Contraceptive prevalence, reproductive health and our common future

CONTRACEPTION

CONTRACEPTIVE PRBVALBICB, RBPRODUCTIVB HEALTH AND OUR coMHolyFUTURE Egon Diczfalusy, M.D. Karolinska Institutet Stockholm, Sweden Abstract

The 1980s will go into history as a decade of lost opportunities to increase contraceptive prevalence and As the decade improve reproductive health worldwide. closes, 500 million couples still have no access to fertility regulation, there are 30-50 million induced abortions each year, 15 million infant and child deaths (30% of all deaths worldwide), an estimated 250 million new cases of sexually transmitted diseases and 60-80 million infertile couples. One of the major problems is that many policy makers are still unimpressed with the global demographic reality. World population was less than 300 million 1991 years ago. It took some 1500 years to double this number by the time of the voyages of Columbus to America. The first billion was reached at the beginning of the last century and the second in the lifetime of the author, in 1927. Then it took less than 50 years to double this number to 4 billion by 1976. Global population is 5.3 billion today. In view of such figures, it is understandable that, historically, it was this demographic concern that in the 1960s persuaded many governments to support family planning programmes. During the subsequent decades, it was gradually recognized by developing country governments that family planning lowers infant, child and maternal mortality and morbidity and reduces the number of illegal abortions and Today, 52 developing country their health hazards. governments support family planning programmes for the demographic rationale, but 65 for the reproductive health and human rights rationale. Where do we go from here? That will mainly depend on the number of years it will take to reach replacement level of fertility (around 2.1 children per couple) worldwide. If the level is reached in 2010 (the low projection of the United Nations), global population will stabilize by the end Some of this paper is based closely on material included in an article by the author entitled Fertility Regulation, Reproductive Health and Our Common Future. In: Female Contraception and Male Fertility Regulation (Runnebaum B, Rabe T, Kiesel L, eds) Parthenon Publishing, Caster Hall, Carnforth, Lancashire, England, 1991.

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CONTRACEPTION of the 21st century at 8 billion; if it is reached in 2035 population will stabilize around 10 (medium projection), if it is reached only in 2065 (high billion: however, projection), the global population in 2100 will consist of more than 14 billion people, with major consequences on every walk of life. To restrict the final population to 10 billion, contraceptive prevalence must increase from 51% to 58% of married women of reproductive age before the year 2000 and to 71% by 2020, implying an increase from the 350 million users to 500 and 800 million, present respectively. Whether or not these ambitious targets can be reached will depend not only on the availability of a wider choice acceptable and affordable contraceptives and of safe, greatly increased international and national funding, but also on fundamental changes in a number of behavioural, sociocultural, economic last but not educational, and, least, political factors. The perception of many governments must also change: they must realize that contraceptive prevalence represents the key not only to improved reproductive and environmental health, but also to demographic and economic development. Introduction,

or What Is Past Is Prologue

It took a very long time for Man to reach the first billion individuals inhabiting the earth, sometime in the early part of the 19th century. Some 150,000 to 200,000 years if the analysis is restricted to Homo sapiens, but some 2 million years if Homo erectus is considered, or even more than 4 million years if we go back to Homo habilis. The growth rate of the species remained very low most of this period; even when Jesus Christ was born, 1991 years It took ago, world population was less than 300 million. some 1500 years to double this number, around the time of the last two voyages of Columbus to America. The beginning of the 19th century signaled the one billion landmark and the second billion was already reached in the lifetime of the author, in 1927. Then it took less than 50 years to double this number to 4 billion by 1976, and the fifth billion was reached 11 years later, in 1987 (1). In the Sleepwalkers (2), Arthur Koestler remarks that "I mistrust the word proaress and much prefer the word evolution simply because progress, by definition, can never go wrong, whereas evolution constantly does and so does the evolution of ideas." In retrospect, the changing ideas of the International Community about population during the second half of the 20th century appear to represent a melange of evolution and true progress. Looking back to the fifties, it appears that in the shadow of World War II we were mainly concerned with

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mortality and morbidity statistics. Then came the sixties and the alarming notion of "population explosion" with the This idea was superseded in "standing room only" threat. the seventies by an over-optimistic view about the unlimited which was expected to solve most power of develonment, problems of mankind, including those created by a rapidly This belief was still the official growing population. position of the Reagan administration at the International Population Conference held in Mexico City in 1984, at a time when most developing country governments were already deeply concerned about the increasingly problematic interrelations resources, between their population, development and environment. As we are now entering the last decade of the and of the millennium as well, international century, concern is centered more and more on the environmental crisis, its interactions with population and fertility regulation within the broad framework of environmental and reproductive health. At the same time a new type of development is called for: "sustainable development'@, which ought to be sustainable during many generations to come. There were, however, a number of indicators of true progress related to the gradual awakening of the The process started in 1962 with International Community. Resolution 18.38 of the United Nations General Assembly, offering assistance, upon request, to developing country governments with demographic and statistical studies (3). Progress continued in 1965 with Resolution WHA 18.49, in Health which the World Assembly (WHA) requested the Director-General of the World Health Organization (WHO) to develop a programme on "fertility control methods and health aspects of population dynamics" (4). The process continued in 1968 with the United Nations Proclamation of Teheran, with a consensus statement that information on and access to family planning are basic human rights This was (5). followed in 1972 by the establishment of the WHO Special Programme of Research, Development and Research Training in Human Reproduction (6) and of the United Nations Fund for Subsequent steps were Population Activities (UNFPA) (7). the United Nations World Population Conference in Bucharest (8) in 1974, the International Conference on Primary Health Nations Care in Alma Ata (9) in 1978 and the United International Conference on Population in Mexico City (10) in 1984. The Bucharest Conference resulted in the World Population Plan of Action, underlining that "All the couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so." (8). The Alma-Ata Declaration affirmed that family planning is a basic component of primary health care (9), and the United in Mexico City urged Nations Conference on Population to allocate increased funding agencies governments and

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TABLE I. Estimates of contraceptive prevalence in developing countries, by region (lJnRedNations,1888).

