World Trends in Population Control

World Trends in Population ControlAuthor(s): RICHMOND K. ANDERSONSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 57, No.2 (FEBRUARY 1966), pp. 51-54Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41983841 .

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Canadian Journal of

PUBLIC HEALTH

VOLUME 57 FEBRUARY 1966 NUMBER 2

World Trends in Population Control1

RICHMOND K. ANDERSON,2 M.D.

TT ERE amid the vast plains and tower- * ing peaks of Western Canada, we feel

detached and remote from the swarming millions of Asia and Africa and even from the teeming masses of some areas of this continent. Yet, the ever increasing inter- dependence of our globe makes it neither possible nor ethical for health workers longer to ignore a problem which they in part helped to create, one which many now believe has become the world's number one public health problem. Recent progress in preventing premature death and assuring longer and more healthful life constitutes one of man's finest achievements, one which all of us have a right to be justly proud of. It would indeed be a tragedy if the fear expressed by one prominent health statesman became reality and the world developed cancer - with man himself being the cancer cell.

Neither time nor place warrant another belabouring of the dimensions and urgency of the so-called "population explosion." A finite world and man's capacity to multiply toward infinity render it obvious that the carrying capacity of our small planet will inevitably be exceeded unless present growth rates can be curtailed. For the present, however, we are not concerned with the somewhat meaningless concept of overpopulation in any absolute sense, but Presented at the 56th annual meeting of the Cana-

dian Public Health Association held in Edmonton, Alberta, May 31- June 3, 1965. 2Director, Technical Assistance Division, The Popu- lation Council Inc., 230 Park Avenue, New York, N.Y., U.S.A.

rather with the rate of population growth in relation to economic resources and development; or, stated in other terms, with the need to channel resources toward economic investment instead of into marginal levels of consumption by a burgeoning population. Population growth can be a good thing. Nineteenth century Canada and the United States grew at rates equal- ling some of the highest in the world today, but land and resources sufficed to provide a reasonably good though hardly affluent life. Unfortunately, conditions in much of the world are now very different. As many authorities have recently pointed out, nations are running out of land before they can develop sufficient economic poten- tial to spur the required dramatic increases in productivity, and in large and important areas food supplies are not keeping pace with population growth.

Fortunately, an increasing understanding of the relationship between population and economic development has influenced a number of countries to adopt national population policies and several, aided by recent technological advances, have em- barked on programs which hold out hope that present high rates of increase can be significantly reduced. Demographic pat- terns plus the constraints of tradition and socio-economic factors preclude an escape from further tremendous increases, but at long last there appears to be prospect that populations can eventually be brought into closer balance with economic development.

51



52 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 57

The intrauterine contraceptive device is a new and encouraging aspect of the population control picture. These successors to the Graefenberg metal ring, which was introduced some 35 years ago and pre- maturely discredited, have been subjected to intensive investigation since 1961. Studies, conducted by leading medical research workers in the United States and in a number of foreign countries, have proved as conclusively as seems possible in the time period available that these devices are rivaled in effectiveness only by "the pill", that they are not harmful, that complications are minimal, that fecundity is not reduced following their removal, and that upwards of three-fourths of women can wear them happily for long periods. Since only a single act of initial acceptance, rather than a continuous high level of motivation is necessary, and the positive act of removal, preferably by a physician, is required to become pregnant, they pro- mise to be particularly applicable to in- habitants of the less developed areas. Of the several types in vogue the one apparently most useful seems to be the so-called "loop" developed by Dr. Lippes of Buffalo, New York. Its use effectiveness in large population groups in developing areas re- mains to be determined accurately, but an educated guess is that five insertions will prevent one birth per year, taking into account effectiveness, age specific acceptance rates, age specific fertility rates, and losses due to expulsions and removals. Fortunately, they can be manufactured for only a few cents, and even when charges for family planning workers and medical fees are included, program costs are not high. In Taiwan, for example, it has been estimated that a realistic figure for the cost of each insertion is $2.50. However, per capita costs are much lower since only a fifth or less of a population is composed of women in the reproductive period and of these only about a third are likely to be truly eligible for contraception at a par- ticular time. Costs will rise as programs expand, but they are now being financed in Korea and Taiwan for three to five cents per capita per year. This compares favourably with other health programs, which in the long run will probably contribute less to the general well-being and economic betterment.

