Eco Science - Four - Population, Humans & China Lauded

TABLE 13-1

Change in Disapproval of Abortion (all white respondents) were still unable to obtain them. More than half of all abortions after 1973 were carried out in specialized clinics, while public hospitals (which provide most medical services to the poor) were lagging even behind private hospitals in providing services. Only one in five U.S. public hospitals reported performing any abortions in 1975. Thus in many areas it was substantially more difficult for poor women to obtain abortions than for middle-class or wealthy women, even though government funds were available to cover the costs. Teenagers, who account for about onethird of the need for abortion services and for a large and growing portion of the illegitimate birth rate, also seem to have poor access to safe abortions. Finally, abortion services were found to be generally less available in the southern and central regions of the U.S. than on either coast. In the United States, the majority of abortion recipients are young and/or unmarried. There is some debate over the degree to which legal abortion has affected American fertility overall, but it seems to have had a significant effect on the rate of illegitimate births. In 1971 reductions in illegitimate births in states with legal abortion ranged as high as 19 percent, while in most states without legal abortion they continued to increase/ Following the Supreme Court decision, the rising rate of illegitimacy halted briefly, then began again. The rise was accounted for by an increase in teenage pregnancy. There is no evidence that abortion has replaced contraceptives to any significant degree, despite the apprehensions of antiabortion groups on this score. Most women seeking abortion have a history of little or no contraceptive practice, and many are essentially ignorant of other means of birth control. Those who return for subsequent abortions have been found to be still ignorant of facts of reproduction, using contraceptives improperly, or to have been poorly guided by their physicians." Paralleling the trend toward liberalized abortion policies in the U.S. has been the growth of right-to-life groups who are adamantly opposed to abortion. These groups have lobbied actively against reform of state laws and, since the Supreme Court decision, have tried to persuade Congress to reimpose sanctions against abortion through Constitutional amendments. Under their pressure, Congress has removed funds for

abortion services from Foreign Aid grants to LDCs. In 1976, Congress also passed a law forbidding federal assistance for abortions in the U.S., a move that denies these services to lowincome women—precisely the group whose chances for a decent and productive life are most likely to be jeopardized by an unwanted child. Whether the courts will consider such a discriminatory law constitutional is another question. Right-to-life groups have also played a part in harassing clinics, hospitals, and other organizations that provide abortion. This activity often embarrasses clients and possibly has also discouraged other institutions from providing abortion services. Action by right-to-life groups in Boston resulted in the trial and conviction for manslaughter in early 1975 of physician Kenneth Edelin following a late-term abortion (about 20 weeks). The prosecution maintained that the fetus might have survived if given life-supporting treatment. (The conviction was overturned in December 1976 by the Massachusetts Supreme Judicial Court.)'1 The consequence of the original verdict nevertheless was to discourage late secondtrimester abortions (31 states already had laws against them except to protect the mother's life or health; in most states abortion by choice was available only through the 20th week). Unfortunately, this change also will affect mainly the poor and/or very young women, who through ignorance or fear are more likely to delay seeking an abortion until the second trimester. In 1976, a Right-to-Life political party was formed, centering on the abortion issue. Its candidate, Ellen McCormack, entered primaries in several states, but never succeeded in winning more than 5 percent of the vote. Most Americans, it appears, accept the present legal situation at least as the lesser of evils.

1. Sklar and B. Berkov, Abortion, illegitimacy, and the American birth rate. "Blame MD mismanagement for contraceptive failure, Family Planning Perspectives, vol. 8, no. 2, March/April 1976, pp. 72-76.

* Time and Nescstceek, March 3, 1975. Both magazines covered the trial and the issues it raised in some detail. See also Barbara Culliton's thoughtful article, Edelin trial; jury not persuaded, and Edelin conviction overturned, Science, vol. 195, January 7, 1977, pp. 36-37.

Percentage of disapproval Reason for abortion

1962

1965

1968

1969

Mother's health endangered Child may be deformed Can't afford child No more children wanted

16 29 74 -

15 31 74 -

10 25 72

25 68

85

79

Source: Judith Blake, Abortion and public opinion.

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admitted having had an abortion; under Italian law she had committed a crime and could be sent to prison. Some years ago in a confidential survey of 4000 married women of all classes, all admitted to having had abortions, most of them many times.48 A movement is now underway to loosen the laws against abortion in Italy, following the limited legalization of the pill in 1971, despite strong opposition from the Vatican and conservative political elements. The Italian constitutional court in early 1975 ruled that abortion is legal if doctors determine that the pregnancy threatens the physical or mental health of the mother. Before the 1970s, variations on the Italian abortion tragedy prevailed in several other Western European countries. In France, contraceptives were available but not openly, and the illegal abortion rate and attendant rates of death and injury nearly matched those of Italy. In late 1974, abortion was legalized in France, shortly after a new law was passed greatly increasing public access to contraceptive devices and information. Similar reversals have occurred in many DCs since 1965. West Germany, Denmark, and Austria legalized abortion on request between 1973 and 1975, although its status in Germany was changed by a court decision and remains to be reestablished by legislation. In 1975 Sweden changed its already moderately liberal law to allow abortion up to the twelfth week as a decision for the woman alone to make. Finland, Norway, and Iceland have long had liberal policies, but they fall short of availability on request. Laws against abortion in Greece and the Netherlands have been neither observed nor enforced and soon may be reversed. The same was formerly true of Switzerland, which in 1975 moved to liberalize its abortion laws. Great Britain has in effect permitted abortion on request since 1967. Spain, Portugal, Belgium, and Ireland still had very restrictive laws in 1976.4' In most of Eastern Europe, abortion has long been legal and usually subsidized by the state. Abortion has been legal since 1920 in the Soviet Union, and in most Eastern European countries (except Albania) since the •"L. Zanetti, The shame of Italy. "Zimmerman, Abortion, law and practice; C. Tietze and M. C. Murstein, Induced abortion: a factbook, 1975. These two are the major sources for what follows.

1950s. Abortion brought birth rates so low that Bulgaria, Czechoslovakia, and Hungary tightened their regulations in 1973. Romania severely restricted access to abortion in 1966, with the result that its birth rate virtually doubled the following year. Since then, the birth rate has declined toward the 1966 level, indicating an increase in illegal abortions. The rates of hospitalizations and deaths from abortion complications have also risen substantially. Meanwhile the huge cohort of children born in 1967 has caused havoc in the Romanian school systems.50 Canada has relaxed its abortion law somewhat; practice is considerably short of "on request," but widely liberal interpretation of the new law might make it close. Canadians denied abortions often go to the United States. Australia is moving toward liberal policies, although access varies by state. New Zealand remains restrictive, but discussion of change has begun. Abortion in LDCs. The tragedy of illegal abortion thus is rapidly becoming a thing of the past in most of the developed world, but change is coming more slowly in much of the less developed world. In some countries the problem of illegal abortion is increasing because the need for abortion seems to be rising. There are important exceptions, particularly China, where abortion has been liberally provided by medical services since 1957. In India abortion was legalized in 1972, but there was so little publicity that even large segments of the medical community as well as the public were unaware of it for the first few years. For those who knew, high costs and excessive red tape were effective deterrents. For at least the first three years, the number of legal abortions was extremely low (41,000 in the first five months), while the number of nonmedical illegal abortions was appallingly high (at least 4 million a year).51 Elsewhere in Asia, abortion has been legalized in South Korea (1973), North Vietnam (1971), Hong Kong (1972), and Singapore (1969, further liberalized in 1974). Abortion is firmly illegal in Taiwan, but apparently easily obtainable from medical practitioners, nonetheless. Laws are still restrictive in Indonesia, Pakistan, Sri Lanka, Thailand, and the Philippines, but there are signs 50 Teitze and Murstein, Induced abortion; Charles F. Westoff, The populations of the developed countries. 51 The abortion dilemma, Atlas, November 1974, pp. 16-18.

POPULATION POLICIES / 759

that they may soon be changed in several of these countries. In the Middle East and North Africa, laws are generally very restrictive, except in Tunisia (which has had abortion on request in the first trimester since 1973) and Cyprus, which partially liberalized its law in 1974. Israel's tough anti-abortion law was weakened by a challenging court decision in 1952 and is seldom observed today. Abortions reportedly are also available through medical facilities in Egypt despite a strict anti-abortion law. In Africa south of the Sahara, abortion is generally prohibited (the exceptions being Zambia since 1972 and some liberalization in South Africa). Ironically, these restrictive laws are holdovers from colonial times; they are not rooted in local culture.52 Abortion is still illegal in most Latin American countries, although laws have recently been relaxed to permit it under certain circumstances in El Salvador, Guatemala, Mexico, Panama, Brazil, Chile, Argentina, Ecuador, and Peru. Abortion essentially on request is available only in Uruguay and Cuba (since 1968 in both cases). Illegal abortion is rampant in Latin America. Contraceptives are legally available in most Latin American countries, but in practice only accessible to the rich. The illiterate poor, who make up a large share of the Latin American population are generally unaware of the existence of birth control other than by ancient folk methods, and could not afford modern methods even if they knew of them. There are exceptions where governments and volunteer organizations such as Planned Parenthood have established free birth control clinics (see next section). Although these can help, they as yet reach only a small fraction of the population, mainly in cities. In rural areas where hunger and malnutrition are often widespread, a failure of primitive birth control methods leaves women with no alternative but to practice equally crude forms of abortion. In the 1960s bungled abortions were estimated to account for more than 40 percent of hospital admissions in Santiago, Chile. In that country, an estimated onethird of all pregnancies end in abortion. In Mexico, "Sue Tuckwell, Abortion, the hidden plague.

400,000 women per year are treated in hospitals for illegal abortions; the abortion rate is conservatively estimated at one-fourth the birth rate.53 For South America as a whole, some authorities believe that onefourth of all pregnancies end in abortion; others estimate that abortions outnumber births. Liberalizing abortion laws in various countries has been shown to have two important effects. The first is a very large decline in maternal deaths and morbidity (illness) associated with illegal abortion. The degree of reduction of death and illness depends on the degree of change in the law, the previous rate of illegal abortions, and how they were usually performed (i.e., self-inflicted under unsanitary circumstances or performed clandestinely by medical personnel). The number of annual abortion deaths in the U.S. dropped from over 150 per year before 1970 to 47 (25 of which were from illegal abortions) in 1973; in England the decline was from 60 before 1968 to 11 in 1974.54 Declines in many European countries and LDCs, where crude self-abortion has been more common, will probably be much greater. Conversely, the number of deaths in Romania, where abortion regulations were tightened, rose from about 70 in 1965 to over 370 in 1971.» The other result of liberalizing abortion laws is to provide such services safely to low-income women. When abortion is illegal, the rich can usually still obtain a safe illegal procedure or can afford to travel to another country where legal abortion is available. The poor have no such options; it is they who suffer most either from the burdens of large families or from dangerously unsafe illegal abortions. The moral issue. The greatest obstacles to freely available, medically safe abortion in many developed countries and in Latin America are the Roman Catholic Church and other religious groups that consider abortion immoral. The crux of the Catholic argument is that the embryo is, from the moment of conception, a complete individual with a soul. In the Catholic view, induced abortion amounts to murder. Some Catholics also oppose 53 /4r/as, The abortion dilemma; Tuckwell, Abortion, p. 20. '4C. Tietze and M. C. Murstein, Induced Abortion: a factbook. The rate of abortion deaths was declining during the 1960s, especially after 1967 when several states relaxed laws to permit more legal abortions. "Ibid.

