Articles

Asia tackles birth control

Forty million babies will be born this year on a continent that can’t feed everybody now. Will one of the most fateful and controversial experiments in history solve the problem?

BLAIR FRASER January 15 1955
Articles

Asia tackles birth control

Forty million babies will be born this year on a continent that can’t feed everybody now. Will one of the most fateful and controversial experiments in history solve the problem?

BLAIR FRASER January 15 1955

Asia tackles birth control

Forty million babies will be born this year on a continent that can’t feed everybody now. Will one of the most fateful and controversial experiments in history solve the problem?

BLAIR FRASER

THE EASTERN HALF OF THE GLOBEs another on-the-spot report by BLAIR FRASER

NEW DELHI

FEW WORLD problems are so important, and none so violently controversial, as the problem of population—the explosive growth of countries that already live on the brink of famine. Recently two nations of Asia—India and Japan— have launched experimental programs to find a lution to it.

"heir projects differ greatly in size, scope and ^thod, but they have a common objective unique '} human history the control of population as deliberate government policy. So far, the results of their experiments are about equally disconcerting to advocates and opponents of artificial birth control.

Both countries can feel the urgency of the problem. Japan has eighty-eight million people crammed into islands that barely supported seventy million

before the war, and two million more babies are born each year. In India the live births are ten million a year, and the death rate is falling—as public health measures take effect India may add as many every two years as the whole population of Canada.

All Asia is in the same boat. About forty million babies are born each year among Asia’s billion people. And the continent is already crammed to the extreme edge of subsistence —165 people to a square mile, compared to fifty in the U. S. and only four in all of Canada. In many fertile areas Asia has a thousand people to the square mile, not only in crowded cities but on farms of pockethandkerchief size.

Most of free Asia already has ambitious projects to feed the new mouths by increasing production,

but no country predicts with confidence that production can keep pace with population. All are wondering what else can be done; Japan and India have tried to find out.

They have been trying for some time—Japan for more than five years, India for more than two. Neither has yet produced a positive answer. They have proved only one thing beyond challenge: the problem isn’t simple.

Japan and India have shown that in the countries where population outruns production by the widest margin birth control by any method now known is difficult and costly. They have shown that merely permissive legislation, or lifting the laws against it, will not be enough. Only with allout government support, if then, can artificial curbs reduce the natural increase rate that now swamps Asia.

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India’s experiment was small tmt of special interest. It tested the so-called “rhythm method” based on the menstrual cycle, a calculated division of the month into “safe days” and “baby days.” This is the only method of birth control that has received the reluctant and qualified sanction of the Roman Catholic Church.

For Asia the rhythm method offered two great advantages over all others: It needs no expensive apparatus and it breaks no religious taboo, either eastern or western. Unhappily, to judge by the Indian experience, it has an even greater disadvantage: It doesn’t work.

India’s two little pilot studies, one rural and one urban, were carried on for two years. Altogether 2,362 couples were canvassed, and about threequarters—1,709—said they’d like to learn a way of limiting their families.

Rut in the end only ten percent of the willing-to-learn couples, 172 to be exact, did learn and follow the rhythm method. Nine out of ten couldn’t learn it for one reason or another. Some wives were already pregnant and had no menstrual cycle to be charted; with others the cycle was too irregular from month to month. Many had no cycle because they were continually either pregnant or nursing babies, from puberty to the menopause. Some who said they wanted to learn changed their minds—their husbands or their mothers-in-law objected, or the neighbors were making fun of them.

All sorts of obstacles cropped up, some expected and some unexpected.

It was known, of course, that rural women would be illiterate (some couldn’t even count to one hundred, though all could count to thirty and all knew the days of the week, though not the months of the year). In lieu of calendars, illiterate women were supplied with strings of beads to keep track of the days. A single red bead marked the expected date of the next menstruation; ahead of it were green beads for the “safe days,” black beads for the “baby days.”

“A major teaching problem,” says the Indian final report, “was to convince each woman that merely moving the beads daily did not protect her from a pregnancy.”

A Disastrous Blow to Morale

Even of the ten percent who did learn more than half followed instructions only intermittently. A scant sixty-six out of 2,362 said they followed the rhythm method faithfully throughout—and nine of these got pregnant anyway.

Whenever that happened, whether by failure of the method or failure of a couple to stick to it, the effect on morale was disastrous. One field worker in the rural project reported vividly the result when one of her instructed couples “suddenly slipped,” as she put it:

“The news spread like wildfire through the village that the woman who was pushing the beads was pregnant, and so what the Family Planning worker had done has failed. Could anything be more annoying to the worker? Wherever she went the same questions were asked:

“ ‘You gave the beads to So-and-so, is it not?’

