Category: Family Planning

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Contraception Family Planning Population Reproductive Health

Reject these Old Memes—2-2014

Recently a friend introduced me to the word “meme”. Now I run across this concept frequently.
The word “meme” is analogous to “gene”, but it is information in our culture rather than in our DNA. A meme is a building block upon which our way of life is built. One definition is: “an idea, belief or belief system, or pattern of behavior that spreads throughout a culture”.
An old example is the Pythagorean theorem—the square of the hypotenuse of a right triangle is equal to the sum of the squares of the other two sides. This meme is ancient.
One accidental meme is changing lives in Brazil. The average family size has dropped rapidly. In 1954, when I visited as a child, women had an average of over 6 children. Now the average is 1.8—less than replacement. This big change is largely because of TV telenovelas, where middle class families are all small.
Some memes are harmful. An example is a tradition in Nigeria that leads to the death of many children. For eons Traditional Birth Attendants used mud or other unclean substances to dress newborn babies’ umbilical cord stumps. If tetanus spores are present, the baby can die a horrible death from tetanus. This improved when TBAs were taught the advantages of cleanliness and sterile instruments. Now pregnant women getting prenatal care are immunized against tetanus and there are many fewer deaths.
Galileo, who was born 450 years ago this month, suffered because of a religious meme. This meme slowed the development of knowledge for centuries.
Ancient Egyptians thought that the sun rotated around them—the geocentric model of the solar system. A Greek may have first proposed that Earth revolved around the sun 2500 years ago—the heliocentric model. For centuries people believed that the earth was the center of the universe, supported by theology that interpreted the Bible thusly. One verse that supports this meme is found in Psalms 104:5: “(God) built the earth on its foundations, so it can never be moved”. There are still people who hold that the sun goes around the earth—including 26% of US citizens, according to a recent National Science Foundation survey!
In the early 17th century Galileo defended the heliocentric theory, for which he was accused of heresy and placed under house arrest for the rest of his life. The Inquisition’s ban on reprinting his works was only lifted a century later. It was not until the 19th century that the Roman Catholic Church removed books advocating heliocentrism from its Index of Prohibited Books. Pius XII was the first Pope to acknowledge the many important contributions of Galileo—in 1939. Yet there are people who believe that heliocentrism is a conspiracy (http://www.johnthebaptist.us/jbw_english/default.htm). It is amazing how long this meme has persisted!
Years ago I sold “green umbrellas” at a public health meeting. From a campaign in Bangladesh (where it rains a lot), these umbrellas carry slogans such as “stay well” and “take health services” in Bengali. A doctor from Bangladesh bought one, then a few minutes later returned and wanted his money back. I asked him what was wrong. He replied that one of the sayings is “small families”, and we should have as many children as Allah gives us. This is another case of a religious meme that has outlived its usefulness, since Bangladesh is very crowded.
I find it amazing that some religions have not yet recognized the benefits of contraception to individuals, to families and to the world. The official doctrine of the Roman Catholic Church is that only periodic abstinence (the “rhythm” method) is acceptable. This policy is ignored by many of the 1.2 billion Roman Catholics worldwide—and many women I have talked with have left the Church because of this policy.
In many Catholic countries, such as Brazil and in Western Europe, couples use modern contraception resulting in average family size less than two. There are places, including some of the poorest countries in the world where this prohibition against effective contraception is followed. They will continue to be stuck in poverty so long as people are prohibited from using modern family planning. Rwanda is an example; its rapid population growth was one factor leading to its genocide 20 years ago.
Memes can outlive their usefulness to society. It is time for women to have the same status and rights as men, and for all people to have the access to the means to manage their fertility.

© Richard Grossman MD, 2014

Categories
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 (www.prb.org) 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