At present, five countries - India, Pakis-

tan, South Korea, Tunisia and Turkey - have governmentally approved, supported and administered national programs. Main- land China and perhaps North Korea can probably be included, based on indirect but apparently reliable reports. Taiwan would be added except for a technicality. Though it has no officially declared population policy, its program is implemented through the official health services and is supported by governmentally controlled funds.

When India set up a National Family Planning Board in the mid-1950s, it became the first country to adopt population control as a national policy. Initially, the approach was primarily through special clinics, but during the past few years the emphasis has been on carrying the program to the people through the efforts of family planning officers and supporting staff at state, district, development "block" and village levels. After careful clinical study the Indian Council of Medical Re- search in January of this year approved the use of intrauterine contraceptive devices (IUDs) in the national program. Recent reviews of its program by a high level India Government committee and by commissions sent to India by the World Bank and the United Nations are expected to result in recommendations leading to stronger central and peripheral organiza- tions and a considerably intensified effort. Over 200 million dollars have been pro- vided for family planning in India's fourth Five Year Plan, an approximately four- fold increase over the previous appropria- tion. Current objectives are to reduce birth rates from 40 to 25 by 1973 through widespread use of intrauterine devices, continued emphasis on sterilization, and promotion of traditional contraceptives.

Progress in Pakistan, which set up a program in 1960, has been slow but organization and personnel are gradually being developed. Its third Five Year Plan, which begins later this year, calls for a greatly enlarged budget of about $60 million and an upgrading of organization and personnel. The newly appointed Commis- sioner of Family Planning has been given increased administrative authority and is developing plans for an intensive program relying heavily on intrauterine devices.

South Korea, the third Asian country to organize a national program, is more



February 1966 POPULATION CONTROL 53

developed and much smaller than India and Pakistan, which probably explains its greater apparent success in promoting family planning. Current goals are a reduction in growth rate from 3% to 2% by 1971. Its government estimates that this will require the insertion of a million IUDs, 200,000 vasectomies, and about 300,000 regular users of traditional contraceptives. Direct responsibility for the program lies with the Ministry of Health and Social Welfare through its MCH Bureau. Korea has a better supply of doc- tors than many other Asian countries and therefore has been able to rely almost entirely on private practitioners for the required medical services. They receive about $1.20 for each IUD insertion and about $2.00 for each vasectomy. The goal of 97,000 IUD insertions by the end of last year was exceeded and the current total is about 190,000. In addition, about 50,000 vasectomies have been performed but the popularity of the IUD seems to have slowed down the vasectomy program and many users of traditional methods are shifting to IUDs. To date, there seems to be a substantial reservoir of acceptors and the chief problem is the availability of sufficient funds. If these can be made available, the prospect of a significant reduction in Korea's birth rate appears good.

Taiwan's program is, in many respects, similar to Korea's. The major difference is government's reluctance to adopt an official population policy, but the progress has nevertheless approximately equalled Ko- rea's. A pilot program undertaken in the city of Taichung in early 1963 resulted in the acceptance of contraception, chiefly IUDs, by approximately 1 1 % of women in the reproductive period, or nearly 40% of those considered truly eligible at that par- ticular time. In 1964, the program was expanded and is now operational in most of the Island, though the major effort is still confined to about one-third of the population. On an Island-wide basis, about 6% of women in the reproductive age group have thus far accepted IUDs. As in Korea, insertions are done primarily by private practitioners who receive about $1.50 per insertion, half being paid by the patient.

By the end of May nearly 300,000 loops had been inserted in Taiwan and Korea, most of them since the middle of last year.

The number of acceptors is rising, and if present trends continue birth rates can hardly fail to be affected.

Tunisia's program got under way only in 1964, and initially relied on a few clinics. Progress was encouraging though rather slow until recently, when the politi- cal party of the present government began to give widespread publicity to family planning, particularly to the availability of IUDs. As a result, difficulty in meeting the demand was encountered and there has been increasing emphasis on the use of hospitals and other government facilities in some of the larger population centers. The Tunisian program may turn out to be the first clearly successful effort in family planning in a Muslim country.

