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Birth control and public health
x92~.
PUBLIC
BIRTH CONTROE AND PUBLIC HEALTH.. BY
C. KILLiCK MILLARD, M.D., D.Sc., M . O . H . Leicester.
for
M a y I be allowed, at the o u t s e t of this discussion, to refer to the fact that it w a s at a meeting of this Branch in October, 1902, just 2I years ago, that I ventured to m a k e m y first public utterance in favour of Birth Control. I t -was in t h e course of an address which I was: giving, as President of the Branch, under the title of " The Role of the ' Anti ' ; an Apology a n d a n Appeal,' I and I wrote :'--" There is another ' anti ' whose special subject is the population question. H e holds that large families a m o n g s t the poor are a fruitful cause of poverty and its attendant evils, and he teaches that h u m a n b e i n g s are not bound, like the lower animals, b y the law of nature under which they must, once they are married, reproduce their species to the utmost extent of their physiological capacity , regardless of their ability to nourish and support t h e i r offspring. One is compelled to admit that s u c h a doctrine has much to commend it on the g r o u n d s o f p r u d e n c e , foresight, and solicitude f o r the welfare o f such offspring as m a y already exist, and certainly, if it were generally adopted and acted upon, it would greatly diminish our terribly high infant mortality. Yet the doctrine has been received w i t h intolerance so bitter that few care to discuss it, and, as a consequence, many people arrive at conclusions on the subject on one-sided evidence a l o n e . " It will be observed that the term " Birth Control " w a s not mentioned, the reason, of course, being that at the time I am speaking of this term, which is a comparatively modern one, had n o t been introduced into this country. As a sample of t h e intolerance with w h i c h the subject was regarded, even as recently as 1911, we may cite a b o o k entitled " Racial D e c a y , " b y O . C. Beale, published in that year. This is an exhaustive work, running to over 4()0 closely-printed pages, in fierce condemnation of birth control and the use of contraceptives, and it.abounds in such expressians a s these, m a n y o f them quoted with approval f r o m other sources: " F i l t h y practices," " bestial corruptions, . . . . . abominations, . . . . immoral filth, ..... Malthusian a p o s t a s y , " " pure and unadulterated selfishness, . . . . . revolting and ter-
HEALTH.
i-~9
rible, ~. . . . Satanic gospel,' .... f i i t h y m e r c h a n d i s e , " " inconceivable blasphemy, " eternal curse, " damnably w r o n g . " It refers to birth control as a " cancerous grOwth g r o w i n g towards our utter destruction," and speaks ~of " children being shut out from the banquet of life." Yet a man of the calibre of T h e o d o r e Roosevelt, referring to this book, said he believed it to be better worth the study of every sincere patriot than any other book that had been w r i t t e n for years ! W e may observe that the view, clearly indicated ,by the above quoted expressions, that thei'e was something inherently " unclean " in the practice of contraception, was formerly very widely held. This has been one of the g r e a t obstacles raised by prejudice to the impartial consideration of the subject which the earlier advocates had to combat. It was no doubt a survival of the old ecclesiastical doctrine that any thing connected with s e x - - e v e n sex i t s e l f was " unclean " and only tolerated by the Deity for the necessary and express purpose of procreation. It is pleasant to reflect on the remarkable c h a n g e which has taken place in the attitude of thinking men and women to-day. Ne0-Malthusianism , rechristened Birth Control, is no longer a tabooed subject as it used to be, n o t to be mentioned in polite society. On the contrary, it has become distinctly fashionable and is openly discussed round dinner tables and over the tea cups in the most irreproachable circles. Bishops and other dignitaries of the Church, eminent physicians and surgeons, distingulshed authors, gallant admiralsl leaders of society, politicians, social workers, all find it necessary n o w a d a y s to be quite au f a i r with the subject of birth control, and many have given ~ it their cordial blessing. The most reputable papers a n d - m a g a z i n e s , including progressive Church papers, which a few years ago would not have looked at the subject , now publish articles on it' and open their columns freely for its discussion : whilst books on the subject , especially by women writers, dealing with the pi~actical Side of the question in the most intimate possible w a y - - t h e authors and vendors of which would almost certainly have been prosecuted a few years a g o - are now sold openly at every bookstall. O f course, it is not suggested that all controversy is.at, an end. There is still a sharp conflict of o p i n i o n , - a n d there are individuals here and there to w h o m the whole subject is still anathema ; but it is: possible now to .discuss the question freely a n d 0 p e n l y , Without ap010g!/, and without necessarily raising hot passions and Storms of moral indignation.
!$o
PUBLIC HEALTH.
F(;r all of which we have much cause to be thankful. Birth control, as the term is usually understood torday , implies the voluntary restriction of the size of the family. The term is not strictly scientific, and a better one is " conception control," but a s t h e term birth control has now become firmly rooted in the English language it wild not be easy to alter it. T h e subject may be approached from many different points of view. W e propose to touch briefly upon the follqwing~ : - 1. 2. 3. 4. 5.
