- Email: [email protected]
Choices and challenges for the Federal family planning program
Choices and challenges for the Federal family planning program LOUIS Washington,
M.
HELLMAN,
M.D.*
D. C.
Primary responsibility for population research in the Federal Government rests with the Center for Population Research of the National Institute of Child Health and Human Development of HEW. Federal assistance for family planning services results in savings to individuals and to the government, and in many benefits beyond dollar savings. Family planning services programs may soon be integrated into the general health services of the nation. A National Institutes of Population may never come into existance, but the imaginative planning indicated by such an approach is necessary if population issues are to be effectively researched.
F o R M o R E than two generations, Americans have been practicing contraception for health reasons, for economic advantage, and because women in our society have increasingly assumed the right to control their own fertility. But until recently a large segment of our people, notably the poor, has been denied contraceptive services. Failure to provide access to this preventive health service was not primarily because of moral reasons or religious prejudice, although these factors played a significant role, but because the health benefits of family planning services were not sufficiently appreciated to merit high priority. The subject of contraception was not taught to medical students and was not even mentioned in our obstetrical texts until 1961.l In 1930 a small portion of Federal Maternal and Child Health funds were used for contraceptive services in the southeastern area of the United States. This was a beginning and since then tax-supported contraception for the economically underpriviliged
*Deputy Assistant Population Affairs, Health, Education
has been gaining increasing acceptance. The New York birth control fight of 19582 and the Supreme Court decision in Griswold vs. Connecticut in 19653 are milestones along the way. The first significant Federal effort to provide family planning services came in 1967 with the passage of the Social Security Amendments4 allotting a percentage of child and maternal health funds to family planning services. Even more important, however, was President Nixon’? Message on Population in July 1969. This Message to Congress recognized the problems created by population growth and by unequal access to contraceptive services because of economic or social barriers. Among other recommended actions, President Nixon requested legislation to increase population research and to make family planning services available to all who need and want such services but who cannot afford them. A little more than a year later Congress responded with the passage of the Family Planning Services and Population Kesearch Act of 1970, P.L. 91-57Z6 Now, after five years of accelerated Federal funding, it is fitting that we look at the achievements of this program. Two questions are paramount to the discussion: ( 1) is the program on track toward meeting its ex-
Secretary for Department of and Welfare.
Presented at the Ninety-sixth Annual Meetine of the American GvnecoloPical Society; Colorado Springs, c!Yoloradg, May 2-5, 1973. 782
Volume Number
117 6
Federal
Table I. Estimated
number
of population
research
projects FY
No. of projects All Federal agencies Three major private
nonprofit
U.
S. agencies
Total
petted goals and (2} are its health and social benefits commensurate with its cost? Furthermore, in view of changing attitudes about large federally funded social programs, we need to assess the future direction of population research and tax-supported family planning services. Looking first .at population research we can see that its objectives are twofold. The most obvious is the support of goal-oriented research to develop improved methods of fertility regulation and to understand the motivations for their use. Success of this specific objective presupposes a base of knowledge of human reproduction sufficiently broad to make achievement of the goal dependent only on the magnitude of the effort. Yet it is clear, in the case of human reproduction, that the gaps in fundamental knowledge are so great that a strictly goal-oriented program to develop an ideal contraceptive stands little chance of success and could more likely lead to eventual scientific bankruptcy. A second major objective must be the maintenance of a balance between research that answers “how” and research that yields a product; thus we have the distinction between basic and applied research. Primary responsibility for population research in the Federal Government rests with the Center for Population Research of the National Institute of Child Health and Human Development of HEW. The Agency for International Development (AID), HEW’s Food and Drug Administration (FDA), and a host of other Federal agencies and offices are also engaged in population research. Their efforts are reported annually by the Interagency Committee on Population Research.7 The Ford and Rockefeller Foundations and
family
planning
783
and funds
1969 I
program
FY
Funds /millions)
No. of projects
1972 I
Funds fmillions)
381 369
22.5 -20.4
766 310
60.6 20.3
750
42.9
1.076
80.9
the Population Council constitute the major private agencies concerned with this field. In addition, several pharmaceutical companies conduct basic and applied research on reproduction and contraceptive development. Many universities also support both basic and goal-oriented research in population. While it is not possible to tabulate the precise magnitude of all of these efforts, some idea of the trend can be seen in Table I. This table compares the number of grants awarded and funds expended by the Federal Government and by private agencies in 1969 and 1972. It is apparent that while the Federal effort, in both dollars and number of projects, increased appreciably, expenditures of the private agencies did not keep pace. The number of private grants actually decreased slightly, indicating either that smaller grants were consolidated or, more likely, that grants were terminated. The conclusion is evident; any growth in research on populatioq’reproduction will probably have to come from additional commitments of the Federal Government. An analysis of the program of the Center for Population Research (CPR) shows a similar upward trend (Table II). The population research budget has grown from $11.5 million in fiscal year (FYj 1969 to an estimated $40 million in FY 1973. Except for training support, each of the Center’s major divisions shown in Table II has had a three to four times increase in budget over the five-year period. Fig. ! divides the program into three major subdivisions progressing from: ( 1) the most fundamental research (2) through directed fundamental research (3) to the most goal-oriented area of product development. Fundamental research originatw with the investigator and is grant-sup-
784
Novrmber Am. J. Obstet.
Hellmarl
Fundamental (imtludes
Fig. 1. Center
Table II. Center
for
Population
for Population
Research,
Research,
NICHD,
population
N.I.C.H.D.“:
15, 1973 Gynecol.
Research Centers and
research
program
Population
research
distribution.
budget
(in millions)
Research projects Contraceptive development reproductive biology) Evaluation of Contraceptives Social sciences Center core support Training Scientific information Staff support (including information)
1 ~~ctYl:p
Institute
services scientific
of Child
) FY (actual)1972
8.8
15.3
24.3
33.4
32.8
(6.5) (1.3) (1.0)
(11.6)
(15.0) (3.2)
2.4
2.7
(22.7) (5.5) (5.2) 1.6 2.8 0.2
(22.6) (5.1) (5.1) 2.0 2.4 0.3
(including
and
Health
(1.6) (2.1)
(6.1) 0.3 3.0
technical
Totals *National
1 FY (actual)1971
/ (estamated) FY 1973
j Ta’cY-;
and Human
0.3
0.7
11.5
18.7
0.8
2.0
28.4
2.3
40.0
39.8
Development.
ported, while research carried out by the other two divisions is initiated by the Center’s staff and is contract-supported. This compartmentalization emphasizes our intent to maintain a balance between basic and goaloriented research and to have at least 50 per cent of the program devoted to basic investigator-oriented research. The five-year span under consideration is too short a period to yield a precise statement of success or failure of the research program. While the perfect contraceptive has not been developed, and there is little likelihood that it will be in the immediate future, there are several areas of progress than can be cited. In recent years a majority of published research on population and reproduction cite support from the Center. Due in large part to Center support there has been a striking
increase in fundamental knowledge of ovulation and of the function of the oviduct. This accumulation of knowledge could easily form the underpinning of more goal-directed research and even product development. Several examples of the Center’s specific achievements during the past year are: 1. Synthesized 4.0 Gm. of hypothalamicreleasing factor for distribution to scientists, thus providing the major low-cost source
of
this
significant
and
promising
regulatory factor. 2. Synthesized a number of prostaglandin analogues, one of which does not stimulate
smooth
muscle,
thus
separating
the
abortifacient action from other potential antifertility effects. 3. Developed a test sensitive enough to detect pregnancy as early as five days
Volume Number
117 6
Table III. and Federal
Federal
Population agencies FY 1971 (est.)
Totals
70-80
research : Five-year (in millions of dollars)
cost projections,
FY 1972 (est.)
