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A discussion of the crisis of population growth must be organized around two sharply contrasting themes: one, of almost unrivaled dangers; the other, of new hope that it may be resolved during the remainder of this century. It is difficult to overstate the importance of either theme. The dangers threaten the entire process of modernization among the two-thirds of the world's people in the technologically backward nations, and thereby the maintenance of their political coherence; they threaten, indeed, a catastrophic loss of life. The hope lies in the fact that there is now new reason to think that, if the world is willing to bend its energies toward solving the problems, it can go far toward doing so during the coming decades. The time has passed when the problem must be viewed as insuperable.
In what follows, I shall be concerned with the technologically backward nations. The question here is not what population they might ultimately be capable of supporting if they achieve a high state of development. At present they are desperately poor, grossly uneducated and badly organized to make use of what knowledge they have. They have to start from where they are, and not from where they should like to be. The problem in the real world is that the rate of population growth is proving to be a major obstacle to economic development. Mounting rates of population growth are proving to be almost insuperable obstacles to the technological development on which our future hopes must depend. The heart of the demographic problem is that of slowing the rate of population growth sufficiently to permit the development of the lagging economies and of doing this in the next two or three decades.
The case is now too well known to require detailed documentation. Most of the newly developing nations have populations that are growing by at least 2.5 percent per year. Moreover, those with slower rates of growth have negligible health protection and will quickly come to that rate whenever rudimentary health services are developed. The rates of growth go up to 3.5 percent and occasionally higher. Growth continuing at 2.5 percent doubles the size of the population in 28 years and growth at 3.5 percent doubles it in 20 years. In short, unless growth slows down, most of the technologically backward countries face the problem of dealing with double their present population well before the end of the century: that is, well before the children born this year have completed their own childbearing.
The sources of this rapid growth are easily identified. Birth rates are very much higher and death rates are very much lower than they were, for example, in the nineteenth-century period of modernization in Europe. There, populations seldom grew by as much as 1 percent per year. Whereas in Europe there tended to be about 35 births a year per 1,000 population, in today's newly developing countries birth rates generally range from 40 to 55. The source of this difference lies mainly in the universality of marriage in the developing nations and in the young ages at which it occurs.
Death rates differ even more spectacularly. In nineteenth-century Europe, death rates of 25 per 1,000 population were common and a rate as high as 30 was not unusual. In today's newly developing countries a rate of 25 is very high, 20 is common and the rates go as low as 6 per 1,000 population. A primary cause of these low figures is, of course, the new efficiency with which disease is controlled by sulpha drugs, antibiotics and insecticides. The expectation of life at birth has risen remarkably in most of the newly developing countries. Indeed, in a few areas it now exceeds 60 years-not so very much less than the U.S. figure of 70 years.
The low death rates also come from another and less commonly recognized source. The death rate is simply the annual number of deaths per 1,000 population and therefore is affected by the age composition of the population. Under anything like reasonable health conditions a young population tends to have a low death rate and an old population a high death rate. One of the important reasons that the newly developing countries have low death rates is that their very high birth rates have generated very young populations. It is this that accounts for the fact that the lowest death rates in the world today are found in newly developing countries that have relatively good health services. Taiwan, for example, has a lower death rate than the United States, and Ceylon has a lower death rate than France or England. Moreover, although death rates in the newly developing world are low by historical standards, many remain very high in the light of modern abilities to control disease. Hence we can expect that death rates will continue to be reduced.
It would be unwise, then, to expect even a very rapid decline of birth rates to reduce population growth below 1 percent by the end of the century. This figure is about the rate of natural increase in the United States at the present time. Barring catastrophe, and under the best possible circumstances, the newly developing world will have to achieve its modernization in spite of rates of population growth running from the present figure of 2.5 to 3.5 percent down to 1.0 or 1.5 percent by the end of the century. Any such trend will clearly require a very rapid reduction of birth rates.
The cost of this growth must be met before new investment can be made in educational and productive facilities. The dilemma is now widely understood: if a nation is increasing its product by 5 percent a year-a level that rather few of the developing nations have thus far been able to sustain-and if its population is growing at 3 percent per year, then per capita income rises at a rate of 2 percent. This means that incomes will not have doubled until after the turn of the century. Per capita incomes would rise from, say, $100 per year to only $200 per year over the next 35 years. But, meanwhile, the population would have increased by a factor of 2.7. In short, an excellent economic performance would result in 2.7 times as many people continuing to live in almost abject poverty, with resources for the improvement of education and productive equipment having increased only minimally.
