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From 'left' to 'right' : a perspective on the role of the volunteers in family planning in the west and… Bishop, Mary F. 1971

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PROM "LEFT" TO "RIGHT": A P e r s p e c t i v e on the Role of the Volunteers i n Family Planning i n the West and i n South A s i a by Mary F. Bishop B.A., Queen's U n i v e r s i t y , 1935 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF Master of A r t s i n the Department of H i s t o r y We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA MAY 1971 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h C olumbia, I a g r e e t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and Study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u rposes may be g r a n t e d by the Head o f my Department or by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g or p u b l i c a t i o n o f t h i s thes,is f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f History The U n i v e r s i t y o f B r i t i s h Columbia Vancouver 8, Canada 2., 6. 71 Date ABSTRACT This thesis i s an examination of the role of the volunteers i n the development of family planning programs in the West and South Asia, and of whether they have a continuing role to play* Through personal experience, interviews and correspondence with some of the leaders, through reports, other readings, and studies of motivation and the provision of family planning services, the writer concludes that the volunteers played an indispensable part. Governments would not have introduced family planning programs i f voluntary organizations had not shown that they were needed and feasible. The volunteers laid the groundwork not only for o f f i c i a l programs but for a variety of careers i n family planning and related f i e l d s . They have a continuing role to play as friendly c r i t i c s ^ n promotion, education, and innovative research, and to , make sure that birth control, once considered to be far to the "Left", becomes firmly entrenched as a Human "Right**, TABLE OP CONTENTS Page ABSTRACT i NOTES ON TERMINOLOGY i i i LIST OP ABBREVIATIONS v i LIST OP TABLES v i i LIST OP ILLUSTRATIONS v i i i PREFACE i x PART ONE I n t r o d u c t i o n Family Planning Was Not New 1 Chapter I The S o c i a l Reformers: United Kingdom . . . 20 Chapter I I The S o c i a l Reformers: United States of America 45 Chapter I I I Some Developments i n Europe and East A s i a 65 PART TWO Chapter IV I n t e r n a t i o n a l Cross F e r t i l i z a t i o n . . . . 79 PART THREE S o c i a l Reformers and Government i n South A s i a Chapter V I n d i a 100 Chapter VI Ceylon I67 Chapter V I I P a k i s t a n 205 Chapter V I I I Nepal 243 PART FOUR Chapter IX Conclusions 252 B i b l i o g r a p h y 263 Appendices 274 NOTES ON TERMINOLOGY "When I_ use a word," Humpty Dumpty s a i d , i n rather a s c o r n f u l tone, " i t means j u s t what I choose i t to mean - n e i t h e r more nor l e s s . " l As i n other f i e l d s , communication i n " f a m i l y planning i s sometimes d i f f i c u l t . Depending on a t t i t u d e and degree of involvement, terms mean d i f f e r e n t t h i n g s to d i f f e r e n t people For example, " B i r t h c o n t r o l " can mean methods of preventing "births or may conjure up ideas of the emancipation of women or racism. "Family planning" can mean spacing or l i m i t i n g preg-nancies, the treatment of i n f e r t i l i t y , or some s o r t of budgeting of f a m i l y income. " S t e r i l i z a t i o n " may mean the simple, v o l u n t a r y o p e r a t i o n on a man or woman which gives permanent freedom from the f e a r of unwanted pregnancy without i m p a i r i n g