POPULATION POLICIES / 761

will lead to genocide. It is hard to see how this could happen if the decision is left to the mother. A mother who takes the moral view that abortion is equivalent to murder is free to bear her child. If she cannot care for it, placement for adoption is still possible in most societies. Few people would claim that abortion is preferable to contraception, not only because of moral questions, but also because the risk of subsequent health problems for the mother may be greater. Death rates for firsttrimester, medically supervised abortions are a fraction of those for pregnancy and childbirth but considerably higher in later months.58 Large and rapidly growing numbers of people nevertheless feel that abortion is vastly preferable to the births of unwanted children, especially in an overpopulated world. Until more effective forms of contraception than now exist are developed, and until people become more conscientious in use of contraceptives, abortion will remain a needed back-up method of birth control when contraception fails. Attitudes on abortion have changed in most countries in recent years, and they can reasonably be expected to change more in the future. The female part of the world's population has long since cast its silent vote. Every year over one million women in the United States, and an estimated 30 to 55 million more elsewhere, have made their desires abundantly clear by seeking and obtaining abortions. Until the 1970s, these women were forced to seek their abortions more often than not in the face of their societies' disapproval and of very real dangers and difficulties. Millions still must do so. There is little question that legalized abortion can contribute to a reduction in birth rates. Wherever liberal laws have been enacted, they have been followed by lowered fertility. Longstanding evidence is available from Japan and Eastern Europe, where abortion was the primary effective form of birth control available for some years after liberalization, and where the decline in fertility was substantial. The extent of decline is bound to be related to the availability of other birth control methods; but even in the United States and England, where contraceptives have been widely available, the decline in fertility after reversal of abortion policies was significant. 58

Tietze and Murstein, Induced abortion.

According to at least one study, availability of abortion (legal or illegal) may be necessary in order for a population to reach and maintain fertility near replacement level, given current contraceptive technology and patterns of sexual behavior.59 Liberalization of abortion policies in those countries where it is still largely or entirely illegal is therefore justifiable both on humanitarian and health grounds and as an aid to population control.

POPULATION POLICIES IN LESS DEVELOPED NATIONS In response to rising alarm during the 1950s over the population explosion in less developed countries, both private and governmental organizations in the United States and other nations began to be involved in population research and overseas family planning programs. First among these, naturally, was the International Planned Parenthood Federatiork which grew out of the established national groups. By 1975 there were Planned,, Parenthood organizations in 84 countries, supported by their own governments, private donations, government grants from developed countries, or some combination of these sources.60 Various other private and governmental organizations followed Planned Parenthood into the field, including the Ford and Rockefeller Foundations, the Population _ Council, the U.S. Agency for International development (AID), and agencies of several other DC governments. International organizations such as the World Bank and various UN agencies, particularly the UN Fund for Population Activities,, had joined bv 197CL The 1960s brought a great proliferation of family planning programs in LDCs, which were assisted or administered by one or another of these groups. Most assistance from DCs was provided through one of the international or private organizations. In 1960 some $2 million was spent by developed countries (and the U.S. was not then among them) to assist LDC family planning programs; by 1974 59 C. Tietze and J. Bongaarts, Fertility rates and abortion rates: simulations of family limitation, Studies in familv planning, vol. 6, no. 5. May 1975, p. 119. ^Population Reference Bureau, World population growth and response, pp. 243-248.

TABLE

13-2

Family Planning in LDCs Population (millions, 1975) 400+

Have an official policy to reduce population growth rate

Have official support of family planning for other reasons

Neither have policy nor support family planning

People's Republic of China (1962) India (1952, reorganized 1965) Indonesia (1968)

Brazil (1974)

50-100

Mexico (1974) Pakistan (1960, reorganized 1965) Bangladesh (1971)

Nigeria (1970)

25-50

Turkey (1965) Egypt (1965) Iran (1967) Philippines (1970) Thailand (1970) South Korea (1961) Vietnam (1962 in North)

Zaire (1973)

Burma Ethiopa Argentina

15-25

Morocco (1968) Taiwan (1968) Colombia (1970)

Tanzania (1970) South Africa (1966) Afghanistan (1970) Sudan (1970) Algeria (1971)

North Korea Peru

10-15

Nepal (1966) Sri Lanka (Ceylon) (1965) Malaysia (1966) Kenya (1966)

Venezuela (1968) Chile (1966) Iraq (1972) Uganda (1972)

Tunisia (1964) Barbados (1967) Dominican Republic (1968) Singapore (1965) Hong Kong (1973) Jamaica (1966) Trinidad and Tobago (1967) Laos (1972, possibly discontinued) Ghana (1969) Mauritius (1965) Puerto Rico (1970) Botswana (1970) Fiji (1962) El Salvador (1968) Gilbert and Ellice Islands (1970) Guatemala (1975) Grenada (1974) Bolivia (1968, reorganized 1973) Costa Rica (1968) El Salvador (1968)

Cuba (early 1960s) Nicaragua (1967) Syria (1974) Panama (1969) Honduras (1966) Dahomey (1969) Gambia (1969) Rhodesia (1968) Senegal (1970) Ecuador (1968) Honduras (1965) Benin (early 1970s) Haiti (1971) Papua-New Guinea (1969) Paraguay (1972) Liberia (1973) Lesotho (1974) Western Samoa (1971) Madagascar (1974) Sierra Leone (early 1970s) Swaziland (1969) Togo (early 1970s) Zambia (early 1970s) Cambodia (1972, possibly discontinued) Guyana (1975) Surinam (1974) Uruguay (1971) Other small Caribbean countries (1960s)

100-400

Less than 10

Cameroon Angola Malawi Jordan Lebanon Saudi Arabia Syria Yemen Mali Upper Volta Mozambique Burundi Central African Republic Chad Comoros Congo Equatorial Guinea Guinea-Bisseau Ivory Coast Libya Mauritania Niger Rwanda Seychelles Somalia Namibia Israel

Sources: Berelson, Population control programs; Nortman, Population and family planning programs, 1975; Population Reference Bureau, World population growth and response.

POPULATION POLICIES

•the amount was over $200 million, more than half of it from USAID. Yet less than two percent of all foreign assistance goes to LDC family planning programs, and most LDCs allot less than one percent of their budgets to it.61 During the 1960s national family planning programs were established in some 25 LDCs, while 17 other governments began supporting or assisting the activities of private Planned Parenthood organizations. The early 1970s saw a further proliferation of these programs until by 1975,34 less developed countries officially favored the reduction of population growth, and 32 more supported family planning activities for other reasons. Some 55 additional LDCs still did not support family planning, or in a few cases opposed it. But the combined 1973 populations of the pro-family planning countries were nearly 2.5 billion, whereas the total combined population of the anti-family planning nations was only about 250 million.62 Table 13-2 shows details. Government Policies in LDCs So far family planning programs are the primary policies that have been brought into action against the population explosion in most LDCs. Outstanding exceptions are the People's Republic of China,63 Indonesia, India, Pakistan, South Korea, Singapore, Tunisia, Egypt, and a few other countries where other social and economic policies have been adopted to supplement family planning.64 However, many family planning programs have been established and are even being supported by governments for reasons other than reduction of population growth, usually to protect the health and welfare of mothers and children. Although no country has yet adopted attainment of ZPG as a goal, many have aimed at an ultimate reduction of growth rates to DC levels— around 1 percent per year or less. A few countries, by "Dorothy Nortman, Population and family planning programs: A factbook, 1974. Population Reference Bureau, World population growth and response. W D. Nortman, Population and family planning programs, 1974 and 1975. "See Edgar Snow, Report from China—III: population care and control, for an early report on China. More recent reports have generally confirmed that first impression: for example, Pi-Chao Chen, China: population program at the grass roots, in Population: perspective 1973, H. Brown, J, Holdren, A. Sweezy, B. West, eds, M

Vumbaco, Recent law and policy changes.

contrast, still want to increase their usually already rapid growth. Many others are beginning to reevaluate their pronatalist policies as consequences of rapid growth become increasingly evident. The following discussion sums up these various approaches by continent.65 Africa. Africa, an extremely diverse continent, growing at about 2.6 percent per year, includes some of the world's poorest and most rapidly growing nations. Because high mortalities, especially of infants, are also commonly found in these countries, concern over rapid growth and action to curb it have developed only relatively recently in most of them. Indeed, some African governments remain staunchly pronatalist. The belief that more people are needed for development is common among African nations south of the Sahara. Policies in Cameroon, Malawi, and Upper Volta still frankly favor growth, while Zambia and the Malagasy Republic have only recently reversed their positions (in 1975). Concern about poorly controlled migration is greater in many of these countries than concern about high birth rates. In general, family planning on a private basis has long been available in former African colonies of England, but not in those of such Catholic countries as France, Belgium, Spain, Italy, and Portugal. Former English colonies were among the first to establish national family planning policies, although emphasis in some cases is put on health and family welfare justifications. Kenya and Ghana have two of the oldest and strongest family planning programs in subSaharan Africa, and both have goals of reducing population growth. Interest in family planning at least for health reasons is growing in most former English colonies, although a few such as Malawi still discourage or ignore the activities of private family planning organizations. Nigeria, the most populous and one of the richest (in terms of resource endowment) African countries, was only beginning to show interest in family planning for health reasons in 1976, despite rapid growth. "For country-by-country details of policies and recent demographic trends, Population Reference Bureau, World population growth and response, prepared with the assistance of the U.S. Agency for International Development, is invaluable.Schroeder and Vumbaco each provide useful summaries, as does the more recent D. Nortman and E. Hofstatter, Population and family planning programs: a factbook, 1976.

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In South Africa and Rhodesia, the dominant European populations have traditionally practiced birth control. These countries are now trying to extend family planning services to their African populations. South Africa's family planning is offered through its Planned Parenthood affiliate and funded by the government; Rhodesia's services are government-supported, but operated by several private international groups. Former French colonies have begun to relax their prohibitions to allow the commercial sale of contraceptives and to support some family planning activities. The first family planning clinics in French-speaking continental Africa have been established in Senegal, whose government is beginning to show interest in family planning. Most former French colonies, however, remain complacent about their rates of population growth. An exception is Mauritius, an island nation with one of the highest population densities in the world (see Chapter 5). Mauritius has a vigorous and comparatively successful family planning program. Since the 1950s, the growth rate has been reduced to about 2.1, despite an unusually low death rate of 7 per 1000 population. The Portuguese colonies, Mozambique and Angola, remained pronatalist and strongly opposed to birth control until they achieved independence in 1975. Establishment of population programs must await the stabilization of the new governments. Some North African countries have initiated family planning programs; Egypt, Tunisia, and Morocco have fairly strong, antinatalist policies. Tunisia, in particular, has ventured beyond family planning to legalize sterilization (considered immoral and against Moslem law in most Islamic countries) and abortion, to limit financial allowances for children to four per family, raise the legal marriage age, and ban polygamy. In addition, women's rights, usually very restricted in Moslem societies, are being promoted. Some other North African countries— Algeria, Libya, Mauritania—remain pronatalist or uninterested. Many African countries still have death rates above 20 per thousand, and some even more than 30. A number of demographers and family planning officials believe that interest in population control will remain low in those countries until the death rates have been substantially

reduced, especially among infants and children. R is vitally important to change this point of view so that efforts can be made to lower birth rates along with death rates; that most family planning efforts have begun in African countries as a part of maternal and child health services is an encouraging sign. Latin America. Latin America as a region, despite having some of the highest population growth rates in the world (about 2.9 percent for the entire region), has also been very reluctant to accept a need for population control. This is probably due in part to the influence of the Roman Catholic Church, but there is also a widespread belief, at least in South America, that the continent still contains vast untapped resources of land and minerals, that the answer to all problems is development, and that more people are needed for development. Latin American politicians, moreover, tend to view proposals originating in the United States for birth control with understandable suspicion. Some seem to believe the U.S. is trying to impose a new and subtle form of imperialism.66 In some countries, this reaction has even had the effect of inhibiting the teaching of demography and family planning in universities. Latin American economists and politicians have come to accept family planning (often referred to as "responsible parenthood") mainly on health and welfare grounds and as a means of reducing the horrendous illegal abortion rate. Some leaders are beginning to realize, however, that the galloping population growth rate is swallowing all the economic progress each year, leaving a per-capita rate of progress of zero or less. A few countries have established essentially, though not always explicitly, antinatalist policies as a result—notably Chile. Colombia, several Caribbean countries, and all of the Central American countries. The efforts of some family planning programs in the Caribbean (mainly former British colonies) have been counted among the most successful, especially those of Barbados and Trinidad and Tobago. Birth rates have declined there since the early 1960s, and have declined as well in Chile, Colombia, Costa Rica, Nicaragua, Panama and Venezuela. "National Academy of Sciences, In starch of population policy: views from the developing world; Population policy in Latin America.

