majority.

Genocide Watch lists 10 stages that are seen in preparation for and carrying out a genocide: Classification, Symbolization, Discrimination, Dehumanization, Organization, Polarization, Preparation, Persecution, Extermination and Denial. Most of these stages can be seen with the treatment of the Rohingyas.

Although they live in Myanmar, the Rohingyas aren’t allowed citizenship—classification. While they are not forced to wear identifying symbols, their freedom is restricted in other ways. They must live in ghettoes and are restricted by curfews—organization and polarization. Mobs attack Rohingya settlements while officials offer no protection—preparation. “Security” forces have killed thousands of Rohingyas while others have been tortured, “disappeared” or have suffered rape—extermination. The country admits to no wrongdoing—denial.

Perhaps the most dire of the measures against the Rohingyas is limitation of their reproductive rights. While there is no limitation on other people in Myanmar, the Rohingyas are only allowed to have two children. Apparently the Muslims tend to have larger families than the Buddhists in the same area. The state officials’ reason for this limitation is to “…ease tensions between Buddhists and their Muslim Rohingya neighbors.” Even if this is the true motivation, legislating the number of children in a family is wrong.

Unfortunately, Myanmar and Rwanda are not unique; there are many historical examples of peoples being singled out and exterminated. In the chapter on genocide, “The Great Big Book of Horrible Things” tallies an estimated 32 million deaths from genocides in the past 3 millennia. This includes a huge but unknown number of indigenous people killed in the Americas when we Europeans invaded.

Currently there are several countries where genocide is happening or is very likely. These include South Sudan, Sudan, Syria, Yemen and the Democratic Republic of Congo, all of which have unstable governments and terrible records of civil rights.

What can we do to prevent genocide? In “Warning Signs of Genocide: an anthropological perspective” Drs. Gene and Barbara Anderson state that the most important protection against genocide is critical thinking—the process of independently analyzing, synthesizing, and evaluating information as a guide to behavior and beliefs. They have written a second book, “Halting Genocide in America”, in which they are concerned that some people in the USA are already taking steps along the road to genocide.

Genocide is perhaps the most vicious way to slow population growth, but there are several others on my list of means to reject. Nature tends to limit populations with disease and famine, over which we have only limited control. Some other ways of slowing growth are imposed by people and governments. These include eugenics, family size coercion, war, gun violence, and the Voluntary Extinction Movement. More about them in future essays.

© Richard Grossman MD, 2018

The graph to the left shows a remarkable dip in the population of Rwanda, with the lowpoint in 1995. The numbers on the vertical axis are population in 1000s. Remember that population figures are approximate–especially in a less developed country.

Note the decrease started before the genocide, as people started to emigrate; and also note that the genocide didn’t seem to cause a permanent decrease in Rwanda’s population.

Update: Although this essay was written in 2015, I never published it on the blog. Since then I have been in Rwanda and witnessed both the horror of the genocide and also resilience of these wonderful people.


Remember Simple Family Planning

The United Nations predicted 7 million additional unintended pregnancies would occur if the coronavirus lockdown lasted 6 months. It is already more than a half year since the pandemic started, but we won’t know the effects on reproductive health services for months to come.

            Part of the problem accessing care in developing countries is what are called “stock-outs”. Where the supply chain is long, supplies often run out. An example of the impact of this problem is that a woman may spend a day and money for the bus to go to the family planning clinic for her 3-monthly shot of DepoProvera, and find out that the clinic has run out of the medicine.

            One solution for this has been explored. Another form of Depo has been developed which also lasts 3 months, is highly effective, but is given under the skin rather than into the muscle. An “appropriate technology” way to package this subcutaneous shot. Sayana® Press is a single-use syringe that contains the medication in a small plastic capsule attached to the short needle. All the woman needs to do after placing the needle is to squeeze the capsule.

            Women in Malawi are first taught how to give themselves the injection, then supervised as they actually do it. Then they are given 3 syringes to take home. It was found that self-injection works well and was more popular with women than having to make 4 trips each year. As a consequence, the continuation rate was higher among women who only visited the clinic annually.

            With the pandemic there are many other reasons than stock-outs that can make it impossible for people to get the most effective, modern family planning. The clinic may be closed, the bus driver sick or the family has run out of money. Many providers, myself included, have disparaged traditional methods of contraception because of their lack of effectiveness. However, during a time of emergency such as the pandemic, any family planning method is better than none for a couple who wants to postpone pregnancy. Knowledge of traditional contraception helps to prepare for disruptive events.

            Many societies have ways of controlling fertility. These include breastfeeding, prolonged abstinence from intercourse after childbirth, abstinence during the fertile time in a woman’s cycle (often called “natural family planning” or “the rhythm method”), and withdrawal.

            It has been known for centuries that nursing a baby makes the mother relatively infertile; the Lactational Amenorrhea Method (LAM) formalizes this knowledge. LAM is 96% effective if: the baby is less than 6 months old, is nursing with little supplementation and the woman hasn’t started to menstruate yet. The reduction of fertility is less, but still significant, if only 1 or 2 of the criteria are met.

            The effectiveness of periodic abstinence is debated. What is not debated, however, is that instruction in the method is helpful, and that a cooperating partner is essential. Some studies report almost 100% effectiveness, while others cite much lower figures. There are many ways of tracking when a woman is fertile, and each has its own success rate—but most are in the range of 80%. This means that about 20 out of 100 women will get pregnant when using periodic abstinence.

            There are two ways of increasing effectiveness of periodic abstinence. Users of the Standard Days Method® (formalized by using CycleBeads®) report an effectiveness approaching that of modern contraception, but it is limited to women who have 26 to 32-day cycles.      The other is with a smartphone app. CycleBeads has one, and there are many others. One, Natural Cycles, is FDA approved and claims to be over 90% effective in preventing pregnancy.

            Withdrawal (“pulling out”) has the distinction of being so old that it is mentioned in Genesis. It is a family planning method that needs no medication or supplies, just perception and willpower on the man’s part. He needs to perceive when ejaculation is imminent and withdraw his penis before it occurs. Overall, withdrawal is about 80% effective. However, for a man who uses this method perfectly, his partner only has a 4% risk of conceiving each year. As I found out in Puerto Rico where many of my patients used withdrawal, in certain populations it may be very effective.

            An article in The Economist “The pandemic may be leading to fewer babies in rich countries” brings no surprise—the birth rate seems to be down in rich countries, but people in poor countries are probably having more babies. Covid is increasing problems for the poor.

© Richard Grossman MD, 2020