Research training in the biomedical aspects of human reproduction and family planning in developing countries

CONT

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A. K e s s l e r Chief, Rep duction World H e a l t h O r g ~ i z a t i o n ,

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it neva

d

C. C St dley Scientist, p r o d u c t i on World H e a l t h O r g Izatlon, G

it e

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P c

ily p l i repres ts a m a j o r c 6 n c e r n for y co tries. es e, h ever, enco t e r l n g m a j o r obstacles, so of ich o y be r e s o l v r o u g h research, d eq n t l y t h r o u g h r e s e a r c h the local level, o r t a g e of trained m power has ba such o sear in de l~ing co rles.

p er des c s tre s o v e r the past ....t dec es in t r a i n i n g for r e s e ch in r e p r o d u c t i o n . . . . f ily pl ~g. It d r e s s e s i t s e l f p r i m a r i l y to the needs of d e v e l o p i co tries for sue!! rese ch tr n i n g the e ent to ich these needs have b e e n t

e

Accepted for publication January 27, 1976.

is

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..V O L .

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a ReVlew of t sponsor~

£pr uctive by ~ e

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a t .... o m e d l c se ch c c trl e to t development of t l e s s p r i v i l e g e d co es i s om that h won" g e n e r a l ace t ce, m e m e a priori e irical gro s. ~ eh of this research s uld ~c ri out in de~lopi co tries, e rm th this reseat might t e are ters of eater c t rsy. S h o u l d , for e le, all s u c h r e s e ch al-or ~t o r is ..t...h e a place well for irected f rese ch? F o r the p t t or fte years, ese issues co . . . . in a ve c crete w i n d e v e l o p i n g eo tries in rela t ion to p ulation. A jot c ce be with i l y pl g p~gr es. te t to s e t p prlate progr es o f s o c i a l a c t i o n , c e r t a obstacles h e been co ter i required r t ir resoluti l e a s t so rese ch i n e co,tries t mselves. For inst ee, s of f e r t i l i t y r e g u l a t i o n s u c h as t h e co r a c e p t i pill, re ily used by Weste n, h a v e equ tly little accept ce i n d e 1 ing co,tries, is m be d u e to t ct th f ily pl g in i t s e l f held little peal, o r t h a t ~ p i l l - t i was a practice rei to t m or to the c u l t u r a l i n a c c e ~ llity of slde-effects su a~ intermenstrual c e d i n g , o r tO t h e d o s a g e of h o r m o s b e i n g in propriate to e b y-size nutritional status of these wo .... other inst ces, s u c h as the i n t r r e f i n e d e v i c e i n I ia, i~ itially high accept ce of a m e t h was followed by catastrophic discontl i rates, is could i n p a r t be c r i b e d to i n proprlate set ce struct es f o r d e l i v e followef il~ p l g c e. All t h e s e are p r o b l e m s to Ich bio ical research h some g to c tribute. C l e a r l y , p r o b l e m s i n v o l v i n g t h e co ity tit e s to f ily pl ing, u t i l i s a t i o n o f s e r v i c e s , pe e p t i o n of m e t h s of rtility co rol .... r e q u i r e st ies in the co tries emsel s, c led out by .national s c i e n t i s t s . Less clear-cut, h e r, is t h e n e e d f o r s c i e n t i s t s in developi co tries t o wo p blems of less i t e ~ plic ility, although directly relev t to t h e d e lop nt of new co raceptives, su as identification of processes in the phys..~iolo of r e p r o d u c t i o n s u b j e c t to r e lati , s t h e s i s or i s o l a t i o n of g ~le chemicals, toxicological screeni in !reals of pot tlal c traceptive drugs, ese questions have been discussed more l l y in ~ r e c e n t a r t i c l e (1) o n s t r e g i e s i n d e v e l o p i n g co t i e s ~for r e s e a t in an r~roducti . C l e a r l y , a k e y e l e m e n t in b u i l d i the n e c e s s a research r e s o u r c e s is m er. Considerable ef rts s have been e e ed over the past s in this area. assessment is t fore timely r t h e pl g of the f u t ~ e devel ment of reseat in reproducti f iiy pl i ; it m so have bro er plic ions to rese in other ..b i o m e d i c a l fields. T o wh e t ~s e rese ch

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tra ing p vided tel ed to. the m a j o r p r i o r i t y e reseat In de loping tries? H~e ade ate rs of ~ci tists e n tr ned in dif r t diseipll ~? ° H r w a s t r a i n i n g rel at to e est lishof rese facilities d to c eer o or i t i e s ? "H valuable ha different es o f c o u r s e s p r o v e d emselves?

the o rl

......

