Health Policy and Ethics Forum: The Population Debate

Editors Note: Public Health Nihilism Revisited

Ronald Bayer, PhD
There is a great tradition in public health that seeks to locate patterns of morbidity and mortality within the broad socioeconomic context that defines peoples lives. From this perspective, the ultimate causes of human suffering and premature death are poverty and inequality. A disregard for fundamental human rights contributes to the mix of pathogenic conditions and increasingly is being addressed in public health research. If these factors account for disease and death, then improvements in health status can only come with the amelioration, if not the radical transformation, of adverse social conditions. Thomas McKeown was a noted proponent of this thesis. He demonstrated that the decline in tuberculosis was the result not of narrowly defined public health interventions such as quarantine, nor of the discovery of antibiotic therapy at the end of the 1940s, but of the impact of improved nutritional status dating from early in the 20th century. Some years ago I termed this perspective public health nihilism, because it suggests that public health officials can do little or nothing to change the prevailing patterns of morbidity and mortality in the absence of social change. Since public health officials rarely wield the requisite instruments of power, they can only fulfill their mission as advocates for social transformation. I believe in social equality and human rights. Quaint as it may seem in a world dominated by markets, I am deeply committed to the values of social democracy. Nevertheless, I have always found the nihilist thesis to be a gross overstatement. Although I am acutely concerned about the ways in which social deprivation fuels patterns of drug use, I am an advocate of needle exchange programs to help prevent the spread of HIV infection. I believe that lives can be saved even if we fail to address the unyielding social factors that contribute to intravenous drug use. In the mid-1990s, the resurgent pattern of tuberculosis was brought to an end not because poverty had vanished, but because the public health infrastructure had been sufficiently enhanced to make possible more effective treatment of the disease. I decided to revisit the public health nihilist argument by examining a debate that had seized the world of population policy. Are major achievements in population health possible through improved access to family planning services? How are these achievements to be defined? Or do sustainable strides require fundamental changes in the status of women? The fervent antagonism over the relative merits of programmatic intervention vs social change has mellowed, allowing thoughtful reflection on the debate itself. The policy analyses by Sinding and Germain and the overview by Rosenfield in this issue of the Journal advance our understanding of the historical basis for and future challenges in the great population debate.
The author is with the Mailman School of Public Health, Columbia University, New York, NY. Requests for reprints should be sent to Ronald Bayer, PhD, 600 W 168th St, Seventh Floor, New York, NY 10032 (e-mail: rb8@columbia.edu). This note was accepted September 19, 2000.

After Cairo: Womens Reproductive and Sexual Health, Rights, and Empowerment
Allan G. Rosenfield, MD
This issue of the Journal contains 2 important contributions to the extensive discussions that have taken place before and after the landmark International Conference on Population and Development (ICPD) held in Cairo in 1994.1,2 Both authors have been deeply involved in this field for more than 20 years, and both have contributed significantly to the dialogue before, during, and since the conference. Adrienne Germain spent many years working abroad in the population and development fields, particularly in the Indian sub1838 American Journal of Public Health

continent, serving in increasingly senior positions with the Ford Foundation. After returning to the United States, together with Joan Dunlop, she helped establish the International Womens Health Coalition (IWHC), which became one of the most active and influential US-based nongovernmental organizations focused on international issues in this field. With significant funding from the Ford and MacArthur foundations, the IWHC played a very important role in helping to galvanize the womens movement worldwide in the years prior to the Cairo conference.

As a member of the US delegation to the ICPD, Germain played a seminal role in the quiet but effective efforts of the delegation. Today she is president of the IWHC, and she is uniquely qualified to comment about the events
The author is with the Mailman School of Public Health, Columbia University, New York, NY. Requests for reprints should be sent to Allan Rosenfield, MD, Mailman School of Public Health, 722 W 168th St, New York, NY 10032 (e-mail: ar32@columbia.edu). This editorial was accepted August 15, 2000.