In the densely settled regions of the world the problem is much more difficult than these simple numbers suggest. Consider the situation of India. A perpetuation of its present rate of growth of 2.4 percent would mean that its present population of about half a billion would rise to one billion before the end of the century. India already faces acute shortages of food. Its agriculture is poorly developed. If it is to support such growth, it must make strenuous efforts to enhance the production of the land. A rapid but theoretically possible development of agricultural technology should enable India to meet at least its minimum needs. But to increase production in this fashion requires very little more labor. It requires instead the rationalization of agriculture through development of better crop practices, transportation, credit facilities, pest control and fertilization. It does not require more people. And yet if its present population growth continues, India faces the problem of finding-within about 29 years-the means to support another half-billion people outside of agriculture. In an era of rising expectations how long can political coherence be maintained in the presence of unemployment on a possibly unprecedented scale?
If political coherence cannot be maintained, the risks change-from those of growth to those of a catastrophic loss of life. The margins of safety are pathetically thin. It would not take much disorganization to block transportation and public health activities so that famine and epidemic disease would stalk the land. To anyone inclined to point out that this would at least be one solution to the problems of population pressure, the reply must be that massive upheavals also jeopardize every aspect of the development process and every hope of representative government in unregimented societies. The risks of events of this kind are real in such densely settled areas as India, Pakistan, Indonesia and Egypt. Mainland China, about which we know very little, may already be experiencing these catastrophes.
In view of the foregoing it may seem reckless to turn to the optimistic side of the picture, but there is such a side which I think is persuasive. Optimism does not carry us to the point of forecasting that the problems will be solved without intervening tragedies. But we do have reason to believe that the problems can be solved by a world fully alert to the dangers and willing to devote serious resources and energy to attacking them. We now have a basis for expecting that a rapid decline in birth rates can be achieved in the next decades. The problems and the crisis need not be prolonged indefinitely. Much will depend on the scale of efforts both in developing the economies and in reducing birth rates in the next 20 or 30 years. We cannot argue that the solution is in sight, but we can argue that the prerequisites for a solution are at hand.
In this hopeful judgment four elements are important: (1) the development of national policies favoring family planning; (2) the demonstrated public interest in limiting childbearing; (3) the improvement of contraceptive technology; and (4) the fact that for the first time in history several Oriental populations have begun to cut their birth rates as a result of governmental programs to spread the practice of birth control. I shall consider each of these topics briefly.
A decade ago, India was the only country that had adopted a national policy to promote the practice of family planning, although for several years the plan had more words than substance. Today, more than half the people of the newly developing world live under governments that have decided to reduce their birth rates by family planning. These include Mainland China, Nepal, Pakistan, India, Ceylon, Malaysia, Indonesia (if still a bit ambiguously), Singapore, Hong Kong, Taiwan (in deed, if not in word), South Korea, Iran, Turkey, Egypt, Tunisia, Morocco, Kenya, Barbados, Jamaica and Honduras. Many other countries, such as Colombia and Chile, are setting up active governmental and quasi-governmental programs. In still other countries substantial efforts are going on in universities, public hospitals and in local health departments. These include, for example, Thailand, the Philippines and Venezuela.
It must immediately be said that a governmental policy does not guarantee an effective program; there has often been a lag of several years between the adoption of a policy and the beginning of effective work. The point, however, is one of future relevance. The fact is that the newly developing nations have themselves been coming to an awareness of the seriousness of their population problems and of the extent to which their best work in economic development is being frustrated by too rapid increases in the numbers of their people. Their awakening to the urgency of the problem has come with remarkable and accelerating speed. It foreshadows energetic work.
The second reason for optimism concerning the possibilities of reducing rates of population growth is that the public has been shown to be interested in limiting family size. The finding is surprising, for students of traditional agrarian societies have long reported that motivation for restricting fertility generally is not high. Many of the attitudes, customs, beliefs and familial arrangements remain those of centuries past in which survival, not over-rapid growth, posed the problem. These factors continue today to weaken interest in family planning.