The The The The The
Cosmopolitan or W~orld-wide Aspect, National o r Imperial Aspect. Public H e a l t h Aspect, Eugenic Aspect. Physiological Aspect.
W e do not propose to deal here with either the Personal or the Ethical Aspect. 1:. THE COSMOPOLITAN OR W O R L D - W I D E ASPECT.
Here we are faced with the question.: Is it desirable that the human race all over the world should continue to increase and multiply to the u t m o s t extent of which, under the conditions existinK, it is capable? The answer to this question involves a consideration of the principle associated w i t h t h e name of Malthus that popula, tlon tends to increase faster than the food supply, with the result that population ever tends to press upon the means of subsistence. W e h a v e further to consider that more and more of the older countries ,of the world are finding their native food resources insufficient to feed their ever-growing populations, and consequently are having to draw upon the food resources o f distant• parts of the world to an ever-increasing extent,;, and: that. simultaneously the undeveloped fertile areas of the world are rapidly diminishing. In view of these indisputable facts we have to face the prospect that should the population of the globe continue to increase at the same rate in the f u t u r e as has been the case during, say, t h e past century, there would be a real danger, at some not very distant time, of a world-shortag e of food. Any ~such shortage would• inevitably lower tile standard of llfe, increase the competition between the different nations, with t h e resultant increased danger of war, disease and famine. The fact that it may be possible, ~by improved methods of agriculture, to increase the yield of t h e land can only p o s t p o n e the day when the inevitable, s h o r t a g e will occur, for we are up against the inexorable Law of Diminishing Returns.
MA~-cH,
~i T H E NATIONAL OR IMPERIAL ASPECT.
From this point of view we have to consider whether birth control would be beneficial or otherwise to our own country irrespective of its effect upon the rest of the world. There are many p e o p l e who would be quite content to see the population of other countries stationary provided that the population of our own country and colonies continued to increase. Such people are influenced by so-called patriotic motives which makes them desire that their own country should g r o w greater relatively to other and rival countries. But if this sentiment is laudable with one country it is laudable also with others. Closely allied to this sentiment is that which regards men as potential • soldiers and pins its faith to big battalions. Before the Great W a r there was a very real fear in the minds o f many that:any falling off in the rate of increase of the population in this country would be disastrous in the event of a war with Germany. Similar fears were felt in France, and were, of course, reciprocated by Germany, with the result that there was a veritable competition in birth-rates comparable to the competition in armaments. W e have to consider whether such a competition is healthy or otherwise, and: whether it can be endorsed by those who put the cause o f international peace above that o f national agrandisement. Incidentally, it may be observ.ed that even in war quality counts for more than quantity, and that it was the high birth-rate nations, Russia and the Balkans, which first gave out in the Great W a r . As regards Britain, the feeling has certainly been growing since the war that this country is over-populated; By this is meant that we should find the conditions of life less difficult for the masses of the people if our population were smaller or at least were increasing less rapidly. Probably the housing shortage, and the obvious impossibility of overtaking it so tong as population continues to grow faster than new houses: are built, partly accounts for this feeling. Moreover, the large number of unemployed has brought home to us the fact that we are dependant upon the markets of the world for the sale of those manufactured articles by which alone we can obtain the necessary supplies of food and raw materials from abroad to support our teeming millions,
Effect of Emigration. To meet this over-population, o r g a n i s e d and State-aided emigration to o u r Colonies on a large scale is b e i n g warmly advocated in certain quarters. Unfortunately, our Colonies are only willing to receive carefully selected lives; they
I924.
PUBLIC HEALTH.
have no use for the old, the weakly or the thriftless ; s o that emigration, however beneficial it may be to the Colonies, is a rather expensive and exhausting process for the old country. Moreover, at the rate of increase of population which has hitherto prevailed it has never been carried out, and is hardly likely ever to be carried out, on any scale at all adequate, if it is to be a real remedy for over-population. 3. THE
PUBLIC
HEALTH
ASPECT.
The aspect of our subiect which specially concerns us as medical officers of health is the effect
which birth control is likely to have upon the public health. This is bound up with the study of vital statistics, birth-rates, death-rates, illegitimacy, infant mortality, etc. This aspect is no longer of academic interest only, but has become a question of practical administration. It is being urged respectively that information and instruction on the practical side of birth control should, or should not, be given in connection with maternity and child welfare work, e.g., at antenatal clinics, and the Ministry of Health is being appealed to by the rival protagonists to allow or to prohibit this. Whether they like it or not, therefore, medical officers of health have now no alternative but to be interested in the question. There are certain facts which are beyond dispute : - (1) The birth-rate is very much higher amongst the poor than amongst the well-to-do. It is generally believed that this is chiefly, if not entirely, to be accounted for by the practice of birth control amongst the well-to-do. In support of this there is the fact that in Victorian days, prior to the advent of the birth control movement, the well-to-do classes had very much larger families than they have to-day ; indeed their birthrate was but little smaller than what we see amongst the poor to-day. The fall in the birthrate, which has been so c~ntinuous for the past half-century, has been chiefly confined to the higher strata of the community, e.g., the birthrate of residential districts has fallen enormously, but that of the slums very much less. Moreover the fall in the birth-rate is gradually invading successively lower strata, which is what we should expect if it be due to voluntary influences. On the other hand, there are those, notably Mr. C. E. Pell, * who believe that the decline in the birth-rate is almost entirely due to natural causes; that there is, in fact, a natural law under which fertility decreases as comfort and * " The Law of Births and Deaths," by C. E. Pell.
