"You health experts are just too efficient; you create more problems than you solve." It is time to challenge statements such as this which result from tacit acceptance of the syllogism that since population growth tends to neutralize other development efforts, and since health programs contribute to population growth, reduction of the health component of international aid is therefore a logical step in promoting economic development.

Health programs, which once represented a major effort in American technical assistance, are now being quietly downgraded or phased out in most countries, except those that are obviously underpopulated, such as Ethiopia. Instead of challenging such decisions, most international health workers react with a puzzled sense of embarrassment. Why should they be apologetic for doing a good job? The humanitarian urge to improve the health of the world's needy people is so much a part of our total value system that it is disillusioning to find that good results have boomeranged.

It is demographic nonsense to think that the population problem can be postponed by maintaining high death rates. In underdeveloped countries, if high birth rates had not been biologically adjusted to the high death rates, the population would have faced extinction. As part of the development process the death rate is bound to fall and recent studies of demographic trends in Western countries show convincingly that health and medical services can claim regrettably little credit for this improvement. In eighteenth-century England mortality rates began to fall long before sanitation improved; the sanitary revolution occurred only after the cholera epidemics of the mid-nineteenth century. The mortality decline was probably due to better economic conditions permitting better nutrition and generally better living conditions. The birth rate also fell spontaneously but only after a lag period of one or more centuries during which the population soared.

The first reason, then, for doing something about the death rate is that with modernization it will come down anyway and equivalent population growth will occur. A characteristic of the development process is that birth rates eventually but somewhat erratically follow the decline of death rates. We have learned a great deal about lowering mortality. We are now beginning to learn what is involved in decreasing natality. As understanding of family planning improves, birth rates should become responsive to social and economic forces. The time lag between falling death rates and falling birth rates, which used to extend over several generations, should now be reduced to one to two generations and the total population growth should be less.

Put in terms of the average village family, the population problem is due to the fact that families previously had to have six or eight children in order to raise three or four. With readily available health improvements, only an occasional child need now be lost. It takes about a generation for parents to feel secure in the conviction that their children will survive and for them to be willing seriously and consistently to practice family limitation. It should be recognized also that even if effective family planning were to be promptly introduced into newly developing countries a high rate of population increase would continue for at least one generation. So many young mothers will be entering the child-bearing age that the number of children they produce will remain high until the population has aged.

Humanitarian and logical considerations justifying a positive health program are strongly supported by political realities. The purpose of economic development is not merely to raise per capita income but more importantly to raise standards of living. Better health is an important part of better living. Though we are primarily concerned here with people as producers, it must not be forgotten that they are also consumers of health services. The people of developing countries are demanding health as a basic right. Even the humblest villagers have learned that it is not necessary for them to continue to carry the present burden of disease. The demand for better health can usually be satisfied with a relatively elementary type of medical care. This is what village people know most about, and immediate relief from physical suffering means more to them than the less tangible benefits of preventive services.

Effectively organized preventive services provide long-range investments in a better way of life even though they do have an immediate collateral effect on population growth. This relationship is most evident with maternal and child-health services and mass programs for controlling communicable diseases such as malaria and smallpox. In many areas half of all children have been lost, while the remainder established immunity to the range of pathogenic organisms in their particular environment and became accustomed to the adult diet of their social group. In much of the world a major restraint on population growth continues to be "weanling diarrhea," a combination of infectious diarrhea and nutritional deficiency which makes the second year of life almost as dangerous as the first. Endemic malaria, typhoid and other infections take a great toll among children who prove unable to develop resistance. Simple and practical training of village midwives prevents most maternal deaths and the women thus saved will continue to have babies.

It is probably the dramatic quality and relative newness of modern health improvements which have led some development economists to conclude that public health programs should be delayed until economic development can accommodate the population growth they bring. They feel that the medical demand of developing countries can, in the meantime, be satisfied with simple therapeutic services. Not only is such an attitude impossible to justify morally, but it is also poor development planning because better health itself contributes to economic development.