Nevertheless, sample surveys conducted in some 20 developing countries show that, without exception, substantial majorities of married couples want to restrict their childbearing. Moreover, these attitudes are found in the villages as well as in the cities-among illiterates as well as among the educated. The women want to limit their childbearing, not necessarily to only two or three children, for they may often want four or five and at least one son. But they want to curtail their childbearing, and this attitude is widespread even in communities in which there is little evidence of modernization.
Actually, these communities often have a great deal more modernization than first strikes the eye of the prosperous Western visitor. His overwhelming impression is that of poverty. But the villager has movies (either regularly or through traveling theaters), transistor radios and a desire to educate his children. He is aware that his children no longer die in infancy as they used to do, that sweeping epidemics no longer appear. He is also aware that more surviving children mean more difficulty in providing enough food, and he sees that today a medium-sized family will provide enough surviving adults to protect him in his old age. All these factors have increased the proportion of couples who say that they would like to practice contraception.
The demonstration of interest is based on much more than responses to surveys. In many societies a large number of crude and illegal abortions gives eloquent testimony to the motivations for restriction. Moreover, wherever there have been well-organized contraceptive services through which information and supplies are readily available, the response has been large. Where there is indifference, it usually has been to poorly organized services poorly supported by educational effort. Any lack of interest on the part of the public is less serious than the apathy of the middle classes and the lesser officials who cannot bring themselves to believe that their illiterate peasants are sufficiently intelligent to understand their own problems. Both surveys and the public response to services clearly demonstrate that ordinary people have a much better understanding of their own problems than their lesser officials appreciate.
The third encouraging fact is the improvement of contraceptive technology. During the past decade we have gained two methods which are safe, cheap and highly effective and that for the first time make no demands on the couple at the time of coition. One is the new plastic intrauterine device (I.U.D.) that, once inserted, remains indefinitely in place for those who tolerate it. Experience with it varies, depending on the quality of service and the the extent to which the patient is warned to expect some initial discomfort. The weight of evidence is that with reasonable care (including re-insertion in some patients who expel it) some 55 or 60 percent of women continue to be completely protected after two years. The other 40 to 45 percent include women whose husbands have died, those who have decided to have a child and those who prefer other methods; only 20 to 30 percent cannot tolerate or retain it. The rate of pregnancy among users, including women who have unknowingly expelled the device, is 2 to 3 a year per hundred women. This is less than half the rate with conventional contraceptives under the best conditions.
The oral steroids offer the other most promising method. Until recently, they were too expensive to meet the needs of the majority in the developing countries. Recently, however, prices for bulk orders have dropped to about 15 cents per cycle, which permits their use in governmental programs, at least for those patients who cannot use the I.U.D. When the pill is systematically taken it is absolutely effective. We do not yet know how effective it is in actual use or what proportion of women will continue to use it. Preliminary indications in Taiwan and Korea are that the rates of discontinuation are, if anything, somewhat higher than those with the I.U.D.
The new methods go far toward meeting the needs of couples so weakly motivated that they will not take troublesome precautions. The limitations loom large only when they are compared with an abstract ideal rather than with earlier experience. Moreover, knowledgeable scientists from several laboratories are saying that we may come much closer to the abstract ideal within the next four years. Several possibilities are now being studied in animals. One of the more promising is an injection, or implant, that will prevent pregnancy for a year or more. It is hoped to release a progestin in such very small amounts that its effect is achieved exclusively at the uterine level without involving either the ovary or pituitary. If this proves to be possible, the reduction of dose and the elimination of estrogen should greatly reduce the undesirable side effects of the present combined pill and bring the cost to well under 50 cents a year. One cannot count on the success of anything in the early research stage, but there are now so many good leads that the prospects for major improvements in contraceptive technology in the near future are excellent.
The fourth reason for optimism about the possibility of reducing birth rates is that some countries have already done so. This is the case in South Korea, Taiwan, Hong Kong and Singapore, and perhaps in other countries where the evidence is more difficult to marshal.