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material prosperity increase. Whilst not denying that there may be some truth in this, it seems hard tO explain, by PelFs theory, the difference in the size of the middle-class family to-day compared with what it was in the Victorian Era, unless we are expected to believe that this natural law has only recently come into existence. Nor does it explain away the remarkable coincidence between the fall in the birthrate and the advent of the birth-control movement. The birth-rate in this country has been falling more or less continuously since 1876,the year in which the Bradlaugh-Besant Trial gave such an advertisement to the movement, and set everyone talking and thinking about it. (2) Another undisputed fact is the high degree of correlation between birth-rates and infant death-rates which, as a general rule, tend to vary directly, though undoubtedly there are some striking exceptions. It is difficult to resist the conclusions that there is a causal relationship at work, and that a high blrth-rate tends to produce a high infant mortality. Certainly it is easy to understand why this should be the case. W'ith a high birth-rate infant life is likely to be " held cheap." Unwanted babies will not receive the same amount of care and attention as those whose advent is desired; and apart f r o m this, with a large family and limited means, it cannot be possible for new arrivals to receive so much care and attention. This is specially true, o f course, where the births in a family succeed each other too rapidly. (3) A third fact, which can hardly be gainsaid, is that a given weekly wage, which will just suffice to maintain a small family of, say, two or three children above the poverty line, will fail to satisfactorily maintain a large family of, say, six or seven. It is true that many working men and women, who are thrifty and capable, do often succeed in rearing a large family on an astonishingly small income, but this does not affect the general truth of our statement. Consequently, so long as t h e amount of wages which a man receives bears no relationship to t h e size o f his family, we are justified in asserting that large families are one cause of poverty. (4) A fourth fact is that too frequent childbearing fias a detrimental effect upon the health and strength of many women, especially amongst the poor, who have to took after their families slnffle-handed and on inadequate means. Although it is true that some women keep well and strong in spite of a numerous family, this again does not disprove the general truth of our statement.
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PUBLIC
(5) Fifthly, it is certainly the case that very many women amongst the poorer classes live in positive dread of becoming pregnant again, because they realise that an additional mouth to feed will only intensify the existing struggl~ for existence. (6) Whilst we must admit the great advantages to the child of being one of a family rather than an only child, it can hardly be denied that the members of a large family amongst the poor are often seriously prejudiced and handicapped by having to start w o r k early in life, and with little training and education. A consideration of all these facts justifies us, I submit, in concluding that birth control tends to be beneficial from the point of view of the public health and that an unrestricted birth-rate tends to be prejudicial. 4. T H E EUGENIC P O I N T O F V I E W .
W e have also to look at this question from the point of view of Eugenics. This is clearly allied to the point of view of Public Health; indeed, Euffenics may be regarded in one sense as the Public Health of future generations. No one will deny that the present position, with its differential birth-rate between the upper and lower strata of society, is most unsatisfactory. birth control is being largely practised by the more desirable stocks, whilst it is being neglected by the less desirable, and although this is compensated to some extent by the reduced infant mortality which usuaIIy accompanies a lower birth-rate, the fact remains that our population is being unduly recruited from those elements which, humanly speaking, are the least fitted to make good parents. It must be frankly admitted, therefore, that birth control, as we see it to-day, is distinctly dysgenic in its operation. How can this be remedied ? It would appear that there are only two alternatives : - (1) birth (2) birth
Induce the more desirable stocks to abandon control and have larger families; or Induce the less desirable stocks to adopt control and have smaller families.
Does anyone seriously think that the first alternative is in the least degree practicable? The educated and " thinking " classes have decided that restriction of the size of "~he family is deslrable. The clergy, doctors, schoolmasters, in short the inteli~entsla of the nation, to-day all have small families. W h o shall go forth and persuade t h e m to act differently? Blrth control has been on its trial for at least two genera-
HEALTH.