Family planning is accorded high priority in Turkey's officially approved plan for economic development. Personnel were appointed, budgets approved, a fertility survey completed and a private family planning association organized considerably in advance of repeal in late April of a long-standing law banning contraception. There is now every expectation that Turkey will promptly embark on an active program.

In addition to these national efforts there are several other countries which have limited programs going forward under government auspices. Egypt has officially declared its need for population control and is now expanding services in a number of government and privately sponsored clinics. The National Research Council and the Health Ministry of Thailand are spon- soring a pilot program in a rural area. In Hong Kong a program of IUD insertions is going forward rapidly under the auspices of a private family planning association which receives considerable support from the Hong Kong Government. In Ceylon, Sweden is providing technical assistance to a government-sponsored pilot program. In Puerto Rico and in Barbados, government is becoming increasingly involved in promoting family planning through MCH services. In Indonesia, the Philippines, Malaysia, Iran, Jamaica, Trinidad and Fiji, pilot clinics are in operation in conjunction with various government medical facilities.

Several aspects of the pilot program in Thailand are probably of sufficient interest to warrant a brief description. It is located in a primarily rural area about 50 miles



54 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 57

west of Bangkok, where a preliminary survey indicated that less than 1 % of women admitted to having practised contraception. However, about 70% said they wanted no more children and were interested in information on family planning. Last Novem- ber, an action program was initiated under the auspices of the Ministry of Health. Within a month, 11% of nearly 4,000 nonpregnant, nonsterile married women of child-bearing age in the area had accepted contraception, and after two more months the percentage had increased to about 25. Over 80% of the women chose IUDs. Here, as was also the case in Taiwan, there was some evidence of interest in spacing. About 40% of acceptors had three or less children, 18% had two or less, and 3% had only one child.

Probably for primarily religious reasons, Latin American countries have heretofore not looked favourably on birth control, but there is a growing consciousness that rates of population increase, which are the highest of any major area in the world, are a serious barrier to economic and social advancement. There is also increasing alarm over the social and health effects of high rates of illegal abortion, including in some areas the heavy load which cases with complications impose on the already overburdened hospital facilities. Even some church authorities are beginning to give tacit approval to contraception as a less undesirable alternative. Studies on abortion have been organized in a number of countries, including Chile, Argentina and Colombia. Chile is now providing family planning services in several hospitals and clinics and is testing the effect of birth control services on abortion rates. Experi- mental clinics are in operation in Brazil, Colombia, Costa Rica, Honduras, Mexico, Peru, Uruguay and Venezuela.

Independent of or in conjunction with these population control efforts, there is widespread interest in obtaining accurate information on population trends and on family planning knowledge, attitudes and practice. Centers for population studies are in various stages of development in Chile, Peru and Venezuela and so-called fertility

surveys, including knowledge and attitude studies, have been conducted in about a dozen Latin American countries. The same is true for a large number of countries in Asia, Africa, Europe and the Middle East. This substantial volume of social and statis- tical information on population trends and attitudes will inevitably play an increasingly important role in creating awareness of population problems and their possible solutions.

African countries south of the Sahara have, in general, been slow to recognize the existence of a population problem. How- ever, the Government of Kenya has recently expressed interest in a national program, and experimental clinics are in operation in several countries including Nigeria, Ghana, Southern Rhodesia and Uganda. It seems likely that interest in family planning will also increase in this area.

What do all these developments mean for the future? Pessimists cannot be con- tradicted when they point out that family planning programs in developing areas have not yet significantly affected birth rates; on the contrary, death rates are falling and therefore rates of population growth are in general accelerating. Others say that it is too early to expect dramatic results, and point to the fact that 15 years ago no government except Japan, which halved its birth rate in about ten years, officially recognized that excessive population growth impeded economic development; yet today the governments of over half the people in developing regions officially favour family planning. The diffi- culties are admittedly staggering and one must remember how long we have struggled with other only partially solved health problems, many of which seem almost ridiculously simple by comparison. No- where in the world have the effort and investment in population control been com- mensurate with the gravity and the difficulty of the problem, but considering the rapid and encouraging developments of the last decade, there is reason to hope for greater achievement in the future.



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World Trends in Population Control