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Originating from the School of Continuing Education on Washington Square at New York University W N Y C presents the N.Y.U. lectures today's topic Planned Parenthood Our guest is Dr Sheldon Siegel embryologist and director of the bio chemical division of the Population Council and affiliate of Rockefeller University a consultant to the Food and Drug Administration Dr Siegel has spent many years working on projects in India and is active in this country with the National Institute of Child Health Dr Siegel. It is really in this day and age impossible to separate the population dynamics from the economic and social dynamics of a country and both planning for and being able to evaluate its prospects for economic development. When I am. I must say that I have not clearly settle on the most significant aspects of the total. Problem of population and. Fertility that. Would be most appropriate to discuss with you tonight so if I have your permission to do so what I would like to attend his to select arbitrarily two aspects which I think are important each one may take perhaps twenty to twenty five minutes to more or less formal presentation. If you find the particular topics boring then you can ask me questions about something completely different but if these. Titillate your interest then perhaps we can continue in an informal way to discuss these two topics the first topic is. The extent to which family planning has indeed become a part of life a way of life around the world we hear great hand-wringing and talks of despair and my my the world is growing at such a great rate and why don't we do something about it. What we don't hear unfortunately is that in fact a great deal is being done about it. It is fair to say that more than two thirds of the women in the world live in countries where the right to get advice and service with respect to family planning has been recognized by the government and indeed is supported and provided by the government. And I will go into that in some detail with you. The second topic after reviewing the global developments with regard to the introduction of family planning in national programs will be a subject a little closer to my professional training and that is the status of research toward the development of new contraceptive methodology which once progressed somewhat farther will mean a great deal in assuring the success of these national programs. But to get the most information into the shortest period of time I'd like to read for you a summary I prepared recently concerning the state of family planning in national health programs. The field of Public Health has seen a quiet transformation of attitude in the last decade a transformation that has brought to a large portion of the world's population official governmentally operated programmes of family planning governments have traditionally accepted their responsibility for programmes of death control now in growing numbers they are turning to birth control. The government of India adopted an official family planning program in one nine hundred fifty four. Pakistan made the move a few years later when the census analysis showed a population of one hundred and one million instead of ninety min The figure that had been used as the basis for economic planning. Mainland China after a period of isolation now has formally adopted a program of population limitation. Government health services in China provide free vasectomy and tubal ligation on request any woman is entitle to present herself Are you having trouble with the last of the. First let's see which candidate it is who will either open the window or close. Well suppose I continue and perhaps you can focus on my voice I'll try to overcome the outside noise. Yes. In China the government health services provide free vasectomy and tubal ligation on request any woman is entitle to present herself for surgical terminations of pregnancy force when she desires a second abortion it is done if she agrees to a subsequent tubal ligation is a female sterilizing operation. Contraceptive materials including interviewed her own devices are freely available in all of the health services of China. The problem incidentally is that the health services in cells are not very well developed if they had a an extensive network particularly in rural China of Rural Health Clinics their efforts at limiting family limiting population growth would be much more effective. In the rest of Asia there is hardly a country of significant size that has not begun some official level of family planning activity Japan cheaply chiefly by changing the abortion laws shortly after World War two reduce the birth rate fifty percent almost overnight. Japan's annual rate of population growth of one point one percent is lower than that of many Western European countries and the United States. Abortions are performed by registered obstetricians and gynecologists and fees are paid by the National Health Insurance Plan. That I lay Szymon Cura Taj is done as an office procedure and does not involve hospitalization. South Korea has launched within the past few years what is probably the world's most active and successful mass family planning program after an extensive medical trial health authorities in Korea decided early in one nine hundred sixty four to emphasize entry uterine contraception a procedure with considerable advantages in many respects. Significantly it provides highly effective safe and reversible contraception without requiring continuous repetitive action on the part of the couple and that's the big advantage of entreaty contraception as far as most of these countries are concerned. This simplifies considerably the logistical educational and administrative needs of a family planning program. The renewed interest in intrigue uterine contraception a procedure that has long been known in medical history derives from two innovations incorporated in modern devices these are the use of inert plastic that do not cause that does not cause tissue reactions and the development of an extremely simple insertion technique that can be performed by a physician in a matter of a few moments without a dilation of the surface by June of one thousand nine hundred sixty four virtually every obstetrician and gynecologist and general practitioner in Korea had been given training