South Korea offers no accurate birth rates, but consider the indirect evidence that they are falling.[i] Last year over 390,000 women had I.U.D.s inserted, bringing the total in the two-and-a-half-year program through 1966 to 737,000. Since 1962 there have been at least 80,000 male sterilizations. At the end of 1966 about 170,000 couples were receiving conventional contraceptive supplies from government stations. Altogether, with allowance for duplications, something like 900,000 couples have been served by the government effort. Since the program began (mostly since 1963), more than 20 percent of the women of childbearing age have taken part, and surveys indicate that about 20 percent of all couples are currently practicing contraception. Moreover, growing acceptance continues in 1967 with no indication that a saturation point has been reached.
According to year-end population registrations, of admittedly defective quality, the ratio of children under age five to women of childbearing age shows a sharp decline between 1962 and 1965, both nationally and in every province of the country. The Planning Board believes that the rate of natural increase has dropped from an estimated 3 percent in 1962 to about 2.5 percent in 1966; it has set a target of 2 percent by 1971. Clearly the birth rate has begun to fall rapidly in response to a strong governmental program.
In Taiwan the birth rate has been dropping for the last ten years, from 45 per 1000 in 1955 to 34.5 in 1964, 32.7 in 1965 and to a record low of 32.4 in 1966. (The actual and comparable figure would have been below 31 if a census in December 1966 had not brought in early birth registrations and omissions from the previous years.) The goal is to reach a birth rate of 20 by 1973. The program has depended heavily on the I.U.D. The target has been 600,000 Lippes loops inserted in five years, and at the halfway point the actual number falls only 39,000 short of 300,000. The fertility rates of women 25 to 29 are beginning to drop and the proportion of I.U.D. acceptors with only three children is rising. The fact that 37 percent of the I.U.D. patients have discontinued after 18 months has led to efforts to improve the service and to make pills available. It appears, however, that even those who discontinue the I.U.D. control their fertility rather effectively. Chow and Freedman find that if they include all the experience of those who have had I.U.D.s inserted, regardless of subsequent use, the fertility rate of the group has been reduced by something between one-half and two-thirds. There can be no doubt that the family-planning program has been highly successful in speeding the reduction of Taiwan's birth rate. Similarly, in Hong Kong and Singapore, family-planning programs have been major factors in producing sharp declines in birth rates.
The glow of optimism that can come from considering these successful programs fades when we consider India and Pakistan. Those nations have had appropriate policies, but they cannot yet point to reduced birth rates with any certainty. It has been only in the last two or three years that the programs have had much substance. Now they are getting under way, and by the end of this year India will apparently have inserted more than two million I.U.D.s and Pakistan nearly one million. In both countries sterilization is beginning to take a significant place, and work with pills is beginning. If the programs continue to go forward at the new pace the efforts can become highly significant in a few years.
Equally encouraging is the breadth of interest around the world. The Population Council alone has filled requests for some 2.6 million Lippes loops from the governments or medical institutions of 39 developing countries, and has helped governments in South Korea, Taiwan, Hong Kong, India, Pakistan, Egypt and Turkey to establish local manufacturing. It has sponsored a coöperative birth-control program in the postpartum services of 26 large delivery hospitals of 20 cities in 15 countries, including the United States. Although this program is only about a year and a half old, some 25 percent of the obstetrical patients have used the contraceptive service, and they have been markedly younger and have had fewer children than the patients attending the usual service. They have flocked to the clinics whether in Alexandria, Ankara, Santiago, Caracas, Mexico City, New York, Manila, Singapore or Bangkok. From this and many other projects it becomes evident that the difficulties do not lie in lack of interest by the public. The main obstacles to the development of highly successful birth- control programs everywhere lie in the organizational and administrative field.
Newly developed nations offer examples of rapidly falling birth rates. Japan's birth rate, for example, had dropped by last year from a postwar high of 34 per thousand to 14; Japan now shares with Hungary the lowest birth rate in the world.[ii] The decline was not the result of a governmental birth-control program; it was mainly due to abortion rather than contraception, and came almost in spite of the government. The public took such enthusiastic advantage of abortion permitted by the "Eugenic Protection Law" that it was politically impossible to interpret the law narrowly. At present there is a marked trend away from abortion and toward contraception, but Japan has shown that population growth can be drastically reduced by a prosperous people having few inhibitions against abortion and served by a competent medical establishment. The Japanese medical community's enthusiasm for abortion has seeped into Taiwan, South Korea, Hong Kong and Singapore, though it remains illegal.