Pemageofmaniedwomen

ofnqmclu&veageusing -on Region

1960-1885 1980/81

1888

All developing countries Africa East Asia-J

SouthAsia and0ceanii~ LatinAmerica Notes: a)

9

36

46

5

11

14

13

69

74

7

24

34

14

43

66

ExcWngJapan

b) Excludii AusWaandNewZealancl

resources for research regulation.

in human

reproduction

and

fertility

associated with an awakening was International impressive increase in the number of governments supporting seven only early sixties, In the family planning. governments provided family planning services, whereas in over 120 governments supported such the early eighties, By the year 1986, out of the 170 Member programmes (11). 122 governments provided States of the United Nations, direct support to family planning, 24 governments indirect support and 18 governments provided no support; access to fertility regulation was limited in six countries (12). The above process was also accompanied by a gradual As shown in Table I, increase in contraceptive prevalence. in the early sixties the percentage of married women of reproductive age in the developing world who were using later Twenty years the only 9%. contraception was The most impressive corresponding figure was around 45%. increase occurred in East Asia and Latin America (12).

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CONTRACEPTION Why Reproductive

Health?

The author feels that from the conceptual point of view the most important development was the gradual realization that fertility regulation is one of the four fundamental pillars of reproductive health. Together with maternal care, infant and child care, and the prevention of sexually transmitted diseases, it provides the solid foundations on which any modern reproductive health policy rests. By now, it is recognized by the overwhelming majority of governments that problems related to reproductive health form a major part of the health needs of most populations, including their needs of family planning. The effective use of family planning will delay the age at first pregnancy and space further births. When integrated into primary health care, both of these will diminish infant, child and maternal morbidity and mortality and significantly reduce illegal abortions and health hazards. Hence, the impact of family planning goes far beyond the issues of population growth and development. It is an irreplaceable tool to improve the general health status of populations, especially so in developing countries. This recognition is reflected more and more by the policy position taken by governments in general and by developing country governments in particular. In 1980, 52 developing country governments stated that they support family planning for the demographic rationale, 65 indicated that they provide support because of the reproductive health and human rights rationale, and 35 indicated that they provide no support (7). What is then the reproductive health situation of The picture is rather dismal, as it mankind like today? of some of the indicators of appears from the perusal In this context it reproductive health shown in Table II. should be borne in mind that what the figures of Table II show is only the tip of the iceberg of preventable human It is probably one of the greatest failures of suffering. our generation that out of roughly 50 million deaths which occur in the world each year, 15 million are infants and The data of Table II children under the age of five (13). also show that some 500 million people have no access to fertility regulating methods and that there are 250 million new cases of sexually transmitted diseases (STDs) each year (14). transmitted diseases that are Communicable predominantly by sexual contact (STDs) constitute today the most common group of notifiable diseases in most countries. Although, by necessity, worldwide data on the incidence of STDs are vague and approximate, WHO minimal estimates for yearly incidence are 80 million for bacterial STDs, 50 million for viral STDs (other than HIV) and 120 million for The impact of STDs on reproductive health trichomoniasis.

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TABLE II.

Indicators of Reproductive Health Or

The Tip of the Iceberg of Human Suffering Millions (Worldwide)

Category No

accessto

fertility regulation a) Infertile couples a)

60-60

Inducedabortionsb,

30-50

Maternal mortality b,

0.5

Maternal morbidity b,

25

Infantswithlowweight at birth b,

20

Infant mortality b,

5

Child mortality b, (1 - 5 years)

10

Sexuallytransmitted diseases(newcases) a)

250

HIV-infected individuals a) Total; minimal Annually

5-10

estimates tJNandWHOeslimates(1988and199O)

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TABLE

III.

ITINERARY OF A BAD TRIP

Long-term UN projectionsshow that at the global level:

*

if replacement-level fertilii is reached in 2010, global population will stabilize at 7.7 billion by 2060;

*

if this rate is reached in 2035, population will stabilize at 10.2 billion by 2095;

*

if, however, the rate is reached only in 2065, global population in 2100 would be 14.2 billion.