in intrigue and device insertion now the government pays a subsidy for each insertion and follow up visit performed by a private physician. Large numbers are of insertions are done also in government clinics in one thousand nine hundred sixty four the target of one hundred thousand insertions was exceeded during one thousand nine hundred sixty five an additional quarter of a million insertions were completed. South Korea's population of twenty nine million was growing at a rate of three percent before the present programm was initiated this would have triple the population in thirty five years. And then if the national program continues to reach its targets as in the two years completed before sixty six the growth rate can be reduced to two percent by the one nine hundred seventy one. Taiwan has a program very similar to that of Korea in practice but not officially organized under the aegis of the National Health Service. The government has adopted a permissive attitude which allows several para governmental organizations and agencies of local government and and agencies of local government to undertake family planning activity. Chinese ingenuity can be credited with coining the phrase preprogramed sea health in place of family planning birth control or Planned Parenthood. In one nine hundred sixty three the Thai tune city pilot project began under the supervision of the Joint Commission on rural reconstruction and the provincial Maternal and Child Health Institute. This study revealed high acceptability of contraception and particularly of entry uterine contraception. A total of six thousand eight hundred cases registered for contraception during a nine month intensive education campaign eighty percent elected I U D S or intruder in devices when offered a choice of all methods. In one nine hundred sixty four the program was generalize so that they not so that now it covers virtually the entire island population of twelve million a large core of village health education nurses has been employed train and organized into teens they stay in a village for one month teaching both sanitation improvement and family planning. By redeemable coupon system women interested in contraception can be referred to any trained doctor who will be paid for his services by the government subsidized by the journal and Child Health Association. By the end of one nine hundred sixty five I.U.D. insertions in Taiwan exceeded one hundred thousand so on Thailand Malaysia Indonesia and Singapore have started pilot projects at least under government auspices in Singapore in fact there is a island wide or countrywide program that offers contraceptive advice to every woman in the reproductive age group at the time of the delivery of her baby. The program and someone is supported by the by the International Assistance Program of the Swedish government. In Thailand the National Research Council has initiated the pilot project and in Indonesia you can see that my right up here is is dated by by political events recent political events in excess he says in Indonesia an autonomous organization headed by Mme Cibot Andrea called the Family Planning Clinic project is fully financed by the government while Mrs said Landry was no no longer in charge of that project as you may imagine. Singapore's program as I mentioned has become a countrywide program and supported very enthusiastically by their energetic minister of health. Singapore incidentally is a special situation. With sixty five thousand deliveries a year the large maternity hospital in Singapore the K.K. hospital handles about sixty five percent of the births occurring in Singapore each year. At sixty five percent of the total births occurring in Singapore each year occur in one single hospital with close to two hundred deliveries a day this is the largest maternity service in the world. And intruder in device service was initiated late in one thousand nine hundred sixty five and within two months fifty insertions a day were being performed. It may well be that Singapore will be able to hold the reins on population growth simply by intensifying its in contraceptive services in a single hospital. A completely different problem both in magnitude and nature exists in India a country where fewer than ten percent of the nineteen million births a year occur in hospitals. India's population is rapidly nearing five hundred million and each year eleven million persons are added to the total. The future depends primarily on the birth rate and no tricks solution will work the matter is indeed complex How does a country with a population that is predominantly illiterate and which is dispersed in over one half a million villages with the poor communication and transportation out of such a country translate intention into action. When India adopted a family planning program in one nine hundred fifty four there were no comparable experiences to draw upon for India it was and still is a matter of learning by doing what is perhaps the most difficult public health undertaking in history. Until one nine hundred sixty three their major strategy was to focus upon the establishment of clinics which would provide contraceptive services by mites nine hundred sixty three there were eight thousand five hundred times receptive centers but very little contraception was initiated Nevertheless by that time extension education programs had achieved an amazing public awareness of the concept of family planning a representative study in Mysore state indicated that thirty eight percent of urban couples and eleven percent of rural couples had knowledge about methods of birth control. Attitudinal surveys or more are even more encouraging in that nearly seventy two percent of India's one hundred million couples in the reproductive age group express a desire to limit the family to three children. Thus the early program serious shortcoming proved to be the providing of the service itself the great gap between precept and practice of birth control was dramatized by the comparison of the number of interested couples seventy two million and actual contraceptive ors a maximum of two million of whom eight hundred thousand were male sub sterilizations subsidized by the government. This realization led in one thousand nine hundred eighty three to a complete revision of the focus of the program the emphasis was placed on providing full