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 provid- ing services. Only one in five U.S. public hospi- tals 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 one- third 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 in- crease/ 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 re- placed 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 sub- sequent abortions have been found to be still ignorant of facts of reproduction, using contra- ceptives improperly, or to have been poorly guided by their physicians." Paralleling the trend toward liberalized abor- tion 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 TABLE 13-1 Change in Disapproval of Abortion (all white respondents) 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 85 13 25 68 79 Source: Judith Blake, Abortion and public opinion. 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 low- income 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 dis- criminatory law constitutional is another ques- tion. Right-to-life groups have also played a part in harassing clinics, hospitals, and other organi- zations that provide abortion. This activity often embarrasses clients and possibly has also dis- couraged other institutions from providing abortion services. Action by right-to-life groups in Boston re- sulted in the trial and conviction for manslaugh- ter 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 second- trimester 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). Unfortu- nately, 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 Ameri- cans, 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.
Transcript
were still unable to obtain them. More than halfof all abortions after 1973 were carried out inspecialized clinics, while public hospitals (whichprovide most medical services to the poor) werelagging even behind private hospitals in provid-ing services. Only one in five U.S. public hospi-tals reported performing any abortions in 1975.Thus in many areas it was substantially moredifficult for poor women to obtain abortions thanfor middle-class or wealthy women, even thoughgovernment funds were available to cover thecosts. Teenagers, who account for about one-third of the need for abortion services and for alarge and growing portion of the illegitimatebirth rate, also seem to have poor access to safeabortions. Finally, abortion services were foundto be generally less available in the southern andcentral regions of the U.S. than on either coast.
In the United States, the majority of abortionrecipients are young and/or unmarried. There issome debate over the degree to which legalabortion has affected American fertility overall,but it seems to have had a significant effect on therate of illegitimate births. In 1971 reductions inillegitimate births in states with legal abortionranged as high as 19 percent, while in most stateswithout legal abortion they continued to in-crease/ Following the Supreme Court decision,the rising rate of illegitimacy halted briefly, thenbegan again. The rise was accounted for by anincrease in teenage pregnancy.
There is no evidence that abortion has re-placed contraceptives to any significant degree,despite the apprehensions of antiabortion groupson this score. Most women seeking abortion havea history of little or no contraceptive practice,and many are essentially ignorant of other meansof birth control. Those who return for sub-sequent abortions have been found to be stillignorant of facts of reproduction, using contra-ceptives improperly, or to have been poorlyguided by their physicians."
Paralleling the trend toward liberalized abor-tion policies in the U.S. has been the growth ofright-to-life groups who are adamantly opposedto abortion. These groups have lobbied activelyagainst reform of state laws and, since theSupreme Court decision, have tried to persuadeCongress to reimpose sanctions against abortionthrough Constitutional amendments. Undertheir pressure, Congress has removed funds for
TABLE 13-1Change in Disapproval of Abortion (all white respondents)
Percentage of disapproval
Reason for abortion 1962 1965 1968 1969
Mother's health endangeredChild may be deformedCan't afford childNo more children wanted
162974-
153174-
10257285
13256879
Source: Judith Blake, Abortion and public opinion.
abortion services from Foreign Aid grants toLDCs. In 1976, Congress also passed a lawforbidding federal assistance for abortions in theU.S., a move that denies these services to low-income women—precisely the group whosechances for a decent and productive life are mostlikely to be jeopardized by an unwanted child.Whether the courts will consider such a dis-criminatory law constitutional is another ques-tion. Right-to-life groups have also played a partin harassing clinics, hospitals, and other organi-zations that provide abortion. This activity oftenembarrasses clients and possibly has also dis-couraged other institutions from providingabortion services.
Action by right-to-life groups in Boston re-sulted in the trial and conviction for manslaugh-ter in early 1975 of physician Kenneth Edelinfollowing a late-term abortion (about 20 weeks).The prosecution maintained that the fetus mighthave survived if given life-supporting treatment.(The conviction was overturned in December1976 by the Massachusetts Supreme JudicialCourt.)'1 The consequence of the original verdictnevertheless was to discourage late second-trimester abortions (31 states already had lawsagainst them except to protect the mother's lifeor health; in most states abortion by choice wasavailable only through the 20th week). Unfortu-nately, this change also will affect mainly thepoor and/or very young women, who throughignorance or fear are more likely to delay seekingan abortion until the second trimester.
In 1976, a Right-to-Life political party wasformed, centering on the abortion issue. Itscandidate, Ellen McCormack, entered primariesin several states, but never succeeded in winningmore than 5 percent of the vote. Most Ameri-cans, it appears, accept the present legal situationat least as the lesser of evils.
1. Sklar and B. Berkov, Abortion, illegitimacy, and theAmerican birth rate."Blame MD mismanagement for contraceptive failure, FamilyPlanning Perspectives, vol. 8, no. 2, March/April 1976, pp.72-76.
* Time and Nescstceek, March 3, 1975. Both magazines coveredthe trial and the issues it raised in some detail. See also BarbaraCulliton's thoughtful article, Edelin trial; jury not persuaded,and Edelin conviction overturned, Science, vol. 195, January 7,1977, pp. 36-37.
758 / THE HUMAN PREDICAMENT: FINDING A WAY OUT
admitted having had an abortion; under Italian law shehad committed a crime and could be sent to prison. Someyears ago in a confidential survey of 4000 married womenof all classes, all admitted to having had abortions, mostof them many times.48
A movement is now underway to loosen the lawsagainst abortion in Italy, following the limited legaliza-tion of the pill in 1971, despite strong opposition fromthe Vatican and conservative political elements. TheItalian constitutional court in early 1975 ruled thatabortion is legal if doctors determine that the pregnancythreatens the physical or mental health of the mother.
Before the 1970s, variations on the Italian abortiontragedy prevailed in several other Western Europeancountries. In France, contraceptives were available butnot openly, and the illegal abortion rate and attendantrates of death and injury nearly matched those of Italy. Inlate 1974, abortion was legalized in France, shortly aftera new law was passed greatly increasing public access tocontraceptive devices and information.
Similar reversals have occurred in many DCs since1965. West Germany, Denmark, and Austria legalizedabortion on request between 1973 and 1975, although itsstatus in Germany was changed by a court decision andremains to be reestablished by legislation. In 1975Sweden changed its already moderately liberal law toallow abortion up to the twelfth week as a decision for thewoman alone to make. Finland, Norway, and Icelandhave long had liberal policies, but they fall short ofavailability on request. Laws against abortion in Greeceand the Netherlands have been neither observed norenforced and soon may be reversed. The same wasformerly true of Switzerland, which in 1975 moved toliberalize its abortion laws. Great Britain has in effectpermitted abortion on request since 1967. Spain, Por-tugal, Belgium, and Ireland still had very restrictive lawsin 1976.4'
In most of Eastern Europe, abortion has long beenlegal and usually subsidized by the state. Abortion hasbeen legal since 1920 in the Soviet Union, and in mostEastern 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 majorsources for what follows.
1950s. Abortion brought birth rates so low that Bulgaria,Czechoslovakia, and Hungary tightened their regulationsin 1973. Romania severely restricted access to abortion in1966, with the result that its birth rate virtually doubledthe following year. Since then, the birth rate has declinedtoward the 1966 level, indicating an increase in illegalabortions. The rates of hospitalizations and deaths fromabortion complications have also risen substantially.Meanwhile the huge cohort of children born in 1967 hascaused havoc in the Romanian school systems.50
Canada has relaxed its abortion law somewhat; prac-tice is considerably short of "on request," but widelyliberal interpretation of the new law might make it close.Canadians denied abortions often go to the UnitedStates. Australia is moving toward liberal policies, al-though access varies by state. New Zealand remainsrestrictive, but discussion of change has begun.
Abortion in LDCs. The tragedy of illegal abortionthus is rapidly becoming a thing of the past in most of thedeveloped world, but change is coming more slowly inmuch of the less developed world. In some countries theproblem of illegal abortion is increasing because the needfor abortion seems to be rising. There are importantexceptions, particularly China, where abortion has beenliberally provided by medical services since 1957. InIndia abortion was legalized in 1972, but there was solittle publicity that even large segments of the medicalcommunity as well as the public were unaware of it forthe first few years. For those who knew, high costs andexcessive red tape were effective deterrents. For at leastthe first three years, the number of legal abortions wasextremely low (41,000 in the first five months), while thenumber of nonmedical illegal abortions was appallinglyhigh (at least 4 million a year).51
Elsewhere in Asia, abortion has been legalized inSouth Korea (1973), North Vietnam (1971), Hong Kong(1972), and Singapore (1969, further liberalized in 1974).Abortion is firmly illegal in Taiwan, but apparentlyeasily obtainable from medical practitioners, nonethe-less. Laws are still restrictive in Indonesia, Pakistan, SriLanka, Thailand, and the Philippines, but there are signs
50Teitze and Murstein, Induced abortion; Charles F. Westoff, Thepopulations of the developed countries.
51The abortion dilemma, Atlas, November 1974, pp. 16-18.
POPULATION POLICIES / 759
that they may soon be changed in several of thesecountries.
In the Middle East and North Africa, laws aregenerally very restrictive, except in Tunisia (which hashad 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 achallenging court decision in 1952 and is seldom ob-served today. Abortions reportedly are also availablethrough medical facilities in Egypt despite a strictanti-abortion law.
In Africa south of the Sahara, abortion is generallyprohibited (the exceptions being Zambia since 1972 andsome liberalization in South Africa). Ironically, theserestrictive laws are holdovers from colonial times; theyare not rooted in local culture.52
Abortion is still illegal in most Latin Americancountries, although laws have recently been relaxed topermit it under certain circumstances in El Salvador,Guatemala, Mexico, Panama, Brazil, Chile, Argentina,Ecuador, and Peru. Abortion essentially on request isavailable only in Uruguay and Cuba (since 1968 in bothcases).
Illegal abortion is rampant in Latin America. Contra-ceptives are legally available in most Latin Americancountries, but in practice only accessible to the rich. Theilliterate poor, who make up a large share of the LatinAmerican population are generally unaware of the exis-tence of birth control other than by ancient folk methods,and could not afford modern methods even if they knewof them. There are exceptions where governments andvolunteer organizations such as Planned Parenthoodhave established free birth control clinics (see nextsection). Although these can help, they as yet reach only asmall fraction of the population, mainly in cities. In ruralareas where hunger and malnutrition are often wide-spread, a failure of primitive birth control methodsleaves women with no alternative but to practice equallycrude forms of abortion.
In the 1960s bungled abortions were estimated toaccount for more than 40 percent of hospital admissionsin Santiago, Chile. In that country, an estimated one-third of all pregnancies end in abortion. In Mexico,
"Sue Tuckwell, Abortion, the hidden plague.
400,000 women per year are treated in hospitals forillegal abortions; the abortion rate is conservativelyestimated at one-fourth the birth rate.53 For SouthAmerica as a whole, some authorities believe that one-fourth of all pregnancies end in abortion; others estimatethat abortions outnumber births.