POPULATION POLICIES / 765

At the other extreme, Brazil and Argentina have policies generally promoting growth. Brazil does permit private family planning groups to operate, however, especially in the poverty-stricken Northeast. Argentina, having a relatively low birth rate and feeling threatened by rapidly growing Brazil, in 1974 banned dissemination of birth control information and closed family planning clinics. Since the practice of birth control is well established in the Argentine population, the action is not likely to have great effect except perhaps to raise the already high abortion rate, mostly illegal. Asia. Asia includes over half of the human population and is growing at about 2.3 percent per year. Both mortality and birth rates are generally lower than those in Africa, and both have been declining in several countries. Asia presents a widely varied picture in regard to population policies. At one extreme, China, India, Thailand, Indonesia, Sri Lanka, Hong Kong, Singapore, Taiwan, and South Korea are pursuing strong family planning policies, in several cases reinforced by social and economic measures, some of which are described below. All of these countries have recorded declines in birth rates, some of them quite substantial. Family planning programs have also been established in Pakistan, Bangladesh, Nepal, Malaysia, and the Philippines, but the impact, if any, on birth rates is negligible so far. A few rapidly growing countries, notably Cambodia and Burma, currently are pursuing pronatalist population policies, although family planning is privately available in the latter country. Other "centrally planned" countries in Southeast Asia seem to be following China's example in population policies; North Vietnam has had a family planning program for some time, which presumably was extended to South Vietnam when the nation was unified. Policies in North Korea are unknown. Middle Eastern nations are still largely pronatalist in their outlook, with the exceptions of Turkey and Iran which have national family planning programs. Several countries, including Afghanistan, Bahrain, Cyprus, Iraq, Jordan, Lebanon, and Syria, are interested in establishing family planning services for health and welfare reasons. The remaining countries favor continued growth, although they may tolerate family planning

activity in the private sector. Among these is Israel, for obvious reasons. At the furthest extreme is Saudi Arabia, which has outlawed importation of contraceptives. Nearly all Middle Eastern countries are growing rapidly with relatively high, although declining death rates. The United Nations. For many years, the United Nations limited its participation in population policies to the gathering of demographic data. This, however, was instrumental in developing awareness of the need for population policies, especially among LDCs, whose governments often had no other information about their population growth. Since the late 1960s the UN has taken an active role in coordinating assistance for and directly participating in family planning programs of various member nations, while continuing the demographic studies. A special body, the UN Fund for Population Activities (UNFPA), advises governments on policies and programs, coordinates private donors and contributions from DC governments, and sometimes directly provides supplies, equipment, and personnel through other UN agencies. In 1967 the UN Declaration on Social Progress and Development stated that "parents have the exclusive right to determine freely and responsibly the number and spacing of their children."67 The statement affirmed the UN's increasing involvement in making family planning available to all peoples everywhere and contained an implicit criticism of any government policy that might deny family planning to people who wanted it. The statement has sometimes been interpreted as a stand against compulsory governmental policies to control births; however, the right to choose whether or not to have children is specifically limited to "responsible" choices. Thus, the Declaration also provides governments with the right to control irresponsible choices. In 1974 the United Nations' World Population Conference, the first worldwide, government-participating forum on the subject, was convened in Bucharest. Publicity attending the event gave an impression of enormous disagreement among participating groups. But in fact it provided a valuable forum for an exchange of "Declaration on Population, Teheran, 1968, Studies in Family Planning, no. 16, January, 1967.

BOX 13-6 China: An Apparent Success Story Any brief treatment of Chinese society is difficult and necessarily contains elements of overgeneralization. First of all, the huge geographical expanse and the vastness of the population—nearly a billion people—are difficult to envision. Second, the Chinese people possess a cultural diversity possibly as rich as that of Europe, and even older traditions. Finally, it seems that there is no overall, systematic keeping of vital statistics and population figures in China, and those statistics that do exist are not readily available to outsiders. The Chinese are traditionally xenophobic, and the Western intrusion of the last century and a quarter—from the Opium Wars through the United States debacle in Vietnam and Soviet pressure on northern Chinese borders—have only heightened this traditional aloofness. The available information is therefore fragmentary and has to some extent been filtered by a highly centralized and autocratic regime. Still, the accounts of foreign travellers in China and the release of official statements and figures allow some conclusions to be drawn about the nature of population policy in the People's Republic." Superficially, the expressed population policies of the People's Republic of China seem slightly schizophrenic. Official rhetoric preached abroad roundly condemns Malthusian ideas: "The poor countries have not always been poor. Nor are they poor because they have too many people. They are poor because they are plundered and exploited by imperialism."6 The same article goes on to blame "relative overpopulation and widespread poverty" in the United States and the Soviet Union on "ruthless oppression and exploitation which the superpowers practice at home." But, despite assertions that there is no such thing as overpopulation, China admits to having a policy of "planned population growth," with this rationale: We do not believe in anarchy in material production, and we do not believe in anarchy in human reproduction. Man must control nature, and he must also control his numbers. . "For a recent overview, see International Planned Parenthood Federation, China 1976: a new perspective. 'China on the Population Question, China Reconstructs.

We believe China's policy benefits many aspects of life—national construction, the emancipation of women, protection of mothers and women and children, proper bringing up of the young, better health for the people and prosperity for the nation. It is, in other words, in the interests of the masses of the people.''

In recent years, as China has begun to open up to the outside world, it has become increasingly clear not only that "birth planning," as it is called, is seriously advocated and supported by the government, but that it has begun to reap results. Exactly how successful the policy has been overall is impossible to say because there are no reliable nationwide population statistics. The last reasonably comprehensive census was conducted in 1953 (when a total mainland population of about 583 million was found), and estimates of vital rates since then are basically guesswork.1' Hence the estimates of total population in 1975 range from below 800 million to 962 million/ China specialist Leo Orleans has proposed a set of estimates and projections of China's population from 1954 to 1980, and his arguments in support of them are convincing. He suggests that the 1975 population was about 850 million, with a birth rate of 27 per thousand, a death rate of 12 per thousand, and a natural increase of 1.5 percent. These figures are slightly above those of the UN. China's efforts to curb population growth began in the 1950s following the release of the census results and a period of heated discussions of the pros and cons of birth control. An organized campaign implemented by the Ministry of Public Health was launched in 1957 but then was suspended in 1958 during the Great Leap Forward, an intensive effort at economic development. The period 1959-1961 was one of food shortage and economic crises, and, although established birth control clinics continued to Ibid.

rf Leo A. Orleans, China: Population in the People's Republic. This is an excellent source for historical background, although otherwise somewhat out of date. c Orleans, China's population figures: Can the contradictions be resolved? The lowest are based on casual statements by Chinese officials at the UN; the highest are from the World Population Estitnates of the Environmental Fund, which bases its estimates on the figures of John Aird, a demographer in the U.S. Department of Commerce Foreign Demographic Analysis Division.

POPULATION POLICIES / 771

function, there was no official encouragement for their use. While China was recovering from this crisis period, the government again began advocating "birth planning" to protect the health of mothers and children. An important part of this campaign was promotion of late marriage (23 to 25 for women, 25 to 28 for men) and the two-child family spaced by 3 to 5 years/ Both abortion and sterilization were legal from the start, but the middle 1960s were a period of active expansion of facilities (along with expansion of health care in general) and experimentation in improved techniques. It was men that the Chinese developed the vacuum technique for abortion, which has made the procedure much safer than before, and which has since been adopted around the world. Active research was also carried out on simplified sterilization procedures. It appears, for instance, that the Chinese may have been the first to do female sterilizations with very small incisions." China has all along manufactured all its own contraceptive devices and Pharmaceuticals, unlike other LDCs. The latest invention is the "paper pill," sheets of water-soluble paper impregnated with oral contraceptives, which are easy to transport, store, and distribute.* Each sheet contains a month's supply of "pills" in perforated squares that dissolve in the mouth when eaten. This development is expected to increase use of oral contraceptives considerably, especially in remote rural areas where the pills have been less accepted than in the cities. Virtually every method of birth control is being actively used in China: sterilization, abortion, the combined steroid pill and the progestin mini-pill, long-term injections, lUDs (the Chinese developed their own, a stainless steel ring), condoms, diaphragms, foams, and jellies. The various forms of birth control have long been available to the people in the major cities and their suburbs. During the 1960s, health care, including birth control services, was increasingly extended to more remote rural areas. As an indication of the success of the health care programs, the death rate for the entire country is estimated to have dropped from nearly 35 per Ti-Chao Chen, China's population program at the grass-roots level. 'Orleans, Family planning developments in China, 19601966: abstracts from medical journals. *Carl Djerassi, Fertility limitation through contraceptive steroids in the People's Republic of China.

1000 population in 1949 to about 17 per 1000 in 1970* and perhaps 13 in 1974.j Infant mortality, which fairly accurately reflects levels of both health care and nutrition, is thought to have been between 20 and 30 per 1000 births in 1974.k In some urban communes (which apparently do keep careful demographic statistics), the crude death rate is 5 or less, and an infant mortality rate of 8.8 per 1000 live births has been claimed for the city of Shanghai.' China's unique health care system, together with greatly improved distribution of the food supply, can claim credit for this remarkable change. At the time of the Revolution, a grossly inadequate corps of trained medical personnel existed, mainly concentrated in the large cities. While actively training thousands of doctors, paramedics, and nurses and establishing hospitals and health centers in smaller cities, the Chinese also promptly tackled sanitation and hygiene at the grass-roots level through educational campaigns. More recently, selected people have been given four to six months' basic medical training and assigned part-time to care for basic health needs in their production brigades. These individuals are called "native doctors" in the cities and "barefoot doctors" in the country. Their responsibilities include giving injections and innoculations, administering first aid and simple treatments for diseases, supervising sanitation measures, teaching hygiene in schools, and distributing contraceptive materials. For medical treatment beyond their competence (including abortions and sterilizations), the barefoot doctors refer patients to the nearest regional hospital. Barefoot doctors in turn are assisted by part-time volunteer health aides, usually housewives, whom they train themselves.'" It now appears that China is attempting to upgrade the quality of grass-roots health care by sending fully trained medical personnel from city hospitals on rotation to rural health centers, where, among other things, they provide additional training for local health workers. Some barefoot doctors have thereby become qualified to do abortions, IUD insertions, and steriliza'Orleans, China: Population in the People's Republic. 'Norman Myers, Of all things people are the most precious. "•Ibid. 'Joe Wray, How China is achieving the unbelievable. '"Pi-Chao Chen, China's population program at the grass-roots level; V. W. Sidel and R. Sidel, The delivery of medical care in China.

