Durango Herald Family Planning Population Public Health

Haunted in India

The image of Varanasi that stays with me is not the chanting and bell ringing while seven saffron-robed priests gesture with incense and flames. It is not the nine clouds of smoke as bodies are cremated on the steps beside the Mother Ganges. It is not the press of dense crowds of people-whom I found to be more comfortable than those in New York City. I am haunted by the lepers.

This is written on a long-awaited trip to India. My invitation came over 40 years ago with a chance meeting with a man from this country. I told him that I was going to medical school because of concern about overpopulation. He responded “Come to India, we need you.”

Varanasi is the heart of Hindu India. Pilgrims have visited there for centuries because of the cleansing water of the Ganges. Believers go there to die, since it is most auspicious to have your soul released by cremation beside this holy river. Perhaps you have seen images of this in glossy magazines. But the pictures leave out an important part of Varanasi.

India’s population more than quadrupled during the twentieth century. Yet during this same period the number of children a woman bears during her lifetime has halved, from 6 to 3. This seeming paradox occurred because of falling infant mortality. In the past, a huge proportion of children died before adulthood. Although medical care has helped, the most important factors for this welcome decline in childhood mortality have been improved nutrition and hygiene.

As a medical student I was curious about Hansen disease, as this scourge is now called. The bacterium that causes it lives in amazing harmony with human nerves, but gradually causes them to fail. Injuries are common because affected people cannot feel pain. Worse, at night rats nibble unprotected fingers and toes.

Cure of the infection is possible, but prolonged and expensive. Often treatment is limited to little more than bandaging and protection of the affected part. Tradition has forced people with Hansen disease to live separate from the rest of society. There is still a strong emotional reaction to the word “leper” even though most people in the USA have never seen one. Perhaps Hansen disease was the first use of quarantine, although the disease isn’t very contagious. What I didn’t learn in medical school is that it is very much a disease of poverty and malnutrition. As proof, well-nourished health workers seldom contract the disease even with constant exposure.

Leprosy still thrives in India because of poverty. Malnutrition is too common here, although less than a century ago. This month the India Times reported the sad results of a national health survey. Only a quarter of newborn babies are given the breast within an hour of birth. This lessens their chances of successful breastfeeding, which could substantially reduce infant mortality. Half of all children under 3 years are underweight, and one in five is stunted by lack of food. Three quarters are anemic, due to parasites or iron deficiency. Another article pointed out that girls are more likely to be starved than boys. In contrast, there are many rich people in India. One woman in seven is overweight. This is a country of contrasts.

To quantify this huge gulf between rich and poor, compare the income of the richest fifth of the world’s people with the poorest fifth. Worldwide this ratio in 1960 was 30 to one. Now it is more than 80 to one. The rich are getting richer-often at the expense of the poor.

Why should we care that this chasm is widening? There are two reasons. First is altruistic-it is sad to have people suffer from poverty. The other is that poverty threatens the security of rich people. Indeed, some feel that the real reason for terrorism against the USA is economic.

The image that sticks with me is of people lining our path to the Ganges. Squatting with quiet, upturned stolid faces, they held empty begging bowls with mutilated hands.

Part of my personal attempt to narrow the chasm between poor and rich has been to help support children in developing countries. For the first 35 years we sponsored a series of boys in Columbia. Filimina Mallik, our current child, lives in a remote part of India, too far from our tour. I believe that she is healthier and better educated for the small donation we make each month through Plan USA.

© Richard Grossman MD, 2007

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Family Planning Medical Population Public Health Women's Issues

Know About Contraception

If you need contraception, use it; if you don’t, be a source of information for other people. For many people, particularly teens, abstinence is the ideal contraception. Since contraception is the best way of decreasing the need for abortion, most people agree that good contraceptive services are beneficial.
We have come a long way in the eighty years since Margaret Sanger started the first family planning clinic in this country. Contraception is legal, we have much more effective methods, and contraception is available from many sources. You don’t have to go to a special clinic any more. Furthermore, people talk about family planning more freely. Do you remember when “rubber” was a dirty word?
There is room for improvement, however. We need new, better methods of family planning. How about a pill for men, for instance? We especially need methods that protect against sexually transmitted diseases (such as AIDS) as well as prevent pregnancy. Most of all, we need less irresponsible sex, both in real life and in the media. In the average year of watching TV an adolescent is exposed to over 12,000 sexual encounters, but only 1 percent mention contraception. Abstinence is still the best way to avoid pregnancy for most teens.
For specific questions about birth control, you should contact your health care provider. The most authoritative source of information on contraception is Contraceptive Technology (Irvington Publishers, New York). My favorite web site is; look under “Health Info”.
Unfortunately, there are many misconceptions about contraceptive methods. For instance, some people are afraid to take birth control pills because they think that “the pill” causes cancer. The truth is that birth control pills protect against cancer of the uterus and of the ovary. They also help prevent anemia, ovarian cysts, breast lumps, menstrual cramps and pelvic inflammatory disease. Although they do have some serious side effects, these are amazingly rare with the newer, low dose pills.
The same hormones as in “the pill” also offer protection against pregnancy if a woman takes them after unprotected intercourse. Called emergency contraception pills (ECP’s) or “the morning after pill”, this is one of the best-kept medical secrets. ECP’s are indicated in cases of rape, a condom failure or if a couple fails to use contraception. ECP’s can reduce the proportion of unplanned pregnancies in the USA.
Innovative means of delivering hormonal contraception are available. Some women love the shot that lasts three months, Depo Povera, although it usually causes menstrual irregularity. It often eventually stops all bleeding, which many women like. There is also a monthly shot. Lunelle has the advantage of relatively normal periods. Using it means a trip to the office or clinic every month, but women appreciate its dependability.
Hormone patches have proven popular with menopausal women. Soon a contraceptive patch, Evra, will be available. Each Evra lasts seven days. The first is placed while the user is menstruating, then she replaces it at the end of a week. After the third, she goes patch-free for a week, during which her period will start.
The Nuvaring is a small ring placed in the woman’s vagina for three weeks. It is then removed, and during the week without the ring, her period will start. Neither man nor woman is aware of Nuvaring when it is in place. Both Evra and Nuvaring have been shown to be more effective than birth control pills, although women who cannot take hormones shouldn’t use them.
Barrier methods are designed to prevent sperm and egg from getting together. They include male and female condoms, diaphragm and cervical cap and several different forms of spermacides (foam, creams, gels and film). Some barrier methods are available without prescription, and some provide partial protection against sexually transmitted diseases.
Perhaps the most cost-effective means of family planning is the Intrauterine Device (IUD). Recent studies suggest that it is even safer than previously thought. There are two available in the U.S.A. The Paragard lasts for up to ten years and uses copper to be 99% effective in preventing pregnancy. Mirena is good for up to five years. It is filled with a hormone to make it 99.7% effective while decreasing menstrual bleeding and cramps. Either can be removed in case of problems of if the woman wishes to conceive.
Fortunately, there are many contraceptive methods that are effective, safe, and some even stop the transmission of disease. Hopefully the future will bring even better methods. We should all be well informed about family planning techniques.

© Richard Grossman MD, 2004