Liberalizing abortion laws in various countries hasbeen shown to have two important effects. The first is avery large decline in maternal deaths and morbidity(illness) associated with illegal abortion. The degree ofreduction of death and illness depends on the degree ofchange in the law, the previous rate of illegal abortions,and how they were usually performed (i.e., self-inflictedunder unsanitary circumstances or performed clandes-tinely by medical personnel). The number of annualabortion deaths in the U.S. dropped from over 150 peryear before 1970 to 47 (25 of which were from illegalabortions) in 1973; in England the decline was from 60before 1968 to 11 in 1974.54 Declines in many Europeancountries and LDCs, where crude self-abortion has beenmore common, will probably be much greater. Con-versely, the number of deaths in Romania, where abor-tion regulations were tightened, rose from about 70 in1965 to over 370 in 1971.»
The other result of liberalizing abortion laws is toprovide such services safely to low-income women.When abortion is illegal, the rich can usually still obtain asafe illegal procedure or can afford to travel to anothercountry where legal abortion is available. The poor haveno such options; it is they who suffer most either from theburdens of large families or from dangerously unsafeillegal abortions.
The moral issue. The greatest obstacles to freelyavailable, medically safe abortion in many developedcountries and in Latin America are the Roman CatholicChurch and other religious groups that consider abortionimmoral. The crux of the Catholic argument is that theembryo is, from the moment of conception, a completeindividual with a soul. In the Catholic view, inducedabortion 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 after1967 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 couldhappen if the decision is left to the mother. A mother whotakes the moral view that abortion is equivalent tomurder 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 tocontraception, not only because of moral questions, butalso because the risk of subsequent health problems forthe mother may be greater. Death rates for first-trimester, medically supervised abortions are a fractionof those for pregnancy and childbirth but considerablyhigher in later months.58 Large and rapidly growingnumbers of people nevertheless feel that abortion isvastly preferable to the births of unwanted children,especially in an overpopulated world. Until more effec-tive forms of contraception than now exist are developed,and until people become more conscientious in use ofcontraceptives, abortion will remain a needed back-upmethod of birth control when contraception fails.
Attitudes on abortion have changed in most countriesin recent years, and they can reasonably be expected tochange more in the future. The female part of the world'spopulation has long since cast its silent vote. Every yearover one million women in the United States, and anestimated 30 to 55 million more elsewhere, have madetheir desires abundantly clear by seeking and obtainingabortions. Until the 1970s, these women were forced toseek their abortions more often than not in the face oftheir societies' disapproval and of very real dangers anddifficulties. Millions still must do so.
There is little question that legalized abortion cancontribute to a reduction in birth rates. Wherever liberallaws have been enacted, they have been followed bylowered fertility. Longstanding evidence is availablefrom Japan and Eastern Europe, where abortion was theprimary effective form of birth control available for someyears after liberalization, and where the decline infertility was substantial. The extent of decline is boundto be related to the availability of other birth controlmethods; but even in the United States and England,where contraceptives have been widely available, thedecline in fertility after reversal of abortion policies wassignificant.
According to at least one study, availability of abortion(legal or illegal) may be necessary in order for apopulation to reach and maintain fertility near replace-ment level, given current contraceptive technology andpatterns of sexual behavior.59 Liberalization of abortionpolicies in those countries where it is still largely orentirely illegal is therefore justifiable both on humani-tarian and health grounds and as an aid to populationcontrol.
POPULATION POLICIES INLESS DEVELOPED NATIONS
In response to rising alarm during the 1950s over thepopulation explosion in less developed countries, bothprivate and governmental organizations in the UnitedStates and other nations began to be involved in popula-tion research and overseas family planning programs.First among these, naturally, was the InternationalPlanned Parenthood Federatiork which grew out of theestablished national groups. By 1975 there were Planned,,Parenthood organizations in 84 countries, supported bytheir own governments, private donations, governmentgrants from developed countries, or some combination ofthese sources.60
Various other private and governmental organizationsfollowed Planned Parenthood into the field, includingthe 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 andvarious UN agencies, particularly the UN Fund forPopulation Activities,, had joined bv 197CL The 1960sbrought a great proliferation of family planning pro-grams in LDCs, which were assisted or administered byone or another of these groups. Most assistance fromDCs was provided through one of the international orprivate organizations. In 1960 some $2 million was spentby developed countries (and the U.S. was not then amongthem) to assist LDC family planning programs; by 1974
58Tietze and Murstein, Induced abortion.
59C. 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)Have an official policy toreduce population growth rate
Have official supportof family planningfor other reasons
Neither have policy norsupport family planning
400+ People's Republic of China (1962)India (1952, reorganized 1965)
Sources: Berelson, Population control programs; Nortman, Population and family planning programs, 1975; Population Reference Bureau, Worldpopulation growth and response.
POPULATION POLICIES 763
•the amount was over $200 million, more than half of itfrom USAID. Yet less than two percent of all foreignassistance goes to LDC family planning programs, andmost LDCs allot less than one percent of their budgets
to it.61
During the 1960s national family planning programswere established in some 25 LDCs, while 17 othergovernments began supporting or assisting the activitiesof private Planned Parenthood organizations. The early1970s saw a further proliferation of these programs untilby 1975,34 less developed countries officially favored thereduction of population growth, and 32 more supportedfamily planning activities for other reasons. Some 55additional LDCs still did not support family planning, orin a few cases opposed it. But the combined 1973populations of the pro-family planning countries werenearly 2.5 billion, whereas the total combined populationof the anti-family planning nations was only about 250million.62 Table 13-2 shows details.
Government Policies in LDCs
So far family planning programs are the primarypolicies that have been brought into action against thepopulation explosion in most LDCs. Outstanding ex-ceptions 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 eco-nomic policies have been adopted to supplement familyplanning.64 However, many family planning programshave been established and are even being supported bygovernments for reasons other than reduction of popula-tion growth, usually to protect the health and welfare ofmothers and children. Although no country has yetadopted attainment of ZPG as a goal, many have aimed atan 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: Afactbook, 1974. Population Reference Bureau, World population growthand response.
WD. Nortman, Population and family planning programs, 1974 and1975.
"See Edgar Snow, Report from China—III: population care andcontrol, for an early report on China. More recent reports have generallyconfirmed 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,
MVumbaco, Recent law and policy changes.
contrast, still want to increase their usually already rapidgrowth. Many others are beginning to reevaluate theirpronatalist policies as consequences of rapid growthbecome increasingly evident. The following discussionsums up these various approaches by continent.65
Africa. Africa, an extremely diverse continent, grow-ing at about 2.6 percent per year, includes some of theworld's poorest and most rapidly growing nations. Be-cause high mortalities, especially of infants, are alsocommonly found in these countries, concern over rapidgrowth and action to curb it have developed onlyrelatively recently in most of them. Indeed, some Africangovernments remain staunchly pronatalist.
The belief that more people are needed for develop-ment is common among African nations south of theSahara. Policies in Cameroon, Malawi, and Upper Voltastill frankly favor growth, while Zambia and the Mala-gasy Republic have only recently reversed their positions(in 1975). Concern about poorly controlled migration isgreater in many of these countries than concern abouthigh birth rates.
In general, family planning on a private basis has longbeen available in former African colonies of England,but not in those of such Catholic countries as France,Belgium, Spain, Italy, and Portugal. Former Englishcolonies were among the first to establish national familyplanning policies, although emphasis in some cases is puton health and family welfare justifications. Kenya andGhana have two of the oldest and strongest familyplanning programs in subSaharan Africa, and both havegoals of reducing population growth. Interest in familyplanning at least for health reasons is growing in mostformer English colonies, although a few such as Malawistill discourage or ignore the activities of private familyplanning organizations. Nigeria, the most populous andone of the richest (in terms of resource endowment)African countries, was only beginning to show interest infamily planning for health reasons in 1976, despite rapidgrowth.
"For country-by-country details of policies and recent demographictrends, Population Reference Bureau, World population growth andresponse, prepared with the assistance of the U.S. Agency for InternationalDevelopment, is invaluable.Schroeder and Vumbaco each provide usefulsummaries, as does the more recent D. Nortman and E. Hofstatter,Population and family planning programs: a factbook, 1976.
764 / THE HUMAN PREDICAMENT: FINDING A WAY OUT
In South Africa and Rhodesia, the dominant Europeanpopulations have traditionally practiced birth control.These countries are now trying to extend family plan-ning services to their African populations. South Africa'sfamily planning is offered through its Planned Parent-hood affiliate and funded by the government; Rhodesia'sservices are government-supported, but operated byseveral private international groups.
Former French colonies have begun to relax theirprohibitions to allow the commercial sale of contracep-tives and to support some family planning activities. Thefirst family planning clinics in French-speaking conti-nental Africa have been established in Senegal, whosegovernment is beginning to show interest in familyplanning. Most former French colonies, however, re-main complacent about their rates of population growth.An exception is Mauritius, an island nation with one ofthe highest population densities in the world (see Chap-ter 5). Mauritius has a vigorous and comparativelysuccessful family planning program. Since the 1950s, thegrowth rate has been reduced to about 2.1, despite anunusually low death rate of 7 per 1000 population.
The Portuguese colonies, Mozambique and Angola,remained pronatalist and strongly opposed to birthcontrol until they achieved independence in 1975. Es-tablishment of population programs must await thestabilization of the new governments.
Some North African countries have initiated familyplanning programs; Egypt, Tunisia, and Morocco havefairly strong, antinatalist policies. Tunisia, in particular,has ventured beyond family planning to legalize sterili-zation (considered immoral and against Moslem law inmost Islamic countries) and abortion, to limit financialallowances for children to four per family, raise the legalmarriage age, and ban polygamy. In addition, women'srights, usually very restricted in Moslem societies, arebeing promoted. Some other North African countries—Algeria, Libya, Mauritania—remain pronatalist oruninterested.
Many African countries still have death rates above 20per thousand, and some even more than 30. A number ofdemographers and family planning officials believe thatinterest in population control will remain low in thosecountries until the death rates have been substantially
reduced, especially among infants and children. R isvitally important to change this point of view so thatefforts can be made to lower birth rates along with deathrates; that most family planning efforts have begun inAfrican countries as a part of maternal and child healthservices is an encouraging sign.
Latin America. Latin America as a region, despitehaving some of the highest population growth rates in theworld (about 2.9 percent for the entire region), has alsobeen very reluctant to accept a need for populationcontrol. This is probably due in part to the influence ofthe Roman Catholic Church, but there is also a wide-spread belief, at least in South America, that the conti-nent still contains vast untapped resources of land andminerals, that the answer to all problems is development,and that more people are needed for development. LatinAmerican politicians, moreover, tend to view proposalsoriginating in the United States for birth control withunderstandable suspicion. Some seem to believe the U.S.is trying to impose a new and subtle form of imperial-ism.66 In some countries, this reaction has even had theeffect of inhibiting the teaching of demography andfamily planning in universities.
Latin American economists and politicians have cometo accept family planning (often referred to as "respon-sible parenthood") mainly on health and welfare groundsand as a means of reducing the horrendous illegalabortion rate. Some leaders are beginning to realize,however, that the galloping population growth rate isswallowing all the economic progress each year, leaving aper-capita rate of progress of zero or less. A few countrieshave established essentially, though not always explic-itly, antinatalist policies as a result—notably Chile.Colombia, several Caribbean countries, and all of theCentral American countries. The efforts of some familyplanning programs in the Caribbean (mainly formerBritish colonies) have been counted among the mostsuccessful, especially those of Barbados and Trinidadand Tobago. Birth rates have declined there since theearly 1960s, and have declined as well in Chile, Colom-bia, Costa Rica, Nicaragua, Panama and Venezuela.
