our greatest problem ever!

M. Campbell, UC Berkeley, 2/15/05

Our Greatest Problem Ever!

Martha M. Campbell, Ph.D.School of Public Health

University of California, Berkeleywww.venturestrategies.org

The Refrigerator Model for Human Fertility

Milton H. Saier, Ph.D. UCSD Division of Biology

Based on work conducted by:

presented by:


GLOBAL POPULATION: >7,000,000,000. Growth:

• 156 more people every minute!

• 9,360 more every hour

• 225,000 every day

• 82,000,000 every year!


What kind of world do we want in 2050? For how many people? With what kind of life style?

With sustainability?


The Face of Poverty


Annalynn on her 9th Birthday


Population/Environment is considered a “sensitive” subject

We’re not supposed to say: “Successfully combating population growth will

allow us to preserve the environment (ecosystems, biological species, our oceans and forests, the atmosphere, etc) for future generations.”

But, the human population is the one most important component of the current environmental equation.


Ergo

Since many believe that couples have the number of children they want to have,

and since many believe it is difficult to bring down family size without limiting people’s freedom,

then, although we know that accelerating the decline in family size will help preserve the environment,

Population and Environment remain “sensitive” topics. For many, it is even taboo. Many others prefer not to discuss it openly for fear of conflict. Politicians are particularly afraid because of past emotional reactions.


The Human Population: a contentious subjectWhy?

• It involves sensitive subjects – including sex and “traditional” catholic values (since the 1400s) concerning birth control and reproduction.

• Tough ethical questions are rarely examined unemotionally & objectively. • Causality is hard to define.


There is much disagreement

about 2 questions:

“Is population growth a problem?”

and

“What reduces fertility?”


A progression…

1 billion 1800 > a million years

2 billion 1930 130 years







Ethiopia 2002 : 72 million 2050: 173 million

Sudan 2002: 38 million 2050: 84 million

Egypt : 2002: 71 million 2050: 127 million

Mediterranean

An environmental challenge: the Nile

South

Total population dependent on the Nile: 2002: 194 million; projected for 2050: 385 million –essentially doubled.

Blue NileWhite Nile

Nile

Today the Nile is dry before it reaches the Mediterranean.


Sinhalese and Tamil Youth Bulges

Sinhalese insurgency

major anti-Tamil rioting in Colombo

20% critical level

peak Tamilinsurgency

Gray Fuller. CIA: The Challenge of Ethnic Conflict. Washington, DC 1995.


Socioeconomic (SE) paradigm

• People want many children until changes occur in external conditions that increase the desire to limit childbearing. These include:

– Education.

– Economic development (wealth).

– Assurance children will survive.

• People make rational decisions about family size based on socioeconomic conditions.


Specific problems of the socioeconomic model

• It does not explain the connection between decision and results.

• It does not consider human reproductive biology.

• It has not been successfully predictive.


The current, dominant SE paradigm…

• Did not predict replacement fertility for the poor in many industrialized nations.

• Does not explain why the use of contraception is equally high among educated and uneducated women where family planning is easy to obtain.

• Cannot explain why desired family size always declines ahead of actual family size.

• Does not explain why Iran’s fertility fell from 6 to 2 in record time when birth control was promoted.

Scientific theories are likely to be correct if they make correct predictions.


The Demographic Conundrum

What alternative theory would more accurately reflect the truth and be correctly predictive?

For this we must consider Human Reproductive Biology.


1. Countries with easy access to family planning options, backed up with safe abortion, have low or rapidly declining fertility – regardless of economic conditions or culture.

2. ALL countries with replacement level TFR or lower have access to a full range of contraception and safe abortion for ALL (including poor) women.

3. Where family planning is easy to get, contraceptive prevalence between groups of different socioeconomic characteristics falls away.

Alternative paradigm – the ‘Ease’ model

Facts:


Time takento go from6.0 to 3.5children ina family

Iran


Spain

Bulgaria

Czech R

ep.ItalyR

omania

Slovenia

Estonia

Germ

anyG

reeceH

ungaryLatviaA

ustriaB

elarusB

osnia and H

erzegovinaLithuaniaR

ussian Federation

Slovakia

Ukraine

JapanP

ortugalC

roatiaN

etherlandsB

arbadosS

witzerland

Poland

Belgium

Canada

Cuba

Sw

edenT

rinidad and Tobago

Arm

eniaD

enmark

France

Moldova, R

ep. ofF

inlandLuxem

bourgU

nited Kingdom

Singapore

Korea, R

ep. ofT

hailandC

hinaY

ugoslaviaA

ustraliaG

eorgiaN

orway

IrelandM

altaM

auritiusA

zerbaijanK

orea, Dem

. People's

Rep.

United S

tatesC

yprusN

ew Z

ealandT

FY

R M

acedoniaIcelandS

ri LankaG

uyanaK

azakstanB

razilS

uriname

Myanm

arA

lbaniaT

urkeyJam

aicaU

ruguayC

hileM

ongoliaT

unisiaV

iet Nam

Argentina

IndonesiaLebanonP

anama

Fiji

IsraelB

ahamas

Mexico

Bahrain

Brunei D

arussalamC

olombia

Dom

inican Rep.