time family planning workers in state health facilities down to the village level. The objective was to make family planning education services and supplies available without the stifling dependency on the clinic. The revised client of mine nine hundred sixty three was intended to place emphasis on the use of condoms and male sterilizations. Meanwhile during one thousand nine hundred fifty three in one thousand nine hundred sixty four the Indian Council of medical research was testing intrauterine contraception and I'm January twentieth one thousand nine hundred sixty five very important day in India history in my opinion the Indian Council of medical research recommended the use of I.U.D. as in the national program. Fortunately the one nine hundred sixty three revision provided a basic administrative framework into which any new contraceptive method may fit so that in several states the use of the I.U.D. began almost at once after medical approval. Between July and December one thousand nine hundred sixty five more than one hundred thousand insertions were completed chiefly in the states of Bengal Punjab Dr Maharashtra and Kerala. By now India has completed over a million insertions of intriguer and devices and therefore has practically doubled in one year the total number of affective contraceptives as compared to the amount the number that they were able to mobilize in the twelve years. Of the program previously. Targets have been established for the next several years and the cumulative goal for the next five years is nineteen million insertions. India is objects it exacted is to reduce the birth rate from forty to twenty five in the next five years. The health ministry has been given a budget of two hundred million dollars and a strong mandate to achieve this objective. Many thoughtful people believe that with this program a rest the difference between success and failure of India's efforts for economic development. In the Middle East Iran has created the post of director of family planning within the Bureau of maternal and child health program planning is just starting but it is certainly far enough along to know that Iran will have a vigorous program within the next few months. Turkey and Tunisia have vigorous well planned national family planning programs of recent origin while Morocco and Egypt appeared to be on the verge of. Important steps forward steps forward in their young programs. And they believe legislation was passed by the Turkish legislature in one thousand nine hundred eighty five without significant political opposition. In Tunisia a country with no tradition for contraception and medical practice or education with a core of physicians trained chiefly in French or by French trained doctors a comprehensive training program has been introduced by the government to train physicians throughout the country and interviewed her in device insertion and contraception in general. In Egypt the universities are providing leadership to establish demonstrated to establish demonstration projects and family planning. The government agency for drug manufacturer is compound ing or a bridge just in tablets from imported bulk material and manufacturing intriguer on devices as yet there is no significant governmental family planning activity in sub-Saharan Africa but evidence of changes is beginning to appear and it is likely that the first national program in tropical Africa will be announced within the next three to four months and most likely hood it will be Kenya. Latin America is the most rapidly growing major area on Earth. At present rates the population of two hundred and thirty million will increase to seven hundred fifty million by the end of the century a period during which North American population will go from essentially the same figure two hundred thirty million to about four hundred thirty min so that while North American continent continental United States and Canada will approximately double the South American and Alaska or sacked and Central American part of our hemisphere will triple. Birth control has been introduced as a fan as a service offered by the Health Services of Chile and Venezuela and by para governmental agencies in Colombia and Peru. In these countries the services provided not directly for family planning but for the Prevention of illegal abortion a survey conducted by the United Nations demographic training and research center revealed that in Santiago Chile one of every three pregnancies is aborted and the attendant maternal mortality and morbidity is high. Other surveys show that this is representative of most of urban South America and probably rural areas as well. In Santiago seventy percent of funds available for Maternal and Child Health are used for hospitalization associated with post abortion sequentially and this is a startling fact when you're confronted with the kind of seventy percent seventy cents out of every dollar available to the health services to improve maternity care seventy cents of each dollar are spent in caring for post-abortion complications. Thus the medical pressure to face up to a medical problem has moved several South American countries into official positions on family planning. The Caribbean region with its total population of twenty three million is growing rapidly and could triple before the end of the century the small islands have high population densities and the opportunities for emigration are shrinking rapidly Barbados for example has over one thousand five hundred people per square mile the government of a Barbados has subsidized a national family planning program through a separate organization outside an industry of health. Government health facilities are made available for this and intriguer in device clinics are held at least weekly at each of the island's health centers. A similar program is in progress in Jamaica with support of the U.S. a ID Agency for International Development. In Puerto Rico the government has requested the university to undertake pilot projects and family planning the tradition for birth control has been established by the vigorous activity of the Private Family Planning Association perhaps Standard been told you something about. Mexico with forty two million people comprises nearly three quarters of the population of middle America. Except for recently established research projects birth control is