II

How can health programs promote economic development? First, better health is an investment in the human resources required for economic development. We have been too much concerned with the quantitative effects of reducing mortality and the frightening population growth which results. The qualitative benefits of increased labor productivity which result from reductions in morbidity are even more important than the effects on mortality. Many dramatic case histories can be cited of the effects of removing long-standing obstacles to development programs through improved health. One instance I observed personally is the opening up of the Rapti Valley in Nepal by a malaria-control program. In 1949 I conducted the first general health survey of Nepal. At that time, the malaria barrier along the southern border strongly reinforced the country's political isolation. For centuries the severe hyperendemic malaria of the Terai forests below the Himalayan foothills had made this area uninhabitable for any except local jungle tribes who had developed a high degree of resistance. A mass mosquito-control program with insecticide spraying has now opened up this fertile area for settlers from the grossly overpopulated hillsides of Nepal. Within five years local immigration produced a tenfold increase in population with dramatic and spreading economic development.

In the case of Ceylon, whose rapid population growth is frequently cited, it is usually overlooked that malaria control has had a net economic benefit. Reduction in morbidity more than offset the effect on mortality. Especially important was the fact that the two-thirds of the island which was malarious and thinly populated became attractive for more intensive settlement. As a result, mass migration from the crowded third of the island occurred with general economic benefit. Similar examples can be cited following the control of other mass diseases such as hookworm, schistosomiasis, yaws, sleeping sickness and mass malnutrition. Opening up new areas to agricultural development provides new opportunities for employment as well as the manpower to fill the new jobs.

In already crowded areas the economic impact of health programs is harder to demonstrate, because chronic local underemployment makes additions to the labor force a less obvious contribution. In such situations benefits are evidenced mostly by increased efficiency and productivity of labor and changing attitudes to work. One factor that is often ignored in general statistical analyses is the selectivity of diseases. Often malaria epidemics hit during harvest or planting seasons and produce a severe labor shortage at a critical time, even when there is a high annual level of underemployment. Or tuberculosis often selectively attacks special groups of young adults such as college and graduate-school students. As a result of health programs, therefore, the size of the effective or most needed labor force is increased by an even larger factor than the population as a whole. Also important is the fact that a further brake on the net rate of economic growth in developing areas is provided by the large proportion of dependent children. As a new demographic balance is achieved, with lowered birth rates following lowered death rates, the proportion of children will be reduced from about one-half to less than one-third. This means that the proportion of producers to consumers will be improved.

A second contribution of health to economic development is that a dramatic demonstration of improved health in a traditional society can spark more widespread acceptance of other innovations. Modern medical care in an area of great need provides a clear demonstration that the past does not have to determine the future. Better health changes motivation. Improved human welfare becomes a reasonable goal. Increased life expectancy in itself changes the human time scale and makes effort and planning for the future worthwhile.

The third and most important way in which health programs contribute to economic development is by providing the best prospects of solving the population problem. In order to get acceptance of family planning, it is essential that parents have some assurance that children already born will have a reasonable chance of surviving to adulthood. The crucial decision to practice family planning on a continuing basis is made by parents in the privacy of the home on the basis of family needs and aspirations. Parents are willing to listen to advice on family planning from the health personnel whose work makes survival of their children possible. It would be difficult for any other agency or service organization to establish equivalent rapport. Advice on child-spacing can be provided as a normal part of post-partum care of mothers, whether by private practitioners or public clinics. Also, the new contraceptive devices tend to require continuing utilization of health services.