IranC

osta Rica

Kuw

aitP

eruM

oroccoV

enezuelaB

angladeshIndiaM

alaysiaE

cuadorK

yrgyzstanS

outh Africa

El S

alvadorE

gyptU

zbekistanU

nited Arab E

mirates

Cape V

erdeT

urkmenistan

Philippines

Belize

Algeria

Qatar

Zim

babwe

LibyaS

yriaT

ajikistanS

amoa

Paraguay

Vanuatu

Honduras

Botsw

anaB

oliviaH

aitiK

enyaN

icaraguaN

epalC

ambodia

Papua N

ew G

uineaS

udanS

waziland

Com

orosLesothoN

amibia

JordanG

uatemala

Solom

on IslandsP

akistanC

entral African R

ep.C

ôte d'IvoireG

ambia

Ghana

Nigeria

Cam

eroonD

jiboutiIraqM

aldivesG

abonM

adagascarZ

ambia

Guinea

Bhutan

Mauritania

Tanzania

Equatorial G

uineaS

enegalE

ritreaS

audi Arabia

Benin

Guinea-B

issauLao P

eople's Dem

. R

ep.O

man

Togo

Sierra Leone

Rw

andaC

hadC

ongoLiberiaB

urundiM

ozambique

Ethiopia

Congo, D

em. R

ep.B

urkina Faso

Mali

Malaw

iA

ngolaN

igerA

fghanistanU

gandaS

omalia

Yem

en

I. Permitted only to save the Woman’s Life or Prohibited Altogether II. Physical Health III. Mental Health IV. Socioeconomic Grounds V. Without Restriction as to Reason

Abortion Law I

(26% world’s population)

Abortion Law II

(9.9% world’s population)

Abortion Law III


Abortion Law IV


Abortion Law V


Sources: The State of the World’s Children 2000, UNICEF; and the Center for Reproductive Law and Policy, 2000

Is Replacement Level Fertility Possible Without Access to Abortion?Martha M. Campbell, Ph.D. and Kimberly Adams, M.P.H.

The Center for Entrepreneurship in International Health and Development (CEIHD, “seed”)

School of Public Health, University of California, Berkeley

Hypothesis

We have observed that all countries with 2 or fewer children have widespread, realistic availability of safe abortion for poor women. (We recognize that rich women have access to safe abortion in virtually every country.)

We hypothesize that all high fertility countries have constrained access to abortion, and that it is necessary to have relatively unconstrained access to back up imperfect use of family planning, to achieve low fertility. (Access to safe abortion is also critically important for reproductive health, including low maternal mortality.)

This graph demonstrates the relationship between countries’ TFR and their types of abortion laws by degree of restriction, across 170 countries.

What about the anomalies? Some countries with high fertility have liberal abortion laws, and some countries with low fertility have restrictive abortion laws. What is going on here?

Zambia (TFR 5.3, law 4) Zambia has a liberal law but with a critical restriction: it requires approval by 3 ObGyn physicians. Few people are able to have legal abortions in Zambia.

India (TFR 3, law 4) A liberal abortion law since 1970s, but restrictive in that only university-trained doctors can provide this service, and those doctors don’t live in most of India’s million villages, which are home to most of India’s low income people.

Tajikistan (TFR 4, law 5) We don’t know about this country, or similar situations in Turkmenistan, Uzbekistan, Kyrgystan.

Ireland (TFR 1.9, law 1) The law forbids abortion but safe abortion services are widely accessed across the channel in England.

Republic of Korea (TFR 1.7, law 2) The law is restrictive but has been interpreted liberally for decades, to make safe abortion available.

Singapore (TFR 1.7, law 3) The law permits abortions for health reasons only, but it is interpreted liberally.

Mauritius (TFR 1.9, law 1) Abortion is not legal and we don’t know what is going on here. One possibility: a single illegal abortion provider could make the demographic difference in a country of only 1 million people.

Myanmar (TFR 2.3, law 1) Abortion is not legal but it is no secret that it is widely practiced in this country. Many procedures are done with unsafe methods.

Thailand (TFR 1.7, law 2) Abortion law is restrictive in language, but safe and low cost abortion services are widely available.

Bangladesh (TFR 3, law 1) Abortion is not permitted, but menstrual regulation (vacuum aspiration in the first 8 weeks to bring on a late menstrual period) is a legal part of family planning. Bangladesh has over 10,000 providers of trained manual vacuum aspiration (MVA) services, only 50% of whom are doctors.

Sri Lanka (TFR 2.1, law 1) Abortion is not formally legal but clinics provide large numbers of safe menstrual regulation services.

Spain (TFR 1.1, law 3) Abortion is permitted for health reasons, but the law is interpreted liberally.

Conclusions

1. What is stated in the law is less important than how the abortion providers interpret the law.

2. A country is not likely to get to replacement level fertility without access to safe abortions for low income women.


Observations

All countries with 2 or fewer children/woman have widespread, realistic availability of safe abortion for poor women. (Rich women

have access to safe abortion in virtually every country.)