not officially provided in governmental hospitals even for such medical indications which would mitigate against a future pregnancy. However the outcome of the pilot project started one thousand nine hundred sixty five and continued into this year in three Mexican hospitals maybe the introduction of contraceptive services in the two large networks of health facilities that serve Mexico. Projections on population trends are truly startling I suppose you have had these thrown at you. Weeks lecture. The United Nations demographers anticipate a growth of four point one billion people in only twenty five years if present rates of growth continue. A world that in one thousand nine hundred sixty five faces food rationing malnutrition and famine for a large portions of its three point three billion people cannot realistically contemplate a banquet of plenty nor even a subsistence ratio for seven point four billion in the next few decades. United Nations estimates reveal that over eighty five percent of this increase will be in the high birth rate developing countries of Asia Africa and Latin America. For these countries the choice is clear birth rates must fall or death rates will rise. Recognizing this most of these countries have passed beyond the birth control debate it is no longer a question of whether to promote programs of voluntary birth control but how to implement a fact of programs. Now I forgive me for the formality of reading that I want to try to take you I world tour as it were of activities and family. Planning to impress upon you something that impresses me every time I take a jet around the world. And see the extent to which the government leaders. In all of the most of the developing countries have made this step they have made the decision and now their problem with regard to birth control is not whether to do it but how to do it most effectively I'm going to as I promised a few moments ago talk to you about the status of research toward the development of new contraceptive methodology but before doing that I'd like to say that some important events have made this kind of thing that we heard about in this lecture possible the important events have been for the first time the contribution of modern medicine. To the problem of controlling human fertility until very recently until say a decade ago the methods available for the control of fertility the so-called conventional methods were certainly not products of modern medicine and or science if you think about it the methods that have been traditionally used for the control of fertility are all methods that have relied upon one simple biologic principle and that is stop the sperm whether it be a condom or diaphragm or a vasectomy operation or well anything. CORNISH interrupt us in fact the Aborigines of Australia have the most ingenious method that I've heard of that they have a tradition or I guess is it your traditional ceremony when a boy reaches puberty to with a sharp and stick create a induced fistula at the side of the base of the penis so that the semen will flow out of this side aperture instead of through its normal passes through your ether it's essentially the same principle as all of our so-called. Traditional methods of contraception preventing egg from eating sperm. In the book I read talking about this for those of you who are curious about the rest of it it said that. The that the aperture was closed for purposes of make sure ition in the manner of a flutist. Don't seems right seems logical well. The. The point then is that a principle that has been known to biologists and scientists since. Certainly from the moment that van Leeuwen Hoke discovered the microscope that there are sperm in the male ejaculate and that this male factor is responsible for participating in the completion of a successful coalition this is been the only principle on which all our methods were based Now these methods for one thing meant that you could not dissociate the practice of contraception from the active codice and the motivational requirement therefore to contraceptive has always been quite high Furthermore the chances for failure have always been quite high because with one or two omissions of even the most successful of the most theoretically practical method your you would soon have the same number of children who you might have had if you hadn't been practicing contraception much at all well then within the last ten years modern science finally began to make a contribution and it has been the new methods that have been being been made available in the last ten years that have made the difference between success and failure of these national family planning programs the first of these methods was the oral contraceptives developed roughly in the early to mid one nine hundred fifty S. adopted on a wide scale bases about one thousand nine hundred fifty six and now used by perhaps eight to ten million women around the world. The second was interviewed her on contraceptives vice of modern design and that serial as I indicated it to you a few moments ago there are great advantages particularly for the emerging countries in the use of an intruder and device as a as a primary method in a family planning program it means motivation one time to do one thing and then the effect of contraception can be continued and for countries like India with tremendous shortages of personnel at all levels. Including health educators and. Visiting Nurses etc The advantage of not having to maintain a continuous motivation is tremendous and as I indicated also a few moments ago in general at every level in the administrative operation of the program if you can use a method that does not require continuation of whatever you've done the first time you have a tremendous advantage and this is what these countries have recognized in the interview trying to buy. One now given then these two new method these two great improvements these national programs have started to fly and I think that for the first time really we have reason to be optimistic about chances to reduce birth rates in these national family planning programs. Still. That's the optimistic side now let's look a little at the pessimistic or maybe realistic side. The interviewer in the first the oral contraceptive pill I mentioned that it's been being used now by perhaps eight to ten million women around the world