women, with chances for success in the former case of 50-80 percent, and in the latter of 52-66 percent.106 However, given the psychological comfort of knowing that it can be done, few individuals of either sex are likely to request restoration of their fertility. To take India as an example again, nearly 7.5 million people there have been sterilized since 1966. Vasectomies have been done on an assembly-line basis, in places such as the Bombay railway station. The Indian government offers a small payment to the individual undergoing a vasectomy. CONVENTIONAL METHODS Although the pill, the IUD, and vasectomy have all gained prominence as technical means of effecting birth control, the so-called conventional methods which have been known for a longer period are still widely used. Some of these methods are relatively effective in preventing conception, others are less so. By and large they are not viewed as acceptably reliable solutions to the problem of population control in the LDCs. It seems likely that they will give way eventually to other methods yet to be discovered. These conventional methods comprise the condom, the diaphragm, the cervical cap, various creams and jellies, the douche, the rhythm method, and others. The condom, or sheath, is widely known and extensively used in the developed countries; when properly used, its failure rate is comparatively low. Among the developing countries, India has a state factory with the capacity to turn out 144 million condoms annually, but whether this method, which to many connotes prostitution and adultery, will find ready acceptance in the LDCs may be problematical. The diaphragm, which has to be prescribed and fitted by a doctor, seems impractical for mass use by the women of the LDCs. The same objection can be made to the cervical cap. Spermicidal jellies and foams are easier to apply, but probably are less effective than the condom or the diaphragm. The rhythm method, which has the sanction of the Catholic Church, involves abstention on those days when conception should be possible. But this period is sometimes so difficult to determine, particularly if the woman has an irregular menstrual cycle, that it may require abstention for a good part of the month. Accordingly, the rhythm method is relatively ineffective, and it may strain conjugal relationships. Also, it seems ill-adapted to the needs of the developing countries. NEW LINES OF SCIENTIFIC RESEARCH Prompted by the widespread concern over the population explosion and the success of the Pill, a substantial scientific effort is underway to develop birth control techniques with fewer disadvantages and greater acceptability. The prime need for additional measures is in the developing countries, but the effort is being carried on in the developed countries, chiefly the United States. Research is going forward on the so-called "micro-dose" pill, which would be taken every day, continuously, regardless of a woman's cycle. Since the dose is so tiny, it may be that such a pill would be safer than 106 Ehrlich and Ehrlich. "Population, Resources, and Environment," op. cit., page 220. those now in use. Research is in progress toward development of a contraceptive injection that would be good for six months. Since the people in developing countries have become more familiar with inoculations, a reliable injectable contraceptive might find wider acceptance among them than the methods now in use. Research with dramatic possibilities is being conducted on what is known as the cylastic (or silastic) implant, a tiny cushion of absorbent plastic, superficially implanted in a muscle and releasing a measured dose of hormone which would prevent conception for a very long period of time, perhaps as much as 20 years. Conception could occur, should a couple desire a child, by removing the cushion, or perhaps by taking estrogen. One of the most promising lines of investigation now underway has to do with prostaglandins-fatty acid compounds occurring naturally in the body. They may be used once a month for fertility control, and may be administered orally, or by injection, or intravaginally.107 Another line of investigation is concentrating on the "morning-after pill," which would be taken for three days after intercourse and would prevent implantation of the ovum in the endometrium (membrane lining the uterus). Whether any of this research will bear fruit in time to benefit the developing countries is uncertain. The Food and Drug Administration (FDA) requires 10 years of testing of chemical contraceptives on monkeys. There are clinical trials involving large numbers of human subjects with follow-up laboratory testing. Because this research is so sophisticated, it can be done only in those countries that are scientifically advanced, and under less pressure to limit births. Obviously, it also takes considerable time. According to Carl Djerassi, before any developing country will accept a contraceptive agent for wide use it must have been approved by the FDA in this country or an equivalent European authority. If the safety of a particular contraceptive is questioned in any developed country, the latter takes both political and moral risks if it encourages a developing country to use the agent in question. The answer that Djerassi envisions to the entire problem of developing new chemical methods of contraception is for independent bodies of experts to act as "final courts of scientific appeal," with authority that supersedes that of government regulatory agencies. Such a body would be chosen in this country by the National Academy of Sciences, and internationally by the World Health Organization. He believes that a solution of this nature will compel the advanced countries, particularly the U.S., "to take a global rather than a parochial view of novel contraceptive approaches." He also foresees that such a solution will force the pace in the development of new approaches, a pace which at present is far too leisurely, given the enormity of the problem. 