sexual performance; or i t may arouse images of experiments i n Na z i concentration camps, c a s t r a t i o n and the st a t e of being "no longer a man" or "no longer a woman". "Abortion" may mean a m e d i c a l l y s a f e , l e g a l , back-up procedure f o r ignorance, rape, or contraceptive f a i l u r e ; or i t may mean a forbidden s o l u t i o n , born of v i c e , c a r r i e d out by a c r i m i n a l , i n which death i s a p o s s i b l e consequence, and the p r i o r r i g h t s of the foetus are i n c o n t r o v e r t i b l e . "Population c o n t r o l " or "population p l a n n i n g " may mean a vol u n t a r y or compulsory f a m i l y planning program w i t h humanitarian i n t e n t , or genocide. H i s t o r i c a l l y , f a m i l y planning terminology evolved i n response to p u b l i c a t t i t u d e s . In the nineteenth century i n d i v i d u a l advocates of s o c i a l reform throtigh b i r t h c o n t r o l e u p h e m i s t i c a l l y c a l l e d c o n t r a c e p t i v e s "preventive checks". L a t e r , when they formed a vo l u n t a r y o r g a n i z a t i o n they c a l l e d i t a "Malthusian league" - even though Malthus opposed "preventive checks", and regarded continence outside marriage as the only acceptable means of c o n t r o l l i n g f e r t i l i t y . In 1914 Margaret Sanger and a group of supporters i n Hew York coined the term " B i r t h C o n t r o l " to symbolize a "wanted c h i l d " and the emancipation of women from the "enslavement of motherhood". In the United Kingdom, i n 1921, to o f f s e t c r i t -i c i s m , Marie Stopes invented "Constructive B i r t h C o n t r o l " . A l e s s f e m i n i s t , but a l s o defensive term, r e l a t e d to general concern over low b i r t h r a t e s i n Europe and North America i n the 1930s, l e d to the adoption i n B r i t a i n i n 1939 of "Family P l a n n i n g " and, i n the United States of America, i n 19^2, of "Planned Parenthood". Both terms were intended to i d e n t i f y the movement more c l o s e l y w i t h the i d e a of f a m i l y w e l l - b e i n g and freedom of choice; but n e i t h e r has ever meant u n l i m i t e d c h i l d - b e a r i n g , as i m p l i e d i n recent c r i t i c i s m s . To-day, "Family P l a n n i n g " i s a l s o the popular term f o r v o l u n t a r y government programs. " B i r t h c o n t r o l " , "Family P l a n n i n g " , and "Population C o n t r o l " i n d i c a t e a l s o the s h i f t s i n o r i e n t a t i o n of the move-ment, over the years and as circumstances allowed - from i n d i v i d u a l t o f a m i l y , to n a t i o n a l , and i n t e r n a t i o n a l w e l l -b e i n g . A few people d i s t i n g u i s h between "Family P l a n n i n g " and "Population C o n t r o l " as a p r i v a t e , v i s - a - v i s a p u b l i c program, but no country has o f f i c i a l l y adopted the l a t t e r d e s i g n a t i o n . Compulsion i s not contemplated - f o r the present, at l e a s t . Depending on the p o l i c y of the o r g a n i z a t i o n or govern-ment, " B i r t h C o n t r o l " can mean mechanical, chemi'cal and b i o l o g i c a l methods of preventing conception, or i t can a l s o embrace s t e r i l i z a t i o n and l e g a l l y induced a b o r t i o n . Like t h e ' f a m i l y planners", I s h a l l t r y to use the terms " b i r t h c o n t r o l " , " f a m i l y planning", "planned parenthood" and "population c o n t r o l " i n t h e i r permissive and interchangeable connotations; and t h a t , as Humpty Dumpty s a i d , i s what I choose i t to mean. x L e w i s C a r r o l l , Through the Looking G l a s s , Modern L i b r a r y e d i t i o n , Hew York, c 1935, P« 214. 