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Still Ticking

Still Ticking

Still Ticking (continued)

By Brian W. Simpson

The case against unfettered population growth seems obvious, so why aren't population issues dominating global health efforts? The short answer is culture, history and differing perspectives within the academic community.

In some cultures, children (and sometimes wives) are seen as signs of wealth. "In the Sahel, children are so valued in the culture. People love kids, and that's a good thing," says Winch. "People don't have other sources of wealth. If you have a 401(k), okay, you can have fewer kids. But if children are your one source of wealth, how do you cut back?" In other contexts, parents consider children a means of support, says Mosley. In many developing countries, "they say, 'One mouth, but two hands'—meaning that they produce more than they consume. And the culture depends on that," says Mosley, a PFRH professor.

"One mouth, two hands" sheds a cultural light on why population issues are a sensitive subject: They can strike at the heart of all that an individual values in life, a family's sense of self and a nation's determination to be vital and growing.

In Uganda, President Yoweri Museveni has called for women to have more children, arguing that his country is underpopulated and that more consumers would mean greater markets and a stronger economy. Such policies ignore the desires of women to have fewer children. The measure of women who want to postpone or limit their births but are not using contraception—"unmet need"—is falling in most countries, but in Uganda it has reached 40 percent and is one of the few countries where unmet need is still increasing, says Tsui. "They are ignoring one of the fundamental health needs," she says. "I just don't understand how in the face of these indicators one can say that it is important to continue to have more births. It's almost like they're finding a way to legitimize those unintended births."

Some leaders in sub-Saharan Africa and other regions consider family planning initiatives sponsored by wealthy countries as "white man's medicine being pushed down their throats," says Tsui, PhD. "For some reason, people see family planning as an exogenous policy that donors are trying to impose on these countries."

While most leaders do support family planning as a means of tempering population growth, they find it difficult to shift scarce resources to family planning when besieged by immediate needs such as prevention and treatment for HIV/AIDS, malaria and other infectious diseases as well as demands for better primary care, immunization coverage and other health programs. "Most of the leaders in these countries have family planning policies. What they don't have are the programs and the support of donors," says Gillespie, PhD. "This is one of the consequences of the U.S. not continuing its leadership role in this area."

The U.S. government is still the leading donor for international family planning efforts, but its support has dropped significantly from its high point in 1995. Its priorities have shifted in recent years to resonate with domestic politics: supporting abstinence programs while withdrawing funds from organizations that provide abortion care or help sex workers. "Everything gets a bit diluted so we don't see as much focus on family planning," says Tsui.

She also notes that funding for academics studying population issues has dropped in recent years as well. With dimmer prospects for future grant support, fewer students are willing to gamble their careers on population issues. This is reflected in curricula as well, as fewer demography courses are offered. "If you are being trained in a U.S. university, you won't find too many courses that address population overall or the formal demography behind it," says Tsui. "The consequence is that most people don't know why a population grows." (An informal faculty group that includes PFRH Professor Stan Becker, Tsui, Winch and others are working to reverse this trend at the School.)

Yet another obstacle to greater action on population issues is debate within the global health community about the propriety of and tactics for reducing population growth rates.

On one hand, Stan Becker states that the only sustainable population growth rate is zero. "Is rapid population growth a problem? In the long term, definitely yes," says Becker, PhD. "We're adding about 200,000 people per day to the world. People are nice, but, you know, in a finite planet, that can't go on forever."

For David Bishai, however, responses to high growth rates are a question of perspective. "In terms of environmental impact, every birth is a pox on the planet. If you're looking from the perspective of nonhumans—from a chimpanzee—every [human] birth is surely a bad thing, but it's not from the perspective of the parents," says Bishai, a PFRH associate professor.

He disputes the notion that high fertility rates in a country are automatically cause for alarm. "The ideal birth rate for a country is the one chosen by the people of that country," Bishai says. "Just as we want individuals to reach their potential, we should want populations to develop their potential."

He also warns against the implicit argument that reducing fertility leads to a surging quality of life. "You can't make a country rich by flying in condoms and contraceptives," says Bishai, MD, PhD, MPH. Nor does he advocate sharp reductions in a population's fertility. Doing this too quickly may ease a country's burden in the near term, but it also makes for a narrow base in the country's population pyramid: too few young people supporting too many old people. "No one in the '70s figured out that if you go around the world reducing fertility, you only have a temporary effect on the dependency ratio," says Bishai. "Like Malthus, they only saw the front end of a decline in fertility. You only buy yourself a 50-year demographic window. Then you have the same proportion of dependent folks—they just happen to be old dependent folks."

He believes the Malthusian "poverty trap" is an over-diagnosed syndrome and that few countries are genuinely at risk. To Bishai, choosing how many children you want to have is one of the most basic of human rights. The world's desperately poor people have more children because they are adapting to an environment in which some may not survive to adulthood, few will receive the education required to lift themselves from poverty, and many hands are needed for physical labor. He decries an attitude he detects among some researchers that "people can't pick their right birth rate" and need U.S. academics to pick it for them.

Gillespie agrees that approach simply doesn't work. "You can't go into a country and say, 'You have a population problem because there's too many of you,'" notes Gillespie. "It's not only inappropriate but it's going to backfire. It has to be shown that it is beneficial for themselves to begin to address this."

Family planning, say Tsui and others, is not about forcing countries to reduce their population but helping individuals—especially women—achieve what they want. In 1960, just 7 million couples in the developing world were using contraception. That number has increased to more than 650 million today. "You can't call that coercion," says Tsui. Even with that increase, more than 120 million women in developing countries today are in need of family planning services.

"That absolutely, definitely is a problem," says Bishai. "The common ground is asking people what they need and helping them get it. You don't tell people what they need. I believe in family planning and I'm trying to make it better [through my research], but I also believe communities know what they want. It's one of the things that I credit to Carl Taylor [who founded the School's Department of International Health]: Get out there and listen."

The point, say Tsui and others, is that those conversations need to be happening more frequently and with more countries because population issues are legitimate and even necessary topics for international discussion. "Nigeria's population is spilling into Ghana and causing social problems. Do the Ghanaians have the right to say something about Nigeria's population growth rate? I think so," says Amy Tsui. "I'd like to know how Nigeria plans to accommodate the next 140 million people when they already cannot provide a humane living situation for their people now."

Family planning is not the only means of slowing population growth. Making it easier for women to receive an education and join the workforce, expanding vaccination and other programs to reduce child mortality, encouraging breastfeeding (which has a contraceptive effect) and delaying marriage—all can influence fertility rates.

The challenge is in working with individual countries to acknowledge population's role—negative or positive—in their destiny. As Henry Mosley, MD, MPH '65, says, "The people on the ground own the problem. They ought to own the solution."

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