80-100
after fertilization, making pregnancy detectable five weeks earlier than previously possible. 4. Supported the recently completed National Fertility Study. This survey devoted particular emphasis to the causes of changes in fertility patterns. One important finding of the study was that unwanted fertility declined 35 per cent for whites and 56 per cent for blacks from 1960 to 1970. Another important finding indicated that one in six couples currently select sterilization as a method of fertility control. These selected examples may seem insignificant in view of the amount of money spent, but I do not believe that scientific advances can be measured by the cost-effective approach, nor is it possible to project future costs based on precisely anticipated results. A more plausible approach is to estimate what can be effectively spent. Table III shows an attempt to estimate the combined Federal and private cost projections through the year 1975. Obviously, these projections are neither commitments by Federal or private funding agencies nor even guarantees of availability of funds within the broad ranges indicated. Realistically, these estimates will probably not be met in the next few years since no significant increase in Federal funding of population research is expected in either FY 1973 or FY 1974. For the short term, then, there are several options: We can eliminate some programs, such as the Population Research Centers, or contraceptive evaluation, or training. If these three activities were phased out, $11 million could be added to the Center’s contraceptive development program and to its social science efforts, thus accounting for an increase of about 35 per cent in each of the latter areas. Another approach
FY 1973 (proj.
range)
100-150
family
planning
by American
FY 1974 range) 130-190
(proj.
program
785
nonprofit
FY 1975 (proj. range) 150-220
is to decide that all of the programs we have initiated during the past five years are worthy of continuing support, but their support levels should be reduced, perhaps by as much as 30 per cent, with an approximately similar saving. Choices of this type will be hard ones, but they will have to be made in view of forthcoming budget constraints. To make these choices intelligently, the review systems for contract and grant awards will have to be examined critically and perhaps changed. The peer review systems were originated and served well in the days when Federal budgets for research were constantly increasing. Their utility during periods of nongrowth or even decline in budgets may be seriously questioned. Service
programs
Federal family planning services are administered by several agencies, the principal one being the National Center for Family Planning Services, The major objectives of the Federal family planning services programs were established by three separate pieces of legislation. The first objective, outlined in the Society Security Amendments of 1967,* required each state to have a plan for extending family planning services to all mothers in all parts of the state by July 1, 1971. The second objective, established by the Family Planning Services and Population Research Act of 1970, Title X,6 is to assist in making voluntary comprehensive family planning services readily available to all persons desiring these services. This legislation now furnishes the major portion of the funds for family planning services programs. The third and most recent objective, stated in the Social Security Amendments of 1972 (H.R. 1) ,8 requires states to make state-wide family planning services available on a voluntary and
786
November Am. J. Obstet.
Hellman
Table IV. Family Projected need over FY 1971 to 1975
planning services: 12 month period,
FY
NO.
I
1971 1972 1973 1974 1975
6,073,OOO 6,189,OOO 6,317,OOO 6,448,OOO 6.582.000
Table V. Family planning services: Distribution of new patients in selected organized programs by poverty status, 1971 Percentage
125% of
No. of new fiatients
518.155
of
new
150% of
patients
200% of
poverty
poverty
#overty
70
79
90
Table VI. Family planning services: Total reported and estimated patients served in FY 1968 to FY 1971 FY
1968 1969” 1970” 1971 1972t *Estimated +Projected.
/
,%::tx
863,000 1,070,000 1,410,000 1,915,ooo 2,612,OOO
/
E;ky”q’
207,000 340,000 505,000 697,000
;:;:ft
ii 32 36 36
by extrapolation.
confidential basis to present, former, or likely recipients of cash assistance who are of child-bearing age and who desire such services. In contrast to research efforts, whose goals cannot be subjected to numerical assessments, the services program has targeted goals to comply with its legislative mandates. Its achievements, therefore, can be easily measured by counting the number of recipients of its services. The Federal program is directed at “lo’w-income women.” Once this category is defined, a target population approximating the magnitude of the task can be determined, as shown in Table IV. This table reflects the increase in the number of women in the age group 15 to 44 years with
15, 1973 Gynecol.
incomes below 150 per cent of the poverty level*g for each year 1971 through 1975. Obviously these estimates will have to be revised periodically in accordance with data from special Census Bureau tabulations. The selection of an income below 150 per cent of the poverty level for the target population is somewhat arbitrary, but it is valid if the purpose of family planning services is to prevent poverty by preventing the birth of an additional child that would tip the balance and place the family on welfare. An improved method of calculating the number of women requiring subsidized family planning services might be obtained by examining the income levels of the patients served. Examination of Table V reveals the difficulty of using an arbitrary income level or even an arbitrary percentage of a given poverty level to measure the population who will require subsidized family planning services. An estimated 70 per cent of the patients now being served have incomes below 125 per cent of poverty, and 90 per cent of patients using subsidized services would have incomes below 200 per cent of the poverty level if that yardstick were selected. The total number of patients served annually from 1968 through 1972 in organized subsidized programs, both Federal and private, is shown in Table VI and Fig. 2. Whereas the cost of the Federal programs and the estimates of the target population are based on 150 per cent of the poverty level, about 25 per cent of the patients in the programs in 1972 had incomes above 150 per cent poverty level. Therefore, of the 2.6 million estimated to have been served in FY 1972, 1.96 million had incomes congruent with the estimates of need. Data obtained from several surveys indicate that a surprising number of low-income patients are provided family planning services by private physicians. A combination of several of these surveys and data from the Fertility Survey of 19701’ showed that an estimated 19 per cent of all low-income women *The of four.
1972 poverty
level
is $4,300 for
a nonfarm
family
Volume Number
117 6
Federal
family
planning
program
787
rhmbcr of Patients (in 000'S)
2.500
2,ooo-
1,500-
l,ooO-
500 1 . 1968
1969
Fig. 2. Family planning services: Reported programs, FY 1968 to FY 1972. in need were currently receiving family planning services from private physicians. Since the proportion of those to be served in this manner is expected to increase, the projections shown in Table VII seem realistic. Organized programs served about 2.6 million patients in FY 1972, an estimated three quarters of whom, or about 1.96 million, had incomes below 150 per cent of poverty. The estimated number of women in need of services over the 12 month period of FY 1972, calculated to approximate 150 per cent of the poverty level, is 6.189 million women; an estimated one fifth, or 1.238 million, received family planning services from private physicians. Table VIII combines these estimates to show that approximately 52 per cent of the need of family planning services at the 150 per cent poverty level is currently being met. In other words, this program is very nearly on track. Cost beneftt Federal assistance for family planning services results in savings to individuals and to
1970
1971
1972
and estimated patients served in family planning the government. These savings can be estimated by making conservative approximations of the number of births averted due to tax-supported family planning programs, the costs of these births, as well as medical care and public assistance during the first years of a child’s life. An analysis of the short-term savings in governmental expenditures is presented in Table IX. From 1967 through 197 1, $174 million was expended, and an estimated savings in excess of half a billion dollars was rea1ized.l’ There are benefits beyond dollar savings that accrue from family planning services. The frequency with which stillbirths occur is influenced by birth intervals, maternal age, and socioeconomic status. Federally supported family planning services, contraception, and voluntary sterilization should therefore have a favorable influence on perinatal mortality rates by permitting mothers of lowincome families to prevent high orders of births and to optimize timing and spacing. Table X shows a decline from 1960 through 1970 in perinatal loss in four selected cities.
788
November
Hellman
Am. J. Obstet.
NATIONAL
Biomedical
I I Basic
INSTITUTES
Sciences
I Goal Oriented
Social
I Product Development
I
I Demography
I Causes of PWtiUty
15, 1973
Gynecol.
OF POPULATION
Sciences
I Consequences of
Environmental
Sciences
I
Ilf
Rqulation Education
I
Resources
1
Pollution
Fertility
Fig. 3.