108 ABORTION One of the oldest forms of birth control, but one which has traditionally been subject to social disapproval, is abortion. To abort a fetus is to terminate a pregnancy in its early stages by one of several 107 Jan Palmer. "Ugandan Presses Prostaglandin Research," War on Hunger. A.I.D. Washington (September, 1971), page 3. 108 Carl Djerassi. "Progress for the Development of Chemical Birth-control Agents." Science (Oct. 24, 1969), pages 469, 473. wwww methods. The standard method of performing abortions had been what is known in medical jargon as a "D and C": that is, dilatation and curettage of the uterus. This process removes and destroys the fetus. Other methods now in use include a vacuum method-developed by doctors in the U.S.S.R.-which is safer than dilatation and curettage, and a saline induction method. The morality of abortion is the subject of debate, not only in the developed countries but in the underdeveloped ones as well. Opposition to abortion as immoral can be found among Roman Catholics, fundamentalist Protestants, and some Orthodox Jews, in this country. Although many clergymen favor legalized abortion, there are a number who would support it only if necessary to save the mother's life.109 A survey made in Nagoya, Japan, in 1964, of 153 married women who applied for abortion, showed that "only 8 percent did not think it was morally evil; 17 percent thought it was evil rather than good; 16 percent thought it was quite evil; and 59 percent thought it was very evil.110 In the United States 33 states permit abortion only to preserve the life of the potential mother or, in some instances, to protect her health as well.111 Seventeen other states have liberalized laws, ranging from those which permit abortion for causes such as fetal deformity or rape of the mother to the absence of any restriction save the recommendation of a physician.112 It has been estimated that in the past fifteen months 400,000 American women obtained legal abortions; comparatively few of these had strictly medical reasons for seeking their abortions.113 While the recent trend has been toward easing abortion laws in this country, it is by no means certain that trend will gather momentum. Indeed, there is little movement on this issue at present. In most of the world, including the developing countries, abortion is illegal. Even those countries with liberal laws do not permit abortion on request. Japan, where the control of runaway population growth is usually attributed to the legalization of abortion, requires that a woman apply for and receive official sanction before the procedure can be performed. Japan is often cited as the model for the underdeveloped countries to follow in checking rampant population growth. Japan legalized abortion, and it is sometimes implied that developing countries should do the same. But Japan is an inappropriate example to hold out to the LDCs. Moral questions aside, it is obvious that Japan is a highly developed country, with the skills and facilities to operate a large scale abortion program. The less developed countries do not have these skills or facilities. They lack sufficient doctors and hospitals to operate national abortion clinics except at high cost to other branches of their health services. In addition, with legalized abortion held out as an alternative, it would become that much harder for a developing coun 10. Time Magazine (September 27, 1971), page 67. 110 Arthur McCormack. "The Population Problem" (New York, Thomas Y. Crowell Company, 1970), pages 196-7. 111 U.S. Department of Health, Education, and Welfare. National Center for Family Planning Services. "Current Status of Abortion Laws January 1971" (Washington, U.S. Government Printing Office, 1971), table. 112 Idem. 11 Time Magazine, op. cit., page 67. try to administer family planning programs based on contraceptive technology. At this juncture there does not appear to be any real thrust in the less developed countries, with the exception of India, for the legalization of abortion. As long as a social stigma attaches to the practice, and as long as it contravenes the moral feelings of many people, it seems unlikely that political leaders in the LDCs will want to roil the waters by championing abortion reform as the key to population control. The Problem of Medical Support There are also operational barriers, in the form of inadequacies in the staffing and administration of family planning programs in the LDCs. The Indian physician needs a present incentive to participate in what are for him the boring and professionally unrewarding tasks of inserting IUDs and lecturing at birth control