"National Academy of Sciences, In starch of population policy: viewsfrom the developing world; Population policy in Latin America.
POPULATION POLICIES / 765
At the other extreme, Brazil and Argentina havepolicies generally promoting growth. Brazil does permitprivate family planning groups to operate, however,especially in the poverty-stricken Northeast. Argentina,having a relatively low birth rate and feeling threatenedby rapidly growing Brazil, in 1974 banned disseminationof birth control information and closed family planningclinics. Since the practice of birth control is wellestablished in the Argentine population, the action is notlikely to have great effect except perhaps to raise thealready high abortion rate, mostly illegal.
Asia. Asia includes over half of the human populationand is growing at about 2.3 percent per year. Bothmortality and birth rates are generally lower than those inAfrica, and both have been declining in several countries.
Asia presents a widely varied picture in regard topopulation policies. At one extreme, China, India, Thai-land, Indonesia, Sri Lanka, Hong Kong, Singapore,Taiwan, and South Korea are pursuing strong familyplanning policies, in several cases reinforced by socialand economic measures, some of which are describedbelow. All of these countries have recorded declines inbirth rates, some of them quite substantial. Familyplanning programs have also been established in Paki-stan, Bangladesh, Nepal, Malaysia, and the Philippines,but the impact, if any, on birth rates is negligible so far.
A few rapidly growing countries, notably Cambodiaand Burma, currently are pursuing pronatalist popula-tion policies, although family planning is privatelyavailable in the latter country. Other "centrally planned"countries in Southeast Asia seem to be following China'sexample in population policies; North Vietnam has had afamily planning program for some time, which presum-ably was extended to South Vietnam when the nation wasunified. Policies in North Korea are unknown.
Middle Eastern nations are still largely pronatalist intheir outlook, with the exceptions of Turkey and Iranwhich have national family planning programs. Severalcountries, including Afghanistan, Bahrain, Cyprus, Iraq,Jordan, Lebanon, and Syria, are interested in establish-ing family planning services for health and welfarereasons. The remaining countries favor continuedgrowth, although they may tolerate family planning
activity in the private sector. Among these is Israel, forobvious reasons. At the furthest extreme is Saudi Arabia,which has outlawed importation of contraceptives.Nearly all Middle Eastern countries are growing rapidlywith relatively high, although declining death rates.
The United Nations. For many years, the UnitedNations limited its participation in population policies tothe gathering of demographic data. This, however, wasinstrumental in developing awareness of the need forpopulation policies, especially among LDCs, whosegovernments often had no other information about theirpopulation growth. Since the late 1960s the UN has takenan active role in coordinating assistance for and directlyparticipating in family planning programs of variousmember nations, while continuing the demographicstudies. A special body, the UN Fund for PopulationActivities (UNFPA), advises governments on policiesand programs, coordinates private donors and contribu-tions from DC governments, and sometimes directlyprovides supplies, equipment, and personnel throughother UN agencies.
In 1967 the UN Declaration on Social Progress andDevelopment stated that "parents have the exclusiveright to determine freely and responsibly the number andspacing of their children."67 The statement affirmed theUN's increasing involvement in making family planningavailable to all peoples everywhere and contained animplicit criticism of any government policy that mightdeny family planning to people who wanted it. Thestatement has sometimes been interpreted as a standagainst compulsory governmental policies to controlbirths; however, the right to choose whether or not tohave children is specifically limited to "responsible"choices. Thus, the Declaration also provides govern-ments with the right to control irresponsible choices.
In 1974 the United Nations' World Population Con-ference, the first worldwide, government-participatingforum on the subject, was convened in Bucharest.Publicity attending the event gave an impression ofenormous disagreement among participating groups. Butin fact it provided a valuable forum for an exchange of
"Declaration on Population, Teheran, 1968, Studies in Family Plan-ning, no. 16, January, 1967.
BOX 13-6 China: An Apparent Success Story
Any brief treatment of Chinese society isdifficult and necessarily contains elements ofovergeneralization. First of all, the huge geo-graphical expanse and the vastness of the popu-lation—nearly a billion people—are difficult toenvision. Second, the Chinese people possess acultural diversity possibly as rich as that ofEurope, and even older traditions. Finally, itseems that there is no overall, systematic keepingof vital statistics and population figures in China,and those statistics that do exist are not readilyavailable to outsiders. The Chinese are tradi-tionally xenophobic, and the Western intrusionof the last century and a quarter—from theOpium Wars through the United States debaclein Vietnam and Soviet pressure on northernChinese borders—have only heightened this tra-ditional aloofness. The available information istherefore fragmentary and has to some extentbeen filtered by a highly centralized and auto-cratic regime. Still, the accounts of foreigntravellers in China and the release of officialstatements and figures allow some conclusions tobe drawn about the nature of population policyin the People's Republic."
Superficially, the expressed population poli-cies of the People's Republic of China seemslightly schizophrenic. Official rhetoric preachedabroad roundly condemns Malthusian ideas:"The poor countries have not always been poor.Nor are they poor because they have too manypeople. They are poor because they are plun-dered and exploited by imperialism."6 The samearticle goes on to blame "relative overpopulationand widespread poverty" in the United Statesand the Soviet Union on "ruthless oppressionand exploitation which the superpowers practiceat home."
But, despite assertions that there is no suchthing as overpopulation, China admits to havinga policy of "planned population growth," withthis rationale:
We do not believe in anarchy in material produc-tion, and we do not believe in anarchy in humanreproduction. Man must control nature, and he mustalso control his numbers. .
We believe China's policy benefits many aspectsof life—national construction, the emancipation ofwomen, protection of mothers and women andchildren, proper bringing up of the young, betterhealth for the people and prosperity for the nation. Itis, in other words, in the interests of the masses of thepeople.''In recent years, as China has begun to open up
to the outside world, it has become increasinglyclear not only that "birth planning," as it iscalled, is seriously advocated and supported bythe government, but that it has begun to reapresults. Exactly how successful the policy hasbeen overall is impossible to say because thereare no reliable nationwide population statistics.The last reasonably comprehensive census wasconducted in 1953 (when a total mainland popu-lation of about 583 million was found), andestimates of vital rates since then are basicallyguesswork.1' Hence the estimates of total popu-lation in 1975 range from below 800 million to962 million/ China specialist Leo Orleans hasproposed a set of estimates and projections ofChina's population from 1954 to 1980, and hisarguments in support of them are convincing. Hesuggests that the 1975 population was about 850million, with a birth rate of 27 per thousand, adeath rate of 12 per thousand, and a naturalincrease of 1.5 percent. These figures are slightlyabove those of the UN.
China's efforts to curb population growthbegan in the 1950s following the release of thecensus results and a period of heated discussionsof the pros and cons of birth control. Anorganized campaign implemented by the Minis-try of Public Health was launched in 1957 butthen was suspended in 1958 during the GreatLeap Forward, an intensive effort at economicdevelopment. The period 1959-1961 was one offood shortage and economic crises, and, althoughestablished birth control clinics continued to
"For a recent overview, see International Planned ParenthoodFederation, China 1976: a new perspective.'China on the Population Question, China Reconstructs.
Ibid.rfLeo A. Orleans, China: Population in the People's Republic.This is an excellent source for historical background, althoughotherwise somewhat out of date.cOrleans, China's population figures: Can the contradictions beresolved? The lowest are based on casual statements by Chineseofficials at the UN; the highest are from the World PopulationEstitnates of the Environmental Fund, which bases its estimateson the figures of John Aird, a demographer in the U.S.Department of Commerce Foreign Demographic AnalysisDivision.
POPULATION POLICIES / 771
function, there was no official encouragement fortheir use.
While China was recovering from this crisisperiod, the government again began advocating"birth planning" to protect the health of mothersand children. An important part of this campaignwas promotion of late marriage (23 to 25 forwomen, 25 to 28 for men) and the two-childfamily spaced by 3 to 5 years/ Both abortion andsterilization were legal from the start, but themiddle 1960s were a period of active expansionof facilities (along with expansion of health carein general) and experimentation in improvedtechniques. It was men that the Chinese devel-oped the vacuum technique for abortion, whichhas made the procedure much safer than before,and which has since been adopted around theworld. Active research was also carried out onsimplified sterilization procedures. It appears,for instance, that the Chinese may have been thefirst to do female sterilizations with very smallincisions."
China has all along manufactured all its owncontraceptive devices and Pharmaceuticals, un-like other LDCs. The latest invention is the"paper pill," sheets of water-soluble paper im-pregnated with oral contraceptives, which areeasy to transport, store, and distribute.* Eachsheet contains a month's supply of "pills" inperforated squares that dissolve in the mouthwhen eaten. This development is expected toincrease use of oral contraceptives considerably,especially in remote rural areas where the pillshave been less accepted than in the cities.
Virtually every method of birth control isbeing actively used in China: sterilization, abor-tion, the combined steroid pill and the progestinmini-pill, long-term injections, lUDs (the Chi-nese developed their own, a stainless steel ring),condoms, diaphragms, foams, and jellies.
The various forms of birth control have longbeen available to the people in the major citiesand their suburbs. During the 1960s, health care,including birth control services, was increasinglyextended to more remote rural areas. As anindication of the success of the health careprograms, the death rate for the entire country isestimated to have dropped from nearly 35 per
Ti-Chao Chen, China's population program at the grass-rootslevel.'Orleans, Family planning developments in China, 1960-1966: abstracts from medical journals.*Carl Djerassi, Fertility limitation through contraceptivesteroids in the People's Republic of China.
1000 population in 1949 to about 17 per 1000 in1970* and perhaps 13 in 1974.j Infant mortality,which fairly accurately reflects levels of bothhealth care and nutrition, is thought to have beenbetween 20 and 30 per 1000 births in 1974.k Insome urban communes (which apparently dokeep careful demographic statistics), the crudedeath rate is 5 or less, and an infant mortality rateof 8.8 per 1000 live births has been claimed forthe city of Shanghai.'
China's unique health care system, togetherwith greatly improved distribution of the foodsupply, can claim credit for this remarkablechange. At the time of the Revolution, a grosslyinadequate corps of trained medical personnelexisted, mainly concentrated in the large cities.While actively training thousands of doctors,paramedics, and nurses and establishing hospi-tals and health centers in smaller cities, theChinese also promptly tackled sanitation andhygiene at the grass-roots level through educa-tional campaigns.
More recently, selected people have beengiven four to six months' basic medical trainingand assigned part-time to care for basic healthneeds in their production brigades. These indi-viduals are called "native doctors" in the citiesand "barefoot doctors" in the country. Theirresponsibilities include giving injections andinnoculations, administering first aid and simpletreatments for diseases, supervising sanitationmeasures, teaching hygiene in schools, and dis-tributing contraceptive materials. For medicaltreatment beyond their competence (includingabortions and sterilizations), the barefoot doctorsrefer patients to the nearest regional hospital.Barefoot doctors in turn are assisted by part-timevolunteer health aides, usually housewives,whom they train themselves.'"