MARCH
tions (in reality very much longer), and I suggest that no civillsation which has once discovered it is at all likely to abandon it. W e may as well recognise frankly tfiat birth control has come to stay. We therefore have to fall back upon the other alternative, viz., to induce the less desirable stocks to follow the example of the more desirable stocks and practise birth control also. This is surely the more natural, the more logical and the more progressive course. How far is it practicable? It may be objected that we shall never succeed in persuading the more reckless, thriftless and thoughtless elements in the population to exercise the considerable measure of forethought, circumspection and self-control which the successful practice of any method of birth control demands. I frankly admit the difficulty, and it is quite possible that we shall never be entirely successful ; but this is no reason why we should not set this alternative before us as an ideal to be aimed at. Much, I believe, could be done by Sympathetic practical instruction, and by providing adequate facilities. Ais0 we may reasonably hope for improvement in methods now that the subject is being seriously studied not only in this but in almost all Civilised countries. W h a t is needed is a method which is at once simple, safe, effective and inexpensive. The experience now being gained in the two birth control clinics which are being carried on in London should help us in deciding how far the lowest strata of the population can be taught birth control. The following is from a description of a visit to Dr. Marie Stopes' Clinic which appeared in the "Daily News " for June 20th, 1921, from the pen of Mr. Herbert Ashley, See. London Council of Social Service. " To social workers who are willing to sweep aside false ' modesty ' and to think with courage, one fact is apparent : that the mother of the poorer classes who bears a child unwillingly, rebelliously, bitterly, and with anguish, is not she who best serves our race. Such children are a loss to the State, an anguish to their mothers, and a misery to t h e m s e l v e s . . . With such thoughts in my mind, I called at Dr. Marie Stopes' Clinic in Holloway. In a drab neighbourhood, it is a beautiful place . . . . The whole atmosphere of the place is one of confidence and p u r i t y . . . The founders of the Clinic, who are supported by many thinkers in many different walks of life, have taken upon themselves a work which will save untold expense to the whole community, as well as untellable misery to individuals."
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PUBLIC HEALTH.
I see no reason why a similar description should not be applicable to all birth control clinics. I would suggest that whatever our views may be on this question of birth control it is up to all of us who are medical officers of health to watch the work of these clinics carefully and sympathetically. The problem of the most degraded stocks, e.g., the feeble minded, calls for special treatment: No doubt, when public opinion is ripe for i t - - a n d it is certainly moving in that direction--measures will be introduced for the permanent sterilisation of those unfortunates as an alternative to segregation. Already, legislation with this end in view has been passed in some countries. 5. THE PHYSIOLOGICAL OR MEDICAL ASPECT.
Lastly, we have to consider the physiological or purely medical point of view. W h a t effects-physiological, pathological, or psychological-have contraceptives on those who habitually use them? This is an aspect which, of course, specially concerns the medical profession. It is much to be regretted, but none the less true, that we are not, as a profession, at present, able to answer this question with any degree of certainty or unanimity. In an anonymous letter which appeared in the July number of " Public H e a l t h , " over the nora de plume of " X and Y , " and headed " The Dangers of Birth Control," the opinions of certain practitioners and gynmcologists were cited expressing the belief that the use of contraceptives was injurious to health. Elsewhere ~ I have collected a number of opinions on the other side, and I have also published t the results of two special inquiries I instituted, by means of questionnaires, amongst medical practitioners, men and women, including gynmcologists. Suffice it to say here that these inquiries satisfied me that the concensus of medical opinion to-day was that no serious illeffects need be apprehended from the use of some at least of the contraceptives in common use. My own feeling is that amongst those who have been most emphatic in alleging that serious ill-effects follow the use of contraceptives there has been a great deal of unconscious exaggeration and of confusion between post hoc and propter hOC, due to strong prejudice on supposed ethical and patriotic grounds, and that this to a large extent * " Responsible Parenthood and Birth Control " : A Memorandum presented to the Bishops attending the Lambeth Conference in 1920. + Journal of State Medicine. Also Report of Fifth Inter. national Birth Control Conference.
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discounts their testimony. In this connection the medical evidence against the use of contraceptives, given in a recent cause cet~bre, and for which large fees were paid, makes interesting reading, especially the answers elicited under cross-examination. CONCLUSION.
Let me conclude with an expression of my own personal opinion. I regard the ideal of responsible parenthood, accompanied as a necessary eorallary by regulation of the size of the family, as a much higher and more worthy ideal than the principle of unrestricted breeding which prevailed prior to the days of birth control. It is all very well for the opponents of birth control to say that responsible parenthood has always been held as an ideal. It is common knowledge that until birth control came into vogue the orthodox teaching used to be that children were " sent " and that it was the duty of married couples to take all that came. I regard the use of contraceptives as the only practicable or desirable method of effectlng regulation of the size of the family in the case of normal individuals, and I regard their use for this purpose as perfectly legitimate and a necessary part of the hygiene of marriage where restriction of the size of the family is indicated. Properly selected and properly used I do not believe that they have, as a general rule, any seriously detrimental effect upon health, though I am quite prepared to believe that their ignorant or improper use may in certain cases have been productive of harm. I regard the suggestion that the use of contraceptives may cause permanent sterility as a bogie, quite unsupported by adequate evidence; but I recognise that if young married couples begin using contraceptives before they have had a child, and if later on, when they desire a child, they fail to get one, it is very probable that they will reproach themselves and regard it as a " judgm e n t . " I recognise also that nowadays many young people are apt to practise birth control where there is no real need for it, and that they do not sufficiently appreciate the immense and permanent value of children in marriage, or the fact that after a certain age in the woman the likelihood of conception diminishes. F o r these reasons I think it better, as a general rule and under normal conditions as regards housing, that young COuples should always make sure of at least one or two children before adopting birth control and I disagree with those who teach otherwise.
