Family Planning Population Public Health

Puerto Rico

This story started 30 years ago when we lived in Puerto Rico. Actually, the real beginning was 15 years before that, in Nicaragua.

We returned to Puerto Rico this spring after a three-decade absence. The island seemed even better than when we lived there. There was less trash, people were friendlier and now toll roads bypass overcrowded arteries.

Of course, Puerto Rico is not a separate country, but a commonwealth of the USA. Fortunately Puerto Rico keeps independent statistics, and one of them was a real surprise.

Flash back to 1968. My best experience in medical school was in the little Nicaraguan town of Puerto Cabezas, on the Caribbean coast. I learned a huge amount from the one physician, Ned Wallace, at the Moravian hospital there.

Gail (then my wife of only two years) and I lived in a tiny cabin with another medical student couple, a short walk to the hospital—and to the Caribbean Ocean. We adopted Noxa (“hello” in Miskito), a sociable green parrot.

We traveled by dugout canoe to provide the first medical care some villagers had ever received. Our wives passed out worm medicine and gave immunization shots, while we medical students saw patients in the four languages of the area—Miskito, Spanish, Creole and English. It was not the best medical care, but our patients were appreciative.

Ned was an excellent role model—he could do just about anything! I realized that living and practicing medicine in the tropics had personal advantages, in addition to helping people. At that time I resolved that, if we ever had kids, they should grow up knowing that the entire world was not like the USA, and that everyone didn’t speak English. Fortunately, Gail agreed.

In 1983 we moved our family from Durango to the little hill town of Castañer in central Puerto Rico. I practiced medicine and our two sons, in 3rd and 6th grades, learned Spanish by immersion. It was an enlightening experience in a different culture.

I was frustrated in Castañer by the number of women who wanted to limit their fertility, but lacked the money. Typically women married young and had 3, 4 or more closely spaced children. When I asked older women what birth control they used, the answer was often “my husband takes care of me” (withdrawal) or “I’ve been operated” (tubal ligation). Birth control pills and IUDs, effective temporary means of contraception, were just too expensive in this impoverished area.

Before returning to Puerto Rico this year I consulted the World Population Data Sheet ( for some demographic information. To my surprise the TFR (Total Fertility Rate—the number of children a woman has during her lifetime) was low. For a society to neither grow nor shrink, the TFR has to be about 2.1–one child to replace teach parent, plus a fraction for children who die before adulthood. Puerto Rico’s TFR is 1.6 now, far below replacement! However, it will take several decades for the population to stabilize.

What brought about this change In Puerto Rico? Did people recognize that the island is limited in size, that it has approached its carrying capacity? Is it that there is less adherence to religious doctrine?

Nobody seems to know exactly what happened. As far as I can make out, however, marriage is later and more couples choose to be childless. More women are employed, a common reason people choose smaller families.  The main change seems to be that contraception and tubal ligation (still very popular) are available with governmental aid, helping people achieve their reproductive and economic goals. Legal abortion is less common now that contraception is easier to obtain.

Puerto Ricans live in a beautiful green place of sun and ocean, but they have low incomes by our standards—only a third of the average income on the mainland. Thanks to government support, now people are able to receive the family planning services they desire. Puerto Rico has joined half of the world’s countries where women have sufficient access to family planning so that their populations will eventually stop growing. Where does the USA fit in? our TFR, at 1.9, is slightly below replacement.

Our return to Puerto Rico was lots of fun. We visited with friends and enjoyed the sun and ocean. Teaching our granddaughters to body surf was special for me. I also learned that even a poor area, if it has the will to help women control their fertility, can achieve zero population growth along with an improved economy.

© Richard Grossman MD, 2013

By Richard

I am a retired obstetrician-gynecologist who has been fortunate to live and work in the wonderful community of Durango, Colorado for 40 years.

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