- Email: [email protected]
BIRTH CONTROL
1231
Points of View
persistence of individual couples, rather than ments, voluntary organisations, or physicians. There medicine
BIRTH CONTROL The Restrictions of the Western
Approach *
J. MAYONE STYCOS Ph.D. Columbia INTERNATIONAL POPULATION PROGRAMME, CORNELL UNIVERSITY. ITHACA, NEW YORK
DIRECTOR,
THE Western system of free enterprise has had interesting consequences for population control. I shall discuss these with respect to the role of voluntary organisations and to the profession of medicine. Under the general philosophy that " government is best which governs least ", the capitalist society (and here I am thinking primarily of the United States) leaves to private enterprise a great many activities in health and social welfare which are assumed by the State in other forms of government. This has led to the existence, unfathomable to the foreigner, of a multitude of private organisations in the United States, devoted to solving, by means of voluntary contributions of time and money, problems such as poliomyelitis, cerebral palsy, heart-disease, tuberculosis, mental disorder, alcoholism, traffic accidents, cruelty to animals, and birth control. In the United States, voluntary agencies often operate side by side with functionally similar Government agencies, and are almost invariably well financed, owing to the American belief in high charitable contributions and low taxes. Thus it comes as no surprise that such an important sphere of health and welfare as family planning has private and voluntary agencies devoted to its promotion. What is surprising is that no parallel Government agencies are devoted to the problem, and that the volunteer agencies for family planning are both poorly financed and poorly staffed. Because of the ideological opposition of Christianity to sex discussion in general and family planning in particular, these organisations not only have had difficulty in extracting contributions from Americans already deluged with requests for non-controversial problems, but have attracted highly atypical segments of society as leaders and members. Both in the United States and the United Kingdom the movement tended to collect people who were enthusiastic and willing to fight but who lacked organisational ability. This is a perfectly natural situation in the early days of any movement. But when a movement achieves authority and respectability, its pioneers disappear and the " establishment takes over. Unfortunately, the birth-control movement has never fully achieved either authority or respectability in the United Kingdom or in the United States, and perhaps for this reason has never had much impact in terms of provision of services. For example, in Great Britain less than 1 of every 10 users of birth control has ever received advice from a family-planning clinic, and the chances are that the user paid for the service. Modest as are their services, half the net income of British family-planning clinics is derived from the sales of contraceptives. Given this history and present circumstances, do we have anything to teach India, for exampleWe have relatively low birth-rates but, for all we know about them, they might have been produced by magic. Indeed, achieved as they were in the face of such odds, it is little short of miraculous, and a tribute to the responsibility and "
*
address to a scientific meeting on Problems of the World Population at the Royal College of Obstetricians and Gynæcologists in London on Oct. 20, 1965.
Part of
an
Expanding
are
as
to
govern-
several limitations of traditional Western
applied
to
underdeveloped
areas.
First,
Western medicine has always been more attracted by the pound of cure than by the ounce of prevention. Second, there has been an emphasis on attention to and treatment of the individual patient rather than on approach to the population as a whole. Thus clinical medicine usually has more prestige than public health, and a certain mystique about the necessity for a close doctor-patient relation emerges. The average physician knows suprisingly little about contraception, and the little he knows he tends to
guard closely. In medicine a feeling of unsuitability of public service educational programme on birth control is common. Knowledge on such matters is the property of the doctor, who must dispense it with discrimination, by means of face-to-face relations in the privacy of his survey. Moreover, excluding birth control from the normal services of hospitals and other health facilities gives family planning an aura of distinctiveness it can ill afford. Whatever the benefit to rich nations, in poorer nations such an approach is not only economically unfeasible but highly ineffectual. There is, in short, an ambience about medicine and birth control in most rich nations which it were better that the student from the underdeveloped country did not absorb. Such countries do not have to produce steam engines before they produce jets, and there is no reason why they should avoid the ignoble and bitter experience of the wealthy nations with respect to birth control. Most of the newer nations do not have a tradition of Christianity, and in the only important exception-Latin Americathe 20th-century Catholic Church bears little resemblance to that of the 19th century with regard to family planning. Nor is there the danger that the emergence of voluntary organisations will allow governments to evade their responsibilities, since voluntary organisations are truly insignificant. Moreover, since there is a firm belief in the active role of government in the process of modernisation, there is little danger that solutions of health problems will be left to amateurs and crusading enthusiasts. Indeed, with such potential advantages, the major danger is that poorer countries will too eagerly copy the organisational technology of their richer brothers. For we have the medical technology to reduce birth-rates. Perhaps the most useful technical assistance Great Britain and the United States could render other countries would be to put our own houses in order-by recognising family-planning services as a normal component of the general health responsibilities of government, and mass family-planning education as a normal part of the general educational responsibilities of governor
ment.