2 G a r r e t Hardin, " M u l t i p l e Paths to Po p u l a t i o n C o n t r o l , " Family P l a n n i n g P e r s p e c t i v e s , New York, June, 1970, p. 26. LIST OP ABBREVIATIONS AID, - or USAID - United States Agency f o r I n t e r n a t i o n a l Development PPA - Family Planning A s s o c i a t i o n PPAC - Family P l a n n i n g A s s o c i a t i o n of Ceylon FPAI - Family Planning A s s o c i a t i o n of I n d i a FPAN - Family Planning A s s o c i a t i o n of Nepal FPAP - Family Planning A s s o c i a t i o n of P a k i s t a n IPPF - I n t e r n a t i o n a l Planned Parenthood Federation IUCD or IUD - I n t r a u t e r i n e Contraceptive Device LI'S - Lanka Manila S a m i t i (Women's I n s t i t u t e of Ceylon) NMB - Nieuw Malthusiaanschen Bond PP-WP - Planned Parenthood-World P o p u l a t i o n (U.S.A.) SIDA - Swedish I n t e r n a t i o n a l Development Agency WHO - World Health Organization UNESCO - United Nations E d u c a t i o n a l , S c i e n t i f i c and C u l t u r a l O r g a n i z a t i o n TJNICEF - United Nations Children's Emergency Fund LIST OP TABLES Table Page I Data on Indian Government Family Planning Program 152 I I Family Planning Component of N a t i o n a l Budget, I n d i a 157 I I I B i r t h r a t e s per 1000, by "Race", I 9 5 I - I 9 6 I , Ceylon 182 IV Attendance at FPAC C l i n i c s I83 V B i r t h s per 1000 P o p u l a t i o n , Ceylon, A l l Races and Indian Tamil 197 VI Data on Ceylon Government Family Planning Program 199 V I I Attendance at FPAP C l i n i c s , 1964 and I967 . . 223 V I I I Number of Acceptors, P a k i s t a n Government Program, I965-I969 224 IX Data on P a k i s t a n Government Family P l a n n i n g Program 236 X Data on Nepal Government Family Planning Program 247 XI Supplementary Data, South A s i a 274 LIST OP ILLUSTRATIONS Figure Page 1 L i v e B i r t h s i n Some Western Countries 1 7 0 0 - 1 9 5 8 . 6 2 Comparison of Scandinavian and Japanese V i t a l Rates I 8 O O - I 9 6 O 2 7 3 P o p u l a t i o n of I n d i a and P r o j e c t i o n , 1 9 6 5 - 2 0 0 0 1 0 0 4 Po p u l a t i o n of Ceylon and P r o j e c t i o n , 1 9 0 1 - 1 9 9 3 . . . . . . 1 6 7 5 Demographic P a t t e r n s , Ceylon and Sweden, 18-10-1960 1 8 5 6 P o p u l a t i o n of P a k i s t a n and P r o j e c t i o n , 1 9 0 0 - 2 0 0 0 2 0 5 PREFACE Space research and photographs of Earth have helped many people to r e a l i z e t h a t we l i v e on a f i n i t e p l a n e t , w i t h f i n i t e r esources, and l i t t l e choice but to l e a r n to l i v e i n harmony w i t h each other and w i t h our environment. The i n -formation e x p l o s i o n of the past quarter century has a l s o made i t c l e a r t h a t many problems are common to a l l c o u n t r i e s , and, g e n e r a l l y , d i f f e r only i n degree. One u n i v e r s a l challenge i s popu l a t i o n growth and what to do about i t . Before 1800, populations were i n c r e a s i n g i n a l l coun-t r i e s , but the rat e was slowed by death from d i s e a s e , famine and war. In the nineteenth century, however, i n the indus-t r i a l i z i n g c o u n t r i e s of Europe, higher standards of l i v i n g , more p o l i t i c a l s t a b i l i t y , and improving h e a l t h s e r v i c e s brought about a gradual d e c l i n e i n m o r t a l i t y . A population " e x p l o s i o n " would have occurred then, had i t not been f o r emigration to other temperate c l i m a t e s , the growing p r a c t i s e of b i r t h con-t r o l , and economic expansion which was able to absorb most of the remaining growth. At no time d i d the r a t e of popu-l a t i o n i n c rease exceed 1 to 1 . 5 percent per year, and i n the past few decades, f o r example, growth r a t e s have de c l i n e d to around 0 . 