A preliminary generalization based on some of the more successful field trials in developing countries is that family planning is accepted most readily where health and medical services have been established longest. Examples of such partial successes are the rural projects in Japan, a study at Singur Health Center outside of Calcutta, and in certain rural health centers outside of Colombo, Ceylon. These family-planning projects were superimposed on local health services which had been running more or less successfully for at least 20 years. The progressive development of prolonged contact between village people and health personnel builds confidence and a willingness to contemplate change. The acceptance of innovation is cumulative. Use of contraceptives is encouraged by past demonstrations of the effectiveness of scientific medicine. Almost all of the experimental family-planning programs which have been started outside such a framework of steadily developing health activities have been notably unsuccessful in winning sufficient general acceptance to alter birth rates. We learned this lesson the hard way in the Punjab where a large staff concentrated on a small population for five years; there was much verbal acceptance but little decrease in the birth rate.

III

A consequence of the logical relationship between health programs and population control is the increasing tendency to assign national family- planning programs to health services. It has been only 15 years since Japan and India pioneered the development of national family-planning programs. Other countries which have joined this growing international movement include Korea, Taiwan, Pakistan, Egypt, Turkey, Tunisia, Czechoslovakia and Poland. To improve understanding of how such national family-planning programs should be organized, a number of intensive local field studies have been conducted.

These field studies have begun to clarify the basic relationship in population dynamics which is the uneasy equilibrium between the technical difficulties of using specific family-planning methods and the motivational level of potential users. Technical considerations influencing the use of a particular method include such practical issues as availability, cost, esthetics, safety, religious beliefs, need for repeatedly remembering, and actual effectiveness in use. To achieve regular use of a method, motivation has to be high enough to rise above what may be seen as a threshold formed by the technical limitations and liabilities of that method. If there is insufficient use to provide balanced population growth, then the national family-planning program must work toward either increasing motivation or lowering the technical threshold.

When conditions get bad enough, people will control population growth by methods that would normally be considered immoral or otherwise objectionable. This is why mathematical predictions of the obviously ridiculous consequences of uncontrolled population increase, leading to "standing room only," have little chance of becoming reality. In Ireland, the population crisis culminating in the potato famines of 100 years ago was solved not only by mass emigration but also by changing inheritance legislation to favor elder sons. As a result, nearly a third of Irish colleens remain spinsters and those who marry have to wait until they are almost 30 years old. In Japan, abortion has been the principal method of population control, with more abortions than live births in an average year. Surveys of urban populations in many parts of the world, and especially Central Europe and South America, also indicate that abortions are numerous and sometimes exceed the number of live births. In Mainland China today demographic analyses suggest that in rural areas there may have been a return to the old custom of female infanticide.

Particular attention is now being given to the problem of motivation in obtaining widespread acceptance and use of contraceptives in family- planning programs. In each social group the complex framework of tradition, religious beliefs and intra-family relationships creates cultural inertia to change. Specific effort is needed to identify the spontaneous social forces which lead to acceptance of innovation. Among the many factors which are being studied, three approaches seem particularly important in planning the course of national programs.

A primary need in program development is to start with families already motivated rather than trying to include everyone at once. An obvious and direct relationship is that motivation increases proportionately with the number of living children. In at least 20 different studies in different parts of India, parents uniformly reported that they wanted only three children. The average couple is, however, unwilling to do anything about this somewhat vague wish until there are six or more living children; they especially need at least two sons to be sure that one will survive to carry out family responsibilities and funeral rites for the father. By that time, of course, the family has more than contributed its share to doubling the population in that generation. Even this level of six to seven children is below the biological norm of ten to twelve for fertile women, so that considerable fertility control is already going on. The methods used, however, are usually social restraints such as taboos on intercourse during lactation. With modernization such restraints tend to break down; this, along with improved health and nutrition, explains the actual rise in birth rate which often occurs as economic development starts. The phenomenon negates the hope of those who claim that lowered fertility will follow economic development as readily and spontaneously as the lamb followed Mary.