It now appears that China is attempting toupgrade the quality of grass-roots health care bysending fully trained medical personnel fromcity hospitals on rotation to rural health centers,where, among other things, they provide addi-tional training for local health workers. Somebarefoot doctors have thereby become qualifiedto 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-rootslevel; V. W. Sidel and R. Sidel, The delivery of medical care inChina.
(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 maternityleave, time off for breast-feeding, free nurserycare, and all needed medical attention are pro-vided for mothers. Paid leave is also given forabortion, sterilization, and IUD insertions, andall birth control services are essentially free.
While the means of birth control are providedthrough the health care system in China, primaryresponsibility for motivating couples to make useof them rests with the Revolutionary Committee(or governing council) of the production brigadeor commune. Usually one member of the com-mittee is the "responsible member" for birthplanning.0 In rural areas, "women's cadres" —married women with children, who are knownand respected by their neighbors—carry contra-ceptives and the pro-birth control message houseto house."
In some of the cities, low birth rates have beenso enthusiastically adopted as a goal that neigh-borhoods collectively decide how many birthswill be allowed each year and award the privilegeof having babies to "deserving couples."" Prior-ity is given to newlyweds, then to couples withonly one child who have waited the favoredperiod of time for the second birth/ The resulthas been phenomenally low birth rates for theseneighborhoods, ranging from 4 to 7 per 1000population. The center city of Shanghai report-edly had a 1972 birth rate of 6.4, while that forthe city plus suburbs was 10.8.s The 1972 birthrate for Peking was reported by Joe Wray to havebeen about 14 per 1000 population; Myersplaced it at 18.8 for city and suburbs combined.
Joe Wray has speculated that these low ratesmay have been helped by a relatively low pro-portion of women in their child-bearing years.Given the recent Chinese policy of sendingurban young people to rural areas to work, thismay be so, even though China's demographichistory would indicate a relatively large andgrowing proportion of people in their teens andtwenties for the country as a whole by 1975.
Exiling young people "temporarily" to ruralcommunes probably was done for political rea-"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 planningprograms.8Wray, Achieving the unbelievable; Myers, People are the mostprecious.
sons. Large numbers of urban youth are apotential source of insurgent trouble, especiallyif insufficient jobs are available. Scattering theyoung people in the countryside could effec-tively defuse that threat. Moreover, the relativelywell-educated city youth could help spread theideology of the central government to remoterural areas. But it appears that the policy mayalso have had demographic effects. Most of thecity children are not happy down on the farm;consequently, they are reluctant to marry, settle,and raise families there. Nor are rural youngpeople eager to marry the sophisticated citypeople with their strange ways.'
The official Chinese position on birth plan-ning—an ideal of late marriage and a small,well-spaced family of two children—appears tohave been overwhelmingly accepted in cities andis rapidly gaining acceptance in rural areas,according to reports from foreign visitors." Theprevailing attitude is that early marriage andhaving more than two children are prime exam-ples of irresponsible behavior. Nevertheless,there is still resistance from older generations,especially mothers-in-law, who by tradition havelong wielded considerable power within familiesand apparently still do.
Besides official encouragement to limit fami-lies, there are other incentives built into thesocial and economic system as well. Emancipa-tion of women and their incorporation as fullworking members of society was an early, im-portant goal of the Revolution. It has apparentlybeen realized to a great extent, especially amongyounger women, and undoubtedly exerts a pow-erful influence on childbearing.
Pi-Chao Chen has pointed out disincentives tofamily limitation in the per capita grain allow-ance, which augments a family's supply when achild is added, and in the addition of anotherworker (preferably a boy who will remain in thefamily) to contribute to family income.1' But ithas also been observed that, even though anotherworker may help increase a family's total income,that income must still be divided among allfamily members. Additional members reduce theshare available per person."' Furthermore, since'Joseph Lelyveld, The great leap farmward."Tameyoshi Katagiri, A report on the family planning programin the People's Republic of China; Sidel and Sidel, Medicalcare; Han, Chinese experiment; Myers, People are the mostprecious; Chen, China's population program; Wray, Achievingthe unbelievable.''Chen, China's population program.'"Sterling Wortman, Agriculture in China.
773
compulsory primary education is rapidly be-coming the rule in China, children's productivityis inevitably deferred at least until the teenageyears.
While there is no question whatever about theChinese leadership's position on birth planning,coercion does not appear to be a part of theprogram beyond the extensive use of peer pres-sure and the dissemination of propaganda on alllevels. There were reports of curtailed maternalbenefits, reduced grain rations, and discrimina-tory housing and employment assignments forparents of three or more children in some areasduring the 1960s, but these measures seem tohave been largely abandoned. Possibly theyaroused more resentment than cooperation andwere found to be less than beneficial to thechildren.
By the mid-1970s, China's far-reaching pop-ulation program evidently had been extended tothe far corners of the nation—no mean trick initself. What the results have been is impossible toassess with accuracy, but it is becoming increas-ingly clear that they are significant indeed. Theremarkable vital rates prevailing in major citieshave already been cited, but those of ruralcommunes for which data exist, while higherthan the cities', show significant reductions frompre-revolutionary levels (birth rate about 45,death rate 34 to 40, infant mortality above 200). *Reported birth rates for rural districts in theearly 1970s range from as low as 14 in an areanear Shanghai" to 20-24 in communes nearPeking- and some others in more remote prov-inces.™ These areas generally report very lowdeath rates also. Levels of contraceptive usage inurban and rural areas are compared in Figure13-4. Certainly the communes visited by outsid-ers are among the most successful by Chinesestandards, and so their birth and death ratesshould not be taken as representative of theentire country. But they may represent theleading edge of an established trend. That thepolicy has been so successful in many areas,especially where it is long established, indicatesthat similar success can be expected elsewhere intime.
1. PERMANENTLYSTERILIZED
Tubal ligation
Vasectomy
2. PRACTICINGCONTRACEPTION
Pill
3. NOT PRACTICINGCONTRACEPTION
FIGURE 13-4
10 20 30
COUPLES (%)
-0
Contraceptive practices in an urban area (light grey)and in a rural area (dark grey) in China arecompared; the urban sample is from the city ofHangchow, a provincial capital, and the ruralsample is from a commune outside Peking.Sterilization is nearly three times commoner inthe urban than in the rural sample, andsubstantially fewer rural males use contraceptives.The bias seems to be reflected in the differencebetween urban and rural birth rates: below 10 per1000 in some urban areas and above 20 per 1000in some rural ones. (From Sidel and Sidel, 1974.)
If available estimates of vital rates for all ofChina reflect reality, there has already been asubstantial reduction in birth and death rates.Norman Myers of the FAO quotes birth rateestimates for large cities of between 10 and 19per 1000 population, for medium-sized cities, 14to 23, and for rural areas 20 to 35. He put thenational 1974 birth rate at 29 and the death rate at13, giving a natural increase of 1.6 percent peryear. Comparison of these estimates with thoseof other Asian nations at similar levels of devel-opment is striking, to say the least. And no doubtother less developed countries—and perhapssome developed countries as well—can learn agreat deal from the Chinese experience.66
'Orleans, China: Population in the People's Republic."Katagiri, A report.'Sidel and Sidel, Medical care.QSChen, China's population program.
MChen, Lessons from the Chinese experience: China's plannedbirth program and its transferability.
780
customs are also subject to varying attitudes and mores.These conflicting attitudes allow societies to fine-tunetheir responses to external changes without having tochange the basic ideological structure itself. Thus, whenoverpopulation threatens food supplies, for example,antinatalist behavior can be encouraged, and whenepidemics or war have decimated a population, antina-talism can again be discouraged. Pronatalist attitudes arevery strong in traditional societies because through mostof humanity's evolutionary history they have beenneeded to maintain populations and to allow a moderateamount of growth when warranted.
The sudden introduction of death control, Westernmorality, and access to communications and other re-sources, as Western technology impinged upon the
.underdeveloped world in the wake of the colonial era andWorld War II, disrupted social perceptions of theconsequences of high birth rates in those areas. Theimpact was characterized by "rapid and fluctuatingchanges in agricultural productivity, labor demand,urbanization, emigration, and military expansion, oftencoupled with introduced epidemic disease."83 Becausemost of these disturbed societies have adopted Westernideology, their traditional methods of controlling popu-lation have been abandoned and unfortunately replacedby less efficient and less desirable ones, mainly self-induced abortion and disguised infanticide throughneglect, abuse, and even starvation. Dickeman concludesthat the world population can only be controlled whenless developed societies are socially stabilized and inte-grated and the people can realistically assess their actualresource and ecological position. Then, she feels, thepeople will make reasonable family-size choices inaccordance with that position.
The Demographic Transition
A great many social and economic factors have beenassociated in the past with declining fertility in varioussocieties. Among them are the general level of education,the availability and quality of health care, the degree ofurbanization, the social and economic status of womenand the opportunities open to them for education and
"Ibid.
employment outside the home, the provision of socialsecurity for old age, and the costs to families of raisingand educating each child. The more extensive each ofthese factors is, the lower fertility generally will be. Inaddition, later marriage, lower tolerance for illegitimacy,low infant mortality, and extended breast-feeding alloperate directly to reduce fertility. In most LDCs, levelsof health care, education, and women's status remain lowfor the poor majority, while marriage comes early andinfant mortality rates are high.
Most family planning programs in the 1960s madelittle effort to influence any of these factors, as demogra-pher Kingsley Davis pointed out in 1967.84 Those thattried to influence people at all confined themselves toemphasizing the economic and health advantages ofsmall families to parents and their children.
In the 1950s and 1960s, government officials, eco-nomic advisors, and many demographers believed thatthe process of economic development would automati-cally bring about the higher levels of education andurbanization in LDCs that have elsewhere been asso-ciated with declines in fertility, and thus would causea "demographic transition" in LDCs. These peoplefavored family planning because they thought it wouldfacilitate the supposedly inevitable demographic transi-tion, although they believed that no significant reductionin fertility could occur until the prerequisite (butunknown) degree of development had been reached.
Numerous studies have established quite clearly thatpopulation growth is in itself a major barrier to economicdevelopment. Economist Goran Ohlin wrote in 1967:
The simple and incontestable case against rapid popu-lation growth in poor countries is that it absorbs verylarge amounts of resources which may otherwise beused both for increased consumption and above all, fordevelopment . . . The stress and strain caused byrapid demographic growth in the developing world isactually so tangible that there are few, and least of allplanners and economists of the countries, who doubtthat per capita incomes would be increased faster iffertility 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 aidprograms to LDCs has also been studied intensively. Thelate economist Stephen Enke did much of the analysis,and his conclusions may be summarized in three points:(1) channeling economic resources into population con-trol rather than into increasing production "could be 100or so times more effective in raising per capita incomes inmany LDCs"; (2) an effective birth control programmight cost only 30 cents per capita per year, about 3percent of current development programs; and (3) the useof bonuses to promote population control is "obvious incountries where the 'worth* of permanently preventing abirth is roughly twice the income per head."86
Enke's results were strongly supported by computersimulation work by systems analyst Douglas Daetz, whoexamined the effects of various kinds of aid in alabor-limited, nonmechanized agricultural society.87 Hisresults brought into sharp question the desirability of aidprograms not coupled with population control programs.They might provide temporary increases in the standardof living, but these would soon be eaten up by populationexpansion. In many circumstances, population growthand aid inputs may interact to cause the standard of livingto 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 assistanceprograms for LDCs in the 1960s. But the purpose in mostcases was only to reduce growth rates to more "manage-able" levels by eliminating "unwanted births." Thisgreat faith of economists and demographers in thepotential of industrial development to bring about aspontaneous demographic transition, which, aided byfamily planning, would reduce population growth andaccelerate the development process, encouraged LDCgovernments to relax under the illusion that all theirsocial and economic problems were being solved. Un-fortunately, their faith was misplaced.