Abortion is legal in the U.S.S.R. and all of Eastern Europe except East Germany and Albania. As in Japan, it has been a major factor in reducing birth rates which were high before the war but now are for the most part lower than in the United States. Abortion is apparently legal under many circumstances in Mainland China, and there is a good deal of talk about making it legal in India and in Pakistan. In view of the dearth of medical personnel and facilities and the improved efficiency of modern contraceptives, it is doubtful that abortion will play the major role in reducing population growth in India and the Moslem world that it did in Japan, the Soviet Union and Eastern Europe.
Abortion is, nevertheless, important today. In Turkey, where until two years ago contraception was illegal, the Ministry of Health estimates that more than one in four pregnancies is terminated by illegal abortion. In Latin America, where church opposition has held back the development of governmental contraceptive services, abortion is rife. No one knows the number even approximately, but the obstetrical services of many hospitals devote from one-quarter to one-half of their beds to patients with incomplete or septic abortions. Professor Freedman suggests that in the world as a whole abortion is today the most common female method of preventing birth. Where abortion is common it is difficult to suggest the absence of motivation for family planning.
This, then, is the optimistic case for saying that the newly developing countries can, if they will, bring their rates of population growth to reasonably low levels in the next two or three decades provided that they have the needed assistance from international, governmental and private agencies in the developed world. In absolute terms the assistance needed from the developed world is large, but it is small compared to that needed for economic development. Aid should include help with training at the professional and sub-professional levels in a wide range of biological, medical and social science specialties; assistance in building and enriching the medical infrastructure on which contraceptive services depend; assistance with organization, logistics, supplies and materials for informational and educational programs. Basic and applied research that seeks to attain new efficiency in the regulation of fertility needs to be increased throughout the world.
There are two kinds of major disagreement with the foregoing summary. One questions the objective of reducing the rates of population growth; the other accepts the goal but doubts that the appropriate means are being used for its attainment.
In both Sub-Saharan Africa and Latin America there is substantial opposition to family planning in official quarters. In most cases it is merely the continuation of the usual pre-modern view. When disease was uncontrolled, healthy and prosperous years produced rapid population growth. Bigger was, indeed, better. Things are still thought of in that light by many leaders who are impressed that they have large territories of undeveloped land. They are inclined to think in terms of traditional agriculture, and have little realization that a slower rate of population growth could mean a faster pace of educational and economic development, greater national prosperity and greater national power. This kind of opposition has been rapidly disappearing as governments gain new experience with the frustrations of development in the face of very rapid population growth.
There is also opposition from the more doctrinaire Catholics and communists, whose preoccupation with the defense of orthodoxy makes them slow to recognize the problem, and when recognizing it, inclined to prefer private and euphemistic to public and explicit solutions. When these groups are very strong, the governments tend to avoid policies and official programs, and the actual work goes on in the medical institutions and local health departments. Even then the assistance given is known not as contraception but as child-spacing, family health, pre-pregnancy health and anti-abortion service. Such opposition will undoubtedly delay somewhat the reduction of the rate of population growth, but everything on the horizon suggests it is rapidly disappearing.
Finally, there are dissident views among persons fully alert to the need for reducing birth rates. Objections have been voiced that too much of the effort is concentrated specifically on family planning, and that this overemphasis is particularly evident in the technical assistance from the developed world. This conclusion is based on a different reading of the record than that presented here. Overstated somewhat, this argument runs as follows: A number of countries such as India, Pakistan and Egypt have had national family-planning policies for a long time with inconsequential results; claims about public interest in family planning drawn from field surveys are worth little because they are too superficial to eliminate the favorable responses given mainly to please the perceived interests of the investigator; the majority of patients attracted to governmental programs are older women who will not have many more children in any event; the new contraceptive methods are proving unsuitable for a substantial proportion of people; and the only programmatic successes are in small Oriental nations.