PUBLIC
BIRTH CONTROE AND PUBLIC HEALTH.. BY
C. KILLiCK MILLARD, M.D., D.Sc., M . O . H . Leicester.
for
M a y I be allowed, at the o u t s e t of this discussion, to refer to the fact that it w a s at a meeting of this Branch in October, 1902, just 2I years ago, that I ventured to m a k e m y first public utterance in favour of Birth Control. I t -was in t h e course of an address which I was: giving, as President of the Branch, under the title of " The Role of the ' Anti ' ; an Apology a n d a n Appeal,' I and I wrote :'--" There is another ' anti ' whose special subject is the population question. H e holds that large families a m o n g s t the poor are a fruitful cause of poverty and its attendant evils, and he teaches that h u m a n b e i n g s are not bound, like the lower animals, b y the law of nature under which they must, once they are married, reproduce their species to the utmost extent of their physiological capacity , regardless of their ability to nourish and support t h e i r offspring. One is compelled to admit that s u c h a doctrine has much to commend it on the g r o u n d s o f p r u d e n c e , foresight, and solicitude f o r the welfare o f such offspring as m a y already exist, and certainly, if it were generally adopted and acted upon, it would greatly diminish our terribly high infant mortality. Yet the doctrine has been received w i t h intolerance so bitter that few care to discuss it, and, as a consequence, many people arrive at conclusions on the subject on one-sided evidence a l o n e . " It will be observed that the term " Birth Control " w a s not mentioned, the reason, of course, being that at the time I am speaking of this term, which is a comparatively modern one, had n o t been introduced into this country. As a sample of t h e intolerance with w h i c h the subject was regarded, even as recently as 1911, we may cite a b o o k entitled " Racial D e c a y , " b y O . C. Beale, published in that year. This is an exhaustive work, running to over 4()0 closely-printed pages, in fierce condemnation of birth control and the use of contraceptives, and it.abounds in such expressians a s these, m a n y o f them quoted with approval f r o m other sources: " F i l t h y practices," " bestial corruptions, . . . . . abominations, . . . . immoral filth, ..... Malthusian a p o s t a s y , " " pure and unadulterated selfishness, . . . . . revolting and ter-
HEALTH.
i-~9
rible, ~. . . . Satanic gospel,' .... f i i t h y m e r c h a n d i s e , " " inconceivable blasphemy, " eternal curse, " damnably w r o n g . " It refers to birth control as a " cancerous grOwth g r o w i n g towards our utter destruction," and speaks ~of " children being shut out from the banquet of life." Yet a man of the calibre of T h e o d o r e Roosevelt, referring to this book, said he believed it to be better worth the study of every sincere patriot than any other book that had been w r i t t e n for years ! W e may observe that the view, clearly indicated ,by the above quoted expressions, that thei'e was something inherently " unclean " in the practice of contraception, was formerly very widely held. This has been one of the g r e a t obstacles raised by prejudice to the impartial consideration of the subject which the earlier advocates had to combat. It was no doubt a survival of the old ecclesiastical doctrine that any thing connected with s e x - - e v e n sex i t s e l f was " unclean " and only tolerated by the Deity for the necessary and express purpose of procreation. It is pleasant to reflect on the remarkable c h a n g e which has taken place in the attitude of thinking men and women to-day. Ne0-Malthusianism , rechristened Birth Control, is no longer a tabooed subject as it used to be, n o t to be mentioned in polite society. On the contrary, it has become distinctly fashionable and is openly discussed round dinner tables and over the tea cups in the most irreproachable circles. Bishops and other dignitaries of the Church, eminent physicians and surgeons, distingulshed authors, gallant admiralsl leaders of society, politicians, social workers, all find it necessary n o w a d a y s to be quite au f a i r with the subject of birth control, and many have given ~ it their cordial blessing. The most reputable papers a n d - m a g a z i n e s , including progressive Church papers, which a few years ago would not have looked at the subject , now publish articles on it' and open their columns freely for its discussion : whilst books on the subject , especially by women writers, dealing with the pi~actical Side of the question in the most intimate possible w a y - - t h e authors and vendors of which would almost certainly have been prosecuted a few years a g o - are now sold openly at every bookstall. O f course, it is not suggested that all controversy is.at, an end. There is still a sharp conflict of o p i n i o n , - a n d there are individuals here and there to w h o m the whole subject is still anathema ; but it is: possible now to .discuss the question freely a n d 0 p e n l y , Without ap010g!/, and without necessarily raising hot passions and Storms of moral indignation.
!$o
PUBLIC HEALTH.
F(;r all of which we have much cause to be thankful. Birth control, as the term is usually understood torday , implies the voluntary restriction of the size of the family. The term is not strictly scientific, and a better one is " conception control," but a s t h e term birth control has now become firmly rooted in the English language it wild not be easy to alter it. T h e subject may be approached from many different points of view. W e propose to touch briefly upon the follqwing~ : - 1. 2. 3. 4. 5.
The The The The The
Cosmopolitan or W~orld-wide Aspect, National o r Imperial Aspect. Public H e a l t h Aspect, Eugenic Aspect. Physiological Aspect.