(Population Bulletin of the United Nations, No. 14,1982)

is further accentuated by the fact that many of them can be transmitted from the mother to the fetus. The gravity of the situation is underlined by the expected social impact of some STDs, like HIV infection. Present projections indicate that within the next 3500 days the percentage of children aged o-15 orphaned by HIV/AIDS in ten countries of Subsaharan Africa will increase from 0.5% to 10.5% (15). The Gigantic Shadows, Which Futurity Casts Upon the Present Whereto is global population heading? What are the projections of the United Nations and of the World Bank? Few people doubt that those numbers will have a major impact on the quality of life of future generations. What will happen within the next 3000 days or so is fairly clear. Before the end of 1998 world population is expected to increase by more than one billion people, or the whole of world population at the beginning of the past century. The next billion is expected to require seven additional years (13)' What will happen thereafter depends mainly on the number of years which will be required to reach the replacement level of fertility (slightly more than two children per couple) worldwide. As indicated in Table III, depending on the number of years needed for achieving the replacement level of fertility, global population is expected to stabilize between less than 8 and more than 14 billion by the end of the next century (16). In this context I would like to emphasize two points. The first is that demographic projections are neither forecasts nor MARCH 1991 VOL. 43 NO. 3

CONTRACEPTION They project the most likely course of future destiny. events, provided that some basic assumptions are fulfilled. All the projections of the United Nations and of the World (lQstandardll) such critical two based on Bank are namely, that (a) mortality will continue to assumptions, fall everywhere until life expectancy at birth for women is 82 years and (b) fertility will eventually reach and Stay at the replacement level everywhere (17). The second point to be emphasized is that in determining the ultimate size of world population, fertility matters much more than mortality If fertility decline is slower than expected, this (17). To underline this will result in a larger final population. second point, we may recall that the World Bank and UNFPA have recently revised their projection of when the world's population will double from its current size to 10 billion. Previously it had been predicted that this would happen at They are now predicting it the end of the 21s.t century. The reason for this revision is that will occur in 2025. not expanded as fast as prevalence has contraceptive Fertility decline has been particularly slow in expected. some parts of South Asia, the Middle East and Subsaharan Africa (18). Why Contraceptive

Prevalence?

The author is firmly convinced that contraceptive prevalence represents the not only to improved key reproductive health and environmental health, but also to demographic and economic development. In this context, contraceptive prevalence rate is defined as the percentage of married women of reproductive age who are using (or whose husbands are using) any form of contraception. What is then worldwide contraceptive prevalence today? The global estimate around the year 1983 indicates a medium prevalence of 51% (with the low estimate at 47% and the high at 55%) (12). Corresponding (rounded) figures in millions are presented in Table IV. The data of Table IV represent worldwide totals, behind which marked national and regional differences are hidden. Obviously, social, cultural, educational, economical and political factors exert a major influence on the prevalence of specific methods in a given country, as illustrated by the data of Table V. The four countries indicated in Table V have uniformly high contraceptive prevalence rates, but the use of intrauterine devices is very high in China (due to economical reasons) and very low in the USA (due to litigation). The use of steroidal contraceptives is high in Indonesia, but relatively few sterilizations are performed as yet because of real or perceived religious objections, although the numbers are increasing. For the time being, sterilization is the most widely used method not only in Korea and China but also in the USA.

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TABLE

IV.

The Year 1983: Estimated total population, number of women aged 15-49, number of married women aged 15-49 and number of married women using specific methods of fertility regulation worldwide (millions) World population Women aged 15-49 Married women aged 15-49 Married women aged 15-49 using various contraceptive

4,709,ooo 1,142,OOO 789,000

methods (total) Female sterilization

403,000

103,000 39,000 55,OOO 8,000 79,000 39,000 8,000 32,000 32,000 8,000

Male sterilieation Oral contraceptives Injectables Intrauterine devices Condoms Barrier methods Periodic abstinence Withdrawal Other

Calculated from the data reported by the UN Department of International Economic and locial Affairs in 1989. Figures rounded to nearest million.

TABLE

V.

CONTFIACEPTlVE METHODS CURRENTLY IN USE IN CHINA, INDONESIA, KOREA AND THE UNlTED STATES (% of contraceptive users) Method

Female sterilization Male sterilization Steroidal contraceptives Intrauterine devices Condom Others a) b) c) d) e)

China@

36.1 11.6 6.1 40.7 88 1.7

Indonesiaw

e) e) 69.4 23.0 3.8 3.8

Korea’,

United States@

44.9 12.7 6.1 10.5 10.2 15.6

20.0 14.0 32.0 3.0 17.0 21 .o

State Family Planning Commission, 1988 BKKBN, 1988 KIPH, 1988 Forrest & Fordyce. Fam Plann Perspec 20~112-18, 1988 Recently initiated programs; in February 1991, 750,000 (4.1%) of a total 18.6 million acceptors. Percentages do not add up because some women used more than one method.