Table VII. Proportion physicians
Table IX. Estimate of savings in immediate governmental expenditures for medical care and public assistance as a result of births averted by organized family planning programs,* 1967 to 1971
Family planning services: of patients served by private in FY 1971 to 1975
FY
%
I
1971 1972 1973 1974 1975
19 20 21 23 25
FY
Table VIII. Family planning services: Need, patients served and unmet need, at 150 per cent of poverty, FY 1972
1967 1968 1969 1970
*Modified
1
Total served Unmet need
programs
physicians
No. 6,189,OOO 1,959,OOO
/ Et 100 32
1,238,OOO 3,197,ooo
20 52
2,992,OOO
48
In three of these cities the decline was greater than 23 per cent for nonwhites. Although the correlation of decreasing perinatal loss with increasing availability of family planning services is not precise, the fact that the major portion of the decrease occurred during the period of rapid growth of these programs implies a most likely relation.‘? I believe that the day of federally funded categorical health programs administered from Washington is rapidly drawing to a close and rightly so. If all of the social and health programs considered “good” and “necessary” were to be fully funded, the cost would exceed the total Federal budget.l” The actual situation is that budget constraints will increasingly force hard choices concerning a
sands 1
tBirths
Savingsx (thousands)
Ratio
18.1 25.2 60.6 70.0
122 144 223 336
68,648 85,368 140,044 211,008
3.8: 1 3.4: 1 2.3: 1 3.0: 1
173.9
825
505,068
2.9:1
1971 Total
Estimated need Served in organized Served by private
Births averted? (thou-
Expenditure (miZZions)
from Jaffe." averted
take
place
in
calendar
year
following
fircal year. $Savings based on cost of birth ($500) and public assistance and justed to consumer price index.
and one-year food stamps
infant ($128)
care ad-
selection of programs that are not only good but that yield the greatest good. This selection process will in time mean a change from central to local-or at least state-selection of programs. What serves the greatest benefit in one community may be of lesser importance in another. Increasingly the people will be given the means to select and to support the programs they believe they need most. In view of the increasing reluctance to support categorical health programs, continuation of the family planning services programs until the stated goal is fully achieved is at best an optimistic hope. Whether the entire target population or only a major percentage of that population is reached, family planning, some time before 1980, will be integrated into the general health services of
Volume Number
117 6
Federal
Table X. Perinatal United
death
rates by race for
1960 and
family
planning
program
789
1970 in selected
States cities
City
1
Atlanta Cleveland New York St. Louis
City
Year
1960 1970 1960 1970 1960 1970 1960 1970
(
Total
42.1 37.9 41.0 31.4 31.6 26.5 42.9 36.1
1 Whit~tYNegro
41.0 29.2 36.2 25.8 25.4 22.4 33.0 28.1
( %Z
43.4 43.4 49.9 38.3 47.7 34.1 58.3 42.7
the nation. If this transfer is attempted too quickly, before the majority of services are in place and functional, the goal of the President’s 1969 Message to make family planning services available to all in need may never be realized. A more rational approach would be to support the program until a critical mass of services is in place and until a plan for phased integration of family planning services into the health care system can be devised. As little as three more years would be required to accomplish this task. Whether or not the projected goal is ever reached, this country will continue to have problems that relate to an expanding population. Research into the causes and consequences of fertility and its control, as well as a host of related issues such as urbanization, migration, utilization of resources, and pollution are not concerns of the individual states or regions. Such research will have to be carried forward on a national basis with national funding. The questions we now have to ask are: What is the best organizational pattern for funding these diverse research efforts? How can their expansion be encouraged? How do we incorporate and utilize this research in governmental and social decision making? The Report of the Commission on Population Growth and the American FutureI’ constantly reminds us that “we do not know” . . . “we need to know.” As family planning services assume their rightful place in the health care system, the need to know the
36.4 25.8 -
1 Total
-10.0 -23.4 -16.1 -15.9
1 Ili::“i
-28.8
‘:I
( ‘,uiZE
0.0
-
-28.7
-23.2
-
-11.8
-28.5
-29.1
-14.8
-26.8
1
answers to the questions just raised takes on an added, crucial dimension. There are several major options to be considered in planning : 1. We can allow things to remain as they are, leaving to the National Institutes of Health what is now theirs and developing new units where they best fit or where they naturally arise through individual interests or expediency. I submit that this laissez-faire response would not produce the focused and coordinated effort that the multiple problems of population growth merit. Rather, the researches would be splintered and minimally effective in formulating action. 2. New institutes can be created within the N.I.H. system as needs arise. In the decades when research funding was continually expanding, new institutes signaled increased visibility, larger budgets, and more prestigious leadership; such is no longer the case. If new institutes are to be added, they must serve a vital public need and must give reasonable promise of providing utilizable answers. 3. We can recognize the population issue as of overriding importance whose research issues, divergent as they may be, have a central core and a need for cohesion so that their results can be brought to bear effectively before the time has come when they are no longer pertinent. Fig. 3 is a sketch of a National Institutes of Population with three subsidiary institutes recognizing these separate but related sci-
790
November Am. J. Obstet.
Hellman
ences : biomedical, social, and environmental. Under each is a number of divisions. These are not all the possible divisions, but they are suggested as most clearly appropriate. A National Institutes of Population is unlikely to be initiated soon. It may never come into existence in the form suggested in Fig. 3 but the imaginative planning indicated in this
Eastman, N. J., and Hellman, L. M.: Williams’ Obstetrics, ed. 12, New York, 1961, Appleton-Century-Crofts, Inc. Hellman, L. M. : Eugen. Rev. 57: 161, 1965. Griswold vs. Connecticut: Report of U. S. Supreme Court 381: 479, 1965. 90th Congress: Social Security Amendments of 1967. P.L. 90-248. Washington., D. C.. G.P.O., Jan. 2, 1968. Nixon, R. M.: Message to the Congress from the President of the United States Relative to Population Growth, Washington, D. C., G.P.O., July 21, 1969. 91st Congress: The Family Planning Services and Population Research Act of 1970, P.L. 91-572, Washington, D. C., G.P.O., Dec. 24, 1970. Interagency Committee on Population Research : Center for Population Research, NICHD, NIH, Department of Health, Education and Welfare, Washington, D. C. 92nd Congress : Social Security Amendment of 1972, P.L. 92-603 (H.R. l), Washington, D. C., Oct. 30, 1972.
2. 3. 4.
5.
6.
7.
8.
approach is necessary if population issues are to be effectively researched. Whatever structure is eventually built to accomplish this objective, the steps taken in the immediate future should be such as to promote, not impede, the development of a new, effective, and encompassing approach.
9. Characteristics
REFERENCES
1.
15, 1973 Gynecol.
Discussion
10.
11.
of the Low-Income Population, 1972, Current Population Reports, Series P60, No. 86, December, 1972, Bureau of the Census, Washington, D. C. 1970 National Fertility Study: Office of Population Research, Princeton University, Princeton, N. J., 1971, Princeton University Press. Jaffe, F. S.: Short-Term Costs and Benefits of the Federal Family Planning Program, Center for Family Planning Program Develop-
ment, Planned Parenthood-World 12.
13.
14.
Population,
New York City, Personal communication, Jan. 3, 1973. Tyler, C. W.: Center for Disease Control, Atlanta, Ga., Personal communication, Jan. 16, 1973. Richardson, E. L. : Responsibility and Responsiveness (II), A Report on the HEW Potential for the Seventies, p. 41, Washington, D. C., Jan. 19, 1973, Department of Health, Education and Welfare. Report by the Commission on Population Growth and the American Future, Washington, D. C., G.P.O., March 1972.
as December, 1959, President Eisenhower referred to birth control by saying “I cannot imagine anything more emphatically a subject
individuals who were most influential in altering policy during this 15 year period, they would be William Draper, Jr., Hugh Moore, Alan Guttmacher, John D. Rockefeller, III, and Louis M. Hellman. Dr. Hellman has presented a fine review of federal accomplishments over the past five years. During this time he has been a cog in the slow-
that
grinding
W. PAGE, San Francisco, California. There has been a remarkable change in the attitude of our state and federal governments DR.
ERNEST
toward
contraception
is
activity later,
not
in the
a proper
or function President
last
political
15 years.
or
governmental
or responsibility.”
Nixon
stated
that
As late
“this
Ten years adminis-
tration does accept a clear responsibility to provide essential leadership” in the field of U. S. and world population growth. The forces which brought about this reversal of policy are complex, but policy process actually takes place at the boundary of the system.’
interaction If I were
between to select
individuals and five charismatic
wheel
of
bureaucracy,
HEW,
of the
work,
system
a
monstrous
administrative
but he has made as I have
observed
his part first-hand
as a member of his Advisory Committee. At the outset of his paper, Dr. Hellman posed two questions: (1) Is the program on track toward meeting its expected goals? and (2) Are the health and social benefits of family planning programs commensurate with their cost? I would like to add my personal views on both questions.