Several studies have shown that these parents with large families compose most of the 10 to 20 percent of village couples who welcome a new family- planning program with an enthusiasm that is somewhat misleading because community birth rates do not fall as expected. The reason is that these couples would have used some method anyhow. An example of such apparent success is provided by the numerous sterilization camps that have been promoted with much publicity by certain states in India. Teams of surgeons go for a few days to a rural school or other public buildings where large numbers of village men are lined up to have the relatively simple operation of vasectomy performed under local anesthesia. The government pays them 15 to 25 rupees compensation for the loss of a day's wages. Even though the first candidates for sterilization tend to be those who have already contributed substantially to population increase, it is hoped that from satisfied patients the notion will progressively filter through their social groups that the procedure is desirable and effective. As the motivational level rises throughout the community, couples with fewer children will also begin to limit family size.

Another factor influencing motivation is the family's view of its own socio- economic condition. When parents realize that they are living below subsistence levels so that family members are obviously suffering, they resort to extreme methods such as abortion. More commonly, a natural optimism leads people to think they are just maintaining a subsistence level, or that things will soon improve. In a traditional agrarian economy, children are considered a sound financial investment. Where old age security depends on the family rather than society, large families provide not only more labor for the farm now, but also a larger credit account for the future. When economic conditions start to improve, these values begin to change as family expectations increase. Motivation for family planning should develop with recognition of the greater good of providing the best possible care and education for a few children rather than struggling with bare subsistence support for many. Somewhat more selfish but useful influences also appear when parents balance the choice of another baby against a team of bullocks, a bicycle or even a tractor.

On the other hand, social and economic development can influence family planning adversely as shown by research conducted in Ludhiana District in the Punjab. When the studies began in the early 1950s, conditions were distinctly unfavorable. The large influx of refugees from Pakistan was accompanied by severe disruption of economic and social stability. We were repeatedly told by village leaders on the panchayat, or elected village council, that important as all of their other problems were, "the biggest problem is that there are just too many of us." By the end of the study period in 1960, a remarkable change had occurred. With the introduction of more irrigation canals and with rural electrification from the Bhakra- Nangal Dam, and with better roads to transport produce to markets, improved seed and other benefits of community development, and especially because there were increasing employment opportunities for Punjabi boys in the cities, a general feeling of optimism had developed. A common response of the same village leaders now was, "Why should we limit our families? India needs all the Punjabis she can get." During this transitional period an important reason for the failure of education in family planning was the favorable pace of economic development. Children were no longer a handicap. Rather than blaming health for the population problem, general development must accept part of the responsibility.

The reasons for the decline in birth rates which spontaneously occurs with education, urbanization and industrialization are not particularly mysterious. Information about family planning spreads more rapidly as people get together more, talk more, read more and have more diverse wants and the ability to satisfy them. The rational approach, then, is to bring this subterranean spread of information out into the open and channel it in appropriate ways. We should not rely only on subtle and uncontrolled social dispersion of knowledge about contraceptive methods, but make it part of health education. Society went through a similar process in bringing the problems of venereal disease, alcoholism and drug addiction out into the open in order to make a rational approach possible.

Population growth is not uniformly bad. Moderate population growth can be an important incentive to economic development. Europe's spontaneous balancing of the demographic gap took one to two centuries, and provided the manpower for the industrial revolution. An optimum rate of increase stimulates hard work, especially where conditions are such that parents have the financial flexibility to think beyond the basic subsistence needs of their families. Population growth interferes with economic development when parents are not able to adjust the number of their children to the supporting resources. In biological terms, a parallel can be drawn with the role of stress on the physical condition of the body. A certain amount of stress is good in that physiological and psychological challenges promote optimum development and function. Too much stress, on the other hand, can overwhelm resistance and produce disease.