~

n

il ~ el i v e l y ~ r e c e n t l y , the o r i e n t a l of r e s e ch ira g w ve bro ; i eed it alleled, a s m i g l a ~. b e e ected, he o r i e n t a t i o ~ of r e s e a t co u c t e d in ~a c emic s e t t i n g s w i t ~ a stro e basis e elucidatl of p h y s i o l o g i c ch i~ms, e i t h e r at t h e cro or m a c r o level. Rese ch tra! was ither goal-orie ed n o r aa~ did it i n c l ~ d e a m j o t c l i n i c co o t. aimed increasing research m p er in .the ~ e l d of r o d u c t i o n , o n a g l o b a l scale, in de loped d developi co tries, wi out d i s t c t i o n of e partict~l e d s of e i t h e r , tlle case o f e major i n g a ncy, is b r o a p p r o a c h was o p t e d a l t h o u g h t h e obj tives of the ncy we more n ly cused the d e v 9P nt of m e o d s of f e r t i l i t y regu ti in the con.e of .population problems the l a s t five ars, the te e n c y has b e e n to r e l e research train re c l o ~ e l ~ t o r e s e p r o b l e m s in f i l y ~l i . is has ~e parti cul ly tr r reseat trai for de 1 ing co '.rles @ is d u e to s e v e r a l f a ors. One ~of~em has b e e n the d i f f i c u l t y o f assessing the i act o f b r o .... t r a i n i n g on rese o~ fertility re lation. other been e incre i ~d em by mini strators deve I ing co tries r res rch m ower for problems "arising in e context of national f i progr es, e.g. in c l i n i c a l t r i a l s of n e w thods of contraception, or in t assessm t in p titular populati s of & h e s i d e - e f f e c t s o f e x i s ~ n g ~th s .... ey h a v e r i g h t l y i n s i s t e d t h this rese is best co ucted by local scientists, trai d, however, in a more p l i e d ~ p p r o a c h th the e a r l i e r ac emic is is perh s e m ifestation of the world-wide t dency to press for g ate~ relation of sear d r e s e a r c h t r a i n i n g to s o c i a l p r o b l e m s . One result has en more t i o n to ~g researc~ tralni the eds of s p e c i f i c p r o j e c t s in f ily pi ing to b u i l d i n g - u p in de loping co tries nucle~ ~r such ~esear in academic cent s, b with close i! s to the s e r v i c e p r o g r es. ~ere s also be.en a m o v e t o w a s de lop n t of p o w e r in discipli~s w h i c h are e s s ~ t i to r e s e a r c h i n f ~ i l y pl i n g s u c h as epidemiolo~, clinical pha acolo~, biosoci s c i e n c e s .... M er in these ~diseiplines is in short s ever ere, t e s p e ....: : : l a l l y ....~ d e v e l o p i n g co es. e more tr itional proa to t r a i n i n g in s u c h discipli s has had to be widened to include ortentati towa~s reproduction f ily ing. is p r o v i n g d i f f i c u l t to i d e n t i f y tr n i institutions ere the e l e m e n t s can be s u c c e s s f u l l y fused. ~

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Tre_nd_s_

1

inore s ~rc~ot0rainin~

Bef e developi co st i st five yea r scie ific le systematic atte erati

e m -nineteen tries in r r ts ing to d a doctoral de ers in their co t has, h e its fate is 1

fi

ies, tra g r sei tistS f m tire biolo consist of a w outeloped co tries usually r t ee to ee. Some of ~hem have emer ities i r; a t i ally. No r, b e e n m e to keep track of this earlier ly o