Newly developing countries aim
to control populawhich the West has never seen nor dreamed of. Pakistan’s newest five-year plan calls for a 20% reduction of the birth-rate by means of 10 million insertions of intrauterine devices at a cost of$2.00 (14s.) per insertion. Tunisia plans 120,000 insertions in the next two years, Korea 200,000, and Turkey half a million. These are " jet-age " programmes unhaunted by moral and technological ghosts of earlier times. The least we can do is to show that we practise what we so fervently preach. And if we cannot practise then let us desist from preaching, and be content with the major
tion
to an extent
1232
contribution we can make at this time-training in the scientific method applied to the medical, educational, and organisational aspects of family-planning. Scientifically sound evaluation programmes, in conjunction with imaginative innovations, will provide the underdeveloped areas with powerful tools for solution of population problems. A judicious combination of native hypotheses and technically assisted evaluation procedures should provide the necessary breakthrough. The new nations of the world have less time than the West had to solve their population problems, but their social climate may be better. Their population problems will be solved, but they will not be solved painlessly. How painful and destructive this process will be depends largely on what we do.
Special
Articles
SOME OBSERVATIONS ON MALARIA IN CHILDREN RETURNING FROM HOLIDAYS IN THE TROPICS P. G. SHUTE M.B.E., F.R.E.S. From the Malaria Reference Laboratory, Horton
Hospital, Epsom
WITH the
speed of modern traffic, relatively short be holidays spent almost anywhere in the world. In B.O.A.C. alone carried over 7000 schoolchildren, 1964, in of what are now known as " Lollipop them many Specials ". Many of these children go to parts of the world where malaria is either holoendemic or hyperendemic. Even children who visit places where malaria is non-endemic (such as the Falkland Islands) break their journey for an hour or so while the aircraft is being refuelled. They land often in the very early hours of the morning on malarious aerodromes just when the anopheles mosquitoes are most active in the search of a blood-meal. Because the temperature and humidity are often very high, most of the children spend the interval sitting on the verandah of the aerodrome and are therefore exposed to the bite of mosquitoes. Recently, during a journey to the Falkland Islands, the usual stop for refuelling was made at Dakar, a highly malarial area. There were about 30 children passengers on board, and it was noticed that every one of them sat about on the verandah of the aerodrome while waiting for the take-off. I was among the passengers, and while sitting on the verandah I caught three Anophelas gambirz in the act of biting; this was at 2 A.M. Dakar is a holoendemic area, and some of the children may well have been bitten by mosquitoes which carried malarial sporozoites in their salivary glands. Yet if on their return to this country any of the passengers had become febrile, malaria would have been an unlikely diagnosis of the cause of fever unless a blood-film was examined, because malaria does not occur in the Falkland Islands.l The actual number of children who spend their holidays in highly malarious areas is unknown, but it is certain that they run into many thousands. Some of them even spend two holidays a year in these areas, the Easter and summer breaks. Inevitably most of them come from preparatory and public schools, because their parents are posted in tropical countries. Inquiries from the airline which caters for the largest number of holiday students has can
1.
Shute, P. G. Br. med. J. 1951, ii, 1280.
elicited the information that prophylactic anti-malarial drugs are carried on all their aeroplanes and are distributed free to any who ask for them. The packets containing the tablets carry the following information: "
danger of your contracting malariawhile in as all B.O.A.C. aircraft are frequently and mine] flight’’ [italic thoroughly treated with insecticides to keep them free from mosquitoes. You may, however, be exposed to infection at airports in malarious areas, especially at night. You may be unaware of having been bitten and you can be infected even There is
no
from one bite. With a view to preventing malaria developing you should take one tablet from this packet daily, preferably at tea time, during the whole of your transit or sojourn in malarious areas and for at least 14 days afterwards ".