Volume 117 Number 6
The attainment of a family planning services goal obviously depends upon its definition. The 1966 estimate of the number of poor or near-poor women in need of contraceptive services was 4.6 million. Last year this figure was re-estimated by Blake and Das Guptas to be only 1.2 million, whereas the new HEW estimate for 1972 was 6 million. By 1975, well over 6 million new patients will have been served. Regardless of numbers, a crucial question is whether this population, served once, needs to revisit clinics at least annually to maintain the goal of preventing unwanted pregnancies. If so, and this may well be true, completion of the task is never ending. As to whether the benefits of the service programs outweigh the costs, my answer is unequivocally yes. Apart from contraception, current federal standards for family planning clinics require many preventive health measures such as the detection of gonorrhea, cancer screening, measurements of blood pressure, pelvic examinations, screening for anemias, and so forth. All of this, plus contraception, costs about $60.00 for a new patient, and for many this may be the woman’s first entry into a health-care system. As opposed to remedial health care, preventive health care is a bargain. Furthermore, the prevention of unwanted pregnancies is of itself an enormous social and economic benefit, and small investments of our tax dollars can be shown to yield many times that amount in future savings of public funds. The administration plans to eliminate categorical programs and combine them with the Mediwhich is tantamount to the caid program, elimination of family planning services for all but about 20 per cent of those in need.3 Is there any more important business for our nation than assuring the birth of an appropriate number of both healthy and wanted children? I wish that Dr. Hellman would be as militant in prodding the government to continue the categorical family planning program indefinitely as he was in 1958 when he fought the New York Health Department. With respect to research in human reproductive biology and population studies, I feel ambivalent about creating a new large and unbelievably heterogeneous federal intramural program, but I believe it is crucial to expand support for extramural programs. Dr. Hellman believes that some research areas must be curtailed or eliminated “in view of forthcoming budget con-
Federal
family
planning
program
791
straints.” Do we need to accept such constraints without loud cries of protest? I feel as strongly about this as I do about the elimination of training programs and fellowships in the area of medical research. Considering the documented health and social benefits of the family planning programs, the continued manpower development needs in the biomedical field and the urgent need for research in human reproductive biology and population, eliminating substantial federal support for all three is truly killing the goose that lays the golden egg. A hopeful note is that because of or perhaps despite the government’s efforts, our crude birth rate has dropped to 16 per 1,000 population, and we are now at the zero population growth rate of less than 2.1 children per couple. This means that in 25 years or so, one out of every three persons in the United States may be 65 or older, which should supply ample membership opportunities for this Society. REFERENCES
1. Piotrow, P. T. : World Population Crisis: The United States Response, New York, 1973, Praeger Publishers, p. 223. 2. Blake, J., and Das Gupta, P.: Demography 9: 569, 1972. 3. Rosoff, J. I.: Family Planning Perspectives 5: 7, 1973. DR. HARRY PRYSTOWSKY, Gainesville, Florida. This is a solid paper that contains considerable information. And most importantly, in contradistinction to the majority of writing that comes from HEW, it is easy to read. I wish to make three points and close with a poem. In the area of service rendered, there is little question that this is an excellent effort and probably one of the best examples of a service-oriented program that has come from HEW in at least the past 15 years. It might well serve as an example for all of us who are interested in the aspects of health care delivery. The service granted a large population is defined, the objectives are defined, the results are given, the cost in dollars is reported, and the benefits accrued in dollars is reported. It disturbs me a bit that Dr. Hellman says we will wait several years and then this is to merge into comprehensive health. I do not quite understand what comprehensive health is; it is perhaps confusion at the state level of how to get at it. And I wonder why wait. This is a program that can be used as a model. It has
792
Novemberl5, 1973 Am. J. Obstet. Gynecol.
Hellman
specific results and data. Why should not this program be moved now into comprehensive health planning and possibly lead those who are in the planning stages in that area? Dr. Hellman speaks of a new institute. I wonder whether this is rhetoric. What is its status? Interestingly, I differ with Dr. Page. I think this is a necessity. I wonder whether the leading organizations that have personnel in obstetrics and gynecology have had input into this concept. For certainly, if this does come about, it will serve as a major national resource for the discipline of obstetrics and gynecology. And my last point is a question: What may be the environment and/or restrictions upon Dr. Hellman? Toward this point, a poem entitled
so ago. The question asked of the person being interviewed was whether I had won any fights with the Administration, and the answer was, “Won any! Hell, he hasn’t even fought any.” I am a little ashamed to be classed among unthinking passive followers of the Administration.
tion,
night
before
Christmas.
T’was the night before Christmas, and all through the halls All the creatures were stirring, and cleaning the walls ; Their stockings care, In hopes that
were St.
hung Casper
by the
chimney
with
would
answer
their
prayer ; The
Branch Chiefs were snug in the conference room, All settled down for some pre-Christmas gloom When out on the street there arose such a clatter I sprang from a desk to see what was the matter. Away to the window I flew on a hunch, Tore open the shutter and threw up my lunch. What did my tired old eyes seem to see, But a jet-propelled sleigh that was marked OMB,
And the jolly old driver, a droll little chap, I knew in an instant it must be St. Cap. The moon on the breast of the new-fallen snow, Showed that jobs were all frozen and so was the dough, And then in a moment, I froze in my tracks, Down the chimney St. Casper, he came with an axe. He spoke not a word, but with deadly intent, He cut all the stockings by 50 per cent; And then without turning or glancing at me, He swiftly proceeded to chop down my tree; Up the chimney he rose, to his team gave a whistle, And away they all flew like a misguided missile. But I heard him exclaim with a wave of his thumb, Merry Christmas to all, Happy New Year to none.
DR. HELLMAN (Closing). As usual, Dr. Page offered a criticism that comes a little close to home. He indicated that I should be more militant in the sense of my program. I am reminded of an anonymous interview that appeared in one of the Washington gossip sheets about a year or
however,
like
to
point
out
some-
namely,
the
dispersal
of health
care
systems
to regions or states. In other words, closer to the people. And the third, is to remove the government
The
I would,
thing about how decision-making is achieved in the health field. The Administration has decided on three principles that form the Secretary’s approach to Congress on all questions of health. The first is economy and efficiency. The second is regionaliza-
from
direct
health
care.
If these objectives are achieved, I suggest that there soon will be very few, if any, govemmentally run health programs; even the Indian Health Service could be threatened. At my level we have no input into such decision-making. Even the Secretary of HEW may be only tangentially concerned. Once these decisions are made, then subsequent decisions fall into place. Again, we are given very
little,
if any,
opportunity
to oppose
such
de-
cisions even in testimony before Congress. Obviously, one of two things can be done. (1) One can resign. If that is the decision, one may
make
headlines
for
half
a day,
but
that
will
be the end of it. Resignation accomplishes nothing. (2) One can revolt and go before Congress and say, a bunch
“I
don’t
believe
of baloney,” If you do that, when office there will be a your desk be emptied ning. Anyone
can
walk
any
of
this
stuff,
is is
and present the reasons. you arrive back at your telephone call asking that by 5 :00 o’clock that eve-
away
from
a situation.
That
is the easiest possible choice. Those who choose to stay select the harder way. Currently, there is little give in Administration policy regarding health no significant increases
in
care. There budget for
have fiscal
been year
1974 and the only chances for growth remain in the public assistance programs that are beyond the control of the Administration. If we are going to have health programs in the future, financed by the Federal Government, then we need to document them both in terms of need and in terms of cost benefits; an exercise that medicine has never before been required to perform. We, the doctors, are not considered neutral; we are not considered individuals whose judgment is
Volume Number
117 6
unbiased. Rather, we are believed to be selfperpetuating proponents of a system that formally raided the budget on an annual basis. For this reason, health care decisions are made by lawyers and business school graduates and not doctors. Dr. Prystowsky, the time is short and I am unable to answer your questions. I would like to
Federal
family
planning
program
793
say, however, that the poem you read was sung to Mr. Weinberger and Mr. Richardson on Christmas Eve afternoon. Both smiled and laughed in the appropriate places, but when Secretary Weinberger testified about health programs before the Congress recently the gentle ribbing in the poem apparently had no effect.