(Continued)

BOX 13-6 (Continued) tions, as well as other minor operations." Both child bearing and birth control are fully supported and helped in China, Paid maternity leave, time off for breast-feeding, free nursery care, and all needed medical attention are provided for mothers. Paid leave is also given for abortion, sterilization, and IUD insertions, and all birth control services are essentially free. While the means of birth control are provided through the health care system in China, primary responsibility for motivating couples to make use of them rests with the Revolutionary Committee (or governing council) of the production brigade or commune. Usually one member of the committee is the "responsible member" for birth planning.0 In rural areas, "women's cadres" — married women with children, who are known and respected by their neighbors—carry contraceptives and the pro-birth control message house to house." In some of the cities, low birth rates have been so enthusiastically adopted as a goal that neighborhoods collectively decide how many births will be allowed each year and award the privilege of having babies to "deserving couples."" Priority is given to newlyweds, then to couples with only one child who have waited the favored period of time for the second birth/ The result has been phenomenally low birth rates for these neighborhoods, ranging from 4 to 7 per 1000 population. The center city of Shanghai reportedly had a 1972 birth rate of 6.4, while that for the city plus suburbs was 10.8.s The 1972 birth rate for Peking was reported by Joe Wray to have been about 14 per 1000 population; Myers placed it at 18.8 for city and suburbs combined. Joe Wray has speculated that these low rates may have been helped by a relatively low proportion of women in their child-bearing years. Given the recent Chinese policy of sending urban young people to rural areas to work, this may be so, even though China's demographic history would indicate a relatively large and growing proportion of people in their teens and twenties for the country as a whole by 1975. Exiling young people "temporarily" to rural communes probably was done for political rea-

sons. Large numbers of urban youth are a potential source of insurgent trouble, especially if insufficient jobs are available. Scattering the young people in the countryside could effectively defuse that threat. Moreover, the relatively well-educated city youth could help spread the ideology of the central government to remote rural areas. But it appears that the policy may also have had demographic effects. Most of the city children are not happy down on the farm; consequently, they are reluctant to marry, settle, and raise families there. Nor are rural young people eager to marry the sophisticated city people with their strange ways.' The official Chinese position on birth planning—an ideal of late marriage and a small, well-spaced family of two children—appears to have been overwhelmingly accepted in cities and is rapidly gaining acceptance in rural areas, according to reports from foreign visitors." The prevailing attitude is that early marriage and having more than two children are prime examples of irresponsible behavior. Nevertheless, there is still resistance from older generations, especially mothers-in-law, who by tradition have long wielded considerable power within families and apparently still do. Besides official encouragement to limit families, there are other incentives built into the social and economic system as well. Emancipation of women and their incorporation as full working members of society was an early, important goal of the Revolution. It has apparently been realized to a great extent, especially among younger women, and undoubtedly exerts a powerful influence on childbearing. Pi-Chao Chen has pointed out disincentives to family limitation in the per capita grain allowance, which augments a family's supply when a child is added, and in the addition of another worker (preferably a boy who will remain in the family) to contribute to family income.1' But it has also been observed that, even though another worker may help increase a family's total income, that income must still be divided among all family members. Additional members reduce the share available per person."' Furthermore, since

"Chen, China's population program. "Wray, How China is achieving the unbelievable. "Han Suyin, The Chinese experiment. "Wray, Achieving the unbelievable; Han, Chinese experiment. Treedman and Berelson, The record of family planning programs. 8 Wray, Achieving the unbelievable; Myers, People are the most precious.

'Joseph Lelyveld, The great leap farmward. "Tameyoshi Katagiri, A report on the family planning program in the People's Republic of China; Sidel and Sidel, Medical care; Han, Chinese experiment; Myers, People are the most precious; Chen, China's population program; Wray, Achieving the unbelievable. ''Chen, China's population program. '"Sterling Wortman, Agriculture in China.

773

compulsory primary education is rapidly becoming the rule in China, children's productivity is inevitably deferred at least until the teenage years. While there is no question whatever about the Chinese leadership's position on birth planning, coercion does not appear to be a part of the program beyond the extensive use of peer pressure and the dissemination of propaganda on all levels. There were reports of curtailed maternal benefits, reduced grain rations, and discriminatory housing and employment assignments for parents of three or more children in some areas during the 1960s, but these measures seem to have been largely abandoned. Possibly they aroused more resentment than cooperation and were found to be less than beneficial to the children. By the mid-1970s, China's far-reaching population program evidently had been extended to the far corners of the nation—no mean trick in itself. What the results have been is impossible to assess with accuracy, but it is becoming increasingly clear that they are significant indeed. The remarkable vital rates prevailing in major cities have already been cited, but those of rural communes for which data exist, while higher than the cities', show significant reductions from pre-revolutionary levels (birth rate about 45, death rate 34 to 40, infant mortality above 200). * Reported birth rates for rural districts in the early 1970s range from as low as 14 in an area near Shanghai" to 20-24 in communes near Peking- and some others in more remote provinces.™ These areas generally report very low death rates also. Levels of contraceptive usage in urban and rural areas are compared in Figure 13-4. Certainly the communes visited by outsiders are among the most successful by Chinese standards, and so their birth and death rates should not be taken as representative of the entire country. But they may represent the leading edge of an established trend. That the policy has been so successful in many areas, especially where it is long established, indicates that similar success can be expected elsewhere in time. 'Orleans, China: Population in the People's Republic. "Katagiri, A report. 'Sidel and Sidel, Medical care. QS Chen, China's population program.

1. PERMANENTLY STERILIZED Tubal ligation Vasectomy 2. PRACTICING CONTRACEPTION Pill

3. NOT PRACTICING CONTRACEPTION

10

20

30

-0

COUPLES (%)

FIGURE 13-4

Contraceptive practices in an urban area (light grey) and in a rural area (dark grey) in China are compared; the urban sample is from the city of Hangchow, a provincial capital, and the rural sample is from a commune outside Peking. Sterilization is nearly three times commoner in the urban than in the rural sample, and substantially fewer rural males use contraceptives. The bias seems to be reflected in the difference between urban and rural birth rates: below 10 per 1000 in some urban areas and above 20 per 1000 in some rural ones. (From Sidel and Sidel, 1974.)

If available estimates of vital rates for all of China reflect reality, there has already been a substantial reduction in birth and death rates. Norman Myers of the FAO quotes birth rate estimates for large cities of between 10 and 19 per 1000 population, for medium-sized cities, 14 to 23, and for rural areas 20 to 35. He put the national 1974 birth rate at 29 and the death rate at 13, giving a natural increase of 1.6 percent per year. Comparison of these estimates with those of other Asian nations at similar levels of development is striking, to say the least. And no doubt other less developed countries—and perhaps some developed countries as well—can learn a great deal from the Chinese experience.66 M Chen, Lessons from the Chinese experience: China's planned birth program and its transferability.

780

customs are also subject to varying attitudes and mores. These conflicting attitudes allow societies to fine-tune their responses to external changes without having to change the basic ideological structure itself. Thus, when overpopulation threatens food supplies, for example, antinatalist behavior can be encouraged, and when epidemics or war have decimated a population, antinatalism can again be discouraged. Pronatalist attitudes are very strong in traditional societies because through most of humanity's evolutionary history they have been needed to maintain populations and to allow a moderate amount of growth when warranted. The sudden introduction of death control, Western morality, and access to communications and other resources, as Western technology impinged upon the .underdeveloped world in the wake of the colonial era and World War II, disrupted social perceptions of the consequences of high birth rates in those areas. The impact was characterized by "rapid and fluctuating changes in agricultural productivity, labor demand, urbanization, emigration, and military expansion, often coupled with introduced epidemic disease."83 Because most of these disturbed societies have adopted Western ideology, their traditional methods of controlling population have been abandoned and unfortunately replaced by less efficient and less desirable ones, mainly selfinduced abortion and disguised infanticide through neglect, abuse, and even starvation. Dickeman concludes that the world population can only be controlled when less developed societies are socially stabilized and integrated and the people can realistically assess their actual resource and ecological position. Then, she feels, the people will make reasonable family-size choices in accordance with that position. The Demographic Transition A great many social and economic factors have been associated in the past with declining fertility in various societies. Among them are the general level of education, the availability and quality of health care, the degree of urbanization, the social and economic status of women and the opportunities open to them for education and "Ibid.

employment outside the home, the provision of social security for old age, and the costs to families of raising and educating each child. The more extensive each of these factors is, the lower fertility generally will be. In addition, later marriage, lower tolerance for illegitimacy, low infant mortality, and extended breast-feeding all operate directly to reduce fertility. In most LDCs, levels of health care, education, and women's status remain low for the poor majority, while marriage comes early and infant mortality rates are high. Most family planning programs in the 1960s made little effort to influence any of these factors, as demographer Kingsley Davis pointed out in 1967.84 Those that tried to influence people at all confined themselves to emphasizing the economic and health advantages of small families to parents and their children. In the 1950s and 1960s, government officials, economic advisors, and many demographers believed that the process of economic development would automatically bring about the higher levels of education and urbanization in LDCs that have elsewhere been associated with declines in fertility, and thus would cause a "demographic transition" in LDCs. These people favored family planning because they thought it would facilitate the supposedly inevitable demographic transition, although they believed that no significant reduction in fertility could occur until the prerequisite (but unknown) degree of development had been reached. Numerous studies have established quite clearly that population growth is in itself a major barrier to economic development. Economist Goran Ohlin wrote in 1967: The simple and incontestable case against rapid population growth in poor countries is that it absorbs very large amounts of resources which may otherwise be used both for increased consumption and above all, for development . . . The stress and strain caused by rapid demographic growth in the developing world is actually so tangible that there are few, and least of all planners and economists of the countries, who doubt that per capita incomes would be increased faster if fertility and growth rates were lower . . . .85 "Population policy: will current programs succeed? See also Davis, Zero population growth: The Goal and the Means. ^Population control and economic development, p. 53.