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and progress that have taken place in the years since the ICPD and to look to the future. Steven Sinding also has had a long and distinguished international career in the population and development fields. Early in his career, he served as a population officer with the US Agency for International Development (USAID) in the Philippines and in Pakistan. He also served as mission director of USAIDs Office of Population; as director of the USAID mission in Kenya, the agencys largest overseas mission at the time; as senior advisor for population at the World Bank; and, most recently, as the director of the Rockefeller Foundations outstanding Population Sciences Department. Prior to the ICPD, Sinding was the senior author of a significant paper that suggested a common ground to bring together the womens movement and those who support population programs for demographic reasons.3 He attended the ICPD as a highly effective member of the US delegation and one of the most respected leaders in the field. Currently he is a professor at Columbias Mailman School of Public Health, where he is conducting a comprehensive 3-year study to help guide the future of US foreign development assistance. Both Germains editorial and Sindings commentary present illuminating perspectives on the range of issues that have developed over the years, albeit with somewhat different conclusions. As Sinding says, Few subjects have engendered more heated debate . . . than population growth.1 He presents a comprehensive discussion of the debates about whether population growth is a problem and, if so, what should be done about it. Germain discusses how the new expanded agenda, focused specifically on the health and well-being of women, developed and where we are in its implementation 6 years after the ICPD. More attention to the issues of reproductive and sexual rights as basic human rights would have been desirable, although clearly these issues are central to Germains own work and that of IWHC. I think it is fair to state that between the late 1960s and the early 1990s national family planning programs became one of the major public health successes of the 20th century, ranking with the eradication of smallpox, the polio campaign, and other major achievements in immunization. This clearly is a strong statement, subject to debate. Neither the more recent focus on womens reproductive and sexual health and rights nor the fact that much of this success came about because the effort was led, as Germain states, by those concerned about population growth2 diminishes the significance of what took place during those years. Having had the opportunity to work in Thailand during the formative years of the countrys hugely successful national family planning program (19671973), I was able to
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witness the impact of a program focused on providing widespread access to a full array of contraceptive services.4 In 1967, less than 5% of the population was using contraception, and Thai women had, on average, 6 or 7 children by the end of their reproductive years. Today, close to 70% of women of reproductive age (or their partners) are using some form of modern contraception, and completed family size is 2 or 3 children. This is a truly dramatic change in a relatively short period of time, a degree of change that none of those who were involved at the beginning would have predicted. Similarly, as Germain notes, contraceptive prevalence levels throughout the developing world have risen during this period from the same low levels as existed in Thailand in the 1960s to a level of 55% or higher today.2 Thus, the efforts of those involved in developing national population and family planning policies and programs were helping to meet the desires of women in cultures throughout the world. Not all programs were perfect by any means; some countries set inappropriate targets for acceptors, and in some places unacceptable levels of coercion were used to reach these targets. Further, as others have pointed out, the quality of services was often far less than desired. But innovative approaches were developed that have had a significant impact not only on family planning programs but also on many other primary health care efforts. The creative use of varying levels of health workers to provide services, the development of community-based programs, and the effective use of social marketing approaches have had impacts well beyond family planning. These programs have made a difference in womens lives, freeing them from frequent, unwanted pregnancies. Some have described the impact of oral contraceptives in the United States as one of the most important liberating forces in the 20th century. Despite these successes, there has been much criticism that population and family planning programs are vertical programs that have a demographic rationale rather than one focused on the health and well-being of women per se. Whereas those who work in such vertical programs as smallpox eradication, malaria control, and HIV/AIDS prevention have never been embarrassed to be called specialists in those areas, professionals in the population and family planning fields have been called population controllers or family planners, both names with a negative connotation. While not all workers in this fieldor for that matter, in any fieldalways have the best of motives, the vast majority are committed to humanitarian goals, fully believing that the programs in which they are involved are providing muchneeded services to underserved people. I believe it is also fair to say that much remains to