5 i n the United Kingdom, 0.8 i n Sweden, 1.0 i n the United States of America, and 1.1 percent i n the Netherlands. (In t h i s century, and f o r s i m i l a r reasons, Japan has al s o f o l l o w e d the same trend to an annual population growth r a t e of 1 . 1 percent.) Thus, the "demographic t r a n s i t i o n " from h i g h b i r t h r a t e s and h i g h deathrates to low b i r t h r a t e s and low deathrates i n the r i c h c o u n t r i e s came about g r a d u a l l y , over a p e r i o d of approximately 1 5 0 years; and, because access to n a t u r a l resources i s s t i l l p o s s i b l e , population growth i s not yet w i d e l y recognized as a t h r e a t (even though, i n s p i t e of the s a f e t y valves mentioned, European stock increased three times at home, and f i v e to seven times abroad). x On the other hand, the t r a n s i t i o n i n the poor c o u n t r i e s of A f r i c a , A s i a and l a t i n America d i d not begin u n t i l a f t e r World War I I . Health measures brought epidemic diseases i n many of them under c o n t r o l , famine r e l i e f became more s o p h i s -t i c a t e d , and, though wars continued to k i l l people, decimation from t h i s cause was not s i g n i f i c a n t i n the o v e r - a l l m o r t a l i t y d e c l i n e . Because the m a j o r i t y were s t i l l engaged i n farming, a g r i c u l t u r a l t r a d i t i o n s p r e v a i l e d , f e r t i l i t y remained h i g h , and population growth r a t e s i n most Asian nations shot upward. In L a t i n America and A f r i c a , though m o r t a l i t y i s higher, popu-l a t i o n growth r a t e s a l s o rose; and now, on the three "developing" c o n t i n e n t s , they range from more than 2 to n e a r l y k percent per y e a r . 2 In a d d i t i o n to growth i n t o t a l numbers, h i g h s u r v i v a l r a t e s have caused imbalance i n the age s t r u c t u r e s of these c o u n t r i e s . Percentages of persons under f i f t e e n years now vary from t h i r t y - f i v e to more than f i f t y , i n c r e a s i n g the demand f o r such b a s i c s e r v i c e s as food, housing, education, h e a l t h , V:-X .., and t r a n s p o r t a t i o n , and d r a i n i n g o f f funds needed f o r other forms of job c r e a t i o n and i n t e r n a t i o n a l t r a d e . Such hig h dependency r a t i o s o b s t r u c t attempts to r a i s e the standard of l i v i n g , and eat up the b e n e f i t s of each hard-won economic advance ? On a world-wide b a s i s , p o p u l a t i o n i s estimated to be more than 3 * 3 b i l l i o n , i n c r e a s i n g at 1 . 9 to 2 percent per year, w i t h approximately 3 7 percent under 1 5 years of age. I f current c o n d i t i o n s p e r s i s t , i t i s expected to double in about 3 5 years, and to reach 1 1 b i l l i o n by 2 0 5 0 A.D. The pr o p o r t i o n of youth i n the world age s t r u c t u r e w i l l i ncrease s t i l l f u r t h e r . Even i f , from now on, a l l couples t r y to r e -s t r i c t f a m i l y s i z e to two c h i l d r e n (replacement l e v e l o n l y ) , s e v e r a l generations w i l l pass before a s t a t i o n a r y population and a balanced age s t r u c t u r e can be achieved. In the mean-time, s o c i a l , economic and p o l i t i c a l problems are sure to m u l t i p l y . In the face of t h i s unpleasant r e a l i t y , there i s grow-in g awareness t h a t economic expansion alone cannot solve the problem, and th a t , growth r a t e s must be brought to zero per year, or even to a d e c l i n e , as soon as p o s s i b l e . ^ But there i s no agreement on the urgency of the problem, or on how to go about a c h i e v i n