This is sound advice but I would offer two criticisms: (1) not enough emphasis is laid on the importance of avoiding bites while grounded for refuelling when in passing from one non-malarious area to another some time is spent in highly malarious areas during transit; and (2) the advice to take prophylactic drugs for 14 days after leaving a malarious area should be extended to 30 days. I understand that B.O.A.C. have now extended the period to 30 days. The onus rests, however, with the individual. Inquiries at a preparatory school of eighty pupils elicited the information from the school medical officer that four had this summer spent their holiday in tropical malarious regions. None of them had received any instructions from their parents about prophylactic drugs, and none of them had been supplied with any tablets. The medical officer continued " during my time as school medical officer, as far as I and the school matron are aware, none of the boys returning from holidays in the tropics had However good the been given antimalarial tablets ". official advice, everything depends on the individual whether or not it is accepted and acted upon. Adults can decide for themselves, but for children, and especially those from preparatory and public schools, it is a different proposition. Our records show that many parents resident in the tropics are extremely careful in seeing that their children take their prophylactic drugs regularly while they are with them, but there is evidence that many parents are unaware that the children should continue taking the drug for at least 1 month beyond the last possible chance of being infected. The number of cases investigated at this laboratory of children who have contracted malaria after returning from their holidays is not large, but it is sufficient to show the great variations in the length of time for which the drugs are taken. Most of them discontinued taking the drug on the day they boarded the plane for the homeward journey and others from 1 to 2 weeks.In not a single case of Plasmodium falciparum malaria which we investigated did any of the children take the drug for a month after leaving, and it is highly probable that, had they done so, not a single case of P. falciparum would have occurred. This, of course, applies only to the species P. falciparum and not to P. vivax, P. ovale, or P. malariae, where latent manifestations may appear up to a year after infection. Although the prevention of these latent attacks is desirable, it is of less importance than the eradication of an infection with the potential killer P. falciparum, which unfortunately is the most widespread in the whole of tropical Africa as well as in some other tropical countries. The cases we have investigated were reported in Distribution of Infectious Diseases based on reports from Public Health and 2.
Shute, P. G. Lancet, 1961, ii,
1038.
Points of View
persistence of individual couples, rather than ments, voluntary organisations, or physicians. There medicine
BIRTH CONTROL The Restrictions of the Western
Approach *
J. MAYONE STYCOS Ph.D. Columbia INTERNATIONAL POPULATION PROGRAMME, CORNELL UNIVERSITY. ITHACA, NEW YORK
DIRECTOR,
THE Western system of free enterprise has had interesting consequences for population control. I shall discuss these with respect to the role of voluntary organisations and to the profession of medicine. Under the general philosophy that " government is best which governs least ", the capitalist society (and here I am thinking primarily of the United States) leaves to private enterprise a great many activities in health and social welfare which are assumed by the State in other forms of government. This has led to the existence, unfathomable to the foreigner, of a multitude of private organisations in the United States, devoted to solving, by means of voluntary contributions of time and money, problems such as poliomyelitis, cerebral palsy, heart-disease, tuberculosis, mental disorder, alcoholism, traffic accidents, cruelty to animals, and birth control. In the United States, voluntary agencies often operate side by side with functionally similar Government agencies, and are almost invariably well financed, owing to the American belief in high charitable contributions and low taxes. Thus it comes as no surprise that such an important sphere of health and welfare as family planning has private and voluntary agencies devoted to its promotion. What is surprising is that no parallel Government agencies are devoted to the problem, and that the volunteer agencies for family planning are both poorly financed and poorly staffed. Because of the ideological opposition of Christianity to sex discussion in general and family planning in particular, these organisations not only have had difficulty in extracting contributions from Americans already deluged with requests for non-controversial problems, but have attracted highly atypical segments of society as leaders and members. Both in the United States and the United Kingdom the movement tended to collect people who were enthusiastic and willing to fight but who lacked organisational ability. This is a perfectly natural situation in the early days of any movement. But when a movement achieves authority and respectability, its pioneers disappear and the " establishment takes over. Unfortunately, the birth-control movement has never fully achieved either authority or respectability in the United Kingdom or in the United States, and perhaps for this reason has never had much impact in terms of provision of services. For example, in Great Britain less than 1 of every 10 users of birth control has ever received advice from a family-planning clinic, and the chances are that the user paid for the service. Modest as are their services, half the net income of British family-planning clinics is derived from the sales of contraceptives. Given this history and present circumstances, do we have anything to teach India, for exampleWe have relatively low birth-rates but, for all we know about them, they might have been produced by magic. Indeed, achieved as they were in the face of such odds, it is little short of miraculous, and a tribute to the responsibility and "
*
address to a scientific meeting on Problems of the World Population at the Royal College of Obstetricians and Gynæcologists in London on Oct. 20, 1965.
