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Action Contraception Family Planning Media Population Public Health Reproductive Health

Take the Next Step

It was an accident. In 1994 I spent a day with the political reporter, Robert Fisk, in Egypt. I had never heard of Fisk before, but the experience changed me.
We were part of a press tour organized by the Egyptian government to look at family planning clinics during the International Conference on Population and Development. Fisk inspired me to become an activist instead of just a doctor.
The tour started in a room crowded with real journalists. Although the Durango Herald provided me with the necessary credentials, I had little idea what a journalist actually did. Fisk told me about his experiences as a war correspondent. He has been in the middle of hostile fire in Bosnia and other hotspots. I remember his stories of reporters with less experience—and less luck—who were caught in crossfire and killed. “It’s a dangerous, lonely life,” he said in a recent interview. If I’m not wrong, Fisk himself has taken a few bullets. He could have been a professor of history, the field of his PhD. “You’ve got to feel the passion,” he exclaimed about his choice of career.
As a man who has experienced war personally, he comments: “War is primarily about the total failure of the human spirit. It is about death. Forget Hollywood.” Although British, Fisk has made his home in Beirut, Lebanon, for over 30 years. He told me that it had been a beautiful city before civil war tore it apart.
The tour showed just what I would expect to find in a developing country. In one women’s clinic I asked (through an interpreter) some of the women in the waiting room if they breastfed their babies. They looked at me as though I was from a different planet! “Of course our babies are breastfed! The Qur’an says that we should nurse for at least seven months.”
Although I had traveled to and practiced medicine in some rudimentary places, this clinic left strong memories. One was a woman arriving for her prenatal visit in beautiful clothes—by oxcart. The posters on the wall were similar to what we might see in this country, except for the Arabic script. There are many differences between our societies other than just the alphabet, however.
The clinic’s doctor spoke excellent English. During her years of service in that clinic she had done an informal survey of female genital mutilation. This cruel procedure is also known as “female circumcision,” and is performed in parts of northern Africa and of the Middle East. Usually a barber or other non-medical person does the cutting using unsterile instruments. The victims are children. FGM can lead to serious infections and even death. Survivors will enjoy sex less and may have serious problems during childbirth due to scarring. The doctor said that, of a hundred women she had asked, 98 had suffered this traumatic maiming.
Fisk put this visit into another perspective. He had been to Egypt many times before and had pushed the frontiers of freedom of speech. On one trip he explored the slums up in the hills surrounding Cairo. This huge city of 17 million people in the metro area has at least a million commuters who venture onto the crowded streets every day. Most commuters live in squalor in the poor areas surrounding the city. Fisk spent a day, he said, documenting people living in those miserable living conditions. Someone evidentially tipped off the officials that a stranger was snooping around, and the police exposed all of his film to the Egyptian sun.
Shortly after this experience in Cairo, I started working less so that I could do other things. Now I have time to write this newspaper column, teach a class at Fort Lewis College and be involved in leading a Quaker environmental group. Many friends in Durango have helped me step into this expanded role.
I now read the Independent of London, Fisk’s paper, online every day. His column on 9/11 reminded me of that accidental day in Egypt and how he inspired me to go beyond the usual role of a physician—to become an activist. The title of that article summarizes his viewpoint: “Nine years, two wars, hundreds of thousands dead – and nothing learnt.”
I am happy that I stepped out of my “comfort zone” sixteen years ago to learn more about family planning in Egypt. In addition, I accidentally learned about the risky life of a war journalist—and was propelled into being more of an activist.

This article may be copied or published but must remain intact, with attribution to the author. I also request that the words “First published in the Durango Herald” accompany any publication. For more information, please write the author at: richard@population-matters.org.

Categories
Contraception Family Planning Medical Reproductive Health

Happy Birthday to “The Pill”

Happy Birthday to “The Pill”—5-2010

© Richard Grossman MD, 2010

It was fifty years ago that the Food and Drug Administration approved “the pill”. What a half-century it has been!

The birth control pill made it possible for couples to have sex without concern about pregnancy. True, before hormonal contraceptives there were other contraceptives—but the condom, diaphragm and spermicide took away much of the spontaneity of sex. One of the advantages of the pill is that it separates contraception from intercourse.

Shortly before getting married in 1966 my wife visited a doctor to get on birth control pills. I remember that she brought home a bottle of tablets. Packaging has changed since then with the package helping the woman to remember to take her pill. There is even a pill pack with a reminder alarm!

The amount of hormone in each tablet has also changed; it has decreased immensely. The estrogen in today’s low dose pill is one seventh that of the first pill. If you have wondered why pills are different colors for different days, it is because many of today’s oral contraceptives vary the dosage during the month to get good cycle control with a very low level of hormones.

One formulation is not optimal for all women. Although all of today’s combined pills contain the same estrogen, the dosage varies between 20 and 50 micrograms. They also have different progestins (hormones similar to the other major hormone the ovary produces, progesterone). Some are excellent in controlling menstruation, others excel at helping with acne and others are best in alleviating PMS.

Initially every woman took active hormone pills for three weeks then stopped (or took placebos) for a week, then went back on the active pills again. That pattern has changed. Some pill formulations are designed so that the woman only menstruates every three months, and one prevents any bleeding at all. Suppressing periods is especially helpful for women who have problems such as heavy bleeding or bad cramps. We now recommend against a “vacation” from hormonal contraception—this only increases the risk of pregnancy.

“The pill” is one of several ways a woman can take hormones. In China the hormones are available as little dots on rice paper. We have patches that women wear; the hormones are delivered through the skin. There is also a plastic vaginal ring that slowly emits the hormones.

Of the two hormones, the progestin is the one most responsible for controlling fertility; the estrogen is added for cycle control. Unfortunately, the estrogen also increases the chances of blood clots, stroke and heart attack, especially in older women and those who smoke.

Progestin-only contraception without estrogen is available in “the minipill”, in a shot that is effective for 3 months, as an implant that goes under the skin of a woman’s arm, and in an IUD. All of these methods have the advantage of safety, but they often cause erratic bleeding.

We prescribe “the minipill” for women who are breastfeeding and for older women and those who are at risk of blood clots. This pill carries a very low risk of blood clots, but has a higher pregnancy rate and many users have irregular bleeding. It is important to take it at the same time every day, preferably at night.

Emergency contraception is a high dose of progestin that can prevent pregnancy when taken after unprotected intercourse. Although it can cause nausea, it has no serious risks and is up to 90 percent effective.

Birth control pills are safe for almost all women despite the slightly increased risk of blood clots. There are many beneficial side effects, including less bleeding and pain with periods, more predictable periods, and fewer ovarian and breast cysts. They also decrease the risk of developing several types of cancer. Overall, studies show that women who use “the pill” live longer than women who are “pill-free”.

“The pill” caused a revolution. This was the first widely available family planning method, and allowed women to have a sexual relationship without fear of pregnancy. It also has been a large part of programs that have slowed the growth of the human population. Historically, our growth was controlled by high mortality rates, especially by the deaths of children. It is much better to prevent undesired pregnancies than to rely on high mortality rates.

We just spent Mother’s Day with our son Dave, who was conceived after we had been married several years. Gail, my wife, took “the pill” and it was a blessing that we could wait before starting our family.

This article may be copied or published but must remain intact, with attribution to the author. I also request that the words “First published in the Durango Herald” accompany any publication. For more information, please write the author at: richard@population-matters.org.