be done to provide these services in many of the poorer countries in sub-Saharan Africa and parts of South Asia. This said, the paradigm developed in the years leading up to the ICPD, and so clearly enunciated in the resultant Programme of Action, moves the field in a direction that has tremendous significance worldwide. For the first time, gender equality and the overall status of women are given the highest priority. The empowerment of women was the underlying theme of the Cairo conference, as it was in the subsequent Beijing meeting on women. Such empowerment is not the task solely of those working in the fields of population and family planning, or of health more generally, but of all sectors of society. Similarly, the focus on the adverse effects on women of poverty, inadequate education, and low social status have elevated the discourse significantly. More specifically, the new agenda focuses on the reproductive and sexual health and rights of all women. In addition to the broad goals of empowerment, this agenda stresses the following: that the need for contraception be met so that women can have the number of children they wish, when they wish to have them; that the needs of young adolescents be met in appropriate, nonjudgmental ways; that the high rates of sexually transmitted diseases, including HIV/AIDS, be given high priority in the development of programs; that prenatal care services be developed to reduce pregnancyrelated mortality (with the annual number of deaths reaching 600000) and morbidity (affecting millions of women each year); that women have access to safe services to terminate unwanted and unplanned pregnancies, and access to treatment of botched abortions in those settings where abortion remains illegal; that womens sexuality be better understood; and, finally, that attention be given to the tragedy of violence against women in its many forms. It would be inappropriate in this discussion not to mention specifically the tragedy of the HIV/AIDS epidemic, particularly as it affects poor countries throughout the world. This modern plague is spreading at rates that are unprecedented. What we are seeing now in large parts of sub-Saharan Africa is beginning to be seen in Asia, especially the Indian subcontinent, and will soon be seen in China. In some African countries, as much as 25% of the population is infected, with most of these infections occurring among people between the ages of 15 and 45 years. The costly medications now in use in the West are not available in these countries, and the development of effective vaccines is still well in the future. Once again, we see the consequences of the inequities between wealthy and poor nations. Through relatively massive research exAmerican Journal of Public Health 1839

penditures leading to a range of new drugs, HIV/AIDS has become, to a certain extent, a chronic disease in the United States and Europe. In poor countries, the disease remains almost uniformly fatal; this situation was a topic of great debate and discussion at the recent international AIDS meeting in Durban, South Africa. Both Uganda and Thailand have demonstrated that HIV/AIDS transmission rates can be decreased by effective public education campaigns promoting safe sexual practices, the widespread distribution of condoms (both male and female), and the use of clean needles by drug users. In both countries, strong commitment by the political leadership, starting with the president or prime minister, has been essential, along with involvement of all relevant governmental ministries and the private sector. The ICPD presented a broad and costly agenda, and if there was a failing in Cairo and Beijing, it was that inadequate attention was given to the costs of implementing this

agenda. Data were available to suggest the level of expenditures needed to provide contraceptives to the growing numbers of women entering reproductive age, but estimates for the rest of the agenda were not well developed and many of the needed data were not readily available. In addition, the fiscal commitments made by both developed and developing countries at Cairo have not come close to being met in the 6 years since the meeting. The 1994 elections in the United States resulted in a new Congress that was basically opposed to the goals set for US assistance in this area. This opposition resulted in cuts and restrictions in funding at a time when a significant increase had been anticipated. The expected funding levels projected for many other countries also have not been reached. The effective implementation of all that was put forward at both the Cairo and Beijing meetings will continue to elude us until governments throughout the world reallocate re-

sources to ensure the full funding of the comprehensive social agenda established at these landmark meetings. None of the specific goals described above are beyond the possible; however, they do require true commitment on the part of both the public and the private sectors. A move away from excessive military expenditures worldwide would be a most important first step.

References
1. Sinding SW. The great population debates: how relevant are they for the 21st century? Am J Public Health. 2000;90:18411845 2. Germain A. Population and reproductive health: where do we go next? Am J Public Health. 2000; 90:18451847. 3. Sinding SW, Ross JA, Rosenfield A. Seeking common ground: unmet needs and demographic goals. Int Fam Plann Perspect. 1994, 20:2327. 4. Rosenfield A, Bennett A, Varakamin S, Lauro D. Thailands family planning program: an Asian success story. Int Fam Plann Perspect. 1982,8(2):43.

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