M.
HELLMAN,
M.D.*
D. C.
Primary responsibility for population research in the Federal Government rests with the Center for Population Research of the National Institute of Child Health and Human Development of HEW. Federal assistance for family planning services results in savings to individuals and to the government, and in many benefits beyond dollar savings. Family planning services programs may soon be integrated into the general health services of the nation. A National Institutes of Population may never come into existance, but the imaginative planning indicated by such an approach is necessary if population issues are to be effectively researched.
F o R M o R E than two generations, Americans have been practicing contraception for health reasons, for economic advantage, and because women in our society have increasingly assumed the right to control their own fertility. But until recently a large segment of our people, notably the poor, has been denied contraceptive services. Failure to provide access to this preventive health service was not primarily because of moral reasons or religious prejudice, although these factors played a significant role, but because the health benefits of family planning services were not sufficiently appreciated to merit high priority. The subject of contraception was not taught to medical students and was not even mentioned in our obstetrical texts until 1961.l In 1930 a small portion of Federal Maternal and Child Health funds were used for contraceptive services in the southeastern area of the United States. This was a beginning and since then tax-supported contraception for the economically underpriviliged
*Deputy Assistant Population Affairs, Health, Education
has been gaining increasing acceptance. The New York birth control fight of 19582 and the Supreme Court decision in Griswold vs. Connecticut in 19653 are milestones along the way. The first significant Federal effort to provide family planning services came in 1967 with the passage of the Social Security Amendments4 allotting a percentage of child and maternal health funds to family planning services. Even more important, however, was President Nixon’? Message on Population in July 1969. This Message to Congress recognized the problems created by population growth and by unequal access to contraceptive services because of economic or social barriers. Among other recommended actions, President Nixon requested legislation to increase population research and to make family planning services available to all who need and want such services but who cannot afford them. A little more than a year later Congress responded with the passage of the Family Planning Services and Population Kesearch Act of 1970, P.L. 91-57Z6 Now, after five years of accelerated Federal funding, it is fitting that we look at the achievements of this program. Two questions are paramount to the discussion: ( 1) is the program on track toward meeting its ex-
Secretary for Department of and Welfare.
Presented at the Ninety-sixth Annual Meetine of the American GvnecoloPical Society; Colorado Springs, c!Yoloradg, May 2-5, 1973. 782
Volume Number
117 6
Federal
Table I. Estimated
number
of population
research
projects FY
No. of projects All Federal agencies Three major private
nonprofit
U.
S. agencies
Total
petted goals and (2} are its health and social benefits commensurate with its cost? Furthermore, in view of changing attitudes about large federally funded social programs, we need to assess the future direction of population research and tax-supported family planning services. Looking first .at population research we can see that its objectives are twofold. The most obvious is the support of goal-oriented research to develop improved methods of fertility regulation and to understand the motivations for their use. Success of this specific objective presupposes a base of knowledge of human reproduction sufficiently broad to make achievement of the goal dependent only on the magnitude of the effort. Yet it is clear, in the case of human reproduction, that the gaps in fundamental knowledge are so great that a strictly goal-oriented program to develop an ideal contraceptive stands little chance of success and could more likely lead to eventual scientific bankruptcy. A second major objective must be the maintenance of a balance between research that answers “how” and research that yields a product; thus we have the distinction between basic and applied research. Primary responsibility for population research in the Federal Government rests with the Center for Population Research of the National Institute of Child Health and Human Development of HEW. The Agency for International Development (AID), HEW’s Food and Drug Administration (FDA), and a host of other Federal agencies and offices are also engaged in population research. Their efforts are reported annually by the Interagency Committee on Population Research.7 The Ford and Rockefeller Foundations and
family
planning
783
and funds
1969 I
program
FY
Funds /millions)
No. of projects
1972 I
Funds fmillions)
381 369
22.5 -20.4
766 310
60.6 20.3
750
42.9
1.076
80.9
the Population Council constitute the major private agencies concerned with this field. In addition, several pharmaceutical companies conduct basic and applied research on reproduction and contraceptive development. Many universities also support both basic and goal-oriented research in population. While it is not possible to tabulate the precise magnitude of all of these efforts, some idea of the trend can be seen in Table I. This table compares the number of grants awarded and funds expended by the Federal Government and by private agencies in 1969 and 1972. It is apparent that while the Federal effort, in both dollars and number of projects, increased appreciably, expenditures of the private agencies did not keep pace. The number of private grants actually decreased slightly, indicating either that smaller grants were consolidated or, more likely, that grants were terminated. The conclusion is evident; any growth in research on populatioq’reproduction will probably have to come from additional commitments of the Federal Government. An analysis of the program of the Center for Population Research (CPR) shows a similar upward trend (Table II). The population research budget has grown from $11.5 million in fiscal year (FYj 1969 to an estimated $40 million in FY 1973. Except for training support, each of the Center’s major divisions shown in Table II has had a three to four times increase in budget over the five-year period. Fig. ! divides the program into three major subdivisions progressing from: ( 1) the most fundamental research (2) through directed fundamental research (3) to the most goal-oriented area of product development. Fundamental research originatw with the investigator and is grant-sup-
784
Novrmber Am. J. Obstet.
Hellmarl
Fundamental (imtludes
Fig. 1. Center
Table II. Center
for
Population
for Population
Research,
Research,
NICHD,
population
N.I.C.H.D.“:
15, 1973 Gynecol.
Research Centers and
research
program
Population
research
distribution.
budget
(in millions)
Research projects Contraceptive development reproductive biology) Evaluation of Contraceptives Social sciences Center core support Training Scientific information Staff support (including information)
1 ~~ctYl:p
Institute
services scientific
of Child
) FY (actual)1972
8.8
15.3
24.3
33.4
32.8
(6.5) (1.3) (1.0)
(11.6)
(15.0) (3.2)
2.4
2.7
(22.7) (5.5) (5.2) 1.6 2.8 0.2
(22.6) (5.1) (5.1) 2.0 2.4 0.3
(including
and
Health
(1.6) (2.1)
(6.1) 0.3 3.0
technical
Totals *National
1 FY (actual)1971
/ (estamated) FY 1973
j Ta’cY-;
and Human
0.3
0.7
11.5
18.7
0.8
2.0
28.4
2.3
40.0
39.8
Development.
ported, while research carried out by the other two divisions is initiated by the Center’s staff and is contract-supported. This compartmentalization emphasizes our intent to maintain a balance between basic and goaloriented research and to have at least 50 per cent of the program devoted to basic investigator-oriented research. The five-year span under consideration is too short a period to yield a precise statement of success or failure of the research program. While the perfect contraceptive has not been developed, and there is little likelihood that it will be in the immediate future, there are several areas of progress than can be cited. In recent years a majority of published research on population and reproduction cite support from the Center. Due in large part to Center support there has been a striking
increase in fundamental knowledge of ovulation and of the function of the oviduct. This accumulation of knowledge could easily form the underpinning of more goal-directed research and even product development. Several examples of the Center’s specific achievements during the past year are: 1. Synthesized 4.0 Gm. of hypothalamicreleasing factor for distribution to scientists, thus providing the major low-cost source
of
this
significant
and
promising
regulatory factor. 2. Synthesized a number of prostaglandin analogues, one of which does not stimulate
smooth
muscle,
thus
separating
the
abortifacient action from other potential antifertility effects. 3. Developed a test sensitive enough to detect pregnancy as early as five days
Volume Number
117 6
Table III. and Federal
Federal
Population agencies FY 1971 (est.)
Totals
70-80
research : Five-year (in millions of dollars)
cost projections,
FY 1972 (est.)