A research

re intensive ef t to sti late c eers in reproduc°5i by s p ring se traini in s eld bee o ye s o, m nly the F ion. e case of the Fo ati , this was part of a more neral e f to pro te on a El al scale inte st c i]ity for resear in repr uctive biolo in the c te of e popul ion problem. I e , s r rese training activities were generally m e s e dep ents ich receiv assist ce r e c uct of resear , mainly in developed e tries in rope rth ca t also in de loping co rles. So of these f s were lled throu t Pc lati Co cil, a priv e a ncy in e ited States ich prov ed so se training in its o 1 orat ies a l s o co ucted a ll ship p~ogr me. On a smaller scale, some gove ments ve a l s o g i v e n di ct assist ce for resear training progr es is eld r de lop g co ries, e.g. t Swedish Inte ional Development Authority (S A) the Overseas Development Administration of the it Kingdom. e i C cil of dical Rese h purs d in I ia some of the research tr ning activities initially sta by o side ag cies. e l a t e n i n e te -si ies, in e co ext of a rld-wide prog r e de lop nt of research rese c ility in h re oduction f ily pl ing, the rld alth Org ization ini a d vari s es of activities - rese ai ng gr ts, o~ t h e s e a c t i v i t i e s were supported seminars, courses wo shops . M m 1 get to leh all M bet States ntrl te. A e si ef rt m e possible diti 1 s provided by S A, t h e ited N ions F r Population Aetivlties, du ng t p t r ye , m special d i to C a, D , Finl , No , Sweden the Fo Fo dation. iS progr for scientists f r ucl s f i

472

's P

e is m de this latl

becoming the major lopi co t es. pu ose bec e of

source for Fo over 1

se i ducti

training is in the

t.

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s

of

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Most of the research training has been of the " p ntlceship" t e, i.e. t h e c a r r y i o u t o f a r e s e a r c h p r o j e c t or p r o j e c t s , der s ervision, with atte ce sem!na t not inte ed i n a fo al c o u r s e , e selection of the reseat project was prlmarlly in uenced by the interests of t host instituti r her th by relev ce o f t h e p r o b l e m to :research p r i o t i e s in t h e t r a i e's co t of o r i g i n . With few excepti s, t h e r e s e ~p r o g r a e of t ac emic departments in training institutions in develop co t r i e s .... the few in devel i n g co ties h e fated to bro uctlve biolo , weFe not goal-o ted towards contr~eepu, e developm t, more often not h lit tle clinical co,orient, value of prenticeship training was 1 a ely dep the ality of the s ervisor, bo as scientist teac r, e co itme time he h r rese ch training, is v a r i e d cons er~ly of course; ly r ely did trainees from devel i n g co ries h e t h e go rt e of having a supervisor willing or l e t o p r o v i d e co reh sire tr ning, r ging from e discussion of possible hypot s e s , t o t h e fo ation of a r i g o r o u s r e s e a r c h p r o t o c o l , e o s u r e to s e v e r a l r a t h e r t h single 1 orato tec iques~ instruction in the alysis o£ data, e writing-up of results, m be ev assist ce w i t h t h e el or :ion o f research projects that could be carri out on retu to t instltuti ..... M y a research trainee, fort ately, s .... t h a t h l s y e a r o r t w o at ...a. ope or N o r t h A m e r i c prestige iversity has o t e d to l i t t l e m o r e a period of service a higher-gr e tec ici , maybe of gre er benefit to the st institution th to the trainee. He m a y h a v e a c q u i r e d c o n s i d e r le in one highly specialized tec ique requiring sophisticated instr ntation, lie will inevit ly, o n re tu h o m e , w i s h to o b t a i n t h i s e q pine d to i o u t a se es o f e erime s d papers based on is t e c ique.

Some institutions training d atte ted teac rs t o atte

.........