“ ‘Yes.’

“ ‘How is it she became pregnant even though she was pushing the beads? We told you in the beginning you are not gods that you can stop having more children. All is nature, and God’s will.’ ”

Japan’s birth rates have fallen steadily but the major reason isn't birth control

This reaction to any failure of an officially sponsored method is relevant to another aspect of the birth control problem, its cost.

Even the rhythm-method projects were not cheap. They called for no outlay on materials, but they did require ¿rained personnel. The rural study employed a total of fifty people altogether in its two years, and never fewer than ten workers engaged at full time. The urban study was easier— its clients all lived in one suburb of New Delhi, and they were far more sophisticated. About a third were already using some contraceptive device. Nevertheless, even the urban project required a staff of nine, including a doctor, a graduate nurse and five trained social workers.

Other birth-control methods, which also have to be taught, need supplies as well At present about eighty clinics in Indian cities are giving information on family planning to an average of 250 people per clinic per year, but in most of them the materials used are sold at cost. For a poor population the cost is too high. Indian clinics report that only ten percent of their meagre clientele can afford it.

True, some known methods are cheap. One favored in Pakistan costs only four annas (eight cents) per family. Hut even its advocates admit that it’s only forty percent effective—it works less than half the time.

Theoretically, it can be argued that forty percent efficiency is better than nothing. In practice, any failure of a government-approved method deals a major blow to birth-control propaganda. All contraceptives are a nuisance and likely to be viewed with suspicion and resentment by the people. When they don’t work, suspicions are confirmed.

India’s study of the rhythm method showed how violent and deep this public indignation can become. To some villagers the “magic” of the beads appeared as not merely futile, but sinister.

“You roam about in the sun writing and writing,” one villager complained to a field worker. “Because you people write so much, the rains have stopped and there is famine and shortage.”

All in all the Indian experiments bear out the glum conclusion of a recent Rockefeller Foundation report:

“The main difficulty is that there is no single contraceptive method likely to prove of any substantial importance to the peasant population of Asia’s mainland. Any such method must be cheap, simple, safe and effective. So far as we know, such a method neither exists nor is on the horizon.”

Even more disconcerting, in a way, has been Japan’s experience in the last six years. Japan has not yet launched an all-out official program of birth control, but the Japanese Government has gone farther than any other in the world. So far, the results are distressing.

Japan offered half a dozen unique advantages to a birth-control campaign. First, there is no religious obstacle, as there is in Roman Catholic, Moslem, Buddhist and Hindu countries. Even Communist countries have dogmatic scruples of a kind, since Karl Marx said Malthus’ population theories were wrong. (“Better living meant a

higher birth rate which meant lower living standards,” said Malthus. “Schoolboyish, superficial plagiarism,” said Marx.) Japan has no such prejudice.

Also, there is in Japan a real and widespread awareness that population pressure is an urgent, desperate problem. Even the humblest peasant has been brought face to face with it in his own life. U. S. occupation authorities abolished the old Japanese custom of primogeniture, by which the family farm was entailed to the eldest son. Now the peasant is supposed to divide his tiny plot of land among several sons, and so he knows how impossible it is.

Moreover, Japan’s is not a “peasant” population in the sense or to the extent that India’s or Pakistan’s or China’s is. Japan has a high literacy level for Asia. The great dailies of Tokyo, which circulate a total of about ten million copies a day, have been beating their drums for birth control for more than five years. Editorials, women’s-page articles and advertisements plug family planning day in and day out. And the Japanese are a docile people, susceptible to propaganda and accustomed to doing as they’re told.

The Mother’s Health Counts

Government action has encouraged and even endorsed the press campaign.

Japan repealed all laws against birth control even before the U. S. occupation ended. In April 1948, a Pharmaceutical Affairs Law permitted the manufacture, sale and open advertisement of contraceptives which met certain specifications.

A year later came the Eugenics Protection Law. It has been amended several times since, always in the direction of greater leniency, and it now authorizes:

1. Sterilization of any mother “who has already had several children and whose health is likely to be remarkably weakened by each occasion of delivery.”

2. Abortion “if the continuance of pregnancy or the delivery is feared remarkably to injure the health of mother, owing to her physical or financial condition.”

3. “Popularization and guidance of proper methods concerning contraception” by an official Eugenic Protection Consultation Office. The Government also set up an Institute of Population Problems in the Welfare Ministry, and encouraged several private bodies of similar kind.

It’s now evident, after five years, that the Japanese birth rate has been lowered not by contraception, but by abortion.

Birth rates have dropped, all right. In 1947 Japan had 34 live births per thousand of population. In 1953 births per thousand were 21.4 — lower than the U. S., almost as low as the British.