Part of
an
Expanding
are
as
to
govern-
several limitations of traditional Western
applied
to
underdeveloped
areas.
First,
Western medicine has always been more attracted by the pound of cure than by the ounce of prevention. Second, there has been an emphasis on attention to and treatment of the individual patient rather than on approach to the population as a whole. Thus clinical medicine usually has more prestige than public health, and a certain mystique about the necessity for a close doctor-patient relation emerges. The average physician knows suprisingly little about contraception, and the little he knows he tends to
guard closely. In medicine a feeling of unsuitability of public service educational programme on birth control is common. Knowledge on such matters is the property of the doctor, who must dispense it with discrimination, by means of face-to-face relations in the privacy of his survey. Moreover, excluding birth control from the normal services of hospitals and other health facilities gives family planning an aura of distinctiveness it can ill afford. Whatever the benefit to rich nations, in poorer nations such an approach is not only economically unfeasible but highly ineffectual. There is, in short, an ambience about medicine and birth control in most rich nations which it were better that the student from the underdeveloped country did not absorb. Such countries do not have to produce steam engines before they produce jets, and there is no reason why they should avoid the ignoble and bitter experience of the wealthy nations with respect to birth control. Most of the newer nations do not have a tradition of Christianity, and in the only important exception-Latin Americathe 20th-century Catholic Church bears little resemblance to that of the 19th century with regard to family planning. Nor is there the danger that the emergence of voluntary organisations will allow governments to evade their responsibilities, since voluntary organisations are truly insignificant. Moreover, since there is a firm belief in the active role of government in the process of modernisation, there is little danger that solutions of health problems will be left to amateurs and crusading enthusiasts. Indeed, with such potential advantages, the major danger is that poorer countries will too eagerly copy the organisational technology of their richer brothers. For we have the medical technology to reduce birth-rates. Perhaps the most useful technical assistance Great Britain and the United States could render other countries would be to put our own houses in order-by recognising family-planning services as a normal component of the general health responsibilities of government, and mass family-planning education as a normal part of the general educational responsibilities of governor
ment.
Newly developing countries aim
to control populawhich the West has never seen nor dreamed of. Pakistan’s newest five-year plan calls for a 20% reduction of the birth-rate by means of 10 million insertions of intrauterine devices at a cost of$2.00 (14s.) per insertion. Tunisia plans 120,000 insertions in the next two years, Korea 200,000, and Turkey half a million. These are " jet-age " programmes unhaunted by moral and technological ghosts of earlier times. The least we can do is to show that we practise what we so fervently preach. And if we cannot practise then let us desist from preaching, and be content with the major
tion
to an extent
1232
contribution we can make at this time-training in the scientific method applied to the medical, educational, and organisational aspects of family-planning. Scientifically sound evaluation programmes, in conjunction with imaginative innovations, will provide the underdeveloped areas with powerful tools for solution of population problems. A judicious combination of native hypotheses and technically assisted evaluation procedures should provide the necessary breakthrough. The new nations of the world have less time than the West had to solve their population problems, but their social climate may be better. Their population problems will be solved, but they will not be solved painlessly. How painful and destructive this process will be depends largely on what we do.