.y...e

did reco Ize the shortcomi of to e o s e .... e t r a i n e e to a I get ce at d ental ot r sere

r ticeshtp bet of ars.

course 9

A bro er bag d more st ctured aeh se ch tr ning has been provid by a s ii r of one-or ~o-year poSt-doctor courses, e ...b .est o of ich are Worcester Fo at£ course, that of t iversity of Sou e C i f o r n i a , ... L.o s les, Latin-Americ Course t~ Biolo of Reproduction. e y te to begln with a core progr e of lect es semin s practical wo , giving overall ew of r roducti blolo~, rese ch t olo te iques estions of inst t i e tr nees select d c a r r y out, d e r s u p e r v i s i o n , a s p e c i f i c r e s e a r c h p r o j e c t .....

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For m trai es from de l o p i n g co ties, it is i ely that this proach may have h gre er value bee se of its c rehensiveness its attenti to e spirit of reseat . ~ wever, given the varied back" gro of group Of tr nees, a core progr e will i vit ly p~sent material of little or no i e s t t o ...a. er of t m.. Noreover, m y of the trainees were cli~ci s wl little ba g in rese oh; t h e s e courses seldom pro ded e search e erience quired to tu them i

o

t

Short

e

rese

ers.

comrses

During e past ten s, a v a r i e t y o f s h o r t c o u r s e s , m a i n l y o n e ee w e s, h a v e b e e n o r g ized. Some dealt o ly with recent v ces in reseat in reproduction d f ily pl ing, others dress emselves to specialized aspects of the field. For ex le, a series of one we sere ars we org ized research in e p siologlcal, clinical, p lic health aspects of h repr uction in E t, dia, Ir , d esia, ail d, T u ey nezuela for scientists, clinici s d iversity teachers from these d nei a r i n g co tries. Sli t l y lo er courses lasting from one to t e e mort s have permitted a more i epth review of current issues in research reseat meth s, equently co ucted by le ing sci tists, t often lying little p ticipation the trainees. Some of these courses have been org ized prim ily r medical school teachers, for at ce in Latin erica d I ia, wi the aim of developing interest in rese ch in their instituti s. to

t

More specific courses have dressed themselves to research eas in re oducti in ich e erience was parti cul ly la ~ng. Assessment of e safety, effectiveness, d accept ility of fertility re ?_ating a g e n t s r a i s e s q u e s t i o n s of research desi not enco tered in o er areas of therapeutics. Several e week courses ha prese ed e main issues of clinical trial methodolo f o r f e r t i l i t y re lating agents to scientists f m develop g co tries. Sucl~ c o ses ha recently been directed to s c i e n t i s t s involved in multi-centred tri s of the netwo of Coll orating C tres for Clinic Research. ey are o y intr uctlons to clinical ph macolo d related disciplines, h ever, c o t rein y " e b a s i c p r o b l e ~ w h i c h is t h e s c a r c i t y o f t r a i n e d research

wo

ers

in

ese

a

as.

R ioi oass as a t e c ique for the study of e ocri logical par eters in p duction has w a popula ty which has been flected in e fairly lar e r o f c o u r s e s h e l d o n it It is ha to a s s e s s the value of m y of e s h o r t co ses in this a a; ey ha frequently attempted to p sent too m y assays d the trainees could not lea to perform them in two or three we s. In dltion, the courses were too o atte e d by y o g scientists from developing coI~-~ ~ies ose home institutions did not have t requi d e slve equipm t required r ~he

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L osc y h so b e e n s u b j e c t o f se ral short A1 o u g h so of e tr es m h~e a p p l i e d this t r a i n i n g on ste liz i , m o s t case.s it s e r v e d o n l y to i . . . . ve, prob ly inte ed, c! ic c e of patients.