but where are these women I think it is fair to say that perhaps ninety nine percent of the women who are now using oral contraceptives are in the United States England Canada Australia New Zealand a few in Mexico and perhaps some in Western Europe but as far as the developing world is concerned the oral contraceptive pill has made a century no impact whatsoever now it doesn't matter what the reasons are and there are some good reasons and some batteries but that's the fact of the situation these substances have been available for perhaps ten years now. There have been serious efforts by all kinds of agencies running from the strict commercially interested companies to the. Not commercially interested philanthropic agencies to get countries like India to introduce oral contraception at least to some extent but not very much has happened. And now what about a realistic look at intrauterine devices I presented to you some dramatic figures and they really are dramatic when when we talk about a million interviewed her and device and surgeons in India. This is this is saying that within a matter of twelve months they have been able to do more with respect to introducing affective contraception than they were able to do in twelve years without this method. But now. Now let's look at the future. Even though the at the initial. Impact it looks as if this is a tremendous tool which could perhaps do a large portion of the needed job a realistic look makes one back away a little and reflect first of all at the onset of such a program one can expect to essentially skim the cream or to find the most highly motivated women showing up at such clinics earliest and first after this is the going gets a little rougher and if one looks at insertion of monthly insertion figures for the Korean Taiwan programs which are farther along they tend to plateau off after the first year or so. But even more discouraging is the fact that intruder in contraception has some built in limitations that must be accepted as part of the method and that is that of those women who want to use the method perhaps twenty five percent cannot because the device will be extradited from the uterus in voluntarily or she will have persistent pain or bleeding and. The doctor will eventually recommend to remove the device so that to begin with you have perhaps twenty five percent of the interested population unable to use the method and then to continue with if one looks at. Continuation of use figures for two to three years it becomes evident that in particularly in situations where there is not careful medical evaluation and follow up there tends to be a rapid loss of users in other words for one reason or another the woman has the device removed frequently doing it herself or sometimes by a village midwife or even a physician. The extent of removal has been rather alarming in some pilot projects in Taiwan and Korea and they indicate that perhaps no more than fifty percent of the initial inserted nationally inserted devices continue in place after three years now there are two ways of looking at that you could say that fifty percent of these cases were lost that's harder or you can say thousand tast fifty percent of these women are continuing to use their contraceptive method and in fact there's a good reason for taking that latter point of view because. Compared to other contraceptives that have been attempted in the past fifty percent continuation of use figure after three years is really fantastic studies on condoms for example in India after one year three percent continue to use. Studies on the famous rhythm the even the probably have heard about those with beads to help women remember when the fertile period was occurring there were red beats and green B. and they had the right kind of Taishan for the color. Well after one year sensibly nobody was using them except the monkeys who played with them and that was that women started to use in character where the around their necks. But they were always hey we had a child on the breast and a child was playing with the beads so they got all mixed up so the next step was hanging in the trees out of reach of the children and the monkeys playing with them in that area so they didn't work well. So that a fifty percent continuation rate as I say does have a certain element of encouragement to it. But still I I feel that. If the real success is going to be written in family planning programs there will be required yet additional method that it to the present armamentarium we you know our World Bank report on India estimated that even under the very best conditions Assuming the most a labyrinth and active use of entry uterine devices possible India could not hope to do more than half of its needed contraception work within two uterine devices they would have to depend on some other methods for the remaining contraception. And now at the present time. There are some hopes on the horizon for methodological advances which may develop soon enough. And be effective enough to plug in as it were to these. National programs there are three stages of research on contraceptive methodology. Or put that another way I suppose you could say that you can divide the kind of research being done into three distinct categories. One is the type of research that is being done to improve existing methods. And there is some significant work going on in that area and next kind of research is the tend to make the transition from good laboratory leads to possible clinical applications and the third is the very basic work in the laboratory that has not yet gone far enough to to warrant clinical application you have just heard Dr Sheldon Siegel embryologist Dan director of the bio chemical division of the Population Council an affiliate of Rockefeller University a consultant to the Food and Drug Administration Dr Siegel has spent many years working on projects in India and is active in this country with the National Institute of Child Health next Tuesday at the same time in the series on the population explosion Our guest will be Dr Richard L. day medical director for the Planned Parenthood world association incorporated and Dr H. CURTIS Would medical consultant to the Association for a voluntary sterilization today's N.Y.U. lecture originating from the School of Continuing Education on Washington Square at New York University was prerecorded.