g a s t a t i o n a r y p o p u l a t i o n . Canadians are only now beginning to consider the question. In the "United S t a t e s , opinions vary. P a u l E r l i c h , a b i o l o g i s t , . claims t h a t zero p o p u l a t i o n growth (ZPG) i s e s s e n t i a l at once, and th a t compulsion may have to be used. G a r r e t t Hardin, a human e c o l o g i s t , a l s o b e l i e v e s that ZPG i s urgent, but i s w i l l i n g to see more e f f o r t put i n t o improving the v o l u n t a r y system before r e s o r t i n g to f o r c e . Prank N o t e s t e i n , a demographer, agrees t h a t the population problem i s c e r t a i n l y urgent, but says i t i s more so i n the developing c o u n t r i e s than i n the ot h e r s . He regards compulsion i n any country as un t h i n k a b l e . He argues t h a t i f b e t t e r i n c e n t i v e s and v o l u n t a r y s e r v i c e s were provided the poor i n a l l c o u n t r i e s , ZPG- would f o l l o w . The d e c l i n e would be gradual enough, however, to be u n l i k e l y 7 to cause panic r e a c t i o n i n favour of increase again.' Jeannie R o s o f f , of Planned Parenthood-World P o p u l a t i o n , views such c r i s i s t h i n k i n g and argument as a waste of time. I t i s known tha t i n a l l co u n t r i e s some people have more c h i l -dren than they want, and t h a t , i n the United S t a t e s , f o r example, twenty to f o r t y percent of pregnancies are unwanted. I t i s al s o known that most people are r e c e p t i v e to the i d e a of f e r t i l i t y l i m i t a t i o n . I f unwanted pregnancies could be prevented, much unhappiness f o r parents and c h i l d r e n a l i k e would be avoided, and the population problem would be eased at the same time. Supporting N o t e s t e i n , Mrs. Rosoff urges gre a t e r e f f o r t to s a t i s f y known demands. B e t t e r v o l u n t a r y programs, b e t t e r methods, .. b e t t e r education, and more opportunity f o r human f u l f i l m e n t are a t t a i n a b l e g o a l s . As a matter of f a c t , forced f e r t i l i t y c o n t r o l i s im-p o s s i b l e . ITo government to-day would r i s k r e v o l u t i o n to t r y i t and, i n any case, the personnel to ca r r y out such a p o l i c y are not a v a i l a b l e . The only s o l u t i o n i n the forseea.ble f u t u r e i s the v o l u n t a r y system, and the o n l y way to make i t r e a l l y e f f e c t i v e i s a combination of s o c i a l change, more a c t i v e l e a d e r s h i p from p u b l i c f i g u r e s , improved methods, and a v a i l -a b i l i t y of b i r t h c o n t r o l . In any plan to persuade people to adopt " f a m i l y p l a n n i n g " , motivation and s e r v i c e s are c r u c i a l . What i n f l u e n c e s people to l i m i t t h e i r f e r t i l i t y ? In 1 9 6 5 Coale l i s t e d the d e c l i n e of m o r t a l i t y , changes i n the economic value of c h i l d r e n i n an urban s o c i e t y , p r o h i b i t i o n of c h i l d l a b o r , higher s t a t u s of women, education, a t t i t u d e s to r e l i g i o n , and the development of s e c u l a r and r a t i o n a l t h i n k i n g as the important f a c t o r s . He a l s o noted that i f n i n e t y percent of c h i l d r e n attended primary s c h o o l , and at l e a s t 5 ° percent of the population was urban-dwelling, de-c l i n e s would take place i n any case. On the other hand, France reduced i t s f e r t i l i t y before any of these f a c t o r s obtained i n that country, but England d i d not f o l l o w s u i t 9 u n t i l most of them e x i s t e d . N o t e s t e i n , K i r k and Segal ac-cepted s i m i l a r categories l e a d i n g to s o c i a l advancement, and