The replies have been suggested. Nations with positive policies did not develop significant programs until the advent of the I.U.D. convinced their leaders that appropriate methods existed. Actual work is scarcely three years old. Responses to surveys are not to be taken at full face value, but the differences by education and income are in the expected direction, as are the changes of responses over time as programs develop. The real danger is that we do not take the surveys seriously enough, because, whenever put to the test, the public has backed its opinion with requests for service. Naturally older women with many children are the first to come for help. To them the problem is desperate. But one must start somewhere, and it can be argued that bringing the older and respected couples to the practice of family planning may well serve to legitimize the practice and to encourage imitation by younger couples for purposes of child spacing. Methods of contraception are less than perfect, but the important fact is that we now have methods with which more than 50 percent of women are happy and successful. For the 30 percent with real difficulties, there are the conventional methods, not to mention the new methods on the horizon. Finally, it is true that the beginnings of success have come only in small Oriental countries. The question, however, is not whether birth rates have been reduced in all the world, but whether they can be reduced by family- planning programs. The successful countries have shown what can be done. To me it seems that the skeptics are concentrating on the problems that remain to be solved rather than reading the lessons for the future in the recent and quite remarkable past.
Perhaps the basic reason for skepticism about the future significance of recent efforts lies in the conviction that institutional structures are too hostile to the very idea of family planning to permit any substantial success. One objection is that efforts to spread the practice of birth control ought to be reduced so that the resources could be devoted to economic development. Might not the construction of a school or a factory do more to spread birth control than the same funds devoted to family- planning services? The alternative is not a real one because of differences in the magnitude of the requirements. Efforts to promote economic development are grossly insufficient to avoid the danger of major catastrophe, and the modernized world, if it values its own interests, will awaken to that fact. The most powerful effort imaginable to spread birth control could not cost anything like 1 percent as much as the cost of economic development. Indeed, the cost of preventing one birth, probably about $20, falls far short of the cost of one year's schooling. Much more costly efforts to reduce birth rates than any that have been attempted can be shown to be worthwhile in speeding the process of development by cutting the burden of population growth.
Another suggestion is to go directly to the problem of institutional change. Some of the resources now devoted to birth control should, the argument runs, be devoted instead to changing the institutional setting in ways that would favor family planning. We should study the possibilities of changing marriage age, of finding ways in which the state can reward the parents of small families, and, perhaps, of penalizing the parents of large families (a policy now being debated in India). Undoubtedly, some support for such studies should be available, but before their results can have any influence on reproduction they will have to be carried through the entire political process. It is my impression that obtaining living examples of family planning will be much more important, even in changing social institutions, than efforts to change the governmental rules. Changes in the institutional setting are needed, but at this stage it seems more important to help those people who are willing to become the innovators.
Whatever happens, it is probable that, short of a major rise in the death rate, population growth will not be stopped for some decades. Given the necessary effort, however, it does seem likely that growth will be reduced to levels that can be coped with in a world of rapidly developing science and technology. In the long run, of course, growth must stop. Quite possibly it will not do so even if every couple is able to limit its childbearing to the precise number of children it wants. But a world in which all couples are able to choose the size of their family will be a world in which an alteration of institutional constraints would prove rather quickly effective. If the developing nations can move from their present growth rates of 2.5 and 3.5 percent to 1 and 1.5 percent while health improves, the problems will not all be solved, but the crisis will be passed.
It would be a great mistake to suppose that we will move into the future with a linear extension of past performance. No one ten years ago would have forecast the rapid changes of the past decade in policies, in contraceptive technology, in public interest and in programmatic successes. We must assume that the future will bring an accelerated pace of change. We have already moved from a position of public apathy to one of deep concern by many people. Today, governments, international agencies and private organizations are talking a great deal about major efforts and new groups are entering the discourse every day. Everything on the horizon suggests a further deepening of interest, both public and private. Our estimate of the future possibilities should be based on the premise that we are at the beginning of an accelerating trend. Almost all of the actual work, national and international, remains to be done. If our efforts are commensurate with our opportunities, however, we have reason to believe that by the end of the century the spectre of poverty perpetuated by population growth can be lifted from the earth.
[i] The following discussion draws heavily on: Mauldin et al., "Retention of IUDs: An International Comparison," and Chow and Freedman, "Taiwan: Births averted by the IUD program," from The Population Council's Studies in Family Planning, issues No. 18, April 1967, and No. 20, June 1967, respectively.
[ii] The rate dropped from 19 to 14 last year, reflecting the fact that girls born in the year of the "fiery horse" have the worst horoscopes as brides of any for the last 60 years. The rate will probably rise this year, but the sharp response to astrological portents shows that fertility is under voluntary control.