W e do not propose to deal here with either the Personal or the Ethical Aspect. 1:. THE COSMOPOLITAN OR W O R L D - W I D E ASPECT.
Here we are faced with the question.: Is it desirable that the human race all over the world should continue to increase and multiply to the u t m o s t extent of which, under the conditions existinK, it is capable? The answer to this question involves a consideration of the principle associated w i t h t h e name of Malthus that popula, tlon tends to increase faster than the food supply, with the result that population ever tends to press upon the means of subsistence. W e h a v e further to consider that more and more of the older countries ,of the world are finding their native food resources insufficient to feed their ever-growing populations, and consequently are having to draw upon the food resources o f distant• parts of the world to an ever-increasing extent,;, and: that. simultaneously the undeveloped fertile areas of the world are rapidly diminishing. In view of these indisputable facts we have to face the prospect that should the population of the globe continue to increase at the same rate in the f u t u r e as has been the case during, say, t h e past century, there would be a real danger, at some not very distant time, of a world-shortag e of food. Any ~such shortage would• inevitably lower tile standard of llfe, increase the competition between the different nations, with t h e resultant increased danger of war, disease and famine. The fact that it may be possible, ~by improved methods of agriculture, to increase the yield of t h e land can only p o s t p o n e the day when the inevitable, s h o r t a g e will occur, for we are up against the inexorable Law of Diminishing Returns.
MA~-cH,
~i T H E NATIONAL OR IMPERIAL ASPECT.
From this point of view we have to consider whether birth control would be beneficial or otherwise to our own country irrespective of its effect upon the rest of the world. There are many p e o p l e who would be quite content to see the population of other countries stationary provided that the population of our own country and colonies continued to increase. Such people are influenced by so-called patriotic motives which makes them desire that their own country should g r o w greater relatively to other and rival countries. But if this sentiment is laudable with one country it is laudable also with others. Closely allied to this sentiment is that which regards men as potential • soldiers and pins its faith to big battalions. Before the Great W a r there was a very real fear in the minds o f many that:any falling off in the rate of increase of the population in this country would be disastrous in the event of a war with Germany. Similar fears were felt in France, and were, of course, reciprocated by Germany, with the result that there was a veritable competition in birth-rates comparable to the competition in armaments. W e have to consider whether such a competition is healthy or otherwise, and: whether it can be endorsed by those who put the cause o f international peace above that o f national agrandisement. Incidentally, it may be observ.ed that even in war quality counts for more than quantity, and that it was the high birth-rate nations, Russia and the Balkans, which first gave out in the Great W a r . As regards Britain, the feeling has certainly been growing since the war that this country is over-populated; By this is meant that we should find the conditions of life less difficult for the masses of the people if our population were smaller or at least were increasing less rapidly. Probably the housing shortage, and the obvious impossibility of overtaking it so tong as population continues to grow faster than new houses: are built, partly accounts for this feeling. Moreover, the large number of unemployed has brought home to us the fact that we are dependant upon the markets of the world for the sale of those manufactured articles by which alone we can obtain the necessary supplies of food and raw materials from abroad to support our teeming millions,
Effect of Emigration. To meet this over-population, o r g a n i s e d and State-aided emigration to o u r Colonies on a large scale is b e i n g warmly advocated in certain quarters. Unfortunately, our Colonies are only willing to receive carefully selected lives; they
I924.
PUBLIC HEALTH.
have no use for the old, the weakly or the thriftless ; s o that emigration, however beneficial it may be to the Colonies, is a rather expensive and exhausting process for the old country. Moreover, at the rate of increase of population which has hitherto prevailed it has never been carried out, and is hardly likely ever to be carried out, on any scale at all adequate, if it is to be a real remedy for over-population. 3. THE
PUBLIC
HEALTH
ASPECT.
The aspect of our subiect which specially concerns us as medical officers of health is the effect
which birth control is likely to have upon the public health. This is bound up with the study of vital statistics, birth-rates, death-rates, illegitimacy, infant mortality, etc. This aspect is no longer of academic interest only, but has become a question of practical administration. It is being urged respectively that information and instruction on the practical side of birth control should, or should not, be given in connection with maternity and child welfare work, e.g., at antenatal clinics, and the Ministry of Health is being appealed to by the rival protagonists to allow or to prohibit this. Whether they like it or not, therefore, medical officers of health have now no alternative but to be interested in the question. There are certain facts which are beyond dispute : - (1) The birth-rate is very much higher amongst the poor than amongst the well-to-do. It is generally believed that this is chiefly, if not entirely, to be accounted for by the practice of birth control amongst the well-to-do. In support of this there is the fact that in Victorian days, prior to the advent of the birth control movement, the well-to-do classes had very much larger families than they have to-day ; indeed their birthrate was but little smaller than what we see amongst the poor to-day. The fall in the birthrate, which has been so c~ntinuous for the past half-century, has been chiefly confined to the higher strata of the community, e.g., the birthrate of residential districts has fallen enormously, but that of the slums very much less. Moreover the fall in the birth-rate is gradually invading successively lower strata, which is what we should expect if it be due to voluntary influences. On the other hand, there are those, notably Mr. C. E. Pell, * who believe that the decline in the birth-rate is almost entirely due to natural causes; that there is, in fact, a natural law under which fertility decreases as comfort and * " The Law of Births and Deaths," by C. E. Pell.
