Our Greatest Problem Ever!

1. Our Greatest Problem Ever! The Refrigerator Model for Human Fertility Martha M. Campbell, Ph.D. School of Public Health University of California, Berkeley www.venturestrategies.org presented by: Milton H. Saier, Ph.D. UCSD Division of Biology Based on work conducted by:

2. GLOBAL POPULATION: >7,000,000,000. Growth: • 9,360 more every hour • 225,000 every day • 82,000,000 every year! 156 more people every minute!

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

5. The Face of Poverty

6. Child Marriage

7. Annalynn on her 9th Birthday

13. 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.

14. 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.

15. The Human Population: a contentious subject • Why? • 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 in complex systems involving humans.

16. There is much disagreement about 2 questions: “Is population growth a problem?” and “What reduces fertility?”

17. A progression… 1 billion 1800 > a million years 2 billion 1930 130 years 3 billion 1960 30 years 4 billion 1975 15 years 5 billion 1987 12 years 6 billion 1999 12 years 7 billion 2011 12 years

19. South White Nile Blue Nile Ethiopia 2002 : 72 million2050: 173 million Sudan 2002: 38 million2050: 84 million Nile An environmental challenge: the Nile Egypt : 2002: 71 million 2050: 127 million Today the Nile is dry before it reaches the Mediterranean. Total population dependent on the Nile: 2002: 194 million; projected for 2050: 385 million –essentially doubled. Mediterranean

20. Sinhalese and Tamil Youth Bulges major anti-Tamil rioting in Colombo Sinhalese insurgency peak Tamil insurgency 20% critical level Gray Fuller. CIA: The Challenge of Ethnic Conflict. Washington, DC 1995.

21. 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.

22. 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.

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

24. The Demographic Conundrum What alternative theory would more accurately reflect the truth and be correctly predictive? For this we must consider Human Reproductive Biology.

25. Alternative paradigm – the ‘Ease’ model Facts: • 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. • ALL countries with replacement level TFR or lower have access to a full range of contraception and safe abortion for ALL (including poor) women. • Where family planning is easy to get, contraceptive prevalence between groups of different socioeconomic characteristics falls away.

26. Time taken to go from 6.0 to 3.5 children in a family Iran

29. Spain Bulgaria Czech Rep. Italy Romania Slovenia Estonia Germany Greece Hungary Latvia Austria Belarus Bosnia and Herzegovina Lithuania Russian Federation Slovakia Ukraine Japan Portugal Croatia Netherlands Barbados Switzerland Poland Belgium Canada Cuba Sweden Trinidad and Tobago Armenia Denmark France Moldova, Rep. of Finland Luxembourg United Kingdom Singapore Korea, Rep. of Thailand China Yugoslavia Australia Georgia Norway Ireland Malta Mauritius Azerbaijan Korea, Dem. People's Rep. United States Cyprus New Zealand TFYR Macedonia Iceland Sri Lanka Guyana Kazakstan Brazil Suriname Myanmar Albania Turkey Jamaica Uruguay Chile Mongolia Tunisia Viet Nam Argentina Indonesia Lebanon Panama Fiji Israel Bahamas Mexico Bahrain Brunei Darussalam Colombia Dominican Rep. Iran Costa Rica Kuwait Peru Morocco Venezuela Bangladesh India Malaysia Ecuador Kyrgyzstan South Africa El Salvador Egypt Uzbekistan United Arab Emirates Cape Verde Turkmenistan Philippines Belize Algeria Qatar Zimbabwe Libya Syria Tajikistan Samoa Paraguay Vanuatu Honduras Botswana Bolivia Haiti Kenya Nicaragua Nepal Cambodia Papua New Guinea Sudan Swaziland Comoros Lesotho Namibia Jordan Guatemala Solomon Islands Pakistan Central African Rep. Côte d'Ivoire Gambia Ghana Nigeria Cameroon Djibouti Iraq Maldives Gabon Madagascar Zambia Guinea Bhutan Mauritania Tanzania Equatorial Guinea Senegal Eritrea Saudi Arabia Benin Guinea-Bissau Lao People's Dem. Rep. Oman Togo Sierra Leone Rwanda Chad Congo Liberia Burundi Mozambique Ethiopia Congo, Dem. Rep. Burkina Faso Mali Malawi Angola Niger Afghanistan Uganda Somalia Yemen Abortion Law I (26% world’s population) Abortion Law II (9.9% world’s population) Abortion Law III (2.6% world’s population) Abortion Law IV (20.7% world’s population) Abortion Law V (40.8% world’s population) 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 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 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. 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. 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. Sources: The State of the World’s Children 2000, UNICEF; and the Center for Reproductive Law and Policy, 2000

30. 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.

31. 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.

32. 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.

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

34. 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.

35. What are the barriers to fertility regulation methods? • 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. • 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.

36. Which of the barriers can be reduced on a large scale by foreign money? • 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. • 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.

37. “We must be courageous in speaking out on the issues that concern us: We must not bend under the weight of spurious arguments invoking culture or traditional values. No value worth the name supports the oppression 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

38. The Refrigerator Model of Fertility

39. Human sex and reproduction do not fit the standard economic model 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.

40. The Refrigerator Model of Fertility #SI = # refrigerators sold, (or # of pregnancies).

41. The Refrigerator Model of Fertility To 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 -

42. The Refrigerator Model of Fertility …there are consequences

43. The Refrigerator Model of Fertility and more consequences!

44. The Refrigerator Model of Fertility girl and boy frigs!