80-100
after fertilization, making pregnancy detectable five weeks earlier than previously possible. 4. Supported the recently completed National Fertility Study. This survey devoted particular emphasis to the causes of changes in fertility patterns. One important finding of the study was that unwanted fertility declined 35 per cent for whites and 56 per cent for blacks from 1960 to 1970. Another important finding indicated that one in six couples currently select sterilization as a method of fertility control. These selected examples may seem insignificant in view of the amount of money spent, but I do not believe that scientific advances can be measured by the cost-effective approach, nor is it possible to project future costs based on precisely anticipated results. A more plausible approach is to estimate what can be effectively spent. Table III shows an attempt to estimate the combined Federal and private cost projections through the year 1975. Obviously, these projections are neither commitments by Federal or private funding agencies nor even guarantees of availability of funds within the broad ranges indicated. Realistically, these estimates will probably not be met in the next few years since no significant increase in Federal funding of population research is expected in either FY 1973 or FY 1974. For the short term, then, there are several options: We can eliminate some programs, such as the Population Research Centers, or contraceptive evaluation, or training. If these three activities were phased out, $11 million could be added to the Center’s contraceptive development program and to its social science efforts, thus accounting for an increase of about 35 per cent in each of the latter areas. Another approach
FY 1973 (proj.
range)
100-150
family
planning
by American
FY 1974 range) 130-190
(proj.
program
785
nonprofit
FY 1975 (proj. range) 150-220
is to decide that all of the programs we have initiated during the past five years are worthy of continuing support, but their support levels should be reduced, perhaps by as much as 30 per cent, with an approximately similar saving. Choices of this type will be hard ones, but they will have to be made in view of forthcoming budget constraints. To make these choices intelligently, the review systems for contract and grant awards will have to be examined critically and perhaps changed. The peer review systems were originated and served well in the days when Federal budgets for research were constantly increasing. Their utility during periods of nongrowth or even decline in budgets may be seriously questioned. Service
programs
Federal family planning services are administered by several agencies, the principal one being the National Center for Family Planning Services, The major objectives of the Federal family planning services programs were established by three separate pieces of legislation. The first objective, outlined in the Society Security Amendments of 1967,* required each state to have a plan for extending family planning services to all mothers in all parts of the state by July 1, 1971. The second objective, established by the Family Planning Services and Population Research Act of 1970, Title X,6 is to assist in making voluntary comprehensive family planning services readily available to all persons desiring these services. This legislation now furnishes the major portion of the funds for family planning services programs. The third and most recent objective, stated in the Social Security Amendments of 1972 (H.R. 1) ,8 requires states to make state-wide family planning services available on a voluntary and
786
November Am. J. Obstet.
Hellman
Table IV. Family Projected need over FY 1971 to 1975
planning services: 12 month period,
FY
NO.
I
1971 1972 1973 1974 1975
6,073,OOO 6,189,OOO 6,317,OOO 6,448,OOO 6.582.000
Table V. Family planning services: Distribution of new patients in selected organized programs by poverty status, 1971 Percentage
125% of
No. of new fiatients
518.155
of
new
150% of
patients
200% of
poverty
poverty
#overty
70
79
90
Table VI. Family planning services: Total reported and estimated patients served in FY 1968 to FY 1971 FY
1968 1969” 1970” 1971 1972t *Estimated +Projected.
/
,%::tx
863,000 1,070,000 1,410,000 1,915,ooo 2,612,OOO
/
E;ky”q’
207,000 340,000 505,000 697,000
;:;:ft
ii 32 36 36
by extrapolation.
confidential basis to present, former, or likely recipients of cash assistance who are of child-bearing age and who desire such services. In contrast to research efforts, whose goals cannot be subjected to numerical assessments, the services program has targeted goals to comply with its legislative mandates. Its achievements, therefore, can be easily measured by counting the number of recipients of its services. The Federal program is directed at “lo’w-income women.” Once this category is defined, a target population approximating the magnitude of the task can be determined, as shown in Table IV. This table reflects the increase in the number of women in the age group 15 to 44 years with
15, 1973 Gynecol.
incomes below 150 per cent of the poverty level*g for each year 1971 through 1975. Obviously these estimates will have to be revised periodically in accordance with data from special Census Bureau tabulations. The selection of an income below 150 per cent of the poverty level for the target population is somewhat arbitrary, but it is valid if the purpose of family planning services is to prevent poverty by preventing the birth of an additional child that would tip the balance and place the family on welfare. An improved method of calculating the number of women requiring subsidized family planning services might be obtained by examining the income levels of the patients served. Examination of Table V reveals the difficulty of using an arbitrary income level or even an arbitrary percentage of a given poverty level to measure the population who will require subsidized family planning services. An estimated 70 per cent of the patients now being served have incomes below 125 per cent of poverty, and 90 per cent of patients using subsidized services would have incomes below 200 per cent of the poverty level if that yardstick were selected. The total number of patients served annually from 1968 through 1972 in organized subsidized programs, both Federal and private, is shown in Table VI and Fig. 2. Whereas the cost of the Federal programs and the estimates of the target population are based on 150 per cent of the poverty level, about 25 per cent of the patients in the programs in 1972 had incomes above 150 per cent poverty level. Therefore, of the 2.6 million estimated to have been served in FY 1972, 1.96 million had incomes congruent with the estimates of need. Data obtained from several surveys indicate that a surprising number of low-income patients are provided family planning services by private physicians. A combination of several of these surveys and data from the Fertility Survey of 19701’ showed that an estimated 19 per cent of all low-income women *The of four.
1972 poverty
level
is $4,300 for
a nonfarm
family
Volume Number
117 6
Federal
family
planning
program
787
rhmbcr of Patients (in 000'S)
2.500
2,ooo-
1,500-
l,ooO-
500 1 . 1968
1969
Fig. 2. Family planning services: Reported programs, FY 1968 to FY 1972. in need were currently receiving family planning services from private physicians. Since the proportion of those to be served in this manner is expected to increase, the projections shown in Table VII seem realistic. Organized programs served about 2.6 million patients in FY 1972, an estimated three quarters of whom, or about 1.96 million, had incomes below 150 per cent of poverty. The estimated number of women in need of services over the 12 month period of FY 1972, calculated to approximate 150 per cent of the poverty level, is 6.189 million women; an estimated one fifth, or 1.238 million, received family planning services from private physicians. Table VIII combines these estimates to show that approximately 52 per cent of the need of family planning services at the 150 per cent poverty level is currently being met. In other words, this program is very nearly on track. Cost beneftt Federal assistance for family planning services results in savings to individuals and to
1970
1971
1972
and estimated patients served in family planning the government. These savings can be estimated by making conservative approximations of the number of births averted due to tax-supported family planning programs, the costs of these births, as well as medical care and public assistance during the first years of a child’s life. An analysis of the short-term savings in governmental expenditures is presented in Table IX. From 1967 through 197 1, $174 million was expended, and an estimated savings in excess of half a billion dollars was rea1ized.l’ There are benefits beyond dollar savings that accrue from family planning services. The frequency with which stillbirths occur is influenced by birth intervals, maternal age, and socioeconomic status. Federally supported family planning services, contraception, and voluntary sterilization should therefore have a favorable influence on perinatal mortality rates by permitting mothers of lowincome families to prevent high orders of births and to optimize timing and spacing. Table X shows a decline from 1960 through 1970 in perinatal loss in four selected cities.
788
November
Hellman
Am. J. Obstet.
NATIONAL
Biomedical
I I Basic
INSTITUTES
Sciences
I Goal Oriented
Social
I Product Development
I
I Demography
I Causes of PWtiUty
15, 1973
Gynecol.
OF POPULATION
Sciences
I Consequences of
Environmental
Sciences
I
Ilf
Rqulation Education
I
Resources
1
Pollution
Fertility
Fig. 3.