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of

209

The regional differences in contraceptive prevalence are equally impressive. The data of Table VI reveal that the prevalence is only 14% in Africa but 74% in East Asia. The condom is utterly unpopular in Africa but very popular in developed countries, while conventional methods are extensively used in the more developed regions but very little in East Asia (12). Developed countries have a uniformly high contraceptive prevalence rate but, as shown in Table VII, there are marked regional differences with regard to the specific methods preferred. Oral contraceptive usage is highest in Western Europe and very low in Japan where condoms represent the preferred contraceptive even today. Female .sterilization is highest in the USA but very low in Eastern Europe where, like in Southern Europe, periodic abstinence and withdrawal still Hence, a high contraceptive enjoy a high popularity. prevalence per se is a poor expression for contraceptive efficacy since the failure rate (per 100 woman-years) for female sterilization was reported in two studies as 0.13 and 0.40, respectively, whereas the failure rates for withdrawal are set at 6.7 and 18 and for periodic abstinence at 15.5 and 20, respectively (19,20). Who controls the Preseat, controls the Future Why is an in-depth assessment of the present levels of contraceptive prevalence so important? Because the studies conducted by Bongaarts and coworkers in more than 100 countries indicate a statistically highly significant correlation between contraceptive prevalence and total (12,21). An increasing contraceptive fertility rate prevalence is associated with a decreasing total fertility Studies by the United Nations point out that a rate. prerequisite for reaching the medium projection of a stable population (10.2 billion by the end of the next century, cf. Table III) is a reduction in total fertility rate from the present rate of 3.5-3.7 to 3.0, or 3.1 by the year 2000 and This presupposes an to 2.4 by the period 2020-2025. increase in contraceptive prevalence to 58% by 2000-2005 and to 71% by 2020-2025 (12). The time frame to reach these objectives consists of the critical 3500 days of the nineties, followed by twice as many critical days between 2000 and 2020. But what are the "reall' numbers--the couples represented by the above Let us consider the situation in the percentages? developing regions where the major problem is located. The data of Table VIII indicate that in 1990 the number of married women aged 15-49 in the less developed regions of the world who used contraception was believed to be 357

210

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TABLE VI.

Prevalenceof specificcontraceptivemethods, by region,around 1963. Percentageof couples with the wife in the reproductiveage.

Method

Africa

South Asia

East Asia

Latin America

+Oceania Female steriliion Male steriliion Intrauterinedevice Oral contraceptive Injectable Condom Other@ All methods(rounded) a)

; 5 1 0.5 4.2 14

; 1.5 74

7 3 6 14

20 1 5 16 1 2 10 55

10 6 2 4 2 3 7.4 34

27 9 29 5

1

DevelOped countries

1; 27 70 ’

Vaginal barriers, periodic abstinence, withdrawal, etc.

Source:UnitedNations,

TABLE VII. Prevalenceof speck contraceptive methods in developed regions, 1963. Percentage of couples with the wife in reproductive age.

Asia

(Japan)

Vaginal barks

Allmethods

Noehem Western

19

7

11

7

1’

2

11

2

Southem &stern 2

0.4

5

4

11

10

3

5

13

1

22

30

13

9

10

45

19

6

10

a

3

1

2

2

5

22

37

45

a0

78

67

70

Nations,

1989

6 5

a)

EUROPE

North America

70

(5 64

Periodic abstinence, withdrawal, etc. Source:

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United

211

1989

CONTRACEPTION

TABLE

VIII.

Estimated and Projected Population, Number of Women Aged 15 - 49 and Contraceptive Users (Millions) in the Less Developed Regionsof the World Year 1983

1990

2ooo

2010

2025

4,709

5,292

6,251

7,191

0,467

Women aged 15 - 49 Married Women

850

1,018

1,259

1,508

1,811

aged 15-49 Contraceptive Users?

505 273

717

874

1,032

1,215

357

493

657

883

World Population

‘Excluding users not in a marital union Source:

UnitedNations; 1989

million. According to the projections for prevalence rates of 58% and 71%, respectively, the number of contraceptive couples must increase by almost 150 million before the end of the century, by another 150 million during the next decade, and by an additional 200 million couples during the 15-year period between 2010 and 2025. The most logical (and fundamental) question is, what will it take to reach the above targets? The famous Austrian General Raimund von Montecuccoli is still widely quoted in Hungary for saying some 300 years ago that three things are essential for a successful warfare-money, money and money (22). Indeed, such a great increase in contraceptive prevalence will, among other things, necessitate a considerably increased amount of funding. The 20 USA UNFPA estimates that it costs between 10 and dollars per year to provide family planning services to a couple, and that worldwide spending on family planning services in 1988 was around 3 billion USA dollars. Of this sum, the governments of China and India provided 1.0 and 0.5 other Indonesia and national billion, respectively, governments 0.5 billion, private users 0.5 billion and Hence the annual international donors 0.5 billion (23). cost of raising contraceptive prevalence to reach a total fertility rate of 3.1 children per woman, on the average, by the year 2000 will have to increase from the current $3 billion to between 5 and 10 billion in constant(1970=100$) dollars. This is a small sum in terms of worldwide military 212

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CONTRACEPTION slightly more than a day of global spending, perhaps military expenditure (24), but a large sum in other respects today when 80% of the world's gross national product (GNP) is provided by a dozen countries, whereas 101 developing countries have readjustment programmes and the per capita income in these countries is much less than lo-15 years ago. It is unlikely that developing countries will be able to Hence the new funds face such an economical challenge. come from international development must, by necessity, assistance. Is there a major commitment there? Perhaps. In 1988, official development assistance was estimated at approximately 55 billion USA dollars. The 18 Member States of the Development Assistance Committee (DAC) of the Organization for Economic Cooperation and Development (OECD) the DAC contributed 85% of the above total. However, directed only 5.3% of its aid to the health and population sector and 6% to water supply programmes (25). Money is obviously very important, but it represents only one of many essential requirements for achieving a rise in contraceptive prevalence. Another rapid requirement --more than one-third of the 140 million women in the developing world who became pregnant in 1988 did not Why did they become want to have another child (26). Estimates of the United Nations for 1982 suggest pregnant? that in only 40% of developing countries did as much as half the national population have ready and easy access to some form of modern contraception (12). Suppose that fertility regulating agents were available in unlimited quantities. How much would reach those who need them? In many countries suitable delivery services are still not available. Another requirement is an improved understanding of our own reproductive behaviour. It would seem that a great deal more research is required in various populations on the factors influencing contraceptive prevalence and decisionThese include community dynamics in facilitating or making. impeding access to family planning, the changing gender roles with regard to reproductive health and reproductive behaviour, the decision to opt for an induced abortion, the costs and benefits of fertility regulation (economical, social and psychological) to couples living under different socio-economic conditions and male reproductive behaviour (27). Another factor of paramount importance for raising contraceptive prevalence is education. The data reported by the World Fertility Survey provide strong evidence indicating a significant correlation between the years of education and the use of efficient methods of contraception in a number of developing countries (28). The particular importance of this factor is underlined by the fact that, estimates, in according to UNESCO 1985 the overall illiteracy rate among women aged 15 and over was 35% worldwide, 49% in the developing countries and 78% in the least developed countries (29). MARCH 1991 VOL. 43 NO. 3