But Japanese demographers say the decline is wholly accounted for by two factors. One is the natural drop from the artificial peak caused by the sudden return of millions of servicemen after the war. The other is an appalling rise in induced abortions.

In 1949, when the Eugenics Protection Law first removed the harsh penalties previously imposed for abortion, 246,000 “suspended pregnancies” were recorded. In 1953 there were 1,067,093. If the same increase took place last year as in each of the previous five the 1954 total will have been about 1,200,000.

Those are the legal, registered aborSince 1950 the sterilization of women has tripled. Many doctors advocate it

tions. Tokyo officials believe these are no more than half of all abortions. Many are unregistered—some because they’re illegal, even by the lax terms of the Eugenics Protection Law; some because doctors are too busy to make out official forms on all occasions.

If this guess is correct the induced abortions in Japan today are about equal to the number of live births.

No one is sure, of course, just why the abortion rate has so rocketed in six years, but several reasons are suggested. One is the torrent of misleading advertisements by manufacturers of Japanese contraceptives. Newspapers, billboards, tram-car cards in Japan carry ads like this:

“Have you enough children in your family? Use Sampoon—every package approved by Japanese Government test. Proven 98% effective.”

This ad is not false. Sampoon is a chemical suppository which is tested to conform with Government specifications. State clinics find it is effective (maybe not 98%, but effective enough) provided it is used with strict attention to the directions in fine print. But when it is sold over the counter without any instructions, it isn’t used with the necessary care and it doesn’t work so well. And other products, just as flamboyantly advertised, proved even less reliable.

“It was only to be expected that unwanted pregnancies would result,” said Ayanori Okazaki, director of the Population Problems Research Institute, in a recent report on the subject. “That was precisely what happened. But a means to deal with this problem was already available under the Eugenic Protection Law of 1948.”

Another reason for the mounting rate of abortion is an ironic one. Far from preventing or discouraging conceptions, the usual abortion technique actually increases fertility. It is, in fact, the standard operation in almost all countries to correct sterility in women — the operation popularly known as “d.&c.,” dilation and curetage. Japanese women are now demonstrating just how effective it is for that purpose. Many are coming back to Japanese clinics and hospitals for two, three, four and in a few cases even six abortions in a single year.

To a layman it seems obvious that this must be having a shocking effect on the health of Japanese women. A hospital in Tokyo will average five to ten abortions a day; no beds are available for such a minor operation, so the patient must go home immediately. There is no indication of a high mortality rate, but there is evidence that the women feel pretty miserable. A recent survey by the Welfare Ministry found that forty-six percent of women felt chronically ill after a first abortion, and fifty-one percent after a second.

Japanese doctors say that “women exaggerate.” They see no bad effect on public health. Many ask why the Government bothers to put out birthcontrol propaganda when “we are becoming so proficient” at abortion.

It is hard to avoid the suspicion that these doctors look on abortion as a stable and easy source of income. The fee is small—anywhere from three to ten dollars—but earning it takes little time or effort.

A recent trend, according to Welfare Ministry officials, is that doctors are advocating outright sterilization for women who have had several abortions. The argument runs like this: “Women

who are competent to use contraceptives are doing so already. Now we have to sterilize the rest.” The Welfare Ministry is sardonically aware that sterility operations mean fees for surgeons, while birth-control methods do not.

In fact, sterilizations have already tripled since the Eugenic Protection Law came into force. There were 11,000 in 1950 and 33,000 in 1953. According to Welfare officials, more and more young women are being sterilized nowadays.

Nationwide, the Japanese have amply proved that merely permissive laws are not enough to make birth control effective. However, they have also run half a dozen pilot projects that indicate the thing can be done. Given enough effort and enough money, a quick reduction in the birth rate is possible.

Japan’s experiment in all-out birthcontrol campaigns has been conducted in a range of typical communities—a mining town, an industrial city, a fishing village, two farm communities with different levels of education and customs, and finally a slum ward of Tokyo. Figures aren’t complete—the projects were started at different times, and none has gone for more than three years—but they show that birth rates can be cut by a third in two years.

Too Shy to Go to a Clinic

The campaigns use every resource, private and public. Big employers set their personnel departments to work boosting “planned parenthood.” Trade unions are persuaded the idea is good for workers and then recruited to encourage it. Women’s committees are organized, and those already formed for other reasons are called into service. Meetings may be held to give a course in cookery or a lecture series on dressmaking. Before the meeting ends someone puts in a word for family planning.

Clinics were already available (there are 800 in Japan) but they weren’t allowed to sit and wait for customers. Experience had already shown that most Japanese wives are too shy to visit a clinic and accept contraceptives, even free of charge.