Reliance on a demographic transition was misplacedfor many reasons, not the least of which is uncertainty asto exactly what caused the original one in nineteenth-
century Europe.88 And, as was pointed out in Chapter 5,conditions in contemporary LDCs in many ways aremarkedly different from those in Europe and NorthAmerica one to two centuries ago when fertility began todecline there.
By the mid-1960s, although several LDCs had ap-parently reached quite advanced degrees of industrialdevelopment, there was little sign of a general decline infertility. Birth rates dropped in some countries, but theyremained high, or in a few cases even rose, in other,supposedly eligible countries. Because of this unex-pected result, there has been some argument amongdemographers whether the theory of the demographictransition can even be applied to LDCs and whetherthere is good reason to hope that it will occur in most ofthem.
An analysis of fertility trends in some Latin Americancountries (often cited as prime examples of nonconfor-mity to demographic transition theory) by demographerStephen Beaver indicates that a demographic transitionhas begun or is at least incipient in the countries heexamined.89 But, he suggests, cultural and economicfactors can cause time lags in the process. A considerablybroader spectrum of factors may influence fertility thanjust reduced mortality (especially of infants), increasingurbanization, and industrialization, which are classicallybelieved to be the primary causes of declining fertility.
It is becoming increasingly clear that industrializa-tion—the style of development undertaken by mostdeveloping countries—is not conducive to a demo-graphic transition. This seems to be so because industryin most LDCs employs and benefits only a fraction of thepopulation, creating a two-tiered society in which themajority are left untouched by modernization.90 Suchunequal distribution of the benefits of modernization(access to adequate food, clothing, decent shelter, educa-tion, full-time employment, medical and health care,etc.) is most pronounced in rural areas, where some 70percent of the population of LDCs live.
""Birth control for economic development.*~ Energy utilization and aid effectiveness in non-mechanised agriculture:
a computer simulation of a socioeconomic system. PhD. diss.. University ofCalifornia, 1968.
ssMichael S. Teitelbaum, Relevance of demographic transition theoryfor developing countries; Alan Svreezy, Recent light on the relationbetween socioeconomic development and fertility decline.
^Demographic transition theory reinterpreted.'"James E. Kocher, Rural development; and James P. Grant, Develop-
ment: the end of trickle down?
55
ccLUQ_
CC<LU
03IFccCD
35
30
25
20
Ethiopia•-Afghanistan
NigeriaSudan* • "Kenya .
Morocco
Algeria
• Iraq
• Iran
Indonesia• • Nepal
• Zaire
•Bangladesh
• Tanzania
_. Uganda
BurmaIndia
North Vietnam
~ Pakistan
Philippines •
Thailand •
South Vietnam •
Eg'ypt
North Korea
••Colombia
Turkey •
•Peru
•Mexico
South Africa Venezuela
> Malaysia
•Brazil
• China
Sri LankaSouth Korea
•Taiwan
Argentina
75 100 150 250 400 600
GROSS NATIONAL PRODUCT ($ PER CAPITA)
1000 1500
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 oftenused to measure the extent of "development" that hastaken place in a given country; per-capita GNP, however,is an averaged figure that may conceal very large differ-ences among income groups. And the correlation ofdegrees of development as measured by per-capita GNPwith reduction in fertility is extremely mixed, to say theleast (Figure 13-5). One explanation is that, in stronglytwo-tiered societies, birth control may be adopted by theaffluent, educated minority, but not by the majority stillliving in poverty. The conclusion from this is thatfertility will decline significantly only when the benefitsof modernization are extended to all economic levels.
Economist Alan Sweezy has pointed out that, whilethis explanation may account for fertility declines insome instances, the expected declines have not occurredin some countries—notably in Latin America—evenamong the affluent and middle classes.90" He suggeststhat lingering strong traditions, including pro-natalistattitudes, may be a reason. In Latin America suchtraditions are supported by the Roman Catholic Church,which still officially opposes "artificial" methods of birthcontrol and abortion.
If a demographic transition should take place in
""'Economic development and fertility change.
POPULATION POLICIES / 783
LDCs, a decline from present high fertility to replace-ment level alone would require considerable time, prob-ably at least a generation. And time is running very short.If appropriate kinds of development and vigorous familyplanning programs had been initiated just after WorldWar II, when death control and the ideas of economicassistance were first introduced in LDCs, the populationproblem might be of more manageable dimensionstoday. But plainly it would still be with us. Without sucha history, even if the strongest feasible population controlmeasures were everywhere in force today, the time lagbefore runaway population growth could be appreciablyslowed, let alone arrested, would still be discouraginglylong. For most LDCs it will be at least four generationsbefore their populations cease to expand—unless catas-trophe intervenes—because of the age composition oftheir populations. Even if replacement reproductionwere attained by 2005, most LDC populations would atleast double their 1970 populations, and some wouldincrease 3.5-fold!*1
This built-in momentum virtually guarantees that, formany less developed countries, shortage of resources andthe environmental and social effects of overpopulationwill combine to prevent sufficient "development" toinduce a demographic transition. Complacently countingon either a spontaneous demographic transition or onvoluntary family planning programs—or even a combi-nation—to reduce population growth and thereby ensuresuccessful development would therefore be a seriousmistake. The establishment of family planning programsmay make it easier to improve social conditions in poorcountries, but it is no substitute for appropriate develop-ment; and it is also clear that development alone cannotlead to a reduction of population growth on the neededscale.
POPULATION CONTROL:DIRECT MEASURES
Before any really effective population control can beestablished, the political leaders, economists, nationalplanners, and others who determine such policies mustbe convinced of its necessity. Most governments have
been reluctant to try measures beyond traditional familyplanning that might be effective because they consideredthem too strong, too restrictive, and too much againsttraditional attitudes. They are also, reasonably enough,concerned about resistance from political opponents orthe populace at large. In many countries such measuresmay never be considered until massive famines, politicalunrest, or ecological disasters make their initiation im-perative. In such emergencies, whatever measures areeconomically and technologically expedient will be like-liest to be imposed, regardless of their political or socialacceptability. A case in point was the sudden impositionin 1976 of compulsory sterilization in some Indian statesand for government employees in Delhi, following twodecades of discouraging results from voluntary familyplanning.
People should long ago have begun exploring, devel-oping, and discussing all possible means of populationcontrol. But they did not, and time has nearly run out.Policies that may seem totally unacceptable today to themajority of people at large or to their national leadersmay be seen as very much the lesser of evils only a fewyears from now. The decade 1965-1975 witnessed avirtual revolution in attitudes toward curbing populationgrowth among LDC leaders, if not necessarily amongtheir people. Even family planning, easily justified onhealth and welfare grounds alone and economicallyfeasible for even the poorest of countries, was widelyconsidered totally unacceptable as a government policyas recently as 1960.
Among objections to population control measurescited by demographer Bernard Berelson in 1969 were theneed for improved contraceptive technology; lack offunds and trained personnel to carry out all proposedprograms; doubt about effectiveness of some measures,leading to failure to implement them; and moral object-ions to some proposals such as abortion, sterilization,various social measures, and especially to any kind ofcompulsion.92
Most objections to population control policies, how-
91Thomas trejka, The future of population growth; alternative patlis toequilibrium.
92 See Berelson's Beyond family planning, for a conservative view ofpotential measures for population control. Since 1969, Berelson has foundmany formerly unacceptable measures to have become much moreacceptable: for instance, An evaluation of the effects of population controlprograms; and Freedman and Berelson, The record of family planningprograms, published in 1974 and 1975 respectively.
784 / THE HUMAN PREDICAMENT: FINDING A WAY OUT
ever, can be overcome or are likely to disappear with timeand changing conditions; indeed man}' of them alreadyhave. Contraceptive technology has been improved inrecent years (see Appendix 4). Promising methods ofbirth control that are not now technologically possibleshould also be developed, so that they can be madeavailable.92" Further generous assistance from developedcountries could remove remaining economic and lack ofpersonnel barriers to population-control programs inLDCs. The effectiveness of a measure can only beevaluated after it has been tried. Moral acceptability isvery likely to change as social and economic conditionschange in most societies, as demonstrated by the rever-sal of abortion policies in many countries between 1967and 1975.
The struggle for economic development in the LDCsis producing considerable social upheaval, which willparticularly affect such basic elements of society asfamily structure. Radical changes in family structure andrelationships are inevitable, whether population controlis instituted or not. Inaction, attended by a steadydeterioration in living conditions for the poor majority,will bring changes everywhere that no one could considerbeneficial. Thus, it is beside the point to object topopulation-control measures simply on the grounds thatthey might change the social structure or familyrelationships.
Among proposed general approaches to populationcontrol are family planning, the use of socioeconomicpressures, and compulsory fertility control. Maximumfreedom of choice is provided by traditional familyplanning; but family planning alone should not beregarded as "population control" when it includes noconsideration of optimum population size for the societyand makes no attempt to influence parental goals.
The use of abortion and voluntary sterilization tosupplement other forms of birth control can quiteproperly be included as part of family planning and made
""Unfortunately, this area is still being seriously neglected. It has beenestimated that funds could fruitfully be tripled over 1974 levels to takeadvantage of existing knowledge and trained personnel in research onreproduction and development of new contraceptives. (M. A. Koblinsky,F. S. Jaffe, and R. O. Greep, Funding for reproductive research: Thestatus and the needs.) See also Barbara J. Culliton, Birth control: Reportargues new leads are neglected (Science, vol. 194, pp. 921 -922, November26, 1976) for a discussion of a forthcoming Ford Foundation Report,Reproduction and human welfare.
available at costs everyone can afford. This, of course, hasbeen done in a few countries with considerable apparentsuccess (Table 13-4). Moreover, there is still a good dealof room for expansion of family planning services inLDCs, where they are not yet available to more than afraction of most populations. Family planning programsnot only provide the means of contraception, but,through their activities and educational campaigns, theyspread the idea of birth control among the people. Theseprograms should be expanded and supported throughout theworld as rapidly and as fully as possible, but other measuresshould lie instituted immediately as well. Given the familysize aspirations of people everywhere, additional mea-sures beyond family planning will unquestionably berequired in order to halt the population explosion—quitepossibly in many DCs as well as LDCs.
Socioeconomic Measures
Population control through the use of socioeconomicpressures to encourage or discourage reproduction is theapproach advocated by, among others, demographerKingsley Davis, who originated many of the followingsuggestions.93 The objective of this approach would be toinfluence the attitudes and motivations of individualcouples. An important aspect would be a large-scaleeducational program through schools and communica-tions media to persuade people of the advantages of smallfamilies to themselves and to their society. Informationon birth control, of course, must accompany such educa-tional efforts. This is one of the first measures that can beadopted, and it has been increasingly employed in manyof the more active family planning programs in LDCs. Ithas also been used in some DCs, notably the U.S. andEngland, mainly, but not entirely, by private groups suchas Planned Parenthood and ZPG.