CONTRACEPTION importance is the A further factor of fundamental status of women in general and in developing countries in WHO points out that one-third of the households particular. constitute oneof the world are headed by women and women -However, women are third of the world's labor force. responsible for nearly two-thirds of the total hours worked, receive only 10% of the world's income and own less than 1% of its property (30). Indeed, a lot of lip service is being The paid to this problem, but there is little action. United Nations Convention on the Elimination of All Forms of Discrimination Against Women celebrated its 10th anniversary As of June 1990, the Convention was ratified year in 1990. Seventeen by 103 Member States of the United Nations. countries, including India, the Netherlands, Switzerland and signed but not ratified the have states, the United only around half of the ratifying Countries Convention. Even where governments offer comprehensive family planning. support and provide family planning, access to services may Young unmarried in rural areas. be limited, especially women are often denied contraception, and laws on minimum age of marriage are often overridden by custom (31). An insufficiently observed factor is the image of a "Population mafia". In developing countries, especially in rural areas, the population observes that at the health centers a variety of fertility regulating agents are provided under circumstances where simple life-saving materials and essential drugs are unavailable. This leads to the perception of a "Population mafia", when, in fact, the real reason is that fertility regulating agents are provided by international development assistance and essential drugs should have been provided by the national or local government. Last, but not least, contraceptive prevalence is also influenced by a wide spectrum of social, cultural, economic and political factors. However, the availability of a variety of safe, acceptable and affordable contraceptive agents is and will be an increasingly critical factor in this respect. Homo scientifiaus, Development

Homo

dogmaticus

and

Contraceptive

What happens in contraceptive development? In short, the need is increasing, but the number of actors and the overall activities are decreasing. The reasons behind this disturbing development are complex, and their discussion may even necessitate consideration of "esotericI* factors, such as human nature. For the scientificus intertangled us represent

214

purposes of the argument, one may consider Homo and Homo dogmaticus as two, almost hopelessly, imaginary subspecies of Homo sapiens. Most of a mixture of both, although not necessarily in

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Following the good habit of the the same proportions. Oxford Dictionary, we may even try to define Homo scientificus as Man occupied in or concerned with science and acting according to scientific principles and Homo dogmaticus as Man asserting dogmas or opinions in an authoritative or arrogant manner and proceeding upon a priori principles accepted as true. My point is that both Homo scientificus and Homo dogmaticus wish to improve the lot of mankind--the former by attempting to change the physical and social environment and thus the human condition, the latter by attempting to change the human nature. Homo scientificus believes in exploration of the experimental approach ’ the probabilistic nature of hiinworld. Homo dogmaticus believes that his views are right and those of his opponents wrong. This often leads to the development of two further evolutionary subspecies: Homo fanaticus and Homo bellicus, as evidenced by history and present events. When it comes to contraceptive development, Homo scientificus claims that the number of unwanted births, the high discontinuation rates, the increasing number of induced abortions, and the increasing reliance on sterilization carried out at earlier and earlier ages convincingly indicate that available methods and services of family planning fail to meet the demand of developing countries. Homo dogmaticus is unimpressed by these arguments. He feels that other priorities are much more important. Homo scientificus is concerned because each year some 15 million births occur to adolescent mothers worldwide and that children born to adolescent mothers are about 40% more likely to die during their first year of life than those born to women in their twenties (32). Homo dogmaticus is also concerned, but his position is the same as the government poster in Kenya, Vhildren should not have children" and, of course, nobody would disagree with this view. There is a problem, however. Children do have children and on an increasing scale. Statistics from cities in Kenya, Liberia, Mali, Nigeria and Zaire show that 38 to 68% of young women taken to the hospital with abortion complications were 19 years old or youn er. In the United States where abortion is legally accessib 9he, childbearing is I4 times more likely to result in death than abortion for girls aged 15-19. In fact, about one-fourth of the 1.5 million abortions performed each year in the United States are on teenagers, and 40% of adolescent pregnancies end in abortion (33). In view of similar data emerging worldwide, Homo scientificus feels that the outbreak of unwanted pregnancies among adolescents is yet another indication of limited However, the reasoning of Homo contraceptive choice. MARCH 1991 VOL. 43 NO. 3