The potential value of population control in aid programs to LDCs has also been studied intensively. The late economist Stephen Enke did much of the analysis, and his conclusions may be summarized in three points: (1) channeling economic resources into population control rather than into increasing production "could be 100 or so times more effective in raising per capita incomes in many LDCs"; (2) an effective birth control program might cost only 30 cents per capita per year, about 3 percent of current development programs; and (3) the use of bonuses to promote population control is "obvious in countries where the 'worth* of permanently preventing a birth is roughly twice the income per head."86 Enke's results were strongly supported by computer simulation work by systems analyst Douglas Daetz, who examined the effects of various kinds of aid in a labor-limited, nonmechanized agricultural society.87 His results brought into sharp question the desirability of aid programs not coupled with population control programs. They might provide temporary increases in the standard of living, but these would soon be eaten up by population expansion. In many circumstances, population growth and aid inputs may interact to cause the standard of living to decline below the pre-aid level. As a result of studies like Ohlin's, Enke's, and Daetz', family planning began to be incorporated into assistance programs for LDCs in the 1960s. But the purpose in most cases was only to reduce growth rates to more "manageable" levels by eliminating "unwanted births." This great faith of economists and demographers in the potential of industrial development to bring about a spontaneous demographic transition, which, aided by family planning, would reduce population growth and accelerate the development process, encouraged LDC governments to relax under the illusion that all their social and economic problems were being solved. Unfortunately, their faith was misplaced. Reliance on a demographic transition was misplaced for many reasons, not the least of which is uncertainty as to exactly what caused the original one in nineteenth""Birth control for economic development. *~ Energy utilization and aid effectiveness in non-mechanised agriculture: a computer simulation of a socioeconomic system. PhD. diss.. University of California, 1968.

century Europe.88 And, as was pointed out in Chapter 5, conditions in contemporary LDCs in many ways are markedly different from those in Europe and North America one to two centuries ago when fertility began to decline there. By the mid-1960s, although several LDCs had apparently reached quite advanced degrees of industrial development, there was little sign of a general decline in fertility. Birth rates dropped in some countries, but they remained high, or in a few cases even rose, in other, supposedly eligible countries. Because of this unexpected result, there has been some argument among demographers whether the theory of the demographic transition can even be applied to LDCs and whether there is good reason to hope that it will occur in most of them. An analysis of fertility trends in some Latin American countries (often cited as prime examples of nonconformity to demographic transition theory) by demographer Stephen Beaver indicates that a demographic transition has begun or is at least incipient in the countries he examined.89 But, he suggests, cultural and economic factors can cause time lags in the process. A considerably broader spectrum of factors may influence fertility than just reduced mortality (especially of infants), increasing urbanization, and industrialization, which are classically believed to be the primary causes of declining fertility. It is becoming increasingly clear that industrialization—the style of development undertaken by most developing countries—is not conducive to a demographic transition. This seems to be so because industry in most LDCs employs and benefits only a fraction of the population, creating a two-tiered society in which the majority are left untouched by modernization.90 Such unequal distribution of the benefits of modernization (access to adequate food, clothing, decent shelter, education, full-time employment, medical and health care, etc.) is most pronounced in rural areas, where some 70 percent of the population of LDCs live. ss Michael S. Teitelbaum, Relevance of demographic transition theory for developing countries; Alan Svreezy, Recent light on the relation between socioeconomic development and fertility decline. ^Demographic transition theory reinterpreted. '"James E. Kocher, Rural development; and James P. Grant, Development: the end of trickle down?

55

Ethiopia •-Afghanistan Sudan*

Algeria

Nigeria • "Kenya

• Iran . Morocco

• Iraq

• Tanzania Indonesia • • Nepal • Zaire

_. Uganda ~ Pakistan

• Colombia

Thailand •

cc

India Burma

Q_

•

Philippines •

• Bangladesh LU

North Korea

• Peru

South Vietnam •

South Africa

Turkey •

CC < LU

Venezuela

> Malaysia North Vietnam

03

• Mexico

• Brazil

Eg'ypt

35

I F

cc

CD

• China 30

Sri Lanka South Korea

25 • Taiwan

Argentina 20 75

100

150

250

400

600

1000

1500

GROSS NATIONAL PRODUCT ($ PER CAPITA) FIGURE 13-5 There is an absence of any clear relation between the birth rate and the level of development (as measured by per-capital GNP) in the less developed countries with more than 10 million population. A decline in birth rates has occurred recently in a number of these nations. (From Demeny, 1974.)

Per capita Gross National Product is a statistic often used to measure the extent of "development" that has taken place in a given country; per-capita GNP, however, is an averaged figure that may conceal very large differences among income groups. And the correlation of degrees of development as measured by per-capita GNP with reduction in fertility is extremely mixed, to say the least (Figure 13-5). One explanation is that, in strongly two-tiered societies, birth control may be adopted by the affluent, educated minority, but not by the majority still living in poverty. The conclusion from this is that fertility will decline significantly only when the benefits of modernization are extended to all economic levels.

Economist Alan Sweezy has pointed out that, while this explanation may account for fertility declines in some instances, the expected declines have not occurred in some countries—notably in Latin America—even among the affluent and middle classes.90" He suggests that lingering strong traditions, including pro-natalist attitudes, may be a reason. In Latin America such traditions are supported by the Roman Catholic Church, which still officially opposes "artificial" methods of birth control and abortion. If a demographic transition should take place in ""'Economic development and fertility change.

POPULATION POLICIES

LDCs, a decline from present high fertility to replacement level alone would require considerable time, probably at least a generation. And time is running very short. If appropriate kinds of development and vigorous family planning programs had been initiated just after World War II, when death control and the ideas of economic assistance were first introduced in LDCs, the population problem might be of more manageable dimensions today. But plainly it would still be with us. Without such a history, even if the strongest feasible population control measures were everywhere in force today, the time lag before runaway population growth could be appreciably slowed, let alone arrested, would still be discouragingly long. For most LDCs it will be at least four generations before their populations cease to expand—unless catastrophe intervenes—because of the age composition of their populations. Even if replacement reproduction were attained by 2005, most LDC populations would at least double their 1970 populations, and some would increase 3.5-fold!*1 This built-in momentum virtually guarantees that, for many less developed countries, shortage of resources and the environmental and social effects of overpopulation will combine to prevent sufficient "development" to induce a demographic transition. Complacently counting on either a spontaneous demographic transition or on voluntary family planning programs—or even a combination—to reduce population growth and thereby ensure successful development would therefore be a serious mistake. The establishment of family planning programs may make it easier to improve social conditions in poor countries, but it is no substitute for appropriate development; and it is also clear that development alone cannot lead to a reduction of population growth on the needed scale.

POPULATION CONTROL: DIRECT MEASURES Before any really effective population control can be established, the political leaders, economists, national planners, and others who determine such policies must be convinced of its necessity. Most governments have 91 Thomas trejka, The future of population growth; alternative patlis to equilibrium.

/

been reluctant to try measures beyond traditional family planning that might be effective because they considered them too strong, too restrictive, and too much against traditional attitudes. They are also, reasonably enough, concerned about resistance from political opponents or the populace at large. In many countries such measures may never be considered until massive famines, political unrest, or ecological disasters make their initiation imperative. In such emergencies, whatever measures are economically and technologically expedient will be likeliest to be imposed, regardless of their political or social acceptability. A case in point was the sudden imposition in 1976 of compulsory sterilization in some Indian states and for government employees in Delhi, following two decades of discouraging results from voluntary family planning. People should long ago have begun exploring, developing, and discussing all possible means of population control. But they did not, and time has nearly run out. Policies that may seem totally unacceptable today to the majority of people at large or to their national leaders may be seen as very much the lesser of evils only a few years from now. The decade 1965-1975 witnessed a virtual revolution in attitudes toward curbing population growth among LDC leaders, if not necessarily among their people. Even family planning, easily justified on health and welfare grounds alone and economically feasible for even the poorest of countries, was widely considered totally unacceptable as a government policy as recently as 1960. Among objections to population control measures cited by demographer Bernard Berelson in 1969 were the need for improved contraceptive technology; lack of funds and trained personnel to carry out all proposed programs; doubt about effectiveness of some measures, leading to failure to implement them; and moral objections to some proposals such as abortion, sterilization, various social measures, and especially to any kind of compulsion.92 Most objections to population control policies, how92 See Berelson's Beyond family planning, for a conservative view of potential measures for population control. Since 1969, Berelson has found many formerly unacceptable measures to have become much more acceptable: for instance, An evaluation of the effects of population control programs; and Freedman and Berelson, The record of family planning programs, published in 1974 and 1975 respectively.

783

784

/ THE HUMAN PREDICAMENT: FINDING A WAY OUT

ever, can be overcome or are likely to disappear with time and changing conditions; indeed man}' of them already have. Contraceptive technology has been improved in recent years (see Appendix 4). Promising methods of birth control that are not now technologically possible should also be developed, so that they can be made available.92" Further generous assistance from developed countries could remove remaining economic and lack of personnel barriers to population-control programs in LDCs. The effectiveness of a measure can only be evaluated after it has been tried. Moral acceptability is very likely to change as social and economic conditions change in most societies, as demonstrated by the reversal of abortion policies in many countries between 1967 and 1975. The struggle for economic development in the LDCs is producing considerable social upheaval, which will particularly affect such basic elements of society as family structure. Radical changes in family structure and relationships are inevitable, whether population control is instituted or not. Inaction, attended by a steady deterioration in living conditions for the poor majority, will bring changes everywhere that no one could consider beneficial. Thus, it is beside the point to object to population-control measures simply on the grounds that they might change the social structure or family relationships. Among proposed general approaches to population control are family planning, the use of socioeconomic pressures, and compulsory fertility control. Maximum freedom of choice is provided by traditional family planning; but family planning alone should not be regarded as "population control" when it includes no consideration of optimum population size for the society and makes no attempt to influence parental goals. The use of abortion and voluntary sterilization to supplement other forms of birth control can quite properly be included as part of family planning and made ""Unfortunately, this area is still being seriously neglected. It has been estimated that funds could fruitfully be tripled over 1974 levels to take advantage of existing knowledge and trained personnel in research on reproduction and development of new contraceptives. (M. A. Koblinsky, F. S. Jaffe, and R. O. Greep, Funding for reproductive research: The status and the needs.) See also Barbara J. Culliton, Birth control: Report argues new leads are neglected (Science, vol. 194, pp. 921 -922, November 26, 1976) for a discussion of a forthcoming Ford Foundation Report, Reproduction and human welfare.

available at costs everyone can afford. This, of course, has been done in a few countries with considerable apparent success (Table 13-4). Moreover, there is still a good deal of room for expansion of family planning services in LDCs, where they are not yet available to more than a fraction of most populations. Family planning programs not only provide the means of contraception, but, through their activities and educational campaigns, they spread the idea of birth control among the people. These programs should be expanded and supported throughout the world as rapidly and asfully as possible, but other measures should lie instituted immediately as well. Given the family size aspirations of people everywhere, additional measures beyond family planning will unquestionably be required in order to halt the population explosion—quite possibly in many DCs as well as LDCs. Socioeconomic Measures Population control through the use of socioeconomic pressures to encourage or discourage reproduction is the approach advocated by, among others, demographer Kingsley Davis, who originated many of the following suggestions.93 The objective of this approach would be to influence the attitudes and motivations of individual couples. An important aspect would be a large-scale educational program through schools and communications media to persuade people of the advantages of small families to themselves and to their society. Information on birth control, of course, must accompany such educational efforts. This is one of the first measures that can be adopted, and it has been increasingly employed in many of the more active family planning programs in LDCs. It has also been used in some DCs, notably the U.S. and England, mainly, but not entirely, by private groups such as Planned Parenthood and ZPG. As United States taxpayers know, income tax laws have long implicitly encouraged marriage and childbearing, although recent changes have reduced the effect somewhat. Such a pronatalist bias of course is no longer appropriate. In countries that are affluent enough for the majority of citizens to pay taxes, tax laws could be adjusted to favor (instead of penalize) single people, ''Davis, Population policy.