All high fertility countries have constrained access to abortion; Access to safe abortion is also critical for reproductive health,

including low maternal mortality.

The graph demonstrates the relationship between countries’ TFR and their types of abortion laws by degree of restriction, across

170 countries.


What about the anomalies? Some countries with high fertility have liberal abortion laws, and some countries with low fertility have restrictive abortion laws. What is going on here?

Zambia (TFR 5.3, law 4) Zambia has a liberal law but with a critical restriction: it requires approval by 3 ObGyn physicians. Few people are able to have legal abortions in Zambia.

India (TFR 3, law 4) A liberal abortion law since 1970s, but restrictive in that only university-trained doctors can provide this service, and those doctors don’t live in most of India’s million villages, which are home to most of India’s low income people.

Ireland (TFR 1.9, law 1) The law forbids abortion, but safe abortion services are widely accessed across the channel in England.

Republic of Korea (TFR 1.7, law 2) The law is restrictive but has been interpreted liberally for decades, to make safe abortion available.

Singapore (TFR 1.7, law 3) The law permits abortions for health reasons only, but it is interpreted liberally.

Myanmar (TFR 2.3, law 1) Abortion is not legal but it is no secret that it is widely practiced in this country. Many procedures are done with unsafe methods.

Thailand (TFR 1.7, law 2) Abortion law is restrictive in language, but safe and low cost abortion services are widely available.

Bangladesh (TFR 3, law 1) Abortion is not permitted, but menstrual regulation (vacuum aspiration in the first 8 weeks to bring on a late menstrual period) is a legal part of family planning. Bangladesh has over 10,000 providers of trained manual vacuum aspiration (MVA) services, only 50% of whom are doctors.

Sri Lanka (TFR 2.1, law 1) Abortion is not formally legal but clinics provide large numbers of safe menstrual regulation services.

Spain (TFR 1.1, law 3) Abortion is permitted for health reasons, but the law is interpreted liberally.


Conclusions

1. What is stated in the law is important, but how the abortion

providers interpret or are allowed to interpret the law is also important.

2. A country is not likely to get to replacement level fertility without

access to safe abortions for low income women.


Percentage Currently Married US Women who had an Unplanned Pregnancy (standardized for age, parity, income and intention)

Method Percent pregnant per yr.

Pill 2.9

IUD 6.0

Condom 14.1

Diaphragm 17.2

Spermicides 22.1

Nothing 41.2


Why does the paradigm matter?

The socioeconomic model has had unintended consequences:

• Population and environmental issues are met with fear and a feeling of futility.

• Control of demographic fertility is politically incorrect.

• Foreign aid for population control is insufficient and spent unproductively; family planning is still hard to get for the poor.

• Population is viewed as the “given” in the population/ environment equation, not as a factor amenable to change.


• Religions constrain providers

• Mothers-in-law are in charge.

• Young brides lack power.• Unmarried young females

are excluded from services.• Prices are too high.• Outlets are unreachable.• Medical rules make getting

contraception difficult.• Misinformation about

contraception.

• Gov’t services are poor.• Advertising isn’t allowed.• Paramedicals are not activated.• Pills are either restricted or not understood. • Method choices are limited.• Safe abortion is hard for poor women to get.

What are the barriers to fertility regulation

methods?


• Religions constrain providers

• Mothers-in-law are in charge.

• Young brides lack power.• Unmarried young females

are excluded from services. Prices are too high. Outlets are unreachable. Medical rules make getting

contraception difficult. Misinformation about

contraception.

• Gov’ts are weak or uncooperative. Advertising isn’t allowed. Paramedicals are not activated. Pills are either restricted or not understood. Method choices are limited. Safe abortion is hard for poor women to get.

Which of the barriers can be reduced on a large scale by

foreign money?


“We must be courageous in speaking outon the issues that concern us:

We must not bend under the weight ofspurious arguments invokingculture or traditional values.

No value worth the name supports theoppression and enslavement of women.The function of culture and tradition is

to provide a framework for human well being.If they are used against us,

we will reject them, and move on.We will not allow ourselves to be silenced.”

Dr. Nafis Sadik, Exec. Director, UNFPA, Under-Secretary of UN, at the United Nations Conference on Women, Beijing, China, September 1995


The Refrigerator Model

of Fertility


The nature of decision making about family size differs from rational choice in the purchase of a normally marketed good or service.

Human sexual intercourse is frequent and usually unrelated to desired reproduction. The decision to have a child is not a positive one of turning childbearing on, but a negative one of turning childbearing off – and negative, preventive action must be taken repeatedly, persistently, perfectly.

Human sex and reproduction do not fit the standard economic model


The Refrigerator Model of Fertility

#SI = # refrigerators sold, (or # of pregnancies).


The Refrigerator Model of FertilityTo buy a refrigerator: Call Sears. Send a fridge.

If buying a refrigerator is like human reproduction: We must call Sears X times a week and say “Do not send a refrigerator.”

If we fail to call Sears every time we do NOT want a refrigerator - repeatedly, persistently, perfectly -



…there are consequences



and more consequences!



girl and boy frigs!

our greatest problem ever!

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