As United States taxpayers know, income tax lawshave long implicitly encouraged marriage and child-bearing, although recent changes have reduced the effectsomewhat. Such a pronatalist bias of course is no longerappropriate. In countries that are affluent enough for themajority of citizens to pay taxes, tax laws could beadjusted to favor (instead of penalize) single people,
''Davis, Population policy.
POPULATION POLICIES / 785
working wives, and small families. Other tax measuresmight also include high marriage fees, taxes on luxurybaby goods and toys, and removal of family allowanceswhere they exist.
Other possibilities include the limitation of maternalor educational benefits to two children per family. Theseproposals, however, have the potential disadvantage ofheavily penalizing children (and in the long run societyas well). The same criticism may be made of some othertax plans, unless they can be carefully adjusted to avoiddenying at least minimum care for poor families, regard-less of the number of children they may have.
A somewhat different approach might be to provideincentives for late marriage and childlessness, such aspaying bonuses to first-time brides who are over 25, tocouples after five childless years, or to men who acceptvasectomies after their wives have had a given number ofchildren.94 Lotteries open only to childless adults havealso been proposed. The savings in environmental de-terioration, education, and other costs would probablyjustify the expenditure. All of these measures, of course,suffer the drawback of influencing the poor to a greaterdegree than the rich. That would be unfortunate, sincethe addition of a child to an affluent family (which has adisproportionate impact on resources and environment)is in many ways more harmful to society than theaddition of a child to a poor family.
Adoption to supplement small families for coupleswho especially enjoy children can be encouraged throughsubsidies and simplified procedures. It can also be a wayto satisfy couples who have a definite desire for a son ordaughter; further research on sex determination shouldbe pursued for the same reason. A special kind ofsocial-security pension or bond could be provided foraging adults who have few or no children to support themin their old age.
The latter idea, proposed in detail by economistRonald Ridker, has been tried with some success on teaestates in southern India.95 As implemented, the planmade monthly deposits in a pension fund for each femaleworker enrolled in the plan as long as she spaced her
MA study has been made o; :he economic feasibility of such a policy forthe United States by Larry D. Barnett (Population policy: payments forfertility limitation in the U.S.).
"Synopsis of a proposal for a family planning bond; and Savingaccounts for family planning, an illustration from the tea estates of India.
children at least three years apart and had no more thanthree. If more children were born, the payments werereduced. Since managers of the tea estates were alreadypaying maternity and health benefits, the costs of thepension fund were at least partially offset by savings fromthose. A large majority of the women signed up for theprogram, and within the first four years there weresubstantial drops not only in fertility, but in infantmortality and in worker absenteeism.96 The first pilotproject included only about 700 women; it remains to beseen whether implementation of the pension plan onother tea estates and in other situations in India will beequally successful.
There are many possibilities in the sphere of familystructure, sexual mores, and the status of women that canbe explored.97 With some exceptions, women havetraditionally been allowed to fulfill only the roles of wifeand mother. Although this has changed in most DCs inrecent decades, it is still the prevailing situation in mostLDCs, particularly among the poor and uneducated.Anything that can be done to diminish the emphasisupon these traditional roles and provide women withequal opportunities in education, employment, and otherareas is likely to reduce the birth rate. Measures thatpostpone marriage and then delay the first child's birthalso help to encourage a reduction in birth rates. Thelater that marriage and the first child occur, the more timethe woman will have to develop other interests. One ofthe most important potential measures for delayingmarriage, and directly influencing childbearing goals aswell, is educating and providing employment for women.
Women can be encouraged to develop interests outsidethe family other than employment, and social life couldbe centered around diese outside interests or the couple'swork, rather than exclusively within the neighborhoodand family. Adequate care for pre-school children shouldbe provided at low cost (which, moreover, could providean important new source of employment). Provision ofchild care seems more likely to encourage employmentoutside the home, with concomitant low reproduction,than to encourage reproduction. Women represent a
"V. I. Chacko, Family planners earn retirement bonus on plantationsin India.
97Judith Blake. Demographic science and the redirection of populationpolicy; Reproductive motivation; Alice Taylor Day, Population controland personal freedom: are they compatible?
786 / THE HUMAN PREDICAMENT: FINDING A WAY OUT
large, relatively untapped pool of intellectual and tech-nical talent; tapping that pool effectively could helpreduce population growth and also would provide manyother 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 necessarilya fulfillment for every married couple."98 If society wereconvinced of the need for low birth rates, no doubt thestigma 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 dis-solved "marriage" for the childless is one possibility.Indeed, many DC societies now seem to be evolving inthis direction as women's liberation gains momentum."It is possible that fully developed societies may producesuch arrangements naturally, and their association withlower fertility is becoming increasingly clear. In LDCs achildless or single lifestyle might be encouraged deliber-ately as the status of women approaches parity with thatof men.
Although free and easy association of the sexes mightbe tolerated in such a society, responsible parenthoodought to be encouraged and illegitimate childbearingcould be strongly discouraged. One way to carry out thisdisapproval might be to insist that all illegitimate babiesbe put up for adoption—especially those born to minors,who generally are not capable of caring properly for achild alone.100 If a single mother really wished to keepher baby, she might be obliged to go through adoptionproceedings and demonstrate her ability to support andcare for it. Adoption proceedings probably should re-main more difficult for single people than for marriedcouples, in recognition of the relative difficulty of raisingchildren alone. It would even be possible to require
9S7976: Agenda for tomorrow."Judith Blake, The changing status of women in developed countries;
E. Peck and J. Senderowitz (eds.), Pronatalism, the myth ofnioni and applepie; Ellen Peck, The baby trap.
100The tragedy of teenage single mothers in the U.S. is described byLeslie Aldridge Westoff in Kids with kids. The adverse health and socialeffects of teenage child-bearing in an affluent society have recently betndocumented by several studies. One good sample can be found in a specialissue 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 discouraginglarge families have also been proposed, such as assigningpublic housing without regard for family size andremoving dependency allowances from student grants ormilitary pay. Some of these have been implemented incrowded Singapore, whose population program has beencounted as one of the most successful.
All socioeconomic measures are derived from knowl-edge of social conditions that have been associated withlow birth rates in the past. The more repressive sugges-tions are based on observations that people have volun-tarily controlled their reproduction most stringentlyduring periods of great social and economic stress andinsecurity, such as the Depression of the 1930s.101 In asense, all such proposals are shots in the dark. Notenough is known about fertility motivation to predict theeffectiveness of such policies. Studies by demographerJudith Blake102 and by economist Alan Sweezy103 forinstance, have cast serious doubt on the belief thateconomic considerations are of the greatest importance indetermining fertility trends. Sweezy has shown that thedecline of fertility in the 1930s in the United States wasmerely a continuation of an earlier trend. If their viewsare correct, then severely repressive economic measuresmight prove to be both ineffective and unnecessary as avehicle for population control, as vrell as sociallyundesirable. At the very least, they should be consideredonly if milder measures fail completely.
Involuntary Fertility Control
The third approach to population limitation is that ofinvoluntary fertility control. Several coercive proposalsdeserve discussion, mainly because some countries mayultimately have to resort to them unless current trends inbirth rates are rapidly reversed by other means.104 Some
101Richard A. Easterlm, Population, labor force, and long swings ineconomic growth. Further discussion of Easterlies ideas can be found inDeborah Freedman. ed., Fertility, aspirations and resources: A sympo-sium on the Easterlin hypothesis.
102 Are babies consumer durables? and Reproductive motivation.""The economic explanation of fertility changes in the U.S.io4Edgar R. Chasteen, The case for compulsory birth control.
POPULATION POLICIES / 787
involuntary measures could be less repressive or dis-criminatory, in fact, than some of the socioeconomicmeasures suggested.
In the 1960s it was proposed to vasectomize all fathersof three or more children in India. The proposal wasdefeated then not only on moral grounds but on practicalones as well; there simply were not enough medicalpersonnel available even to start on the eligible candi-dates, let alone to deal with the new recruits added eachday! Massive assistance from the developed world in theform of medical and paramedical personnel and/or atraining program for local people nevertheless mighthave put the policy within the realm of possibility. Indiain the mid-1970s not only entertained the idea of com-pulsory sterilization, but moved toward implementingit, perhaps fearing that famine, war, or disease mightotherwise take the problem out of its hands. This deci-sion was greeted with dismay abroad, but Indira Gandhi'sgovernment felt it had little other choice. There is toolittle time left to experiment further with educationalprograms and hope that social change will generate aspontaneous fertility decline, and most of the Indianpopulation is too poor for direct economic pressures(especially penalties) to be effective.
A program of sterilizing women after their second orthird child, despite the relatively greater difficulty of theoperation than vasectomy, might be easier to implementthan trying to sterilize men. This of course would befeasible only in countries where the majority of births aremedically assisted. Unfortunately, such a programtherefore is not practical for most less developed coun-tries (although in China mothers of three children arecommonly "expected" to undergo sterilization).
The development of a long-term sterilizing capsulethat could be implanted under the skin and removedwhen pregnancy is desired opens additional possibilitiesfor coercive fertility control. The capsule could beimplanted at puberty and might be removable, withofficial permission, for a limited number of births. Nocapsule that would last that long (30 years or more) hasyet been developed, but it is technically within the realmof possibility.
Various approaches to administering such a systemhave been offeredj including one by economist Kenneth
Boulding.105 His proposal was to issue to each woman atmaturity a marketable license that would entitle her to agiven number of children—say, 2.2 in order to have anNRR = 1. Under such a system the number could be twoif the society desired to reduce the population size slowly.To maintain a steady size, some couples might beallowed to have a third child if they purchased "deci-child" units from the government or from other womenwho had decided not to have their full allotments ofchildren or who found they had a greater need for themoney. Others have elaborated on Boulding's idea,discussing possible ways of regulating the license schemeand alternative ways of alloting the third children.106
One such idea is that permission to have a third childmight be granted to a limited number of couples bylottery. This system would allow governments to regu-late more or less exactly the number of births over a givenperiod of time.
Social scientist David Heer has compared the socialeffects of marketable license schemes with some of themore repressive economic incentives that have beenproposed and with straightforward quota systems.107 Hisconclusions are shown in Table 13-5.
Of course, a government might require only implan-tation of the contraceptive capsule, leaving its removal tothe individual's discretion but requiring reimplantationafter childbirth^ Since having a child would requirepositive action (removal of the capsule), many morebirths would be prevented than in the reverse situation.Certainly unwanted births and the problem of abortionwould both be entirely avoided. The disadvantages(apart from the obvious moral objections) include thequestionable desirability of keeping the entire femalepopulation on a continuous steroid dosage with thecontingent health risks, and the logistics of implantingcapsules in 50 percent of the population between the agesof 15 and 50.
Adding a sterilant to drinking water or staple foods is asuggestion that seems to horrify people more than mostproposals for involuntary fertility control. Indeed, this
lG5The meaning ofiht 20th csnmrv, pp. 135—136.106Bruce M. Russect. Licensing: for cars and babies; David M. Heer,
Marketing licenses for babies; Boulding's proposal revisited.'"Ibid.