215

dogmaticus follows an entirely different line, even if he is living in a developing country; "All contraceptives until now are abortifacients, and if it is abortifacient, it means...it is killing, it is murder" (34). Since Homo dogmaticus knows that his views are right and those of "Stop Population others wrong, he goes even further: Control ...stand up to pressures from international funding agencies, conferences and initiatives which insist on propagating the MYTH that problems of developing nations will be alleviated through reduction in population growth" (35). In all fairness, it would be simplistic and naive to attribute the limited contraceptive choice predominantly to As always, the the tough resistance of Homo dogmaticus. problem is more complex and multifaceted. It is clear, however, that in 1970 there were 13 major pharmaceutical contraceptive companies that conducted research and development and that by 1987 the number had dropped to four (44). Among the most important reasons for the retrenchment of the industry, Djerassi mentions the high expenses of the studies specially animal toxicological required ’ contraceptive development, the poor public image of tii field due to negative publicity, the fear of litigation and the unavailability of insurance to protect the industry in case of litigation (36). In order to fill the gap produced by the withdrawal of the pharmaceutical industry, in the early seventies several public sector agencies initiated contraceptive research and development programmes, and by the early eighties the yearly expenditures of these agencies on contraceptive development exceeded those of the private industry, as shown in Table IX (37). When we enter the nineties, the withdrawal of the industry is felt more and more, as indicated by the fact that the majority of new technologies under clinical evaluation are products developed by the public sector. Examples of these are the once-a-month and three-monthly injectables, implantable contraceptives, hormone-releasing vaginal rings and intrauterine devices, the frameless intrauterine device, birth control vaccines and new sterilization techniques for men (27). It is obvious, however, that the field is grossly underfunded, that the level of funding did not increase since the mid-seventies and that with a total yearly expenditure of 26 million constant (1970) US dollars, the public sector agencies cannot go very far in replacing the activities of the private industry (37). Even more serious is the reduced funding directed towards fundamental research and research training, since the repercussion of this will be long-lasting and will adversely affect contraceptive development even beyond the year 2000. In retrospect it becomes clear that this type of funding rapidly rose during the sixties, peaked in 1973, and thereafter started a stable downward trend (37). 216

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TABLE IX.

Worldwide expenditures on contraceptive development, 1980-l 983

Sponsor

Yearly expenditure (1ooosof alnstant us $)’

Public sector agencies* Private industry Academic institutions3

25,494 21,717 15,514

Total

62,725

”

(1970= loos)

4 NICHD. WHO, ICCR. FHI. PAFWI, PIACT, ICMR 9 MlSSlON-ORENTATED FUNDAMENTAL RE!EARCH

Modified

from

Atkinson

et al., 1985

In 1984, the United Nations Conference on Population (10) urged governments and funding agencies to allocate increased resources for research in human reproduction and but with singularly little effect. fertility regulation, The data of Table X taken from a recent report by the Commission on Health Research for Development (38) are in this respect--only 14% of the official illustrative development assistance funding for research goes to the Another United entire sector of health and education. Nations Conference is around the corner: it will take place in 1994. Will it result in another plea to governments and funding agencies to provide more support to research and Is it really development or in something more substantial? impossible to redirect a tiny little part of the yearly development assistance of 55 billion US international dollars to increase the yearly expenditure of the public Quo vadis homunculus? sector beyond 26 million US dollars? It appears to be difficult for Homo politicus to understand that the most essential prerequisite for any development (including contraceptive development) is and It seems also always will be fundamental basic research. difficult for him in a world of multiple unmet needs to realize that the unique drug-developing ability, know-how and impressive track-record of the pharmaceutical industry cannot completely be replaced by underfunded public sector is facing a major programmes. Hence, Homo scientificus challenge. He must convince Homo politicus that in the MARCH 1991 VOL. 43 NO. 3

217

TABLE X.

OFFICIAL DEVELOPMENT ASSISTANCE FUNDING FOR RESEARCH, BY SECTOR RESEARCH AREA

PERCENTAGE

Agriculture and rural development

68

Science and technology

14

Heatth and education

14

Other TOTAL

4 100

Source : Commission on Health Research for Development (1990)

critical decade of the nineties it will be crucial to provide more funding for basic research and to bring the back the frontline of industry into pharmaceutical Will he succeed? Maybe, but it contraceptive development. will cost more effort than to discover the brave new world in the outer spaces of the universe. other factors adversely affect A number of contraceptive development and contribute to the Seven Obstacles Confronting Research (39). In a few economically powerful industrial countries there are influential and "anti-contraception" groups and, as shown by aggressive history, Homo dogmaticus is not always reticent to use political pressures of different kinds. The assessment of safety is never simple (40), and certain experimental results may equally well be used to reinforce diametrically opposite views. There is also a shortage in manpower and sometimes even a paucity of ideas, as a logical consequence of inadequate funding of basic research and training during the past two "lost decades". Last, but not least, there is a major communication gap which is much more serious than it appears on the surface. We usually efficient in communicating with other are After all, we are addressing the converted and scientists.