clinics. The same arguments would apply to the trained physician in other developing countries. Presumably the antipathy of most physicians to this type of work might be overcome if the financial incentives were high enough. Yet even with sufficient remuneration many physicians might participate unenthusiastically. Furthermore, doctors could find themselves in a conflict of values. On the one hand they may be trying to reduce infant mortality, on the other to reduce fertility. Many find at least a surface incompatibility between these two programs. Some doctors may be able to work on both with equal dedication, viewing them as different aspects of the broad concept of health care. Others however, more deeply affected by the traditional outlook of the medical profession, may feel more comfortable with programs to reduce infant mortality than with those seeking to reduce parental fertility. The shortage of trained physicians, and the ambivalent attitude with which a number of them approach the subject of birth control, points up the need for large numbers of paramedical personnel to carry out programs of family limitation. Such personnel could be given sufficient training to advise on contraception, insert IUDs, etc., but need not receive the broader training of regular nurses. Paramedical people trained in this fashion might not only be useful in the execution of family planning programs, but in some instances might spell the difference between success and failure. Before adequate numbers can be trained, however, the medical associations in a number of countries would have to abandon the rather unsympathetic attitude they have usually tended to hold toward paramedical personnel. In addition, there would have to be adequate incentives for the paramedics, just as for regular medical workers, and for the men and women at whom the birth control programs are aimed. One category of paramedical personnel already on the scene are the village midwives who sometimes serve as abortionists as well. These women have a certain amount of influence with the other women in the villages and may feel threatened by the introduction of family planning programs. Hence it may be important for the success of such programs to win these women over. The easiest way to do so would probably be through some form of financial inducement. The most effective way might be to combine such inducement with training in the administration of the family planning programs, where feasible, to preserve but redirect their influence in the community. VI. POLITICAL AND DIPLOMATIC ISSUES OF THE POPULATION PROBLEM IN THE LDCs Despite the persuasive logic, at the national level, of applying restraints to the multiplication of populations, powerful economic and cultural forces resist the implementation of national policy in villages and households. Administrative resources and skills in the governments of the LDCs are quickly overtaxed and their efforts tend to be modulated by fear of antagonizing the electorates. A different problem confronts the United States. There seems to be a clear perception in this country of the need to achieve a food/population balance, and of the need for population measures in particular in those countries receiving U.S. assistance. However, bilateral programs of aid conditioned on population measures run the risk of engendering hostility among populations of recipient countries as well as a sense of frustration among their leaders. It is possible that a more promising approach to the population problem is by the combining of resources of developed and underdeveloped countries alike in multilateral programs under U.N. or regional sponsorship. However undertaken, the invasion of this sensitive and deeply emotional issue is fraught with great difficulties. Only the vital necessity of solving the problem justifies the attempt. Social Resistance to Birth Control and Family Planning Programs Probably the main hurdle to the successful implementation of birth control and family planning programs in the LDCs is the system of cultural and social values that confront these programs. That system has traditionally placed a premium on large numbers of children for religious, economic, and societal reasons. THE STATUS OF WOMEN One reason why women in the LDCs lack motivation to take the pill regularly, or employ other contraceptive methods, is that in traditional societies such as those that prevail in Asia and Africa, a woman's prime obligation is to provide sons for her husband. A childless woman bears a stigma, and an unmarried one may be even less well regarded. In India, the expression "Two hands, one mouth" epitomizes the usefulness that children are thought to have as potential agricultural workers, producing more than they consume and thereby enriching the farm family. Children, particularly sons, in a country without old age insurance constitute a form of social security. The more children a woman bears, the more assurance she has that she will be taken care of in her old age. Social and economic pressures thus militate in the direction of high fertility, and the ordinary woman has little incentive to resist these pressures. Indeed, studies made in Asia, Africa, and Latin America suggest that couples in a number of countries consider four to eight children to be an ideal number, de (66) |