Category: Public Health

Categories
Family Planning Medical Public Health

Condemn “Assembly Line” Sterilizations

News media focused in November on deaths in India after women had surgery at a sterilization “camp”. Authorities suspect that the surgeon caused more than a dozen deaths, so he is in prison.

More people are added to the population of India each year than to any other country. India has family planning programs, but abuses occur. This epidemic of deaths may have occurred because of disregard for established standards.

Indian gynecologist Pravin Mehta holds the world’s record for the number of tubal ligations that one doctor has done—over a quarter million. He told me how he could do 300 surgeries in one day; Henry Ford would have been amazed!

I didn’t realize how crude Mehta’s process was until I saw a movie of him working in a surgery camp. Operations were performed in a tent, and conditions were very primitive.

Nevertheless, Dr. Mehta’s safety record was remarkable. He offered a reward for anyone who reported a problem, including pregnancy, after his surgery, but gave out very few rewards. Indeed, I believe that his complication rate was lower than surgeons doing tubal ligations under modern conditions.

Were all these surgeries truly voluntary? During the era when Dr. Mehta worked—1970s and 1980s—India had aggressive sterilization programs for both men and women. Acceptors were given a small stipend if they agreed to the surgery. Recently the stipend for a person getting sterilized was equivalent to less than $10—a small sum by our standards but more than a villager might see in a month.

Reports of the recent sterilization tragedy frequently mention that women wanted to limit their family size, but that they were not given information about temporary methods of family planning. Even if women knew about temporary methods, they were not available.

Many problems were found after these Indian surgeries that killed many young mothers. The operating room was not clean, the staff were untrained, the medicine was contaminated. The same syringe and needle were used to inject local anesthesia for many women. Even worse were systemic problems: almost all of the funding was used for administration and too little paid for actual health care, there was little counseling or informed consent, no access to temporary contraceptive methods, and providers were pressured by numerical targets.

Two Americans are making a documentary about sterilization. Quartz published quotes from some of the Indian women they interviewed; here is the link: http://qz.com/299712/these-are-the-voices-you-did-not-hear-after-the-chhattisgarh-sterilization-tragedy/. One of the women, Archana, said:

“I was 19 when I got married and I have 3 kids. I don’t have much income, that’s why I got sterilized. When our income is limited what’s the use of having so many kids? ASHAs [Accredited Social Health Activists] came to visit me and told me about sterilization. When I got sterilized I went with my sister-in-law to the hospital and was given Rs600 in compensation. My husband and my mother-in-law were supportive. It took me about a month to recover fully. After a week I had to cook for my kids and take care of the house. I would have liked an entire month to recover, but we didn’t have anyone else to do the work. I chose this method because I had so many kids, and I didn’t know of other methods of contraception at that time. Now I’ve learned about more temporary methods. Copper T is not available here, you have to go to the cities, but you can get pills and condoms here.”

Please remember that conditions and standards in developing countries are different from what we know. Nevertheless, people must be respected and well informed about their health care.

Can family planning programs provide services to millions of people and yet assure that care is truly voluntary? Delegates at the International Conference on Population and Development 20 years ago felt that it is best if family planning were a part of comprehensive reproductive health programs. Since then our population has grown by 1,600 million people, with consequent increasing problems. Much of this growth is in developing countries, but remember that it is we in the rich countries who cause the worst impact because of our consumption!

Some of the family planning workers have real concern for the people they serve. After this tragedy one ASHA (health activist), Mitanin, is quoted as saying: “with what face we will tell people to go for sterilization?  Now, even if they come to us for it, we will hesitate.”

A new program, FP2020, is working to provide quality family planning services while respecting reproductive justice. More about FP2020 soon.

© Richard Grossman MD, 2014

Woman after sterilsation surgery in Bilaspur

Categories
Population Public Health

Age Gracefully—1-2014

Last July, when I turned 70, I wrote about my own aging. What happens as a large group of people age?

Let’s look at the start of the process of demographic change, when birthrates fall. This causes a decrease in the number of young people so there are fewer dependents. With more people in the working age range and not many old people yet, the group can prosper; this is the “demographic dividend”. Many regions have experienced this, notably in Africa and Asia. A European example will serve us better, however, since the information is more complete.

The Republic of Ireland is strongly Roman Catholic. In 1935 the government made contraception illegal, except for fertility awareness methods.  Their Total Fertility Rate (TFR—the average number of children a woman will bear during her lifetime) climbed to 4.  Despite its strong religious heritage, the country legalized contraception in 1979. Then TFR gradually dropped to about 2—below replacement and in the current range of other European countries. During the 1990s Ireland enjoyed a period of economic growth.

What is going to happen to countries as their populations age? Will it be as much of an detriment to economies as the demographic dividend was a benefit?

Never before have whole countries had their populations shrink voluntarily so markedly as is happening now. Perhaps the closest western civilization encountered was in Europe during the mid-14th century—the Black Death. This pandemic is estimated to have killed half of all Europeans. Indeed, the popular press has drawn the analogy of population shrinkage to a plague.

Half of the world’s countries have a TFR less than replacement—less than 2.1—which means they will decrease in population. This shrinkage has been slow at first, but birthrates seem to continue dropping. What some people fear is the change in the age structure. There will be an advantage because there will be fewer dependent young people. At the same time, people are living significantly longer than previously, so the number of older people will increase, increasing the number of dependents for each working person.

How can countries deal with this change in demographics? Will this transformation in age structure spell economic disaster? Some writers think so.

Perhaps the best glimpse into the future is the example of Japan, where one quarter of its population is 65 years old or older. It has the very low TFR of 1.4, little immigration and its population is shrinking at about 0.2 % annually. Furthermore, because of good diet and fine medical care, the life expectancy for a child born now is 83 years—about the best in the world.

How has the graying of its population affected the Japanese people? One trivia is the sale of diapers. They are unique in the world because sales of baby diapers will soon be by equaled by sales of adult diapers.

Birth control pills were not available in Japan until 1999. For many years people relied on just condoms and abortion to plan their families. Nevertheless, the TFR dropped below 2.0 in 1975. The sociological changes that have catalyzed this low reproductive rate include the changing role of women. Instead of staying home, now many women are well educated, work outside the home and postpone marriage until they are older.

Japan has avoided economic disaster despite the aging of its people, although they did suffer from the 2008 recession. The average retirement age is close to 70—since people are healthier, they can work longer. Because of the smaller number of children, there are still plenty of workers to support each dependent person.

Many European countries also have aging populations, but they use a different method to deal with the decreasing number of native young, low-skilled workers. They have “guest worker” programs, which allow people to immigrate from poorer countries to do work that the locals don’t want to perform.

Demographics are changing in many countries. In cultures that are aging, some occupations and businesses will have decreased demand, including obstetricians, childcare and teachers. Other occupations and businesses will increase—geriatricians, retirement communities and physical therapists.

The “population explosion” is not over. We are still growing by almost 80 million people yearly—mainly in poor, southern countries. Many people have enjoyed the demographic dividend, but the time has come to adjust to a new reality. Since growth cannot go on forever, it is absolutely necessary to reach a stable population, which means a period of population aging.

© Richard Grossman MD, 2014