J
TABLE 13-5
Evaluation of Some Relatively Coercive Measures for Fertility Reduction
.^f One-time tax \1 for excess babies J\^^ over two /
^^*^~~j ,Moderately severe
Probablybeneficial
Effectiveenforcement atpossible priceof deprivingsome childrenof a familyenvironment
Low
Quota systems
Identical quotafor all couples
Very severe
Slightly beneficial
Effectiveenforcement atpossible priceof deprivingsome childrenof a familyenvironment
Moderate
Source: Adapted from David Heer, Marketing licenses.
would pose some very difficult political, legal, and socialquestions, to say nothing of the technical problems. Nosuch sterilant exists today, nor does one appear to beunder development. To be acceptable, such a substancewould have to meet some rather stiff requirements: itmust be uniformly effective, despite widely varyingdoses received by individuals, and despite varying de-grees of fertility and sensitivity among individuals; itmust be free of dangerous or unpleasant side effects; andit must have no effect on members of the opposite sex,children, old people, pets, or livestock.
Physiologist Melvin Ketchel, of the Tufts UniversitySchool of Medicine, suggested that a sterilant could bedeveloped that would have a very specific action—forexample, preventing implantation of the fertilizedovum.108 He proposed that it be used to reduce fertilitylevels by adjustable amounts, anywhere from 5 to 75percent, rather than to sterilize the whole populationcompletely. In this way, fertility could be adjusted fromtime to time to meet a society's changing needs, and therewould be no need to provide an antidote. Contraceptiveswould still be needed for couples who were highly
""Fertility control agents as a possible solution to the world popula-tion problem, pp. 687-703.
motivated to have small families. Subfertile and func-tionally sterile couples who strongly desired childrenwould be medically assisted, as they are now, or en-couraged to adopt. Again, there is no sign of such anagent on the horizon. And the risk of serious, unforeseenside effects would, in our opinion, militate against the useof any such agent, even though this plan has theadvantage of avoiding the need for socioeconomic pres-sures that might tend to discriminate against particulargroups or penalize children.
Most of the population control measures beyondfamily planning discussed above have never been tried.Some are as yet technically impossible and others are andprobably will remain unacceptable to most societies(although, of course, the potential effectiveness of thoseleast acceptable measures may be great).
Compulsory control of family size is an unpalatableidea, but the alternatives may be much more horrifying.As those alternatives become clearer to an increasingnumber of people in the 1980s, they may begin demand-ing such control. A far better choice, in our view, is toexpand the use of milder methods of influencing familysize preferences, while redoubling efforts to ensure thatthe means of birth control, including abortion and
POPULATION POLICIES / 789
sterilization, are accessible to every human being onEarth within the shortest possible time. If effective actionis taken promptly against population growth, perhaps theneed for the more extreme involuntary or repressivemeasures can be averted in most countries.
POPULATION CONTROLAND DEVELOPMENT
Population control cannot be achieved in a social oreconomic vacuum, of course. To formulate effectivepopulation control measures, much greater understand-ing is needed about all peoples' attitudes toward repro-duction, and how these attitudes are affected by variousliving conditions, including some that seem virtuallyintolerable to people in developed countries. Even more,it is essential to know what influences and conditions willlead to changes in attitudes in favor of smaller families.
The economists and demographers who believed thaturbanization and industrialization of LDCs would auto-matically induce a demographic transition in thosesocieties seem to have been disastrously wrong. Whilethey waited for the birth rate to fall, one billion peoplewere added to the human population. At the very least, itis obvious that the causes of demographic transitions arefar more complex than was once believed. But the socialscientists may have been wrong mainly in their approach.Many aspects of modernization may indeed have impor-tant influences on reproductive behavior.
Such influences, of course, fall outside the purview ofpopulation programs; they are an integral part of devel-opment as it affects—or fails to affect—each member of asociety. When development is the kind that improves theliving conditions of everyone down to the poorest farmworker, development that starts at the grass roots level,then there is hope that poverty, hunger, disease, andhopelessness might be reduced—and along with them thedesire for many children.109
The general problems of LDC development are dis-cussed in detail in Chapter 15, but its indirect effects onfertility are worth mentioning here. While no one factorof development can be singled out as ever having
"triggered" a decline in fertility—no particular level ofinfant mortality or per-capita GNP, for instance—aconstellation of factors does often seem to be associatedwith such declines. Among these are rural developmentand land reform favoring small, family-owned farms;availability of adequate food, basic health care, andeducation (especially of women) to the entire population;industries favoring labor-intensive, rather than capital-intensive, means of production; and a relatively smallincome gap between the richest and poorest segments ofthe population.110
Table 13-6 compares some of these interrelated factorsin nine less developed nations, four of which have shownsignificant drops in fertility since 1960 and five of whichhave not. While each of the nine countries, like nearly allLDCs, exhibits some of the salient factors listed above,those with substantially reduced fertility much morecommonly manifest them. Understanding of the impor-tant influences on reproductive behavior and how theyoperate is so far sketchy at best. Achieving a solid base forpopulation policy may be one of the most important—and perhaps most difficult—research assignments for thenext decade.
Since the goals of both development and populationcontrol are supposedly identical—an improvement in thewell-being of all human beings in this and futuregenerations—it seems only reasonable to plan each toreinforce the other. Emphasis accordingly should beplaced on policies that would further the goals of bothfamily limitation and development—for example, ruraldevelopment and land tenure reform; increased agricul-tural output; universal primary education for children;old-age support schemes; and improved health care andnutrition, especially for mothers and children.
Survival of human society nevertheless seems likely torequire the imposition of direct population controlmeasures beyond family planning in most LDCs. Thereis no guarantee that processes of modernization canquickly enough induce the necessary changes in attitudesthat might bring growth to a halt. High priority should begiven to stimulating those attitude changes and counter-acting the effects of pronatalist traditions.
""William Rich, Smaller families through social and economic prog-ress; Kocher, Rural development; Grant, Development.
"°Ibid. See also Freedman and Bcrclson, The record of familyplanning programs.
POPULATION POLICIES / 791
But while some people seek the best means of achiev-ing population control, in other quarters the debatecontinues as to whether it is necessary—or evendesirable.
Population Politics
/ am not sure that the dictatorship of the proletariat,especially if led by an elite, will solve the problem ofsocial justice; I am certain starvation will not solvethe problem of overpopulation.
-Tom O'Brien,Marrying Malthas and Marx
Family planning programs have spread throughout theless developed world and are now established in themajority of less developed countries. Many countries,especially those with long-established programs thathave been frustrated by lack of success in reducing birthrates simply through making means of birth controlavailable, have progressed to measures beyond familyplanning. As could be expected, this has aroused opposi-tion, informed and uninformed, from many quarters.Some groups see threats to their personal liberties; evenmore commonly, people see threats to their economic orpolitical interests. In addition, there are many propo-nents of population control who strongly disagree on themost appropriate approach.'n By 1974, when the UnitedNations World Population Conference took place inBucharest, the chorus of clashing viewpoints was almostdeafening."2 Most press reports and coverage of theConference by special groups conveyed an impression ofenormous 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 populationconferences; 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., Areport on Bucharest; Marcus P. Franda, Reactions to America atBucharest; Concerned Demography, Emerging population alternatives;International Planned Parenthood Federation, (IPPF) People, specialissue, vol. 1, no. 3,1974; in addition, Ifff published a daily newspapercalled Planet during the conference.
despite the ultimate ratification of a World PopulationPlan of Action and 21 resolutions.114
A very useful summary of all the various views of thepopulation problem and how (or whether) to deal with ithas been compiled by demographer Michael S. Teitel-baum.''' Because it is the best listing we have seen, weare borrowing Teitelbaum's outline for the framework ofthe following discussion.115
Positions Against Special PopulationPrograms and Policies
Pronatalist. This viewpoint favors rapid populationgrowth to boost economic growth and an expandinglabor supply, as well as to increase opportunities foreconomies of scale in small countries. Pronatalists be-lieve there is strength in numbers (both political andmilitary) and are more concerned about competition withrapidly growing neighboring countries or among seg-ments of their own populations than about the disadvan-tages of rapid growth. This group now seems to be adiminishing minority.
Revolutionist. Revolutionaries oppose populationprograms because they may alleviate the social andpolitical injustices that might otherwise lead to therevolution they seek. This view is particularly commonin Latin America.1'7 (Conversely, many politicians sup-port family planning in the hope that it will dampen therevolutionary fires.)
Anti-colonial and genocide positions. This groupis very suspicious of the motives of Western populationcontrol advocates. Some believe that effective populationprograms would retard development and maintain LDCsin 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, andThe great debate on population policy. The latter was written as a dialogamong three 'Voices," representing the family planning advocates, thosewho see "development" as the important issue, and academic critics of thefamily planning approach to population control. The dialog is informa-tive, often witty, but unfortunately leaves the reader with an impressionof 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 developmentcheaply." The most extreme position is taken by thosewho regard population control as a racist or genocidalplot against nonwhite citizens of LDCs. Holders of thisposition blame resource shortage and environmentalproblems 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 inturn is caused by overconsumption in DCs.118
Accommodationist. This viewpoint is basicallyanti-Malthusian: because history shows that Earth iscapable of supporting far more people than Malthusthought, he was wrong; these people believe that furtherimprovements in agriculture and technology will permitaccommodation of a much larger population thantoday's. To them what is called overpopulation is reallyunderemployment; restructuring the economic systemwill allow societies to provide jobs and meet the basicneeds of everyone, no matter how many. The sloganadopted by the New Internationalist for the PopulationConference—"Look after the people and population willlook after itself—epitomizes this position.119
The problem-is-population-distribution. Somepeople holding this view simplistically compare popula-tion densities of different regions without regard toavailable resources and means of support. They alsofocus on the serious problem of urban migration inLDCs and conclude that policies should concentrate onpopulation redistribution rather than on birth control.120
Mortality and social security. This view concen-trates on the significance of infant and child mortality inmotivating reproductive behavior; if infant mortalitywere reduced, fertility would automatically decline. Thisview is also held in varying degrees by many pro-population control advocates as well as those against it.
"8This perspective has been put forth by Barry Commoner, Howpoverty breeds overpopulation (and not the other way around); and PierrePradervand, The Malthusian man. Pradervand and Commoner, amongothers, also oppose present population programs on anticolonialistgrounds.
119Peter Adamson, A population policy and a development policy areone and the same thing.
l20Maaza Bekele, False prophets of doom. This article expresses thisand the above three viewpoints dearly.
Barry Commoner121 subscribes to it, but he quotes aformula devised by AID. Whether the relationship is asclear as is commonly believed has been called intoquestion by Alan Sweezy, among others.122
The other side of this coin is social security-the needfor children, especially sons, to support parents in old
Status and roles of women. Social pressures defin-ing the role of women as wives and mothers, with statusattached primarily to that role, are a major cause of highfertility, according to this view. Large families are likelyto prevail until alternative roles are made available to allwomen.124
The religious doctrinal position. There are twodistinct, but not necessarily mutually exclusive viewshere. One is essentially fatalistic: "Be fruitful andmultiply, God will provide." This view is commonamong both Western and Eastern religions. The other(mainly the Roman Catholic Church) sees populationgrowth as a problem, but regards most forms of birthcontrol as more or less immoral.125
Medical risk. People holding this view are moreimpressed by the risks that attend the use of contracep-tives such as the pill and the IUD, and surgical proce-dures such as abortion and sterilization than by the risksrun by not using them. (The risk of death from child-bearing alone is considerably higher, especially amongthe poor in LDCs, than any of these, and both maternaland infant mortality are known to be reduced substan-tially by the use of birth control for birth spacing.)126 Amilder version of this view is held by large segments ofthe medical profession who oppose the distribution ofthe pill without prescription and the insertion of ITJDsby paramedical personnel, despite the established safetyof both procedures compared to the consequences of notusing them.127
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.125Pope Paul VI, Humanae Viiae.126A. Omran, Health benefits; Buchanan, Effects of childbearing;
Eckholm and Newland, Health.'27Mauldin, Family planning programs and fertility declines.