Each clinic was staffed with three doctors from the Public Health Institute and three visiting nurses. One community hired twenty midwives, having first learned by experience that wives pay more attention to these middle-aged women than to young unmarried nurses, and sent them out on door-to-door canvass.

I asked a Welfare Ministry official what methods were taught.

“All methods,” he said. “After three years we still can’t decide on any single one as the best. Conditions are different in each home - so we give instruction in them all.

“Privacy is a big problem. We find that in eighty percent of rural homes in Japan husband and wife share the bedroom with their children or their parents or both. A method that might be best in a private bedroom would be no use there.

“We teach the rhythm method, too.

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We find it doesn’t work very well by itself—theoretically it’s completely effective, but in practice people won’t stick to it. However, it’s helpful in conjunction with other methods.”

Materials for all known methods of birth control are supplied free. This is expensive, but the realistic Japanese argue it’s cheaper than raising more mouths than the country can feed. This is easier to demonstrate in Japan than in most countries, because Japanese wage scales include a family-allowance system—the more children a man has, the more he earns. One employer was induced to spend three million yen on a birth-control campaign and found he saved it all in family allowances. Since the family allowance is less than it costs to rear a child the trade union was persuaded to support the plan too.

But these pilot projects, while they show what can be done with an all-out campaign, also point up the obstacles to such campaigns in every country.

Even in Japan, where no religious impediment exists, politicians have been wary of open support for birth control. When the powerful Japanese Wives Association formed a special committee last fall to encourage population control, it entitled itself the “Bettering Daily Life Committee.”

“Our politicians are thinking in terms of winning elections,” a Tokyo civil servant said, “and they thought birth control would be unpopular. They used to pretend, for example, that the Eugenics Protection Law was solely designed to protect mother’s health.”

Only within the last few months have Japanese politicians changed their way of talking and now, for the first time, speak openly of limiting population. The Minister of Welfare has asked the Finance Department for $150,000 a year to provide, free of charge, contraceptive devices to the 700,000 families drawing unemployment relief in Japan.

If inhibitions exist in Japan, you can. imagine how strong they are in other countries.

In Buddhist Ceylon, for instance, leaders among the clergy have conceded that to prevent conception is not a violation of Buddha’s injunction against taking life—but the bulk of the priests do not accept this doctrine. Most of them oppose all methods of limiting population, except the monastic one of complete continence. A recent enquiry among eighty-six Buddhist priests in Ceylon showed that the lower their level of education, the stronger their belief that any prevention of birth was equivalent to killing.

In India, $1,500,000 has been voted by the federal Government as a fund for state projects in birth control, but the program is opposed by the cabinet minister responsible for carrying it out. The Minister of Health, Rajkumari Amrit Kaur, is a devout spinster who was a disciple of Gandhi. She reluctantly agreed to the pilot studies in the rhythm method, but she regards all other birth-control methods as wicked.

In Moslem Indonesia, an article on birth control by a woman doctor last year raised such a storm the vicepresident had to intervene to protect her. In Pakistan, though the government is giving lukewarm support to family-planning clinics, officials admit that “there is very great prejudice for religious reasons” against it, and that the government cannot give it enough backing to make much difference in the birth rate.

As for western countries, their own population pressures can still be alleviated by migration, and their politicians hive no wish to annoy the Roman Catholic vote. So great is their caution that United Nations agencies such as

the World Health Organization do not dare take part in schemes to limit population, lest their funds be cut off by agitation in the contributing countries.

Meanwhile, time is running out. It’s already too late to prevent a vast increase in Asia’s billion people.

Japan, for example, where the birth rate has already dropped and where more than a quarter of all married couples practice contraception, is nevertheless headed for a population peak of 110 millions before there can be much hope of a downturn. The reason is that although the birth rate may go

down, the number of fertile women will be twenty-seven percent greater by 1968 as the little girls grow up who are already born.

There are some signs of awareness among Roman Catholics that it is not enough simply to condemn birth control and suggest no alternative. In a recent article in the Jesuit monthly Relations Rev. Robert J. Ballon, S.J., a former missionary in Japan, summarized the Catholic dilemma.

In western countries, he said, the argument for contraception “springs from a hedonism of the crudest sort,”

but in Japan it is different. There, “the reasons invoked are of the primary order of subsistence and minimum employment.” Even in Japan, the Roman Catholic Church must “demand of everyone, pagan or Catholic, obedience to the Creator”—but it is “a heroic obedience, in present circumstances.” Father Ballon went on: “No Catholic can in conscience condone a state of affairs that makes impossible or even heroic the carrying out of God’s will.” But even Father Ballon had no concrete suggestion of what, if anything, can be done about it. Ac