Category: Population

Related directly to population issues.

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Family Planning Population Public Health

Puerto Rico

This story started 30 years ago when we lived in Puerto Rico. Actually, the real beginning was 15 years before that, in Nicaragua.

We returned to Puerto Rico this spring after a three-decade absence. The island seemed even better than when we lived there. There was less trash, people were friendlier and now toll roads bypass overcrowded arteries.

Of course, Puerto Rico is not a separate country, but a commonwealth of the USA. Fortunately Puerto Rico keeps independent statistics, and one of them was a real surprise.

Flash back to 1968. My best experience in medical school was in the little Nicaraguan town of Puerto Cabezas, on the Caribbean coast. I learned a huge amount from the one physician, Ned Wallace, at the Moravian hospital there.

Gail (then my wife of only two years) and I lived in a tiny cabin with another medical student couple, a short walk to the hospital—and to the Caribbean Ocean. We adopted Noxa (“hello” in Miskito), a sociable green parrot.

We traveled by dugout canoe to provide the first medical care some villagers had ever received. Our wives passed out worm medicine and gave immunization shots, while we medical students saw patients in the four languages of the area—Miskito, Spanish, Creole and English. It was not the best medical care, but our patients were appreciative.

Ned was an excellent role model—he could do just about anything! I realized that living and practicing medicine in the tropics had personal advantages, in addition to helping people. At that time I resolved that, if we ever had kids, they should grow up knowing that the entire world was not like the USA, and that everyone didn’t speak English. Fortunately, Gail agreed.

In 1983 we moved our family from Durango to the little hill town of Castañer in central Puerto Rico. I practiced medicine and our two sons, in 3rd and 6th grades, learned Spanish by immersion. It was an enlightening experience in a different culture.

I was frustrated in Castañer by the number of women who wanted to limit their fertility, but lacked the money. Typically women married young and had 3, 4 or more closely spaced children. When I asked older women what birth control they used, the answer was often “my husband takes care of me” (withdrawal) or “I’ve been operated” (tubal ligation). Birth control pills and IUDs, effective temporary means of contraception, were just too expensive in this impoverished area.

Before returning to Puerto Rico this year I consulted the World Population Data Sheet (www.prb.org) for some demographic information. To my surprise the TFR (Total Fertility Rate—the number of children a woman has during her lifetime) was low. For a society to neither grow nor shrink, the TFR has to be about 2.1–one child to replace teach parent, plus a fraction for children who die before adulthood. Puerto Rico’s TFR is 1.6 now, far below replacement! However, it will take several decades for the population to stabilize.

What brought about this change In Puerto Rico? Did people recognize that the island is limited in size, that it has approached its carrying capacity? Is it that there is less adherence to religious doctrine?

Nobody seems to know exactly what happened. As far as I can make out, however, marriage is later and more couples choose to be childless. More women are employed, a common reason people choose smaller families.  The main change seems to be that contraception and tubal ligation (still very popular) are available with governmental aid, helping people achieve their reproductive and economic goals. Legal abortion is less common now that contraception is easier to obtain.

Puerto Ricans live in a beautiful green place of sun and ocean, but they have low incomes by our standards—only a third of the average income on the mainland. Thanks to government support, now people are able to receive the family planning services they desire. Puerto Rico has joined half of the world’s countries where women have sufficient access to family planning so that their populations will eventually stop growing. Where does the USA fit in? our TFR, at 1.9, is slightly below replacement.

Our return to Puerto Rico was lots of fun. We visited with friends and enjoyed the sun and ocean. Teaching our granddaughters to body surf was special for me. I also learned that even a poor area, if it has the will to help women control their fertility, can achieve zero population growth along with an improved economy.

© Richard Grossman MD, 2013

Categories
Population

Respect Women’s Choices

“What does a woman want?”

Sigmund Freud

 

Freud’s question obviously has many answers. Some women are happy with their role as wife and mother, the picture that some men still have of “the perfect woman”.

My mother, who was born in 1903, decided her future when she was just eight. She told me that she asked her third grade teacher what they had just read. “That is a story” was the teacher’s reply.

“No, what is it called when you study all sorts of stories?”

“That’s called ‘literature’.”

“When I grow up, I want to teach literature”. And she did for almost 40 years in the Philadelphia Public Schools.

She graduated from high school at 16. Her father believed that the woman’s place was in the home, so disapproved of higher education for my mother. Nevertheless, she went through teacher training with no support from her family. She had to be top in her class to receive one of only two scholarships. At age 18 she was teaching a class of 40 fourth graders.

During the past century a woman’s role in US society has changed drastically. For instance, when I entered medical school in 1965 there were only six women in my class of 125. Now there are equal numbers of men and women in medical schools. My specialty, OB-GYN, used to be ruled by men but now women make up the preponderance.

More important, women increasingly take leadership roles. Whereas males used to preside over politics, we’re seeing more and more women in Denver and Washington. Many captains of industry and of education are now women. Indeed, it was Dr. Dene Thomas, the first female president of Fort Lewis College, who inspired this column.

In our country the movement for women’s suffrage started in the late 19th century. Colorado was early in recognizing a woman’s right to vote—in 1893! This movement ended in 1920 with passage of the 19th Amendment to our Constitution. It reads: “The right of citizens of the United States to vote shall not be denied or abridged by the United States or by any State on account of sex.”

Unfortunately there are still people who think that a woman’s place is at home, and women must be subservient to men. Some candidates in the last election came up with some really stupid statements.

“If it’s a legitimate rape, the female body has ways to try to shut that whole thing down.” As a specialist in reproductive health, I am not sure what “that whole thing” refers to, but I suspect that Mr. Todd Akin was referring to a woman’s ability to conceive.

Thirty years ago I investigated a statement in the antiabortion literature. Antiabortion people maintained that women don’t get pregnant from rape. I tracked down this untruth to a statement that 200 women who had been raped were followed and none of them conceived. The man who started this falsehood admitted to me that it had no basis in reality. The reality is that rape often leads to pregnancy.

This fall another Republican candidate, Richard Mourdock, said: “When life begins with that horrible situation of rape, that is something that God intended to happen.” Was he implying that God intended the rape to happen?

Todd and Murdoch disagree whether rape can result in pregnancy. I cannot agree with either of their attitudes toward women. Neither could 55 % of female voters, according to exit polls at the November election, since a large majority of women voted for Democratic candidates. How could Romney and Ryan tolerate to be associated with these clowns?

Fortunately President Obama has recognized the importance of contraception to America’s women. Starting in 2012 all insurance plans must pay for any birth control without copayment. This mandate has the great promise of decreasing our atrociously high rate of unplanned pregnancies, and of slowing growth of our population.

Why do women value family planning services? They say that access to contraception allows them to take better care of themselves and of their families, helps them support themselves financially, and permits them to complete their education and to be employable. This information is from a recent survey of over 2000 women using family planning clinics across the country.

Barak Obama has just been inaugurated for his second term of office. His popularity confirms that people want a change from archaic concepts of the role of women. We want healthcare for all, freedom to access contraception and, when necessary, safe abortion services.

© Richard Grossman MD, 2013