co ses. to r e s e ~ c h was

e n er of scientists o m de I ! n g co es ha received d i e past ty ~ e s at l e a s t e ye 's t r a i n m be estim as b e t w e 5 . e Ere majority of them ained i n N o r t h A ~ea rope; the r e m a der we ly entirely scie ists f m ia o w to Delhi for tr ning, or om t A m e r i c a wh 9 p t i c i p a t e d in C ( e " tee Natl s" co se i n A a, C h i l e U gu ). It is d i f f i c u l t to e s t i m a t e t h e s s ed su ira ing; so ing agencies only repo t h e c o s t of t r a 1 stip s of the t r a i n e e s , o t h e r s incl e the cost of t u ! t i u s e of 1 or ory facilities, M e estim ed total e it e o v e r the p a s t enty yea of so $ 8 m i l l i o n c o m e s f a i r l y c l o s e to ma d c o v e r s the contrib ions of e in ing agencies, including e Fo Fo atl , t Po lati Co oil, e ited tions for p u l a t i o n A c t i v i t i e s , the N ional s t i t u t e s of H e a l t h ~e World Health Org iz ion. It is a l s o d i f f i c u l t to o b t a i n fig es o n e r of: s c i e n t i s t s f r o m d e v e l o p i n g co ries te ing sho c o u r s e s ....Abo sci tists have been em by , ich h a s p r o b ly been the main source of s port to such courseS. It is 1 ely that "e e it e on a gl al ... sc e h a s e x c e e d e d $1 million," t s i i n g to a (very t t~ive) total of $ 9 m i l l i o n e e it e o v e r the p a s t t w e n t y y e a r s O n r e s e ch t r a i n i n g r d e v e l o p i n g co tries. ....

A si le meas e of e success of is training ef rt is the n er o f t r a i n e e s w h o h a v e r e t u ed to t h e i r c tries, have remain ...a ..c t i v e in the f i e l d o f s e a r c h of reproduction f ily p l ing. e ency, e Fo Fo ationi s atte ted to swer t se q u e s t i o n s in co il g its D i r e c t o r y of F e l l s R ~ r o d u c t i ve B i o l o 1960-1972. Of e 152 ~ s p o e s to its questio aire who o gin ed i n d e ~ l o p i co ties, o v e r 50 est l i s h e d the e l v e s i n a de 1 ed co try. Of those o ret ed to t h e i r co tries, less t h h a l f spe at l e a s t 50 p e r cent o f £ e i r time research in r ucti biolo the r e m a i er being pr arily clinlci s. G i v .... t h e h i g h r e of n o n .....spo ency ( o~ 140 o u t o f ), is is i n c o ~ l e t e , , were e non-respo e inc ed ....e a t t r i t i o n r e ...m ..~ b~ e v e n hi r. I ~ w e v e r , it d o e s s e t to g i v e ...~ . i c a t i ....o f the .....ma ..... i t u d e o f ...the . brain-drain p b l e m in ~ e past

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ty years, d':,,ie t s w i l l rein n i n h i s

te t to .... e tr nee iI r e t u co r several

nst

it, s o m e e n c ies r e q u i r e his home institution

ars.

f i n a l test, h o w e r, o f s u c c e s s o f r e s e a r c h t r ning lies the reseat t p u t of t h e w tr e s i n t e r m s o f co ri tions to k l e d ge te o l o g y re le t to e need s o f deve i i co rles. As w i t h a l l r e s e a t quality d le ce a r e d i f f i c u l t t o a s s e s s , b t evaluatl is m e I "the re d i f f l c u l t b y t h e f a c t at research output depe s ...... m ~ factors th just the quality of rese ch tr nl : see e research positions, equ e equip nt facilities, r Id a c c e s s t o l l t e r a t e, d i r e c t c tacts with other scientists in e insti ti r o .... r e a r e f e w ~instl t i o n s in d e v e l o p i n g co tries e r e a l l ..... t se Irements c b e fo together, i s h a s p ....b l y co rlbut more t sl e s s w i t h w h i c h r e s e a r c h i n h ~ ....r e p r o d u c t i o n h a s g r in d e v e l o p i n g co tries th h a v e the s h o r t c o m i n g s o f r e s e a r c h t r ning desc bed a ve. Neve heless, the fact remains that proaches to rese ai n g in t h e p a s t h a v e s u f f e r e d f m a er of f lts th c be died. re

.....