t3I
material prosperity increase. Whilst not denying that there may be some truth in this, it seems hard tO explain, by PelFs theory, the difference in the size of the middle-class family to-day compared with what it was in the Victorian Era, unless we are expected to believe that this natural law has only recently come into existence. Nor does it explain away the remarkable coincidence between the fall in the birthrate and the advent of the birth-control movement. The birth-rate in this country has been falling more or less continuously since 1876,the year in which the Bradlaugh-Besant Trial gave such an advertisement to the movement, and set everyone talking and thinking about it. (2) Another undisputed fact is the high degree of correlation between birth-rates and infant death-rates which, as a general rule, tend to vary directly, though undoubtedly there are some striking exceptions. It is difficult to resist the conclusions that there is a causal relationship at work, and that a high blrth-rate tends to produce a high infant mortality. Certainly it is easy to understand why this should be the case. W'ith a high birth-rate infant life is likely to be " held cheap." Unwanted babies will not receive the same amount of care and attention as those whose advent is desired; and apart f r o m this, with a large family and limited means, it cannot be possible for new arrivals to receive so much care and attention. This is specially true, o f course, where the births in a family succeed each other too rapidly. (3) A third fact, which can hardly be gainsaid, is that a given weekly wage, which will just suffice to maintain a small family of, say, two or three children above the poverty line, will fail to satisfactorily maintain a large family of, say, six or seven. It is true that many working men and women, who are thrifty and capable, do often succeed in rearing a large family on an astonishingly small income, but this does not affect the general truth of our statement. Consequently, so long as t h e amount of wages which a man receives bears no relationship to t h e size o f his family, we are justified in asserting that large families are one cause of poverty. (4) A fourth fact is that too frequent childbearing fias a detrimental effect upon the health and strength of many women, especially amongst the poor, who have to took after their families slnffle-handed and on inadequate means. Although it is true that some women keep well and strong in spite of a numerous family, this again does not disprove the general truth of our statement.
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PUBLIC
(5) Fifthly, it is certainly the case that very many women amongst the poorer classes live in positive dread of becoming pregnant again, because they realise that an additional mouth to feed will only intensify the existing struggl~ for existence. (6) Whilst we must admit the great advantages to the child of being one of a family rather than an only child, it can hardly be denied that the members of a large family amongst the poor are often seriously prejudiced and handicapped by having to start w o r k early in life, and with little training and education. A consideration of all these facts justifies us, I submit, in concluding that birth control tends to be beneficial from the point of view of the public health and that an unrestricted birth-rate tends to be prejudicial. 4. T H E EUGENIC P O I N T O F V I E W .
W e have also to look at this question from the point of view of Eugenics. This is clearly allied to the point of view of Public Health; indeed, Euffenics may be regarded in one sense as the Public Health of future generations. No one will deny that the present position, with its differential birth-rate between the upper and lower strata of society, is most unsatisfactory. birth control is being largely practised by the more desirable stocks, whilst it is being neglected by the less desirable, and although this is compensated to some extent by the reduced infant mortality which usuaIIy accompanies a lower birth-rate, the fact remains that our population is being unduly recruited from those elements which, humanly speaking, are the least fitted to make good parents. It must be frankly admitted, therefore, that birth control, as we see it to-day, is distinctly dysgenic in its operation. How can this be remedied ? It would appear that there are only two alternatives : - (1) birth (2) birth
Induce the more desirable stocks to abandon control and have larger families; or Induce the less desirable stocks to adopt control and have smaller families.
Does anyone seriously think that the first alternative is in the least degree practicable? The educated and " thinking " classes have decided that restriction of the size of "~he family is deslrable. The clergy, doctors, schoolmasters, in short the inteli~entsla of the nation, to-day all have small families. W h o shall go forth and persuade t h e m to act differently? Blrth control has been on its trial for at least two genera-
HEALTH.