Table VII. Proportion physicians
Table IX. Estimate of savings in immediate governmental expenditures for medical care and public assistance as a result of births averted by organized family planning programs,* 1967 to 1971
Family planning services: of patients served by private in FY 1971 to 1975
FY
%
I
1971 1972 1973 1974 1975
19 20 21 23 25
FY
Table VIII. Family planning services: Need, patients served and unmet need, at 150 per cent of poverty, FY 1972
1967 1968 1969 1970
*Modified
1
Total served Unmet need
programs
physicians
No. 6,189,OOO 1,959,OOO
/ Et 100 32
1,238,OOO 3,197,ooo
20 52
2,992,OOO
48
In three of these cities the decline was greater than 23 per cent for nonwhites. Although the correlation of decreasing perinatal loss with increasing availability of family planning services is not precise, the fact that the major portion of the decrease occurred during the period of rapid growth of these programs implies a most likely relation.‘? I believe that the day of federally funded categorical health programs administered from Washington is rapidly drawing to a close and rightly so. If all of the social and health programs considered “good” and “necessary” were to be fully funded, the cost would exceed the total Federal budget.l” The actual situation is that budget constraints will increasingly force hard choices concerning a
sands 1
tBirths
Savingsx (thousands)
Ratio
18.1 25.2 60.6 70.0
122 144 223 336
68,648 85,368 140,044 211,008
3.8: 1 3.4: 1 2.3: 1 3.0: 1
173.9
825
505,068
2.9:1
1971 Total
Estimated need Served in organized Served by private
Births averted? (thou-
Expenditure (miZZions)
from Jaffe." averted
take
place
in
calendar
year
following
fircal year. $Savings based on cost of birth ($500) and public assistance and justed to consumer price index.
and one-year food stamps
infant ($128)
care ad-
selection of programs that are not only good but that yield the greatest good. This selection process will in time mean a change from central to local-or at least state-selection of programs. What serves the greatest benefit in one community may be of lesser importance in another. Increasingly the people will be given the means to select and to support the programs they believe they need most. In view of the increasing reluctance to support categorical health programs, continuation of the family planning services programs until the stated goal is fully achieved is at best an optimistic hope. Whether the entire target population or only a major percentage of that population is reached, family planning, some time before 1980, will be integrated into the general health services of
Volume Number
117 6
Federal
Table X. Perinatal United
death
rates by race for
1960 and
family
planning
program
789
1970 in selected
States cities
City
1
Atlanta Cleveland New York St. Louis
City
Year
1960 1970 1960 1970 1960 1970 1960 1970
(
Total
42.1 37.9 41.0 31.4 31.6 26.5 42.9 36.1
1 Whit~tYNegro
41.0 29.2 36.2 25.8 25.4 22.4 33.0 28.1
( %Z
43.4 43.4 49.9 38.3 47.7 34.1 58.3 42.7
the nation. If this transfer is attempted too quickly, before the majority of services are in place and functional, the goal of the President’s 1969 Message to make family planning services available to all in need may never be realized. A more rational approach would be to support the program until a critical mass of services is in place and until a plan for phased integration of family planning services into the health care system can be devised. As little as three more years would be required to accomplish this task. Whether or not the projected goal is ever reached, this country will continue to have problems that relate to an expanding population. Research into the causes and consequences of fertility and its control, as well as a host of related issues such as urbanization, migration, utilization of resources, and pollution are not concerns of the individual states or regions. Such research will have to be carried forward on a national basis with national funding. The questions we now have to ask are: What is the best organizational pattern for funding these diverse research efforts? How can their expansion be encouraged? How do we incorporate and utilize this research in governmental and social decision making? The Report of the Commission on Population Growth and the American FutureI’ constantly reminds us that “we do not know” . . . “we need to know.” As family planning services assume their rightful place in the health care system, the need to know the
36.4 25.8 -
1 Total
-10.0 -23.4 -16.1 -15.9
1 Ili::“i
-28.8
‘:I
( ‘,uiZE
0.0
-
-28.7
-23.2
-
-11.8
-28.5
-29.1
-14.8
-26.8
1
answers to the questions just raised takes on an added, crucial dimension. There are several major options to be considered in planning : 1. We can allow things to remain as they are, leaving to the National Institutes of Health what is now theirs and developing new units where they best fit or where they naturally arise through individual interests or expediency. I submit that this laissez-faire response would not produce the focused and coordinated effort that the multiple problems of population growth merit. Rather, the researches would be splintered and minimally effective in formulating action. 2. New institutes can be created within the N.I.H. system as needs arise. In the decades when research funding was continually expanding, new institutes signaled increased visibility, larger budgets, and more prestigious leadership; such is no longer the case. If new institutes are to be added, they must serve a vital public need and must give reasonable promise of providing utilizable answers. 3. We can recognize the population issue as of overriding importance whose research issues, divergent as they may be, have a central core and a need for cohesion so that their results can be brought to bear effectively before the time has come when they are no longer pertinent. Fig. 3 is a sketch of a National Institutes of Population with three subsidiary institutes recognizing these separate but related sci-
790
November Am. J. Obstet.
Hellman
ences : biomedical, social, and environmental. Under each is a number of divisions. These are not all the possible divisions, but they are suggested as most clearly appropriate. A National Institutes of Population is unlikely to be initiated soon. It may never come into existence in the form suggested in Fig. 3 but the imaginative planning indicated in this
Eastman, N. J., and Hellman, L. M.: Williams’ Obstetrics, ed. 12, New York, 1961, Appleton-Century-Crofts, Inc. Hellman, L. M. : Eugen. Rev. 57: 161, 1965. Griswold vs. Connecticut: Report of U. S. Supreme Court 381: 479, 1965. 90th Congress: Social Security Amendments of 1967. P.L. 90-248. Washington., D. C.. G.P.O., Jan. 2, 1968. Nixon, R. M.: Message to the Congress from the President of the United States Relative to Population Growth, Washington, D. C., G.P.O., July 21, 1969. 91st Congress: The Family Planning Services and Population Research Act of 1970, P.L. 91-572, Washington, D. C., G.P.O., Dec. 24, 1970. Interagency Committee on Population Research : Center for Population Research, NICHD, NIH, Department of Health, Education and Welfare, Washington, D. C. 92nd Congress : Social Security Amendment of 1972, P.L. 92-603 (H.R. l), Washington, D. C., Oct. 30, 1972.
2. 3. 4.
5.
6.
7.
8.
approach is necessary if population issues are to be effectively researched. Whatever structure is eventually built to accomplish this objective, the steps taken in the immediate future should be such as to promote, not impede, the development of a new, effective, and encompassing approach.
9. Characteristics
REFERENCES
1.
15, 1973 Gynecol.
Discussion
10.
11.
of the Low-Income Population, 1972, Current Population Reports, Series P60, No. 86, December, 1972, Bureau of the Census, Washington, D. C. 1970 National Fertility Study: Office of Population Research, Princeton University, Princeton, N. J., 1971, Princeton University Press. Jaffe, F. S.: Short-Term Costs and Benefits of the Federal Family Planning Program, Center for Family Planning Program Develop-
ment, Planned Parenthood-World 12.
13.
14.
Population,
New York City, Personal communication, Jan. 3, 1973. Tyler, C. W.: Center for Disease Control, Atlanta, Ga., Personal communication, Jan. 16, 1973. Richardson, E. L. : Responsibility and Responsiveness (II), A Report on the HEW Potential for the Seventies, p. 41, Washington, D. C., Jan. 19, 1973, Department of Health, Education and Welfare. Report by the Commission on Population Growth and the American Future, Washington, D. C., G.P.O., March 1972.
as December, 1959, President Eisenhower referred to birth control by saying “I cannot imagine anything more emphatically a subject
individuals who were most influential in altering policy during this 15 year period, they would be William Draper, Jr., Hugh Moore, Alan Guttmacher, John D. Rockefeller, III, and Louis M. Hellman. Dr. Hellman has presented a fine review of federal accomplishments over the past five years. During this time he has been a cog in the slow-
that
grinding
W. PAGE, San Francisco, California. There has been a remarkable change in the attitude of our state and federal governments DR.
ERNEST
toward
contraception
is
activity later,
not
in the
a proper
or function President
last
political
15 years.
or
governmental
or responsibility.”
Nixon
stated
that
As late
“this
Ten years adminis-
tration does accept a clear responsibility to provide essential leadership” in the field of U. S. and world population growth. The forces which brought about this reversal of policy are complex, but policy process actually takes place at the boundary of the system.’
interaction If I were
between to select
individuals and five charismatic
wheel
of
bureaucracy,
HEW,
of the
work,
system
a
monstrous
administrative
but he has made as I have
observed
his part first-hand
as a member of his Advisory Committee. At the outset of his paper, Dr. Hellman posed two questions: (1) Is the program on track toward meeting its expected goals? and (2) Are the health and social benefits of family planning programs commensurate with their cost? I would like to add my personal views on both questions.