218

MARCH 1991 VOL. 43 NO. 3

we speak a common language, that of Homo scientificus. The problem arises when other sectors of society have to be approached. Maybe we take too much for granted when we try to convey the available information and especially the uncertainties, limitations and multiple interpretations. This is not the bread and butter of Homo dogmaticus. He prefers simple, straightforward and definite answers also from nature, and his perceptions are based on different premises. Unfortunately, the problem is fundamental because in the final analysis all of us are prisoners of our perceptions, watching shadows on Platen's wall. This applies equally to scientists, politicians, decision-makers, "opinion-managers" and last, but not least, people in general. In a time of so many unmet needs and global concerns, what will or will not happen in contraceptive research and development in the nineties and beyond will be the function of the perception of immediate consequences by the peoples and by their governments. Homo scientificus is convinced that contraceptive prevalence and contraceptive Homo development represent key issues for mankind. dogmaticus does not think so. Homo politicus has his own priorities, and the years are rapidly passing. Environmental Health and Reproductive Health The report of the World Commission on Environment and Development (the Brundtland Report) states that 18Economic activity has multiplied to create a $13 trillion world economy, and this could grow 5- to lo-fold in the coming half-century. Industrial production has grown more than 50fold over the past century; four-fifths of this growth since 1950" (41). However, Dr. H. Nakajima, the Director-General of WHO, calls attention to the sometimes forgotten fact that VVEconomic and industrial development are not ends in themselves; they are means towards health and an acceptable quality of life for mankind. Yet nearly every step toward such a development is accompanied by potential risks to health and quality of life, if not survival itself.... The world is heading for an environmental crisis and the final price will be paid in terms of human health" (42). Then the Brundtland Commission concludes, "When the century began, neither human numbers nor technology had the power radically to alter planetary systems. As the century closes, not only do vastly increased human numbers and their activities have that power, but major, unintended changes are occurring in the atmosphere, in soils, in waters, among plants and animals and in the relationship among all of these... The rate of change is outstripping the ability of scientific disciplines and our current capabilities to assess and advise" (41). A new dimension of global concern is unfolding before our eyes with health risks associated with almost every step

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CONTRACEPTION

TABLE Xl.

ECOLOGIC INJURIES or ENVIRONMENTAL

CHALLENGES?

(An incomplete and somewhat overlapping alphabet) Acid rain

Occupational hazards

Deforestation

Ozone depletion

Desert&&ion

Radiation effects

Environmental catastropMes

Toxic substances in

Greenhouse effect

water & food

Hazardous wastes Microroganisms in

Traffic damages Urbanization

water & food The incomplete alphabet shown in Table in our daily life. XI is just a short reminder of some of these concerns. China reports Are specific examples really needed? suffer from polluted that 41 out of 44 large cities groundwater and in the United States, out of 120,000 wells sampled, 24,000 proved to be contaminated with high levels of nitrates (43). WHO estimates that more than 600 million people are exposed to sulphur dioxide concentrations well above what is considered medically safe, and estimates for 1985 show about one million cases of accidental acute poisoning by pesticides, mostly in the Third World (44). What has all this to do with human reproduction and reproductive health! health? It is reproductive Reproduction impacts on the environment and environment impacts on reproductive health. This is nothing new. The United Nations "One Earth" Conference on the Human Environment (Stockholm, 1972) pinpointed the urgent need to control population growth so as to prevent environmental degradation due to the population explosion and called for in-depth studies worldwide to assess the effect of environmental factors on health (7). The year was 1972 and the global population was still below 4 billion. It is also established that vulnerability to environmental hazards is highest during the fetal and postnatal period and infancy--neurotoxic agents can then inflict irreversible damage (36). That we are not dealing only with theoretical considerations or alarmistic views is indicated by the data of Table XII, based on a presentation 220

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CONTRACEPTION

TABLE

XII.

RECENT ECOLOGICAL ACCIDENTS IN THE USSR WITH MAJOR ADVERSE EFFECTS ON THE HEALTH OF INFANTS AND CHILDREN LOCATION

CAUSE

ADVERSE EFFECTS

ALTAI

Pesticides in drinking water

Haemolytic anemia (infants)

ASTRACHAN

Acid-leakage into drinking water

Increased intant mortal&y

BASHKlRlA

Phenol-leakage (Drinking water)

Increased infant mortaiii

CHERNOBYL

Ionizing radiation (air, water, soil)

Increased infant and child morbidi

CHERNOWSY

Unknown environmental accident

Acute neurological disease followed by alopecia in children

UZBEKlSTAN

Pesticides in drinking water.

Nitrate poisoning of infants. Source :

USSR Minisby of Health,

1990

by Professor A.A. Baranov, vice-Minister of Public Health, The data of Table XII USSR, in Chernovtsy last June (45). indicate some recent ecological accidents in the USSR which morbidity and and child infant increased resulted in mortality. Under the heading, Why Reproductive Health?, in this the author emphasized that fertility regulation, paper, maternal care, infant and child care and the prevention of sexually transmitted diseases constitute the four pillars of It appears that during the nineties, reproductive health. environmental health will assume the role of the fifth pillar. There Are Priorities

and Priorities

In the international context, it is considered to be bad bedside manner (or in the best case, boring and irrelevant) to mention worldwide military expenditures in It is relation to expenditures on health and environment. the forbidden empire of Homo hypocriticus. So, let us be The Brundtland Report summarizes the quintessence of brief. "Globally, military expenditures total about the problem: $1 trillion a year and continue to grow... There are no military solutions to environmental insecurity...", and they should agencies international conclude lVGovernments and achieving terms of cost-effectiveness, in assess the

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CONTRACEPTION

TABLE XIII.