added the breakdown of the extended (or j o i n t ) f a m i l y system. But they, t o o , agreed t h a t t h i s i s an o v e r s i m p l i f i c a t i o n of the qu e s t i o n . Berelson suggested t h a t f a m i l y w e l f a r e and educ a t i o n a l o p p o r t u n i t i e s f o r the c h i l d r e n are" key f a c t o r s . In any event, the p r a c t i c e of contraception begins w i t h the "middle c l a s s e s " among whom motivation i s h i g h , and access to i n f o r m a t i o n and means i s r e l a t i v e l y easy. lower income groups l a g behind, e i t h e r because they are not i n t e r e s t e d , are unaware th a t a choice i s p o s s i b l e , or the means to make i t e f f e c t i v e i s not r e a d i l y a c c e s s i b l e . Therefore, i t may he concluded t h a t , even when "birth c o n t r o l i s w i d e l y prac-t i s e d , there i s no u n i v e r s a l p a t t e r n of i n c e n t i v e s . Declines i n f e r t i l i t y occur because i n d i v i d u a l d e c i s i o n s are made f o r personal reasons. I f more s o p h i s t i c a t e d methods are not a v a i l a b l e , the attempt i s made through such f o l k methods as c o i t u s i n t e r r u p t u s (withdrawal or "being c a r e f u l " ) , induced a b o r t i o n or even i n f a n t i c i d e . The i n f l u e n c e of the f a m i l y planners i s another q u e s t i o n . This study w i l l examine the r o l e of the f a m i l y planners i n three s i g n i f i c a n t geographic areas - the i n d u s t r i a l i z e d c o u n t r i e s i n which the movement f i r s t developed; the i n t e r -n a t i o n a l area, i n which i t grew, and South A s i a , the f i r s t modernizing area i n which e i t h e r a v o l u n t a r y or a government program was introd u c e d . Two fundamental aspects - motivation ( l e a d e r s h i p , o p p o s i t i o n , acceptance) and s e r v i c e s (programs and r e s u l t s ) ; and two rough time periods - one long (from 1800 u n t i l World War I I ) , and the other short (from 1945 to the end of the 1960s) - w i l l provide the framework f o r a s h i f t i n image from r a d i c a l " L e f t " to "Human R i g h t " . I have drawn from personal experience as a volunteer i n f a m i l y planning both i n a developing country (Ceylon) and i n Canada, on correspondence and i n t e r v i e w s w i t h some of the leaders of the v o l u n t a r y movement, annual r e p o r t s , conference proceedings, speeches, published and unpublished papers, and supplementary research. I am indebted to Hon. James George, Canadian High Commissioner to I n d i a , and h i s w i f e , C a r o l , f o r i n t r o d u c i n g me, when they were s t a t i o n e d i n Ceylon, to the v o l u n t e e r s : p a r t i c u l a r l y , Mrs. E. C. ( S y l v i a ) Fernando, Honorary Secretary of the Family Planning A s s o c i a t i o n (FPA) of Ceylon and a V i c e -President of the I n t e r n a t i o n a l Planned Parenthood Federation (IPPF); Dr. (Miss) S i v a Chinnatamby, FRCS, FRCOG; and P r o f e s s o r and Mrs. C. C. D e S i l v a . For two years I served w i t h them i n two weekly c l i n i c s (one i n a Colombo s o c i a l s e r v i c e o r g a n i -z a t i o n and the other i n a suburban p u b l i c h o s p i t a l ) and as a member of the Executive Committee of the Family Planning Asso-c i a t i o n . Each has given me much i n f o r m a t i o n , both i n conver-s a t i o n and correspondence. P r o f . C.H.S. Jayewardene, co-author w i t h the l a t e P r o f . O.E.R. Abhayaratne, of F e r t i l i t y  Trends i n Ceylon, sent f u r t h e r i n f o r m a t i o n , and Mr. L.O. D e S i l v a some p o l i t i c a l comment. Miss Ray Blaze' has sent i n f o r m a