Pe s the e a t e s t d e f i c i e n c y of r e s e ch t r a i n i n g f o r d e v e l o p i n g ties s lain in e f a i l u r e to r e l a t e t r a i n i n g d i r e c t l y to t h e lop nt of specific sources for research, either within e sti res, o r b y h e l p i n g e s t lish new rese ch i n s t i tlons. Such roach will quire pl ing for the traini of a g of resear wo ers, b o t h p r o f e s s i o n a l s of diffe~rent d i s c i p l i n e s d supporti tec ici s. n i n g has, i n fact, s e l d o m be directed t s 1 orato tec ici s, inten ce e n g i n e e r s , d a t a - p r o c e s s i n g p e r s o el, resear n ses, etc., the specific needs of developi co tries r such pets nel have been little cater for. co de ce

perspecti o p t e d i n r e s e a r c h t r a i n i n g h a s so f a r b e e n a ort-te e. de 1 m e n t of c a p i lities for reseat has lo er-te i lie ions: in t h e S e l e c t i o n of t r a i es o f d i f rent back o s, in t p i n g of eir training, d~ i n t h e i r i n t e ation in e resear pro es o f t h e i r me insti tlons, e is ing n te s o f ei - to tenco Itm ts r to ei t scientists, propriate er o f t e c Ici s, r a t h e r t h in te s of hoc llowshlps for i ividu t i es o f a co le o f ars' d i . L o c a l co i e to the d epe the extent to ich nationally relev t p blems,

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s p o r t ~of s u c h r e s e they dress themselves oice of discipline

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training will therefore be dictated more by considerations of the p b l e m s to w h i c h t h e ....t.r a i n e e s w i l l a d d r e s s t h e elves in e future th by the prestl -r g of the diseipl e; i t m a y , f o r i n s t ce, be necessa to train fewer elect n microscopists more clinical ph acologlsts. It is i e l y t h a t o n e - o r t w o - y e a r co ses, h o w e v e r g o o d t h e s e m be, would produce scientists capable of pl g co uctlng rese ch in the setting of developing co tries. F o u r to f i v e y e a r s training of e .D. o r D . S c . t y p e m a y b e r e q u i r e d f o r at l e a s t a c o r e oup of sol tists to able them to acquire the skills knowledge needed. It has

been

send

questioned

ether

g scientists

these

skills

ledge

Europe e r e it is v i r t u a l l y i ossible to orient their t a s their o local or national problems. T h e r e are, few centres in developing co tries c le o f p viding

research

training,

of

them

developing should

scientists co

co

have

tries

tries

to

sufficient

from other

provide p r e ~~ t i g e

developing th

the

co

e i vo

towers

to

be

America training however,

r e m o v e d f r o m thos( ~ o f the d e v e l p r i o r i t i e s s h o u l d b e to b u i l d - u p

countries

c

by

most

om d e v e l o p i n g

kn

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far

ing world. Maybe e of e first a few research institutions in

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es.

A c t v i ati to t h i s a roach s b e e n to b r i the ning to t h e t r a i n e e s , o n a l o n g - t e r m b a s i s , i n t h e i r h o m e i n s t i t u t i o n . ex le o f t h i s is the W Resear Team On e Evaluation of Fertility C rol t h o d s , l o c a t e d at t h e ulalon o Hospital in B gk . a l n l n g in r e s e a r c h f o r a g r o u p o f ai s c i tists has been provided e co se of est fishing i ratory facilities, sett clinical trials d conducting field st ies in conj cti wl a itidisciplinary group of scientists from abro , based for several y e a r s at C h u l a l o n o . is in s i t u t r a i n i n g h a s b e e n c o m p l e m e ed for the ai s c i e n t i s t s ort pe s of well-pl ed d hi ly focused training abro , by e ally cused training given visiting consult ts. Provisi for conti ed c o n s u l t t assist ce will be m e to ai r e s e ch g a er the dep t e of e inte ional staff. ture of is ai r e s e ch o , however well-tralned, will depe st le c o n t i n u e d f ding for its reseat prog e. is considerati is t ental issue which erlies all discussion of research traini in m reproduction for developl co rles. E

i.

Kessler, A. d St PI ins: Research "~i :577-579 (1974). ~

A P R I L 1976

ley, C . C . : m pr Strategies in D e v e l o p i n g

VOL. 13 N O . 4

ucti Countries.

ily Nature.

477