POPULATION POLICIES / 785

working wives, and small families. Other tax measures might also include high marriage fees, taxes on luxury baby goods and toys, and removal of family allowances where they exist. Other possibilities include the limitation of maternal or educational benefits to two children per family. These proposals, however, have the potential disadvantage of heavily penalizing children (and in the long run society as well). The same criticism may be made of some other tax plans, unless they can be carefully adjusted to avoid denying at least minimum care for poor families, regardless of the number of children they may have. A somewhat different approach might be to provide incentives for late marriage and childlessness, such as paying bonuses to first-time brides who are over 25, to couples after five childless years, or to men who accept vasectomies after their wives have had a given number of children.94 Lotteries open only to childless adults have also been proposed. The savings in environmental deterioration, education, and other costs would probably justify the expenditure. All of these measures, of course, suffer the drawback of influencing the poor to a greater degree than the rich. That would be unfortunate, since the addition of a child to an affluent family (which has a disproportionate impact on resources and environment) is in many ways more harmful to society than the addition of a child to a poor family. Adoption to supplement small families for couples who especially enjoy children can be encouraged through subsidies and simplified procedures. It can also be a way to satisfy couples who have a definite desire for a son or daughter; further research on sex determination should be pursued for the same reason. A special kind of social-security pension or bond could be provided for aging adults who have few or no children to support them in their old age. The latter idea, proposed in detail by economist Ronald Ridker, has been tried with some success on tea estates in southern India.95 As implemented, the plan made monthly deposits in a pension fund for each female worker enrolled in the plan as long as she spaced her

children at least three years apart and had no more than three. If more children were born, the payments were reduced. Since managers of the tea estates were already paying maternity and health benefits, the costs of the pension fund were at least partially offset by savings from those. A large majority of the women signed up for the program, and within the first four years there were substantial drops not only in fertility, but in infant mortality and in worker absenteeism.96 The first pilot project included only about 700 women; it remains to be seen whether implementation of the pension plan on other tea estates and in other situations in India will be equally successful. There are many possibilities in the sphere of family structure, sexual mores, and the status of women that can be explored.97 With some exceptions, women have traditionally been allowed to fulfill only the roles of wife and mother. Although this has changed in most DCs in recent decades, it is still the prevailing situation in most LDCs, particularly among the poor and uneducated. Anything that can be done to diminish the emphasis upon these traditional roles and provide women with equal opportunities in education, employment, and other areas is likely to reduce the birth rate. Measures that postpone marriage and then delay the first child's birth also help to encourage a reduction in birth rates. The later that marriage and the first child occur, the more time the woman will have to develop other interests. One of the most important potential measures for delaying marriage, and directly influencing childbearing goals as well, is educating and providing employment for women. Women can be encouraged to develop interests outside the family other than employment, and social life could be centered around diese outside interests or the couple's work, rather than exclusively within the neighborhood and family. Adequate care for pre-school children should be provided at low cost (which, moreover, could provide an important new source of employment). Provision of child care seems more likely to encourage employment outside the home, with concomitant low reproduction, than to encourage reproduction. Women represent a

M A study has been made o; :he economic feasibility of such a policy for the United States by Larry D. Barnett (Population policy: payments for fertility limitation in the U.S.). "Synopsis of a proposal for a family planning bond; and Saving accounts for family planning, an illustration from the tea estates of India.

"V. I. Chacko, Family planners earn retirement bonus on plantations in India. 97 Judith Blake. Demographic science and the redirection of population policy; Reproductive motivation; Alice Taylor Day, Population control and personal freedom: are they compatible?

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/ THE HUMAN PREDICAMENT: FINDING A WAY OUT

large, relatively untapped pool of intellectual and technical talent; tapping that pool effectively could help reduce population growth and also would provide many other direct benefits to any society. Social pressures on both men and women to marry and. have children must be removed. As former Secretary of __ Tptprjnr Stewart Udall observed, "All lives are not. enhanced by marital union; parenthood is not necessarily a fulfillment for every married couple."98 If society were convinced of the need for low birth rates, no doubt the stigma that has customarily been assigned to bachelors, spinsters, and childless couples would soon disappear. But alternative lifestyles should be open to single people, and perhaps the institution of an informal, easily dissolved "marriage" for the childless is one possibility. Indeed, many DC societies now seem to be evolving in this direction as women's liberation gains momentum." It is possible that fully developed societies may produce such arrangements naturally, and their association with lower fertility is becoming increasingly clear. In LDCs a childless or single lifestyle might be encouraged deliberately as the status of women approaches parity with that of men. Although free and easy association of the sexes might be tolerated in such a society, responsible parenthood ought to be encouraged and illegitimate childbearing could be strongly discouraged. One way to carry out this disapproval might be to insist that all illegitimate babies be put up for adoption—especially those born to minors, who generally are not capable of caring properly for a child alone.100 If a single mother really wished to keep her baby, she might be obliged to go through adoption proceedings and demonstrate her ability to support and care for it. Adoption proceedings probably should remain more difficult for single people than for married couples, in recognition of the relative difficulty of raising children alone. It would even be possible to require 9S 7976: Agenda for tomorrow. "Judith Blake, The changing status of women in developed countries; E. Peck and J. Senderowitz (eds.), Pronatalism, the myth ofnioni and apple pie; Ellen Peck, The baby trap. 100 The tragedy of teenage single mothers in the U.S. is described by Leslie Aldridge Westoff in Kids with kids. The adverse health and social effects of teenage child-bearing in an affluent society have recently betn documented by several studies. One good sample can be found in a special issue of Family planning perspectives, Teenagers. USA.

pregnant single women to marry or have abortions, perhaps as an alternative to placement for adoption, depending on the society. Somewhat more repressive measures for discouraging large families have also been proposed, such as assigning public housing without regard for family size and removing dependency allowances from student grants or military pay. Some of these have been implemented in crowded Singapore, whose population program has been counted as one of the most successful. All socioeconomic measures are derived from knowledge of social conditions that have been associated with low birth rates in the past. The more repressive suggestions are based on observations that people have voluntarily controlled their reproduction most stringently during periods of great social and economic stress and insecurity, such as the Depression of the 1930s.101 In a sense, all such proposals are shots in the dark. Not enough is known about fertility motivation to predict the effectiveness of such policies. Studies by demographer Judith Blake102 and by economist Alan Sweezy103 for instance, have cast serious doubt on the belief that economic considerations are of the greatest importance in determining fertility trends. Sweezy has shown that the decline of fertility in the 1930s in the United States was merely a continuation of an earlier trend. If their views are correct, then severely repressive economic measures might prove to be both ineffective and unnecessary as a vehicle for population control, as vrell as socially undesirable. At the very least, they should be considered only if milder measures fail completely. Involuntary Fertility Control The third approach to population limitation is that of involuntary fertility control. Several coercive proposals deserve discussion, mainly because some countries may ultimately have to resort to them unless current trends in birth rates are rapidly reversed by other means.104 Some 101 Richard A. Easterlm, Population, labor force, and long swings in economic growth. Further discussion of Easterlies ideas can be found in Deborah Freedman. ed., Fertility, aspirations and resources: A symposium on the Easterlin hypothesis. 102 Are babies consumer durables? and Reproductive motivation. ""The economic explanation of fertility changes in the U.S. io4 Edgar R. Chasteen, The case for compulsory birth control.

POPULATION POLICIES / 787

involuntary measures could be less repressive or discriminatory, in fact, than some of the socioeconomic measures suggested. In the 1960s it was proposed to vasectomize all fathers of three or more children in India. The proposal was defeated then not only on moral grounds but on practical ones as well; there simply were not enough medical personnel available even to start on the eligible candidates, let alone to deal with the new recruits added each day! Massive assistance from the developed world in the form of medical and paramedical personnel and/or a training program for local people nevertheless might have put the policy within the realm of possibility. India in the mid-1970s not only entertained the idea of compulsory sterilization, but moved toward implementing it, perhaps fearing that famine, war, or disease might otherwise take the problem out of its hands. This decision was greeted with dismay abroad, but Indira Gandhi's government felt it had little other choice. There is too little time left to experiment further with educational programs and hope that social change will generate a spontaneous fertility decline, and most of the Indian population is too poor for direct economic pressures (especially penalties) to be effective. A program of sterilizing women after their second or third child, despite the relatively greater difficulty of the operation than vasectomy, might be easier to implement than trying to sterilize men. This of course would be feasible only in countries where the majority of births are medically assisted. Unfortunately, such a program therefore is not practical for most less developed countries (although in China mothers of three children are commonly "expected" to undergo sterilization). The development of a long-term sterilizing capsule that could be implanted under the skin and removed when pregnancy is desired opens additional possibilities for coercive fertility control. The capsule could be implanted at puberty and might be removable, with official permission, for a limited number of births. No capsule that would last that long (30 years or more) has yet been developed, but it is technically within the realm of possibility. Various approaches to administering such a system have been offeredj including one by economist Kenneth

Boulding.105 His proposal was to issue to each woman at maturity a marketable license that would entitle her to a given number of children—say, 2.2 in order to have an NRR = 1. Under such a system the number could be two if the society desired to reduce the population size slowly. To maintain a steady size, some couples might be allowed to have a third child if they purchased "decichild" units from the government or from other women who had decided not to have their full allotments of children or who found they had a greater need for the money. Others have elaborated on Boulding's idea, discussing possible ways of regulating the license scheme and alternative ways of alloting the third children.106 One such idea is that permission to have a third child might be granted to a limited number of couples by lottery. This system would allow governments to regulate more or less exactly the number of births over a given period of time. Social scientist David Heer has compared the social effects of marketable license schemes with some of the more repressive economic incentives that have been proposed and with straightforward quota systems.107 His conclusions are shown in Table 13-5. Of course, a government might require only implantation of the contraceptive capsule, leaving its removal to the individual's discretion but requiring reimplantation after childbirth^ Since having a child would require positive action (removal of the capsule), many more births would be prevented than in the reverse situation. Certainly unwanted births and the problem of abortion would both be entirely avoided. The disadvantages (apart from the obvious moral objections) include the questionable desirability of keeping the entire female population on a continuous steroid dosage with the contingent health risks, and the logistics of implanting capsules in 50 percent of the population between the ages of 15 and 50. Adding a sterilant to drinking water or staple foods is a suggestion that seems to horrify people more than most proposals for involuntary fertility control. Indeed, this lG5

The meaning ofiht 20th csnmrv, pp. 135—136. Bruce M. Russect. Licensing: for cars and babies; David M. Heer, Marketing licenses for babies; Boulding's proposal revisited. '"Ibid. 106

J

TABLE

13-5

Evaluation of Some Relatively Coercive Measures for Fertility Reduction Effect

Restriction on individual liberty Effect on quality of children's financial support Effecti%7eness and acceptability of enforcement mechanisms

Effectiveness for precise regulation of the birth rate

Marketable license systems Financialjucentiaie^ystems Quota systems CBqby licenses'} /monthly subsidy\ / Monthly tax*\ .^ that may be sold One-time tax \ to persons X on persons \ f Identical quota or lent at interest \ uith no more than Jl with more than 1 1 for excess babies J Boulding proposal for all couples two / to the government \^ two children ^X N ^ f r o o children^/ \^^ over for baby licenses j ^^*^~~ , Very severe Moderately severe Moderately severe Moderately severe Moderately severe Moderately severe Probably beneficial

Probably beneficial

Unknown

Unknown

Probably beneficial

Slightly beneficial

Effective enforcement at possible price of depriving some children of a family environment Moderate

Effective enforcement at possible price of depriving some children of a family environment High

Fairly effective enforcement

Fairly effective enforcement

Effective enforcement at possible price of depriving some children of a family environment

Low

Low

Low

Effective enforcement at possible price of depriving some children of a family environment Moderate

Source: Adapted from David Heer, Marketing licenses.

would pose some very difficult political, legal, and social questions, to say nothing of the technical problems. No such sterilant exists today, nor does one appear to be under development. To be acceptable, such a substance would have to meet some rather stiff requirements: it must be uniformly effective, despite widely varying doses received by individuals, and despite varying degrees of fertility and sensitivity among individuals; it must be free of dangerous or unpleasant side effects; and it must have no effect on members of the opposite sex, children, old people, pets, or livestock. Physiologist Melvin Ketchel, of the Tufts University School of Medicine, suggested that a sterilant could be developed that would have a very specific action—for example, preventing implantation of the fertilized ovum.108 He proposed that it be used to reduce fertility levels by adjustable amounts, anywhere from 5 to 75 percent, rather than to sterilize the whole population completely. In this way, fertility could be adjusted from time to time to meet a society's changing needs, and there would be no need to provide an antidote. Contraceptives would still be needed for couples who were highly ""Fertility control agents as a possible solution to the world population problem, pp. 687-703.

