Category: Population

Related directly to population issues.

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Population

Observe World Contraception Day

            Recently I responded to a blog that was decrying the lack of male contraception. I wish I had better news on that front, but there is good news about women’s birth control.

            In response to the question: “Why do women have to take the hit of contraception?” I wrote that I am a retired male OB-GYN who has had a vasectomy. I believe in contraception for men! The blog”s author only listed two male methods: condom and vasectomy. She apparently didn’t know about withdrawal.

            In the 1980s I practiced in Puerto Rico where people typically had large families. Often women had several children close together, then went a decade or more without modern contraception and without a pregnancy. When I inquired about birth control, some women replied “My husband takes care of me.” My wonderful nurse/translator told me that the couple was using withdrawal. Currently the Puerto Rican Total Fertility Rate is an incredibly low 1.1: most women on the crowded island are having only one child! Although withdrawal statistics show a high failure rate, this method seems to work well for some couples.

            What makes it easier to halt female fertility rather than men’s? Remember from that 8th grade sex talk that women usually create one egg a month? Men make a thousand sperm every second! Egg production depends on a woman’s hormones working in an amazing, well-balanced sequence. It is fairly easy to disrupt the sequence with tiny amounts of exogenous hormones, as with the birth control pill.

            In 1963 I met an assistant of Dr. John Rock, one of the developers of “the pill”. She told me that another of Rock’s projects was nicknamed “the Rock Strap”. Insulated briefs for men raised testicular temperature high enough to stop sperm production. Research along these lines is still ongoing in France.

            The good news is that there are 4 new contraceptive methods for women. One is a hormonal IUD that is a little smaller and has less levonorgestrel than others, but is still effective for 5 years. It has a very low failure rate similar to other LARCs (Long Acting Reversible Contraceptives)–less than 1% per year. Kyleena® is similar to Mirena®, the first hormonal IUD, but may be better tolerated by some women because of its smaller size.

            Currently, nonoxynol-9 is the most common agent used in vaginal spermicides. While the vagina is acidic and hostile to sperm, alkaline cervical mucus helps guide them as they swim toward fertilization. Phexxi, a new spermicide, is a “Vaginal pH Regulator” that is 90+% effective in preventing pregnancy. It also acts as a lubricant and may increase sexual satisfaction, but is expensive if you don’t have insurance.

            Contraceptive diaphragms have been around longer than a century. They have none of the side effects of hormonal contraception, but their failure rate is higher. Although most diaphragms require fitting, Caya® is available in just one size and fits most women. It should be used with a spermicidal jelly or cream, like any other diaphragm. People with latex allergy can use it since it is made from silicone rubber. A Caya® costs about $85 and should last for years.

            All IUDs currently available in the USA are “T” shaped. Most women tolerate them well, but some don’t. A novel IUD, Ballerine®, provides an alternative. Unique in design, a soft, springy strand in spherical shape has 17 tiny copper balls strung on it. The Ballerine® is straight in its inserter, then curls up to conform to the uterine cavity. It has been well received for a number of years in Europe and other countries where it has been used by over 94,000 women. Like other LARCs, fewer than one woman in 100 will conceive with Ballerine®, and its complication rate is low. Although not available yet in the USA, its manufacturer is planning to start the approval process soon.

            Annovera® is a hormonal contraceptive vaginal ring that lasts a whole year. After it has been in place for 21 days, the user removes it for a week to bring on her period. It has two drawbacks: the cost, for someone who doesn’t have insurance, is about $2000! Also, the failure rate is higher than a LARC, although better than “the pill”.

            With new contraceptive methods there is more choice–for women, at least. Please observe World Contraception Day, September 26th, whose purpose “…is to improve awareness of contraception and to enable young people to make informed choices on their sexual and reproductive health.”

© Richard Grossman MD, 2020

Categories
Population

Fend off Famine

By 2025, half of the world’s population will be living in water -stressed areas                   World Health Organization

When I wrote Julys essay on the mega-drought in southwestern North America, we were in “extreme drought”. The rain started toward the end of July, although the drought hasn’t ended. Unfortunately, we are not the only area contending with drought.

Natural variability in weather patterns combined with anthropogenic climate heating have created drought in some places and flooding in others. Although those “natural” disasters are destructive in a rich country, they are often devastating in a low resource area. An example is found on the southeast coast of Africa, where some areas have too much rain and others have too little.

In March through May massive storms hit parts of Eastern Africa. From Ethiopia south to Tanzania heavy rains caused landslides, overflowing rivers and flash floods. Tens of thousands of people were displaced and hundreds killed. Crops were destroyed and many animals drowned.

The climate is much dryer in regions of the south of Africa. We visited Cape Town in November of 2018 and were careful to obey the water restrictions at that time: quick showers, only flush when you have to. The water in the reservoirs had been down to just weeks’ supply when, fortunately, the rains returned.

Some other areas in the south are not so fortunate. Currently, the Global Disaster Alerting and Coordination System reports serious droughts in parts of Malawi, Mozambique, Zambia and South Africa. Many people in these countries are subsistence farmers who depend on rain to nourish the crops they raise to feed their children. When it is dry, the land cannot support as many people as when rains are normal. A drought can put people’s livelihood–indeed their lives–in jeopardy. All too many starve to death in a serious drought, unless external aid comes to the rescue.

There is another plague haunting the Horn of Africa. In just one day unbelievable swarms of desert locusts consume enough food for thousands of people. Vast numbers of these insects, which can eat their body weight each day, proliferated in last year’s heavy rainfall. Scientists blame the unusual moisture on record high temperatures in the Indian Ocean, which in turn were caused by climate heating.

As these examples show, anthropogenic climate change causes different effects in different areas, even on the same coast of Africa. Although Africa is suffering, people in South America may feel the effects even more strongly.

At least 9 Latin American countries are experiencing drought. Even worse, some places have flooding, which washes away some crops, followed by drought, which kills what’s left. A recent report “Where Will Everyone Go?” (available at https://tinyurl.com/WhereWillEveryoneGo) looks at the effects of climate heating on the people in Central America. Co-researched by the New York Times and ProPublica, the authors tell the story of Jorge, a farmer in Guatemala. His crops suffer first from drought, then are washed away by flooding, then drought destroys any hope to feed his family.

Jorge pawned his last 4 goats to hire a “coyote”. He left his wife and 2 youngest children at home and entered the USA illegally over the border fence. Jorge and son are now in Houston, perhaps trying to earn enough money to bring his wife and children to safety.

This reminded me of my father’s trip to the USA. At age 4, in 1906, Louis arrived with his mother to be met by his father at Ellis Island. My grandfather had come over a year earlier to earn boat fare for the rest of the family. However, that was a different era when refugees were welcomed–in my father’s case, from religious persecution–and the barriers they faced didn’t include a 20-foot border wall.

As in all parts of the world, people in Guatemala want the best for their children. They have realized that kids do better when families are smaller. In the past decade the average number of children a woman will bear during her life has dropped from 4.4 to 2.7. However, more than a third of Guatemalans are under 15 years old, meaning that rapid growth will continue for many years.

What can we do? Fortunately, there is local action that will help make more water available locally and also slow climate change. Fossil fuel fired power plants use huge volumes of water for cooling. Trillions of gallons of Colorado water will be made available for agriculture and other uses as we shut down fossil fuel power plants and switch to wind and solar electrical generation.

© Richard Grossman MD, 2020