Public Health – Page 4 – Population Matters-USA

Last month I wrote about the 5 countries I have enjoyed visiting in Africa, including citing their amazingly low per capita GDP. Although most of the population growth over the next decades is predicted to occur on that continent, I see some rays of hope.

There are two places in the world where studies have been done on ways to increase voluntary family planning, along with other important medical research. One is Matlab, Bangladesh and the other is Navrongo, northern Ghana. I had never heard of the Navrongo studies until shortly before visiting there!

Both Matlab and Navrongo have shown that community health workers can improve health significantly. In addition to family planning, the Ghanaian studies studied several successful interventions, including vitamin supplementation and mosquito nets treated with an insect repellant. Their family planning research showed that it is possible to increase contraceptive use and slow population growth even in an impoverished, poorly educated population. This is especially important research since Navrongo is close to the Sahel, and the people there are similar to Sahelians in their preference for large families.

In 1995, the beginning of the Navrongo studies, the average woman had about 5 children. Fifteen years later, in 2010, that number had dropped to a bit over 4, both in the Navrongo control group and in the country as a whole. One of the interventions decreased the fertility further, to 3.7; a significant reduction. Now, a decade later, the fertility rate for the whole country is 3.7 children per woman. That group was ten years ahead of the rest of the country! This group combined specially trained community health nurses (as opposed to stationing them at a clinic or hospital) and “zurugelu”.

“Zurugelu” means “togetherness for the common good”, and was male-centered in the past. For a better explanation, I asked one of the investigators who had worked in Navrongo what “zurugelu” meant. Here is Dr. James Phillips’ reply:

“The zurugelu approach is a social engagement strategy that involves merging the organizational system of primary health care provision with the traditional system of social organization and governance. When gender problems were evident, we attempted to turn patriarchy on end by working with women’s social groups in ways that were traditionally dominated by men. Social events, termed “durbars”, were traditionally male events that were led by traditional male social leaders. To build women’s autonomy and roles, we worked with leaders to eventually have women’s convened and women’s led durbars. We also had gender outreach activities for responding to the needs of women. As such, the “zurugelu” approach was a gender development strategy.”

(A “durbar” is a meeting of men with their chiefs.)

It is interesting that neither community health nurses nor zurugelu alone had much effect on fertility. Even though the nurses educated women about family planning and supplied the necessary materials, fertility did not decrease significantly in the regions where they were introduced but didn’t have zurugelu. Nor did zurugelu alone have much effect by itself. It took both working together for the fertility to come down.

The need for both nurses and zurugelu is a very important observation. The statement has been made frequently that worldwide over 200 million women want to limit their fertility but don’t have access to modern contraception. Since the nurses provided that access, we know that access alone isn’t enough—at least in this group of people. Apparently tradition and paternalism were significant barriers to using contraception. It took zurugelu to change attitudes before people made the most of what family planning was available.

What difference did zurugelu make? This traditionally male function opened the eyes of men to the needs of women. Furthermore, the Navrongo programs strengthen the roles of women.

Now, back to my visit in Ghana. It was dusk as we were driving from Navrongo back to Nalerigu. We passed a straw hut with smoke emerging from its roof.

“Is it on fire?” I asked.

“No”, my host replied. “She’s just cooking the evening meal.”

Although there is much beauty in northern Ghana, and everyone I met was friendly and warm, my impression is that life is difficult. Now that child mortality is a fourth of what it was 50 years ago, people will benefit from smaller families as well as more education.

We’re all aware that the role of women has changed in the last centuries, but probably less aware that their biology has also changed. Together, these changes have helped change society.

Currently an average girl in the USA undergoes menarche (starts to menstruate) before age 13. In the 19^th century a girl was 4 years older before reaching that landmark. We aren’t sure why girls are maturing earlier, but there are probably multiple factors. Better diet is definitely a contributing cause, as is obesity. Chronic stress may also be a factor, and endocrine disrupting chemicals such as BPA probably have an effect. Interestingly, menopause (the permanent cessation of periods) may occur slightly later than a century ago.

Menstrual problems may come along with menarche. Usually this is just cramps that are controlled with over-the-counter medication. Because girls often don’t ovulate for the first months after menarche, a girl may have heavy and/or irregular periods that may lead to anemia. These problems can interfere with the young woman’s life, causing her to miss school, sports or other important activities.

Interest in boys usually follows menarche. The same hormones that cause a young woman to menstruate also affect her libido. Since girls are maturing earlier, it follows that they will also be interested in sex at an earlier age. On the other hand, the average woman’s education lasts many years longer than it did a century ago. Our mores are still based on the way people lived in the 19^th century, when it was common for a woman to wed shortly after graduation from high school, or even to drop out to marry. Her husband was usually the breadwinner and she stayed home to care for the children—the first of whom was born not long after marriage.

One of my heroes, Dr. Malcolm Potts, has observed: “…the modern woman can have 300 or more menstrual cycles. Given a later puberty and pregnancies separated by long intervals of ovulation-suppressing breastfeeding, women in the few surviving hunter gatherer societies, may have as few as 60 life time cycles.”

Can “the pill” safely help young women? Oral contraceptives are the most effective way to regulate periods. They decrease blood loss and reduce cramping, plus they make periods predictable. It is even also possible to skip periods by changing how pills are taken. For some, oral contraceptives will help with the moodiness (PMS) that may come before a period.

Young women may benefit from other good side effects of “the pill”, including improving acne, decreasing the risk of anemia or ovarian cysts, and later decreasing the chances of a woman developing ovarian or uterine cancer.

Menstruation interferes with the lives of many women. In less developing countries girls often miss school when menstruating, or drop out entirely—especially if they cannot afford pads. That is also true for some girls in the USA: Chicago Public Schools have a policy which “…requires that schools provide free menstrual products in bathrooms to improve gender equity for people who miss school because they don’t have access to these products.” Denver Public Schools and some other Colorado schools also provide easy access to free menstrual products. Scotland has gone a step further—menstrual products are free to all who need them.

Another problem in developing countries is that many schools lack clean and private washrooms. “Days for Girls”, an international nonprofit organization, provides help to many young students. In addition to making and supplying reusable pads and ways to carry and clean them, instructors go to schools and talk to young women about menstrual care and staying safe.

The cost of menstrual protection can add up, and it is an expense that boys and men don’t have. To make things worse, in many states (including Colorado) these products are taxed because they are not considered “necessities of life”. Organizations such as Period Equity are tackling the “pink tax”. In Colorado, House Bill 1127 was introduced in the Legislature in 2017 to do away with this unfair tax, but the bill was postponed indefinitely. The City of Denver has already stopped taxing these necessities for women; isn’t it time that the whole state follows along?