motivated to have small families. Subfertile and functionally sterile couples who strongly desired children would be medically assisted, as they are now, or encouraged to adopt. Again, there is no sign of such an agent on the horizon. And the risk of serious, unforeseen side effects would, in our opinion, militate against the use of any such agent, even though this plan has the advantage of avoiding the need for socioeconomic pressures that might tend to discriminate against particular groups or penalize children. Most of the population control measures beyond family planning discussed above have never been tried. Some are as yet technically impossible and others are and probably will remain unacceptable to most societies (although, of course, the potential effectiveness of those least acceptable measures may be great). Compulsory control of family size is an unpalatable idea, but the alternatives may be much more horrifying. As those alternatives become clearer to an increasing number of people in the 1980s, they may begin demanding such control. A far better choice, in our view, is to expand the use of milder methods of influencing family size preferences, while redoubling efforts to ensure that the means of birth control, including abortion and

POPULATION POLICIES / 789

sterilization, are accessible to every human being on Earth within the shortest possible time. If effective action is taken promptly against population growth, perhaps the need for the more extreme involuntary or repressive measures can be averted in most countries. POPULATION CONTROL AND DEVELOPMENT Population control cannot be achieved in a social or economic vacuum, of course. To formulate effective population control measures, much greater understanding is needed about all peoples' attitudes toward reproduction, and how these attitudes are affected by various living conditions, including some that seem virtually intolerable to people in developed countries. Even more, it is essential to know what influences and conditions will lead to changes in attitudes in favor of smaller families. The economists and demographers who believed that urbanization and industrialization of LDCs would automatically induce a demographic transition in those societies seem to have been disastrously wrong. While they waited for the birth rate to fall, one billion people were added to the human population. At the very least, it is obvious that the causes of demographic transitions are far more complex than was once believed. But the social scientists may have been wrong mainly in their approach. Many aspects of modernization may indeed have important influences on reproductive behavior. Such influences, of course, fall outside the purview of population programs; they are an integral part of development as it affects—or fails to affect—each member of a society. When development is the kind that improves the living conditions of everyone down to the poorest farm worker, development that starts at the grass roots level, then there is hope that poverty, hunger, disease, and hopelessness might be reduced—and along with them the desire for many children.109 The general problems of LDC development are discussed in detail in Chapter 15, but its indirect effects on fertility are worth mentioning here. While no one factor of development can be singled out as ever having ""William Rich, Smaller families through social and economic progress; Kocher, Rural development; Grant, Development.

"triggered" a decline in fertility—no particular level of infant mortality or per-capita GNP, for instance—a constellation of factors does often seem to be associated with such declines. Among these are rural development and land reform favoring small, family-owned farms; availability of adequate food, basic health care, and education (especially of women) to the entire population; industries favoring labor-intensive, rather than capitalintensive, means of production; and a relatively small income gap between the richest and poorest segments of the population.110 Table 13-6 compares some of these interrelated factors in nine less developed nations, four of which have shown significant drops in fertility since 1960 and five of which have not. While each of the nine countries, like nearly all LDCs, exhibits some of the salient factors listed above, those with substantially reduced fertility much more commonly manifest them. Understanding of the important influences on reproductive behavior and how they operate is so far sketchy at best. Achieving a solid base for population policy may be one of the most important— and perhaps most difficult—research assignments for the next decade. Since the goals of both development and population control are supposedly identical—an improvement in the well-being of all human beings in this and future generations—it seems only reasonable to plan each to reinforce the other. Emphasis accordingly should be placed on policies that would further the goals of both family limitation and development—for example, rural development and land tenure reform; increased agricultural output; universal primary education for children; old-age support schemes; and improved health care and nutrition, especially for mothers and children. Survival of human society nevertheless seems likely to require the imposition of direct population control measures beyond family planning in most LDCs. There is no guarantee that processes of modernization can quickly enough induce the necessary changes in attitudes that might bring growth to a halt. High priority should be given to stimulating those attitude changes and counteracting the effects of pronatalist traditions. "°Ibid. See also Freedman and Bcrclson, The record of family planning programs.

POPULATION POLICIES / 791

But while some people seek the best means of achieving population control, in other quarters the debate continues as to whether it is necessary—or even desirable.

Population Politics / am not sure that the dictatorship of the proletariat, especially if led by an elite, will solve the problem of social justice; I am certain starvation will not solve the problem of overpopulation. -Tom O'Brien, Marrying Malthas and Marx

Family planning programs have spread throughout the less developed world and are now established in the majority of less developed countries. Many countries, especially those with long-established programs that have been frustrated by lack of success in reducing birth rates simply through making means of birth control available, have progressed to measures beyond family planning. As could be expected, this has aroused opposition, informed and uninformed, from many quarters. Some groups see threats to their personal liberties; even more commonly, people see threats to their economic or political interests. In addition, there are many proponents of population control who strongly disagree on the most appropriate approach.'n By 1974, when the United Nations World Population Conference took place in Bucharest, the chorus of clashing viewpoints was almost deafening."2 Most press reports and coverage of the Conference by special groups conveyed an impression of enormous confusion and prevailing disagreement,113 1

' 'National Academy of Sciences, In search of population policy. "2J. Mayone Stycos, Demographic chic at the UN. "3The list of accounts is very long, even leaving out a plethora of anticipatory books and articles. Here is a partial one: Anthony Astrachan, People are the most precious; Donald Gould, Population polarized; P. T. Piotrow, World plan of action and health strategy approved at population conferences; Conrad Taeuber, Policies on population around the world; Brian Johnson, The recycling of Count Malthus; M. Carder and B. Park, Bombast in Bucharest; D. B. Brooks and L. Douglas, Population, resources, environment: the view from the UN; W. P. Mauldin, et al., A report on Bucharest; Marcus P. Franda, Reactions to America at Bucharest; Concerned Demography, Emerging population alternatives; International Planned Parenthood Federation, (IPPF) People, special issue, vol. 1, no. 3,1974; in addition, Ifff published a daily newspaper called Planet during the conference.

despite the ultimate ratification of a World Population Plan of Action and 21 resolutions.114 A very useful summary of all the various views of the population problem and how (or whether) to deal with it has been compiled by demographer Michael S. Teitelbaum.''' Because it is the best listing we have seen, we are borrowing Teitelbaum's outline for the framework of the following discussion.115

Positions Against Special Population Programs and Policies Pronatalist. This viewpoint favors rapid population growth to boost economic growth and an expanding labor supply, as well as to increase opportunities for economies of scale in small countries. Pronatalists believe there is strength in numbers (both political and military) and are more concerned about competition with rapidly growing neighboring countries or among segments of their own populations than about the disadvantages of rapid growth. This group now seems to be a diminishing minority. Revolutionist. Revolutionaries oppose population programs because they may alleviate the social and political injustices that might otherwise lead to the revolution they seek. This view is particularly common in Latin America.1'7 (Conversely, many politicians support family planning in the hope that it will dampen the revolutionary fires.) Anti-colonial and genocide positions. This group is very suspicious of the motives of Western population control advocates. Some believe that effective population programs would retard development and maintain LDCs in economic subservience to DCs. Others see population '"UnitedNarions, Report ofthe UN World Population Conference, 1974. "'Population and development: is a consensus possible? 11 'Bernard Berelson has also described the conflicting views on population in the Population Council Annual Report 1973, pp. 19—27, and The great debate on population policy. The latter was written as a dialog among three 'Voices," representing the family planning advocates, those who see "development" as the important issue, and academic critics of the family planning approach to population control. The dialog is informative, often witty, but unfortunately leaves the reader with an impression of much greater consensus than probably exists among the viewpoints. "7J. Mayone Stycos, Family planning: reform and revolution.

792

/ THE HUMAN PREDICAMENT: FINDING A WAY OUT

programs as an effort by DCs to "buy development cheaply." The most extreme position is taken by those who regard population control as a racist or genocidal plot against nonwhite citizens of LDCs. Holders of this position blame resource shortage and environmental problems exclusively on the greediness of rich countries. To the extent that high fertility in LDCs is a problem, they emphasize that it is due to their poverty, which in turn is caused by overconsumption in DCs.118 Accommodationist. This viewpoint is basically anti-Malthusian: because history shows that Earth is capable of supporting far more people than Malthus thought, he was wrong; these people believe that further improvements in agriculture and technology will permit accommodation of a much larger population than today's. To them what is called overpopulation is really underemployment; restructuring the economic system will allow societies to provide jobs and meet the basic needs of everyone, no matter how many. The slogan adopted by the New Internationalist for the Population Conference—"Look after the people and population will look after itself—epitomizes this position.119

Barry Commoner121 subscribes to it, but he quotes a formula devised by AID. Whether the relationship is as clear as is commonly believed has been called into question by Alan Sweezy, among others.122 The other side of this coin is social security-the need for children, especially sons, to support parents in old Status and roles of women. Social pressures defining the role of women as wives and mothers, with status attached primarily to that role, are a major cause of high fertility, according to this view. Large families are likely to prevail until alternative roles are made available to all women.124 The religious doctrinal position. There are two distinct, but not necessarily mutually exclusive views here. One is essentially fatalistic: "Be fruitful and multiply, God will provide." This view is common among both Western and Eastern religions. The other (mainly the Roman Catholic Church) sees population growth as a problem, but regards most forms of birth control as more or less immoral.125

Mortality and social security. This view concentrates on the significance of infant and child mortality in motivating reproductive behavior; if infant mortality were reduced, fertility would automatically decline. This view is also held in varying degrees by many propopulation control advocates as well as those against it.

Medical risk. People holding this view are more impressed by the risks that attend the use of contraceptives such as the pill and the IUD, and surgical procedures such as abortion and sterilization than by the risks run by not using them. (The risk of death from childbearing alone is considerably higher, especially among the poor in LDCs, than any of these, and both maternal and infant mortality are known to be reduced substantially by the use of birth control for birth spacing.)126 A milder version of this view is held by large segments of the medical profession who oppose the distribution of the pill without prescription and the insertion of ITJDs by paramedical personnel, despite the established safety of both procedures compared to the consequences of not using them.127

"8This perspective has been put forth by Barry Commoner, How poverty breeds overpopulation (and not the other way around); and Pierre Pradervand, The Malthusian man. Pradervand and Commoner, among others, also oppose present population programs on anticolonialist grounds. 119 Peter Adamson, A population policy and a development policy are one and the same thing. l20 Maaza Bekele, False prophets of doom. This article expresses this and the above three viewpoints dearly.

12 'Commoner, How poverty breeds overpopulation. '"Recent light. '"Mamdani, Myth of population control. '24Blake, Reproductive motivation; Day, Population control and personal freedom; Ceres, Women: a long-silent majority. 125 Pope Paul VI, Humanae Viiae. 126 A. Omran, Health benefits; Buchanan, Effects of childbearing; Eckholm and Newland, Health. '27Mauldin, Family planning programs and fertility declines.

The problem-is-population-distribution. Some people holding this view simplistically compare population densities of different regions without regard to available resources and means of support. They also focus on the serious problem of urban migration in LDCs and conclude that policies should concentrate on population redistribution rather than on birth control.120

POPULATION POLICIES /

Holistic development. Holders of this view are "demographic transition" believers who are convinced that social and economic development are responsible for whatever declines in fertility have occurred in LDCs, not family planning programs, which they consider a waste of effort and funds that should be put into development.128 Social justice. This position emphasizes redistribution of wealth within and among nations to improve the condition of the poor.129 It is related to the idea of grassroots development, but is somewhat more extreme in that many of its proponents feel that redistribution of wealth is the only policy that will reduce population growth and solve other problems as well.