Percentages of Total Central GovernmentExpenditureAllocated for Health, compared with Education and Defense (1986) TYPEOFECZOtKWY

HEALTH

Low-income economies a) (Excluding China and India)

3.6

9.8

17.7

Lower middle b) income economies

4.0

14.5

15.8

Upper middle income economies ‘)

5.1

10.2

10.3

Industrial market economies d,

12.9

4.5

16.4

a) Per capita b) Per capita c) Per captia

GNP <480 US% GNP ~480 41,940

US%

EDlKmoN

DEFENSE

Source: The Work3 Bank, World Devdopmant Ftepott. 1988

GNP ~1,940 <6,000 US% d) Member countries of OECD, except Greece, Portugal

and Turkey. Since 1988 the World Bank has changed its classification of economies; this group is called “High Income Economies” with a per capita GNP *6,000 US%.

security, of money spent on armaments compared with money spent on reducing poverty or restoring a ravaged environment" (41). True, but what about the costeffectiveness of money spent on increasing contraceptive prevalence contraceptive research? and I was told (confidentially) of OECD by an officer that the sums required for this are not large enough to be handled by the Development Assistance Committee. The figures shown in Table XIII have been condensed from the data published by the World Bank in 1988 and indicate the worldwide relationship in government spending on health, educationand defense (46). Four short comments may not entirely be out of place. The first, that $1 trillion constitutes 7.7% of the entire world economy of $13 trillion. The second, that in 1987, out of 166 Member States of WHO, 72 spent less than 5% of their gross national product on health, 57 spent more than 5% and 37 did not provide any information (30). The third remark is from the historian Arnold Toynbee: "The human race is far more able at technology than it is in dealing with itself" (47). The last comment is from a speech of the United States Ambassador to the United Nations, Adlai F. Stevenson, in 1963: tVWill Man ever recognize that his needs for his fellow men far outweigh his arguments with them?*@ 222

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The Future Belongs

to 8CienCe

humorist, Henry Wheeler Shaw In 1865, the American ('Josh Billings'), remarked that "As scarce as truth is, the supply has always been in excess of the demand" (48), and the Nobel Laureate in Physics, vintage 1922, Niels Bohr in a more sophisticated way, that pointed out, perhaps "profound truths are recognized by the fact that the opposite is also a profound truth" (49). What both of them imply is that truth can be used in a selective way to in polarized areas of public reinforce opposite views debate. In their attempts to improve the human condition, Scientific International Organizations as well as the Community are frequently confronted with three levels of the economic and the political. reality--the scientific, When those three levels converge, progress can be very If not, the political reality appears, at least impressive. to have the controlling influence. It is, superficially, but not necessarily justified, therefore, understandable, that scientists are sometimes discouraged and wonder how much influence is left to science, where doctrine indicates Homo about the otherwise. scientificus is concerned seemingly strong power of Homo dogmaticus in shaping Our Common Future. I find little justification for an overall pessimistic attitude, and I believe that the controlling power of Homo dogmaticus belongs to the past rather than to the future. Throughout history, and especially during its recent phases, technological progress has always been the greatest enemy of Indeed, traditional taboos in any society. what is Volerated" or accepted today was a no-no 500, or even 50, years ago. The remark made by Lowell, "Not a change for the better in our human housekeeping has ever taken place that wise and good men have not opposed it--have not prophesied that the word would wake up to find its throat cut in consequenceV1 (50), is as valid today as it was more than a century ago. And evolution would not be complete without occasional bursts of fundamentalism and obscurantism, but I sense a major need to carry a simple, forceful message to the general public and to governments, reminding them that fundamentalism and obscurantism will not improve the human condition-- only Science has the proven ability to do so. what Homo scientificus requires in order to generate more hope among fellow scientists is a long enough perspective. I started this review by mentioning the evolution of Homo sapiens in the demographic context without mentioning the technological progress achieved by the species. What about the life of the numerous generations which lived in caves, could not communicate with each other and never saw a printed word before 1440 or an electric motor before the second part of the last century? Radio, television, computer technology, the conquest of the moon and the

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CONTRACEPTION of thousands of items we take for granted in our daily life--all this happened in my lifetime. It may also be worthwhile to remember that more than 90% of all drugs now being prescribed have been developed by our generation, including the steroidal contraceptive and intrauterine device used by many millions of women.

development

What could Homo dogmaticus do against all this? Argue and threaten. Although he still tries hard, he has been in constant retreat since the 163Os, the time of Galileo. Yes, it is likely that within the next 40 years there will be twice as many people on Earth, consuming three times as much food and fibre, seeking four times as much energy and engaging in five to ten times as much economic activity (41). It is also likely that these developments will create major problems and much turbulence for the generations to However, it is more than likely that the coming come. generations will find scientific and technological solutions to the majority of the problems indicated. Only the new generations of scientists will be able to Yes, it will be easier to find find those solutions. solutions for the problems of Spaceship Earth with a final population of 10 billion, rather than the more likely 14 billion. However, solutions will be found and life will go on. The prophets of "gloom and doom" are wrong. There is a Future for Man, because that Future is created in the mind of every single scientist today and tomorrow. The message to carry home comes from an exceptional Homo politicus, the late Prime Minister of India, Jawaharlal Nehru: "The future belongs to science and to those who make friends with science IV (51). References 1.

2. 3. 4. 5. 6.

7.

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