POPULATION POLICIES / 793
Holistic development. Holders of this view are"demographic transition" believers who are convincedthat social and economic development are responsible forwhatever declines in fertility have occurred in LDCs, notfamily planning programs, which they consider a wasteof effort and funds that should be put intodevelopment.128
Social justice. This position emphasizes redistribu-tion of wealth within and among nations to improve thecondition of the poor.129 It is related to the idea ofgrassroots development, but is somewhat more extremein that many of its proponents feel that redistribution ofwealth is the only policy that will reduce populationgrowth and solve other problems as well.
Positions Supporting the Needfor Population Programs and Policies
Population hawks. Teitelbaum sums up this positionas follows:
. . . Unrestrained population growth is the principalcause of poverty, malnutrition, and environmentaldisruption, and other social problems. Indeed we arefaced with impending catastrophe on food and en-vironmental fronts.130
. . . Such a desperate situation necessitates draconianaction to restrain population growth, even if coercion
' 28Bekele, False prophets; Commoner, How poverty breeds overpopu-lation. A more sophisticated form is Adamson's (A population policy)—atleast he advocates development at the grass-roots level (see Social Justicesection).
129Pradervand, Malthusian man; some writers for ConcernedDemography.
130We, along with some colleagues, are considered among the principalproponents of this position (see especially P. Ehrlich, The populationbomb, which is the most commonly cited source). Like most of thestatements in this summary, this one is both exaggerated and over-simplified. We would not, for example, blame poverty or malnutritionprincipally on overpopulation, although it certainly contributes to theirperpetuation. Likewise, population growth is one of three interactingcauses of environmental deterioration; the others are misused technologyand increasing affluence (see Chapter 12). As an aside, it is interesting thatthe first edition of the Population bomb, written almost a decade beforethis book, is still often cited both as if it reflected the situation in themid-1970s and as if we still held precisely the same views today as we didthen.
is required. "Mutual coercion, mutually agreedupon."131
. . . Population programs are fine as far as they go,but they are wholly insufficient in scope and strengthto meet the desperate situation.132
Provision of services. This viewpoint holds thatfamily planning programs are essential for reducing birthrates and that there is still a great unmet demand for birthcontrol in LDCs; what is needed is to expand familyplanning services to meet the demand.133 Part of thefailure of family planning is due to provision of inade-quate contraceptive technologies.134 This position is heldmost strongly by administrators and associates of familyplanning programs and their donor agencies.
Human rights. This position, held by virtuallyeveryone who is in favor of family planning or otherpopulation control policies, derives from the idea thatthere is a fundamental human right for each personresponsibly to determine the size of his or her family.135
Another right that has been recognized in manycountries including the United States'36 is that of womento control their bodies. This is especially relevant to theissue of abortion, but applies also to contraception andsterilization. Family planning also contributes to health,especially of women and children; and one more humanright is that to health care.
Population programs plus development. Hereagain we quote Teitelbaum, who expressed it well:
. . . Social and economic development are necessarybut not sufficient to bring about a new equilibrium ofpopulation at low mortality and fertility levels. Specialpopulation programs are also required.137
J '' Garrett Hardin, The tragedy of the commons.1 "Davis, Population policy; P. R. Ehrlich and A. H. Ehrlich, Popula-
tion resources environment, W. H. Freeman and Company, San Francisco,1970 and 1972, chapter 10.
'"Stj'cos. Demographic chic; Berelson, Effects of Population ControlPrograms.
mMauldin, Family planning programs and fertility declines.115UN 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.
136Supreme Court decision on abortion, 1973.137Advocates of this include Rich. Smaller families; James E. Kocher,
Rural development; Grant, Development; and Lester R. Brown, In thehuman interest.
794 / THE HUMAN PREDICAMENT: FINDING A WAY OUT
While we are usually classified by others as "populationhawks," we agree more closely with this position in termsof what should be done. What follows, however, is far toomild a statement on the urgency of ending populationgrowth; Teitelbaum discusses only the social aspects andcompletely leaves out environmental and resource con-straints on population growth:
Too rapid population growth is a serious intensifierof other social and economic problems, and is one,though only one, of a number of factors behind laggingsocial and economic progress in many countries.
Some countries might benefit from larger popula-tions, but would be better served by moderate rates ofgrowth over a long period than by very rapid rates ofgrowth over a shorter period.
An effective population program therefore is anessential component of any sensible developmentprogram.
This general position (including the portion just quoted)is widely held by social scientists, politicians, econ-omists, and quite likely by Teitelbaum himself.
Like the blind men with the elephant, each viewpointgrasps a piece of the truth, but none encompasses all of it.As should be evident, the above positions are by nomeans mutually exclusive, and probably none is heldmonolithically by anyone. Rather, most people arguefrom several related positions at once. Some apparentlyviolent disagreements, when analyzed, turn out to beonly a matter of emphasis or of leaving something out ofthe picture.
Teitelbaum, Berelson, and others see the germ of aconsensus emerging from the debate. If so, and if theconsensus produces an effective approach to the popula-tion problem that all can more or less agree on, thecontroversy will have been worthwhile. But to the extentthat population policies are connected to the largerconfrontation between the rich developed world and thepoor less developed world (with waters frequently mud-died by China and the Soviet Union who say one thingabout population control and practice another), con-sensus may prove to be elusive. Even more important,LDCs are unlikely to take very seriously population goalsand policies recommended by DCs that do not imposesuch goals and policies upon their own people.
World Population Plan of Action
In view of the diversity of opinions held by variousindividuals and groups on population control, it is notsurprising that the United Nations' World PopulationPlan of Action turned out to be a bulky, nearly unread-able document some 50 pages long.158 Summing it up isalmost impossible; the 20 resolutions and numerousrecommendations covered virtually every subject thatmight affect or be affected by population growth. In theinitial statement of "Principles and Objectives," the Plandeclared:
The principal aim of social, economic and culturaldevelopment, of which population goals and policiesare integral parts, is to improve levels of living and thequality 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 toformulate their own population policies, of couples andindividuals to plan their families, and of women toparticipate fully in the development process. It con-demned racial and ethnic discrimination, colonialism,foreign domination, and war. And it also expressedconcern for preserving environmental quality, for main-taining supplies and distribution of resources, and forincreasing food production to meet growing needs.
More specifically with regard to population policies,the following recommendations were made:139
• Governments should develop national policies onpopulation growth and distribution, and shouldincorporate demographic factors into their devel-opment planning.
• Developed countries should also develop policieson population, investment, and consumption withan eye to increasing international equity.
• Nations should strive for low rather than highbirth 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 aninfant mortality rate below 120 by 2000.All nations should ensure the rights of parents "todetermine in a free, informed and responsiblemanner the number and spacing of their chil-dren," and provide the information and means fordoing so.Family planning programs should be coordinatedwith health and other social services, and the poorin rural and urban areas should receive specialattention.Efforts should be made to reduce LDC birth ratesfrom an average of 38 in 1974 to 30 per 1000 by1985.Nations are encouraged to set their own birth rategoals for 1985 and to implement policies to reachthem.Nations should make special efforts to assistfamilies as the basic social unit.Equality of opportunity for women in education,employment and social and political spheresshould be ensured.Undesired migration, especially to cities, shouldbe discouraged, principally by concentrating de-velopment in rural areas and small towns, butwithout restricting people's rights to move withintheir nation.International agreements are needed to protectrights and welfare of migrant workers betweencountries and to decrease the "brain drain."Demographic information should be collected,including censuses, in all countries.More research is needed on the relation ofpopulation to various institutions and to socialand economic trends and policies; on improvinghealth; on better contraceptive technologies; onthe relation of health, nutrition, and reproduc-tion; and on ways to improve delivery of socialservices (including family planning).Education programs in population should bestrengthened.Population assistance from international, govern-mental, 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 appropriatelymodified.
Unfortunately, a sense of urgency about reducingpopulation growth, which had been present in the draftPlan, was lost in the final version under the pressure ofpolitical disagreement. The environmental and resourceconstraints on population growth were essentially left outof conference discussions and hence omitted from thePlan of Action.140 Also, the value of family planningprograms tended to be downgraded in favor of anoverwhelming emphasis on "development" as the way toreduce birth rates.
The conference may not have blazed any radically newtrails in its recommendations, but it still cannot beaccused of taking a strictly narrow view of the populationproblem. Its neglect of environmental and resourceaspects and the political problems that will accrue tothose limitations is deplorable, but social and economicaspects were fully explored. Probably the conference'sgreatest value was to expose participants (many of whomdid hold narrow views or were uninformed about some ofthe issues) to the information and viewpoints of others.And the mere existence of a world conference helpeddraw world attention to the population issue and empha-sized that nations have a responsibility to manage theirpopulations. Before the conference most national gov-ernments still seemed to believe that population prob-lems were neither their concern nor within their ability tocontrol.
The final Plan of Action was adopted by consensus ofthe 136 member nations (with reservations by theVatican). Whether the resolutions and recommendationswill be taken with the seriousness the problem warrantsremains to be seen. For many countries it will not beeasy, given the overwhelming problems their govern-ments face. But on the answer hangs the future ofhumanity.
It was repeatedly emphasized at Bucharest that popu-lation control is no panacea for solving the problems ofdevelopment or social and economic justice. This isperfectly true, of course; but unless the runaway human
WOW. P. Mauldin et al., A report on Bucharest.
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population is brought under control—and soon—theresult will be catastrophe. What kind of catastrophecannot be predicted, but numerous candidates have beendiscussed in this book: ecological collapses of variouskinds, large-scale crop failures due to ecological stress orchanges in climate and leading to mass famine; severeresource shortages, which could lead either to crop
failures or to social problems or both; epidemic diseases;wars over diminishing resources; perhaps even thermo-nuclear war. The list of possibilities is long, and over-population enhances the probability that any one of themwill occur. Population control may be no panacea, butwithout 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 thecontroversy by a distinguished demographer active in the family planning field.
Chen, Pi-Chao. 1973. China's population program at the grass-roots level. Studies inFamily Planning, vol. 4, no. 8, pp. 219-227. Also published in Populationperspective: 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 informationalso.
Kocher, James E. 1973. Rural development, income distribution and fertility decline.Population Council Occasional Papers. An important work on the connectionbetween grass-roots development and fertility.
Population Reference Bureau, Inc. 1975. Family size and the black American. PopulationBulletin vol. 30, no. 4. A study of black reproductive behavior and attitudes inthe 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 populationpolicies 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 ofpopulation 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 viewpointson population control.