Positions Supporting the Need for Population Programs and Policies Population hawks. Teitelbaum sums up this position as follows: . . . Unrestrained population growth is the principal cause of poverty, malnutrition, and environmental disruption, and other social problems. Indeed we are faced with impending catastrophe on food and environmental fronts.130 . . . Such a desperate situation necessitates draconian action to restrain population growth, even if coercion ' 28Bekele, False prophets; Commoner, How poverty breeds overpopulation. A more sophisticated form is Adamson's (A population policy)—at least he advocates development at the grass-roots level (see Social Justice section). 129 Pradervand, Malthusian man; some writers for Concerned Demography. 130 We, along with some colleagues, are considered among the principal proponents of this position (see especially P. Ehrlich, The population bomb, which is the most commonly cited source). Like most of the statements in this summary, this one is both exaggerated and oversimplified. We would not, for example, blame poverty or malnutrition principally on overpopulation, although it certainly contributes to their perpetuation. Likewise, population growth is one of three interacting causes of environmental deterioration; the others are misused technology and increasing affluence (see Chapter 12). As an aside, it is interesting that the first edition of the Population bomb, written almost a decade before this book, is still often cited both as if it reflected the situation in the mid-1970s and as if we still held precisely the same views today as we did then.

is required. "Mutual coercion, mutually agreed upon."131 . . . Population programs are fine as far as they go, but they are wholly insufficient in scope and strength to meet the desperate situation.132 Provision of services. This viewpoint holds that family planning programs are essential for reducing birth rates and that there is still a great unmet demand for birth control in LDCs; what is needed is to expand family planning services to meet the demand.133 Part of the failure of family planning is due to provision of inadequate contraceptive technologies.134 This position is held most strongly by administrators and associates of family planning programs and their donor agencies. Human rights. This position, held by virtually everyone who is in favor of family planning or other population control policies, derives from the idea that there is a fundamental human right for each person responsibly to determine the size of his or her family.135 Another right that has been recognized in many countries including the United States'36 is that of women to control their bodies. This is especially relevant to the issue of abortion, but applies also to contraception and sterilization. Family planning also contributes to health, especially of women and children; and one more human right is that to health care. Population programs plus development. Here again we quote Teitelbaum, who expressed it well: . . . Social and economic development are necessary but not sufficient to bring about a new equilibrium of population at low mortality and fertility levels. Special population programs are also required.137 J

'' Garrett Hardin, The tragedy of the commons. "Davis, Population policy; P. R. Ehrlich and A. H. Ehrlich, Population resources environment, W. H. Freeman and Company, San Francisco, 1970 and 1972, chapter 10. '"Stj'cos. Demographic chic; Berelson, Effects of Population Control Programs. m Mauldin, Family planning programs and fertility declines. 115 UN Declaration on Population, Tehran, 1968, printed in Studies in Family Planning, no. 16, January 1967 and no. 26, January 1968. Teitelbaum omitted the important word "responsibly" in his discussion. 136 Supreme Court decision on abortion, 1973. 137 Advocates of this include Rich. Smaller families; James E. Kocher, Rural development; Grant, Development; and Lester R. Brown, In the human interest. 1

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THE HUMAN PREDICAMENT: FINDING A WAY OUT

While we are usually classified by others as "population hawks," we agree more closely with this position in terms of what should be done. What follows, however, is far too mild a statement on the urgency of ending population growth; Teitelbaum discusses only the social aspects and completely leaves out environmental and resource constraints on population growth: Too rapid population growth is a serious intensifier of other social and economic problems, and is one, though only one, of a number of factors behind lagging social and economic progress in many countries. Some countries might benefit from larger populations, but would be better served by moderate rates of growth over a long period than by very rapid rates of growth over a shorter period. An effective population program therefore is an essential component of any sensible development program. This general position (including the portion just quoted) is widely held by social scientists, politicians, economists, and quite likely by Teitelbaum himself. Like the blind men with the elephant, each viewpoint grasps a piece of the truth, but none encompasses all of it. As should be evident, the above positions are by no means mutually exclusive, and probably none is held monolithically by anyone. Rather, most people argue from several related positions at once. Some apparently violent disagreements, when analyzed, turn out to be only a matter of emphasis or of leaving something out of the picture. Teitelbaum, Berelson, and others see the germ of a consensus emerging from the debate. If so, and if the consensus produces an effective approach to the population problem that all can more or less agree on, the controversy will have been worthwhile. But to the extent that population policies are connected to the larger confrontation between the rich developed world and the poor less developed world (with waters frequently muddied by China and the Soviet Union who say one thing about population control and practice another), consensus may prove to be elusive. Even more important, LDCs are unlikely to take very seriously population goals and policies recommended by DCs that do not impose such goals and policies upon their own people.

World Population Plan of Action In view of the diversity of opinions held by various individuals and groups on population control, it is not surprising that the United Nations' World Population Plan of Action turned out to be a bulky, nearly unreadable document some 50 pages long.158 Summing it up is almost impossible; the 20 resolutions and numerous recommendations covered virtually every subject that might affect or be affected by population growth. In the initial statement of "Principles and Objectives," the Plan declared: The principal aim of social, economic and cultural development, of which population goals and policies are integral parts, is to improve levels of living and the quality of life of the people. Of all things in the world, people are the most precious. . . . It then proceeded to affirm the rights of nations to formulate their own population policies, of couples and individuals to plan their families, and of women to participate fully in the development process. It condemned racial and ethnic discrimination, colonialism, foreign domination, and war. And it also expressed concern for preserving environmental quality, for maintaining supplies and distribution of resources, and for increasing food production to meet growing needs. More specifically with regard to population policies, the following recommendations were made:139 • Governments should develop national policies on population growth and distribution, and should incorporate demographic factors into their development planning. • Developed countries should also develop policies on population, investment, and consumption with an eye to increasing international equity. • Nations should strive for low rather than high birth and death rates. • Reducing death rates should be a priority goal, aiming for an average life expectancy in all 1 "United Nations, Report of the UN World Population Conference, 1974. 1 "Adapted from a summary by Piotrow, World Plan of Action.

POPULATION POLICIES / 795

countries of 62 by 1985 and 74 by 2000, and an infant mortality rate below 120 by 2000. All nations should ensure the rights of parents "to determine in a free, informed and responsible manner the number and spacing of their children," and provide the information and means for doing so. Family planning programs should be coordinated with health and other social services, and the poor in rural and urban areas should receive special attention. Efforts should be made to reduce LDC birth rates from an average of 38 in 1974 to 30 per 1000 by 1985. Nations are encouraged to set their own birth rate goals for 1985 and to implement policies to reach them. Nations should make special efforts to assist families as the basic social unit. Equality of opportunity for women in education, employment and social and political spheres should be ensured. Undesired migration, especially to cities, should be discouraged, principally by concentrating development in rural areas and small towns, but without restricting people's rights to move within their nation. International agreements are needed to protect rights and welfare of migrant workers between countries and to decrease the "brain drain." Demographic information should be collected, including censuses, in all countries. More research is needed on the relation of population to various institutions and to social and economic trends and policies; on improving health; on better contraceptive technologies; on the relation of health, nutrition, and reproduction; and on ways to improve delivery of social services (including family planning). Education programs in population should be strengthened. Population assistance from international, governmental, and private agencies should be increased. The Plan of Action should be coordinated with

the UN's Second Development Decade strategy, reviewed every five years, and appropriately modified. Unfortunately, a sense of urgency about reducing population growth, which had been present in the draft Plan, was lost in the final version under the pressure of political disagreement. The environmental and resource constraints on population growth were essentially left out of conference discussions and hence omitted from the Plan of Action.140 Also, the value of family planning programs tended to be downgraded in favor of an overwhelming emphasis on "development" as the way to reduce birth rates. The conference may not have blazed any radically new trails in its recommendations, but it still cannot be accused of taking a strictly narrow view of the population problem. Its neglect of environmental and resource aspects and the political problems that will accrue to those limitations is deplorable, but social and economic aspects were fully explored. Probably the conference's greatest value was to expose participants (many of whom did hold narrow views or were uninformed about some of the issues) to the information and viewpoints of others. And the mere existence of a world conference helped draw world attention to the population issue and emphasized that nations have a responsibility to manage their populations. Before the conference most national governments still seemed to believe that population problems were neither their concern nor within their ability to control. The final Plan of Action was adopted by consensus of the 136 member nations (with reservations by the Vatican). Whether the resolutions and recommendations will be taken with the seriousness the problem warrants remains to be seen. For many countries it will not be easy, given the overwhelming problems their governments face. But on the answer hangs the future of humanity. It was repeatedly emphasized at Bucharest that population control is no panacea for solving the problems of development or social and economic justice. This is perfectly true, of course; but unless the runaway human WO

W. P. Mauldin et al., A report on Bucharest.

796 / THE HUMAN PREDICAMENT: FINDING A WAY OUT

population is brought under control—and soon—the result will be catastrophe. What kind of catastrophe cannot be predicted, but numerous candidates have been discussed in this book: ecological collapses of various kinds, large-scale crop failures due to ecological stress or changes in climate and leading to mass famine; severe resource shortages, which could lead either to crop

failures or to social problems or both; epidemic diseases; wars over diminishing resources; perhaps even thermonuclear war. The list of possibilities is long, and overpopulation enhances the probability that any one of them will occur. Population control may be no panacea, but without it there is no way to win.

Recommended for Further Reading Blake, Judith. 1971. Reproductive motivation and population policy. BioScience, vol. 21, no. 5, pp. 215-220. An analysis of what sorts of policies might lower U.S. birth rate. Berelson, Bernard. 1974. An evaluation of the effects of population control programs. Studies in Family Planning, vol. 5, no. 1. An important contribution to the controversy by a distinguished demographer active in the family planning field. Chen, Pi-Chao. 1973. China's population program at the grass-roots level. Studies in Family Planning, vol. 4, no. 8, pp. 219-227. Also published in Population perspective: 1973, Brown, Holdren, Sweezy, and West, eds. Excellent summary'. Davis, Kingsley. 1973. Zero population growth: The goal and the means. Daedalus, vol. 102, no. 4, pp. 15-30. Useful critique of population policies, actual and proposed, especially of the United States. Katchadourian, H. A., and D. T. Lunde. 1975. Fundamentals of human sexuality. 2nd ed. Holt, New York. A superb text for sex education; useful for birth control information also. Kocher, James E. 1973. Rural development, income distribution and fertility decline. Population Council Occasional Papers. An important work on the connection between grass-roots development and fertility. Population Reference Bureau, Inc. 1975. Family size and the black American. Population Bulletin vol. 30, no. 4. A study of black reproductive behavior and attitudes in the U.S. —. 1976. World population grotvth and response 1965-1975: A decade of global action. A compendium on recent demographic trends and the evolution of population policies around the world. Revelle, Roger. 1971. Rapid population growth: Consequences and policy implications. Report of a study committee, National Academy of Sciences. Johns Hopkins Press, Baltimore. Contains a number of interesting papers on social and economic effects of population growth, but weak on environmental and resource aspects. Teitelbaum, Michael S. 1974. Population and development: Is a consensus possible? Foreign Affairs, July, pp. 742-760. An excellent discussion of the myriad viewpoints on population control.