The third major consideration which can influence motivation for family planning is the effect of multiple and rapid child-bearing on the health of mothers and children. This relationship has received surprisingly little study and data are still incomplete. For mothers, a sequence of health hazards results from having too many babies too fast, in the absence of prenatal and postnatal care, with inadequate nutrition, and with deliveries conducted by untutored midwives whose ignorance leads to damaging intervention. These dangers are often cumulative. Second, third and additional pregnancies lead to progressive conditions such as osteomalacia- a calcium deficiency which causes gross caricaturing of the skeletal structure, the shadowy pallor and weakness of anemia, the still somewhat mysterious explosion of blood pressure and metabolites known as eclampsia or toxemia, and the sharp increase of almost all complications of the delivery process itself. Contrary to the usual pattern in Western countries where women outnumber and live longer than men, the vital statistics of many developing countries show 20 percent fewer women than men during the childbearing period. Almost as serious are the effects on children of having to compete for limited nutrition and care. In much of Africa a major cause of death is Kwashiorkor, a symptom complex due to protein deficiency that follows weaning; its tribal names carry the connotation that it is a disease of third children or of twins among whom sibling competition for food determines survival. The women of Asia, Africa and Latin America are intuitively aware of these hazards. Appropriate health education couched in terms that they can understand should significantly raise their motivation. On the other hand, a purely maternal and child-health approach will probably not be enough because of the dominant role of the male, especially in developing countries. Husbands have to be educated, too.

National family-planning programs have been concentrating on trying to increase motivation. Although this is important, there is a more immediate and practical need for health education, especially in the countries with the biggest population problems. The first need is to give simple and direct information about family-planning methods and where contraceptive devices can be obtained.

IV

What are the possibilities of improving family planning methods? As we have noted above, if methods become simpler, cheaper, safer, more effective and more esthetic, a lower level of motivation will be sufficient to provide more widespread use.

Any method requiring repetitive use will be troublesome. If preventive measures must be taken at the time of intercourse, the procedure tends to be inconvenient for a variety of reasons inherent in the simple living conditions of poor people. If women have to remember to take a pill every day for a portion of a month, they need relatively high motivation and an ability to calculate. Such methods compete with Ayurvedic and other indigenous practitioners who promise that their pills will suppress fertility for at least a year and who continue to do a great business in spite of obvious failures. Complicated directions lead to situations such as that of the village woman we encountered in a region where polyandry is practiced. Because she was told to use foam tablets before intercourse with her husband, she carefully refrained from using them when having intercourse with the younger brothers.

It seems probable that the best solution for village people will be the temporary infertility which is obtained with the increasingly popular intrauterine devices. Intrauterine contraceptive devices first were used widely in Europe some 50 years ago when metal Gräfenberg rings were found to be effective. However, the fact that complications frequently resulted caused them to fall into professional disrepute. Within the last ten years modern plastic devices have been developed which largely eliminate previous hazards. In spite of continuing alarmist predictions, there is rapidly accumulating evidence that major dangers, such as the possibility of precipitating cancer, are essentially nonexistent. Furthermore, the minor hazards such as slight bleeding and cramping or unnoticed expulsion are being rapidly reduced by improvements in the design of the devices. Their effectiveness is only slightly below the 100 percent effectiveness of oral contraceptives. They are cheap and need be applied only once. Some public health experts are beginning to feel that these devices may provide the sort of technical breakthrough which came with the discovery of D.D.T. in malaria control.

The first indications of dramatic success are beginning to come from mass programs in Taiwan and Korea. The high rate of acceptance there, largely through spontaneous spread of information from woman to woman, is already leading to sharp differences in birth rates as between areas where the method is available and where it is not. Wide and rapidly increasing acceptance of the method is also occurring in the slums of Santiago, Chile, and in rural Pakistan. The present feeling of optimism is based on the conviction that if couples can go through a relatively simple procedure and then forget about the need for contraceptives until they are ready to have a child, and if they can then have fertility reëstablished with another simple procedure, we will be approaching the ideal family-planning method.

There is now an encouraging tendency for international agencies to respond to requests from developing countries for help in finding ways of meeting their population problems. This will lead to continuing need for more careful analysis of the relationships between population growth and health, and the ways in which this interaction influences economic development.

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