Volume 117 Number 6
The attainment of a family planning services goal obviously depends upon its definition. The 1966 estimate of the number of poor or near-poor women in need of contraceptive services was 4.6 million. Last year this figure was re-estimated by Blake and Das Guptas to be only 1.2 million, whereas the new HEW estimate for 1972 was 6 million. By 1975, well over 6 million new patients will have been served. Regardless of numbers, a crucial question is whether this population, served once, needs to revisit clinics at least annually to maintain the goal of preventing unwanted pregnancies. If so, and this may well be true, completion of the task is never ending. As to whether the benefits of the service programs outweigh the costs, my answer is unequivocally yes. Apart from contraception, current federal standards for family planning clinics require many preventive health measures such as the detection of gonorrhea, cancer screening, measurements of blood pressure, pelvic examinations, screening for anemias, and so forth. All of this, plus contraception, costs about $60.00 for a new patient, and for many this may be the woman’s first entry into a health-care system. As opposed to remedial health care, preventive health care is a bargain. Furthermore, the prevention of unwanted pregnancies is of itself an enormous social and economic benefit, and small investments of our tax dollars can be shown to yield many times that amount in future savings of public funds. The administration plans to eliminate categorical programs and combine them with the Mediwhich is tantamount to the caid program, elimination of family planning services for all but about 20 per cent of those in need.3 Is there any more important business for our nation than assuring the birth of an appropriate number of both healthy and wanted children? I wish that Dr. Hellman would be as militant in prodding the government to continue the categorical family planning program indefinitely as he was in 1958 when he fought the New York Health Department. With respect to research in human reproductive biology and population studies, I feel ambivalent about creating a new large and unbelievably heterogeneous federal intramural program, but I believe it is crucial to expand support for extramural programs. Dr. Hellman believes that some research areas must be curtailed or eliminated “in view of forthcoming budget con-
Federal
family
planning
program
791
straints.” Do we need to accept such constraints without loud cries of protest? I feel as strongly about this as I do about the elimination of training programs and fellowships in the area of medical research. Considering the documented health and social benefits of the family planning programs, the continued manpower development needs in the biomedical field and the urgent need for research in human reproductive biology and population, eliminating substantial federal support for all three is truly killing the goose that lays the golden egg. A hopeful note is that because of or perhaps despite the government’s efforts, our crude birth rate has dropped to 16 per 1,000 population, and we are now at the zero population growth rate of less than 2.1 children per couple. This means that in 25 years or so, one out of every three persons in the United States may be 65 or older, which should supply ample membership opportunities for this Society. REFERENCES
1. Piotrow, P. T. : World Population Crisis: The United States Response, New York, 1973, Praeger Publishers, p. 223. 2. Blake, J., and Das Gupta, P.: Demography 9: 569, 1972. 3. Rosoff, J. I.: Family Planning Perspectives 5: 7, 1973. DR. HARRY PRYSTOWSKY, Gainesville, Florida. This is a solid paper that contains considerable information. And most importantly, in contradistinction to the majority of writing that comes from HEW, it is easy to read. I wish to make three points and close with a poem. In the area of service rendered, there is little question that this is an excellent effort and probably one of the best examples of a service-oriented program that has come from HEW in at least the past 15 years. It might well serve as an example for all of us who are interested in the aspects of health care delivery. The service granted a large population is defined, the objectives are defined, the results are given, the cost in dollars is reported, and the benefits accrued in dollars is reported. It disturbs me a bit that Dr. Hellman says we will wait several years and then this is to merge into comprehensive health. I do not quite understand what comprehensive health is; it is perhaps confusion at the state level of how to get at it. And I wonder why wait. This is a program that can be used as a model. It has
792
Novemberl5, 1973 Am. J. Obstet. Gynecol.
Hellman
specific results and data. Why should not this program be moved now into comprehensive health planning and possibly lead those who are in the planning stages in that area? Dr. Hellman speaks of a new institute. I wonder whether this is rhetoric. What is its status? Interestingly, I differ with Dr. Page. I think this is a necessity. I wonder whether the leading organizations that have personnel in obstetrics and gynecology have had input into this concept. For certainly, if this does come about, it will serve as a major national resource for the discipline of obstetrics and gynecology. And my last point is a question: What may be the environment and/or restrictions upon Dr. Hellman? Toward this point, a poem entitled
so ago. The question asked of the person being interviewed was whether I had won any fights with the Administration, and the answer was, “Won any! Hell, he hasn’t even fought any.” I am a little ashamed to be classed among unthinking passive followers of the Administration.
tion,
night
before
Christmas.
T’was the night before Christmas, and all through the halls All the creatures were stirring, and cleaning the walls ; Their stockings care, In hopes that
were St.
hung Casper
by the
chimney
with
would
answer
their
prayer ; The
Branch Chiefs were snug in the conference room, All settled down for some pre-Christmas gloom When out on the street there arose such a clatter I sprang from a desk to see what was the matter. Away to the window I flew on a hunch, Tore open the shutter and threw up my lunch. What did my tired old eyes seem to see, But a jet-propelled sleigh that was marked OMB,
And the jolly old driver, a droll little chap, I knew in an instant it must be St. Cap. The moon on the breast of the new-fallen snow, Showed that jobs were all frozen and so was the dough, And then in a moment, I froze in my tracks, Down the chimney St. Casper, he came with an axe. He spoke not a word, but with deadly intent, He cut all the stockings by 50 per cent; And then without turning or glancing at me, He swiftly proceeded to chop down my tree; Up the chimney he rose, to his team gave a whistle, And away they all flew like a misguided missile. But I heard him exclaim with a wave of his thumb, Merry Christmas to all, Happy New Year to none.
DR. HELLMAN (Closing). As usual, Dr. Page offered a criticism that comes a little close to home. He indicated that I should be more militant in the sense of my program. I am reminded of an anonymous interview that appeared in one of the Washington gossip sheets about a year or
however,
like
to
point
out
some-
namely,
the
dispersal
of health
care
systems
to regions or states. In other words, closer to the people. And the third, is to remove the government
The
I would,
thing about how decision-making is achieved in the health field. The Administration has decided on three principles that form the Secretary’s approach to Congress on all questions of health. The first is economy and efficiency. The second is regionaliza-
from
direct
health
care.
If these objectives are achieved, I suggest that there soon will be very few, if any, govemmentally run health programs; even the Indian Health Service could be threatened. At my level we have no input into such decision-making. Even the Secretary of HEW may be only tangentially concerned. Once these decisions are made, then subsequent decisions fall into place. Again, we are given very
little,
if any,
opportunity
to oppose
such
de-
cisions even in testimony before Congress. Obviously, one of two things can be done. (1) One can resign. If that is the decision, one may
make
headlines
for
half
a day,
but
that
will
be the end of it. Resignation accomplishes nothing. (2) One can revolt and go before Congress and say, a bunch
“I
don’t
believe
of baloney,” If you do that, when office there will be a your desk be emptied ning. Anyone
can
walk
any
of
this
stuff,
is is
and present the reasons. you arrive back at your telephone call asking that by 5 :00 o’clock that eve-
away
from
a situation.
That
is the easiest possible choice. Those who choose to stay select the harder way. Currently, there is little give in Administration policy regarding health no significant increases
in
care. There budget for
have fiscal
been year
1974 and the only chances for growth remain in the public assistance programs that are beyond the control of the Administration. If we are going to have health programs in the future, financed by the Federal Government, then we need to document them both in terms of need and in terms of cost benefits; an exercise that medicine has never before been required to perform. We, the doctors, are not considered neutral; we are not considered individuals whose judgment is
Volume Number
117 6
unbiased. Rather, we are believed to be selfperpetuating proponents of a system that formally raided the budget on an annual basis. For this reason, health care decisions are made by lawyers and business school graduates and not doctors. Dr. Prystowsky, the time is short and I am unable to answer your questions. I would like to
Federal
family
planning
program
793
say, however, that the poem you read was sung to Mr. Weinberger and Mr. Richardson on Christmas Eve afternoon. Both smiled and laughed in the appropriate places, but when Secretary Weinberger testified about health programs before the Congress recently the gentle ribbing in the poem apparently had no effect.