t i o n on the a t t i t u d e s of other v o l u n t a r y o r g a n i z a t i o n s i n Ceylon. Mr. J.R. McPhail (Colombo) and Mr. Alan langmuir (Vancouver), then of T. Ingledow and A s s o c i a t e s , a l s o sent r e l e v a n t Ceylon government p u b l i c a t i o n s . Mrs. W i l f r e d Graham, Vancouver, k i n d l y s u p p l i e d background i n f o r m a t i o n on her s i s t e r , Dr. Mary Rutnam. Smt. Avabai Wadia, ^ r e s i d e n t of the Family Planning A s s o c i a t i o n of I n d i a , Bombay, sent me numerous published r e p o r t s and p e r i o d i c a l s , as d i d Smt. Dhanvanthi Rama Rau, a l s o of Bombay, founder of the FPA of I n d i a (FPAI), and r e c e n t l y r e t i r e d as P r e s i d e n t of the I n t e r n a t i o n a l Planned Parenthood Fe d e r a t i o n . Dr. Alan B. G i l r o y , P r i n c i p a l of the Ross I n s t i t u t e of T r o p i c a l Hygiene, I n d i a Branch, J o r h a t , sent i n f o r m a t i o n and monthly r e p o r t s of ITJD i n s e r t i o n s and s t e r i l i z a t i o n s i n the program being financed i n Assam and West Bengal by the Indian Tea A s s o c i a t i o n . Dr. Marian B. H a l l , Richmond, B.C., f o r 23 years a medical missionary i n Ajmer, Rajasthan, and, so f a r as I know, the only non-Indian to be a member of the n a t i o n a l c o u n c i l of the FPAI, has allowed me access to her papers. The C h r i s t i a n Medical A s s o c i a t i o n of I n d i a has sent me r e p o r t s , and I have had h e l p f u l conversa-t i o n s w i t h Dr. Robert McClure of Toronto, Dr. David Kennedy of Vernon, B.C., and Mrs. Wendy Marson of Ottawa, who worked i n I n d i a w i t h that o r g a n i z a t i o n . Dean C.F. B e n t l e y , ,of the U n i v e r s i t y of A l b e r t a , passed on i n f o r m a t i o n on I n d i a , i n -c l u d i n g speeches and a r t i c l e s by Dr. S, Chandrasekhar, when M i n i s t e r of State f o r Family P l a n n i n g , I n d i a . Hr. A.M.A. K a b i r , Dacca, Senior V i c e - P r e s i d e n t , FPA of P a k i s t a n , has a l s o been very h e l p f u l . Dr. J.P. Sharma, Pr e s i d e n t of the FPA of Nepal, Kathmandu, and Mrs. Shanti Rana, General S e c r e t a r y , sent i n f o r m a t i o n ; and Dr. (Mrs.) A t t i y a I n a y a t u l l a h , Honorary S e c r e t a r y , Indian Ocean Region, IPPF, Lahore, gave her help as w e l l . Mr. George Cadbury, Chairman of the Governing Body, IPPF, and Mrs. Cadbury, of O a k v i l l e , O n t a r i o , have given me two i n t e r v i e w s , and Mrs. F r a n c i s Dennis, Information O f f i c e r , IPPF, London, deserves s p e c i a l thanks f o r her c o n t i n u i n g a s s i s t a n c e . Thanks are also due to Miss B e r y l S u i t t e r s of the IPPF s t a f f f o r h i s t o r i c a l i n f o r m a t i o n . Miss Cassandra Kent, of the FPA (UK) also sent i n f o r m a t i o n . The Swedish I n t e r n a t i o n a l Development Agency sent me r e p o r t s of SIDA programs i n South A s i a . P r e s i d e n t Emeritus Frank N o t e s t e i n , of the P o p u l a t i o n C o u n c i l and P r i n c e t o n U n i v e r s i t y , took time f o r a conversation i n Vancouver i n November, 1969> and Dr. Nicholas Wright, P o p u l a t i o n C o u n c i l Adviser i n Ceylon, sent i n f o r m a t i o n and comments. Dr. John F r i e s e n , a l s o of the P o p u l a t i o n C o u n c i l , now i n I r a n , sent i n f o r m a t i o n on Muslim a t t i t u d e s to f a m i l y p l a n n i n g . Dr. John E d l e f s e n , P o p u l a t i o n A d v i s e r to the Colombo P l a n Bureau, Colombo, a l s o took time to t a l k to me i n V i c t o r i a , B.C., i n October, 1969. Mr. Richard Gamble, sonc of the l a t e Dr. Clarence