MARCH
tions (in reality very much longer), and I suggest that no civillsation which has once discovered it is at all likely to abandon it. W e may as well recognise frankly tfiat birth control has come to stay. We therefore have to fall back upon the other alternative, viz., to induce the less desirable stocks to follow the example of the more desirable stocks and practise birth control also. This is surely the more natural, the more logical and the more progressive course. How far is it practicable? It may be objected that we shall never succeed in persuading the more reckless, thriftless and thoughtless elements in the population to exercise the considerable measure of forethought, circumspection and self-control which the successful practice of any method of birth control demands. I frankly admit the difficulty, and it is quite possible that we shall never be entirely successful ; but this is no reason why we should not set this alternative before us as an ideal to be aimed at. Much, I believe, could be done by Sympathetic practical instruction, and by providing adequate facilities. Ais0 we may reasonably hope for improvement in methods now that the subject is being seriously studied not only in this but in almost all Civilised countries. W h a t is needed is a method which is at once simple, safe, effective and inexpensive. The experience now being gained in the two birth control clinics which are being carried on in London should help us in deciding how far the lowest strata of the population can be taught birth control. The following is from a description of a visit to Dr. Marie Stopes' Clinic which appeared in the "Daily News " for June 20th, 1921, from the pen of Mr. Herbert Ashley, See. London Council of Social Service. " To social workers who are willing to sweep aside false ' modesty ' and to think with courage, one fact is apparent : that the mother of the poorer classes who bears a child unwillingly, rebelliously, bitterly, and with anguish, is not she who best serves our race. Such children are a loss to the State, an anguish to their mothers, and a misery to t h e m s e l v e s . . . With such thoughts in my mind, I called at Dr. Marie Stopes' Clinic in Holloway. In a drab neighbourhood, it is a beautiful place . . . . The whole atmosphere of the place is one of confidence and p u r i t y . . . The founders of the Clinic, who are supported by many thinkers in many different walks of life, have taken upon themselves a work which will save untold expense to the whole community, as well as untellable misery to individuals."
i924.
PUBLIC HEALTH.
I see no reason why a similar description should not be applicable to all birth control clinics. I would suggest that whatever our views may be on this question of birth control it is up to all of us who are medical officers of health to watch the work of these clinics carefully and sympathetically. The problem of the most degraded stocks, e.g., the feeble minded, calls for special treatment: No doubt, when public opinion is ripe for i t - - a n d it is certainly moving in that direction--measures will be introduced for the permanent sterilisation of those unfortunates as an alternative to segregation. Already, legislation with this end in view has been passed in some countries. 5. THE PHYSIOLOGICAL OR MEDICAL ASPECT.
Lastly, we have to consider the physiological or purely medical point of view. W h a t effects-physiological, pathological, or psychological-have contraceptives on those who habitually use them? This is an aspect which, of course, specially concerns the medical profession. It is much to be regretted, but none the less true, that we are not, as a profession, at present, able to answer this question with any degree of certainty or unanimity. In an anonymous letter which appeared in the July number of " Public H e a l t h , " over the nora de plume of " X and Y , " and headed " The Dangers of Birth Control," the opinions of certain practitioners and gynmcologists were cited expressing the belief that the use of contraceptives was injurious to health. Elsewhere ~ I have collected a number of opinions on the other side, and I have also published t the results of two special inquiries I instituted, by means of questionnaires, amongst medical practitioners, men and women, including gynmcologists. Suffice it to say here that these inquiries satisfied me that the concensus of medical opinion to-day was that no serious illeffects need be apprehended from the use of some at least of the contraceptives in common use. My own feeling is that amongst those who have been most emphatic in alleging that serious ill-effects follow the use of contraceptives there has been a great deal of unconscious exaggeration and of confusion between post hoc and propter hOC, due to strong prejudice on supposed ethical and patriotic grounds, and that this to a large extent * " Responsible Parenthood and Birth Control " : A Memorandum presented to the Bishops attending the Lambeth Conference in 1920. + Journal of State Medicine. Also Report of Fifth Inter. national Birth Control Conference.
I33
discounts their testimony. In this connection the medical evidence against the use of contraceptives, given in a recent cause cet~bre, and for which large fees were paid, makes interesting reading, especially the answers elicited under cross-examination. CONCLUSION.
Let me conclude with an expression of my own personal opinion. I regard the ideal of responsible parenthood, accompanied as a necessary eorallary by regulation of the size of the family, as a much higher and more worthy ideal than the principle of unrestricted breeding which prevailed prior to the days of birth control. It is all very well for the opponents of birth control to say that responsible parenthood has always been held as an ideal. It is common knowledge that until birth control came into vogue the orthodox teaching used to be that children were " sent " and that it was the duty of married couples to take all that came. I regard the use of contraceptives as the only practicable or desirable method of effectlng regulation of the size of the family in the case of normal individuals, and I regard their use for this purpose as perfectly legitimate and a necessary part of the hygiene of marriage where restriction of the size of the family is indicated. Properly selected and properly used I do not believe that they have, as a general rule, any seriously detrimental effect upon health, though I am quite prepared to believe that their ignorant or improper use may in certain cases have been productive of harm. I regard the suggestion that the use of contraceptives may cause permanent sterility as a bogie, quite unsupported by adequate evidence; but I recognise that if young married couples begin using contraceptives before they have had a child, and if later on, when they desire a child, they fail to get one, it is very probable that they will reproach themselves and regard it as a " judgm e n t . " I recognise also that nowadays many young people are apt to practise birth control where there is no real need for it, and that they do not sufficiently appreciate the immense and permanent value of children in marriage, or the fact that after a certain age in the woman the likelihood of conception diminishes. F o r these reasons I think it better, as a general rule and under normal conditions as regards housing, that young COuples should always make sure of at least one or two children before adopting birth control and I disagree with those who teach otherwise.