Special
Articles
SOME OBSERVATIONS ON MALARIA IN CHILDREN RETURNING FROM HOLIDAYS IN THE TROPICS P. G. SHUTE M.B.E., F.R.E.S. From the Malaria Reference Laboratory, Horton
Hospital, Epsom
WITH the
speed of modern traffic, relatively short be holidays spent almost anywhere in the world. In B.O.A.C. alone carried over 7000 schoolchildren, 1964, in of what are now known as " Lollipop them many Specials ". Many of these children go to parts of the world where malaria is either holoendemic or hyperendemic. Even children who visit places where malaria is non-endemic (such as the Falkland Islands) break their journey for an hour or so while the aircraft is being refuelled. They land often in the very early hours of the morning on malarious aerodromes just when the anopheles mosquitoes are most active in the search of a blood-meal. Because the temperature and humidity are often very high, most of the children spend the interval sitting on the verandah of the aerodrome and are therefore exposed to the bite of mosquitoes. Recently, during a journey to the Falkland Islands, the usual stop for refuelling was made at Dakar, a highly malarial area. There were about 30 children passengers on board, and it was noticed that every one of them sat about on the verandah of the aerodrome while waiting for the take-off. I was among the passengers, and while sitting on the verandah I caught three Anophelas gambirz in the act of biting; this was at 2 A.M. Dakar is a holoendemic area, and some of the children may well have been bitten by mosquitoes which carried malarial sporozoites in their salivary glands. Yet if on their return to this country any of the passengers had become febrile, malaria would have been an unlikely diagnosis of the cause of fever unless a blood-film was examined, because malaria does not occur in the Falkland Islands.l The actual number of children who spend their holidays in highly malarious areas is unknown, but it is certain that they run into many thousands. Some of them even spend two holidays a year in these areas, the Easter and summer breaks. Inevitably most of them come from preparatory and public schools, because their parents are posted in tropical countries. Inquiries from the airline which caters for the largest number of holiday students has can
1.
Shute, P. G. Br. med. J. 1951, ii, 1280.
elicited the information that prophylactic anti-malarial drugs are carried on all their aeroplanes and are distributed free to any who ask for them. The packets containing the tablets carry the following information: "
danger of your contracting malariawhile in as all B.O.A.C. aircraft are frequently and mine] flight’’ [italic thoroughly treated with insecticides to keep them free from mosquitoes. You may, however, be exposed to infection at airports in malarious areas, especially at night. You may be unaware of having been bitten and you can be infected even There is
no
from one bite. With a view to preventing malaria developing you should take one tablet from this packet daily, preferably at tea time, during the whole of your transit or sojourn in malarious areas and for at least 14 days afterwards ".
This is sound advice but I would offer two criticisms: (1) not enough emphasis is laid on the importance of avoiding bites while grounded for refuelling when in passing from one non-malarious area to another some time is spent in highly malarious areas during transit; and (2) the advice to take prophylactic drugs for 14 days after leaving a malarious area should be extended to 30 days. I understand that B.O.A.C. have now extended the period to 30 days. The onus rests, however, with the individual. Inquiries at a preparatory school of eighty pupils elicited the information from the school medical officer that four had this summer spent their holiday in tropical malarious regions. None of them had received any instructions from their parents about prophylactic drugs, and none of them had been supplied with any tablets. The medical officer continued " during my time as school medical officer, as far as I and the school matron are aware, none of the boys returning from holidays in the tropics had However good the been given antimalarial tablets ". official advice, everything depends on the individual whether or not it is accepted and acted upon. Adults can decide for themselves, but for children, and especially those from preparatory and public schools, it is a different proposition. Our records show that many parents resident in the tropics are extremely careful in seeing that their children take their prophylactic drugs regularly while they are with them, but there is evidence that many parents are unaware that the children should continue taking the drug for at least 1 month beyond the last possible chance of being infected. The number of cases investigated at this laboratory of children who have contracted malaria after returning from their holidays is not large, but it is sufficient to show the great variations in the length of time for which the drugs are taken. Most of them discontinued taking the drug on the day they boarded the plane for the homeward journey and others from 1 to 2 weeks.In not a single case of Plasmodium falciparum malaria which we investigated did any of the children take the drug for a month after leaving, and it is highly probable that, had they done so, not a single case of P. falciparum would have occurred. This, of course, applies only to the species P. falciparum and not to P. vivax, P. ovale, or P. malariae, where latent manifestations may appear up to a year after infection. Although the prevention of these latent attacks is desirable, it is of less importance than the eradication of an infection with the potential killer P. falciparum, which unfortunately is the most widespread in the whole of tropical Africa as well as in some other tropical countries. The cases we have investigated were reported in Distribution of Infectious Diseases based on reports from Public Health and 2.
Shute, P. G. Lancet, 1961, ii,
1038.