This graph shows the rate of covert contraception usage in Kenya

55 years ago a young patient and I were standing in the sun just outside the clinic doorway when a butterfly alighted on my left ear. “Yes, I would like to try an IUD” the patient said, amazed and apparently encouraged by the butterfly.

It was the summer between my 3^rd and 4^th years of medical school. My new wife and I were having a wonderful adventure at the Moravian Hospital in Puerto Cabezas, Nicaragua. The patient I had been persuading to try an IUD was also newly married and wanted something to keep from conceiving right away. She didn’t think her husband would approve of using birth control, however.

“If you had an IUD, he wouldn’t know about it unless you told him,” I had encouraged her. Apparently, the butterfly landing on my ear was the deciding factor, and I was able to insert a Lippes loop.

Hiding contraceptive use is a common strategy in many countries where patriarchy rules. Men in patriarchal societies usually desire large families, and don’t want their partners to make decisions about childbearing. Research has found that covert use of contraception is common in some African countries, especially for wives of polygamous marriages. As many as a third of women in some places conceal their use of birth control! Although I am certain that some women in the USA use contraception without their partner’s knowledge, I have not been able to find a study of its prevalence in this country.

Some birth control methods are easier to hide than others. A pack of pills would be easy to conceal, but it would be a dead giveaway if found. DepoProvera® shots are effective for 3 months and are easy to keep secret. A wife could go into town to shop, as usual, but also stop at the health clinic for her birth control shot. Indeed, some women have stated that is one of the reasons they chose thei method.

There is a new form of DepoProvera® that is packaged so that a woman can give it to herself at home. It is small enough that the pre-filled injection unit would be easy to conceal. Large studies in African countries have found women like this formulation, but unfortunately Sayana®Press is not available yet in the USA. There are other LARCs (Long-Acting Reversible Contraception): Nexplanon®, good for 3 years, and several IUDs, which last up to 10 years, are all easily concealed.

I do not recommend covert use of contraception. However, in some cases it is the only way that women can avoid unwanted pregnancies. Since the majority of family planning methods are female-controlled, the wife should—and can (by hiding her birth control)—have the last word about childbearing.

It only seems right that women should decide about family planning since birthing and most of the responsibilities for childcare rest on women’s shoulders. However, it is best if husbands and wives talk about whether to use contraception, and together choose the method that would be best. This is supported by a statement of friend, Dr. Stan Becker, who has studied reproductive health decisions among couples: “…reproductive health interventions that target couples are found to be more effective than those directed to only one sex.”

However, we don’t live in a perfect world—unfortunately, there are many couples where power and decision-making are not shared. Since family planning is recognized as potential driver of women’s autonomy and health, covert use of family planning can be seen as a symbol of agency for the women in these relationships.

Overpopulation and War

Aerial view of a residential section of the Gaza Strip

When I was in high school, I read an advertisement in Scientific American magazine. It said, in part: “…unless a favorable balance of population and resources is achieved with a minimum of delay, there is in prospect a Dark Age of human misery, famine and unrest;”

This statement, which was signed by 34 Nobel Laureates (among other dignitaries) went on to say: “We believe that widespread, effective and voluntary use of medically sound and individually acceptable birth control is an essential factor in any humane design to raise world living standards and achieve world peace.”
To me, this is as true now as it was in 1960.
I give thanks that so many people recognize the importance of family planning, and that we have so many options for medically sound, voluntary family planning..
Thank you for reading.
Richard

Can high population density lead to war? Recent events suggest that it can.

You are probably aware that, on October 7^th, the Palestinian Islamic Resistance Movement (also called “Hamas”) launched a surprise attack on its neighbor, Israel. Israel has retaliated with most of the terrible devices of modern warfare and thousands of deaths.

Although Hamas rules the Gaza Strip, Gaza is not an independent entity. It is surrounded on 3 sides by Israel. Israel has surrounded Gaza with an almost impenetrable wall to control the passage of people and goods. Israelis guard the handful of gates through the wall, and have watch towers and other means of controlling Palestinians’ passage.

Israel also controls access to Gaza from the Mediterranean Sea on the west. Much of Gaza’s potable water comes from Israel, as does their electric power. Both of these necessities are now severely restricted, causing a humanitarian crisis in Gaza. Because Israel controls Gaza Strip’s airspace, territorial waters and also controls the movement of people and goods in or out of Gaza by air or sea, Human Rights Watch has advised the UN Human Rights Council that it considers Israel to be occupying the Gaza Strip.

From what I can discern, there are several reasons for high levels of aggression in the Palestinian Territories. The population density in the Strip is one of the highest in the world. Because of this, homes are crowded together with little room for parks or even an occasional tree. Living in close proximity, with little access to nature, increases stress. Hot conditions have been shown to increase aggression. Finally, the unemployment rate in Gaza is the highest in the world, at 45%. For young people, it is even higher, at 70%! Unemployed young men are the most likely group to be belligerent.

Despite its crowded conditions, people in the Palestinian Territories have high fertility. It is commonly thought that this is a consequence of their embattled position—that more people will give the Palestinians more strength. Although slightly lower, the Israeli fertility is also high, especially for a relatively rich country.

The Palestinians in Gaza are in a terrible situation, and Hamas made it worse by their aggression against their neighbor. Then Israeli Prime Minister Benjamin Netanyahu escalated the aggression by quoting 1 Samuel 15:2, 3 from the Bible, likening Hamas to the ancient Amalekites:

²This is what the Lord Almighty says: ‘I will punish the Amalekites for what they did to Israel when they waylaid them as they came up from Egypt. ³Now go, attack the Amalekites and totally destroy all that belongs to them. Do not spare them; put to death men and women, children and infants, cattle and sheep, camels and donkeys.

Despite the fact that Palestinians occupied the land before Israel was created, they have had a terrible deal. There are similarities with the American Natives, with several differences: we European settlers killed off a huge percentage of the indigenous people; North America is larger and less crowded than the Levant, and our land is more productive; and Israel has had significant international financial support.

I have two personal conclusions about this conflict. Amongst other issues, the high population density in Gaza may be a contributing factor to the war with Israel. This factor is not mentioned in most media reports on the conflict. Furthermore, for all its benefits, religion can be terribly destructive, especially if it fails to reflect current, more peaceful, ethics.