Gamble, founder of the P a t h f i n d e r Fund, and pioneer i n f a m i l y planning work i n South A s i a , was a l s o h e l p f u l ; as were two former em-ployees of the Fund, the l a t e Mrs. Margaret F. Roots, of V i c t o r i a , B.C., and Mrs. Edna McKinnon, of Carmel, C a l i f o r n i a . Miss Dorothy Martin and Miss Dorothy Dutton, of the UBC l i b r a r y s t a f f were very h e l p f u l . My s u p e r v i s o r s i n the Departments of H i s t o r y and Anthropology, P r o f s . Peter Harnetty and Michael Ames were p a t i e n t , h e l p f u l and long s u f f e r i n g . To a l l these and any others i n a d v e r t e n t l y omitted, my h e a r t f e l t thanks. Without t h e i r co-operation, t h i s study would not have been p o s s i b l e . FOOTNOTES - Preface •'•Philip M. Hauser, "World P o p u l a t i o n Growth", P h i l i p M. Hauser, ed., The Po p u l a t i o n Dilemma, 2nd ed., Englewood C l i f f s , N.J., 1969, PP. 15-17; Frank W. N o t e s t e i n , Dudley K i r k and Sheldon Segal, "The Problem of Po p u l a t i o n C o n t r o l " , I b i d . , p. 144; 1970 World P o p u l a t i o n Data Sheet, The P o p u l a t i o n Reference Bureau, I n c . , Washington, D.C., A p r i l , 1970. 21970 World P o p u l a t i o n Data Sheet. ^Ansley J . Coale, "Population and Economic Development", Hauser, o p . c i t . , p. 84. ^1970 World P o p u l a t i o n Data Sheet. Also Vancouver Sun. 3 J u l y 1970, c i t i n g AP d i s p a t c h from the United Nations. 5 T . F r e j k a , " R e f l e c t i o n s on the Demographic Conditions Needed to E s t a b l i s h a U.S. S t a t i o n a r y P o p u l a t i o n Growth'!, P o p u l a t i o n S t u d i e s . 1 9 6 8 , 2 2 : 3 7 9 . 6Frank l o r i m e r , "Issues of P o p u l a t i o n P o l i c y " , Hauser, o p . c i t . , p. 1 7 5 . 7Paul R. E r l i c h , The Pop u l a t i o n Bomb. New York, 1 9 6 8 , p. 81, 83; G a r r e t t Hardin, " M u l t i p l e Paths to P o p u l a t i o n C o n t r o l " , Family Planning P e r s p e c t i v e s , New York, June, 1970, pp. 24-26; Frank W. .Notestein, "Zero P o p u l a t i o n Growth: What I s I t ? " i b i d . , pp. 23-4. eannie Rosoff, " C r i s i s T hinking: R h e t o r i c vs.. A c t i o n " , I b i d . , pp. 27-8; I . Bumpass and C.F. Westoff, "The P e r f e c t Contraceptive P o p u l a t i o n : Extent and I m p l i c a t i o n s of Un-wanted F e r t i l i t y i n the U.S.", Science i n pres s , c i t e d , i b i d , p. 28. 9Ansley J . Coale, "The Decline of F e r t i l i t y i n Europe", S.J. Behrman, L e s l i e Corsa, J r . , and Ronald Freedman, eds., F e r t i l i t y and Family P l a n n i n g , Ann Arbor, 1 9 6 9 , pp. 17-19. l°Frank W. N o t e s t e i n , Dudley K i r k , and Sheldon Segal, "The Problem of Po p u l a t i o n C o n t r o l , Hauser, pp. 1 3 9 - 5 2 ; Bernard B e r e l s o n , "Family Planning Programs and Po p u l a t i o n C o n t r o l " , Bernard B e r e l s o n , ed., Family Planning Programs: An I n t e r n a t i o n a l Survey, New York, 1 9 6 9 , p. 297? Ansley J . Coale, "Population and Economic Development", Hauser, op.ci"fc., p. 6 0 . PART ONE INTRODUCTION "Family P l a n n i n g " Was Not New Because of the need to compensate f o r population l o s s e s caused by d i s e a s e , famine or war, p r e - i n d u s t r i a l s o c i e t i e s i n many parts of the world venerated f e r t i l i t y and thus encour-aged h i g h birthratesP~ But, when numbers threatened group s u r v i v a l , or i n d i v i d u a l i n t e r e s t s were at stake, f e r t i l i t y c o n t r o l was p r a c t i s e d , even to o b t a i n "zero p o p u l a t i o n growth". D i r e c t means, such as induced a b o r t i o n , i n f a n t i -c i d e , and the k i l l i n g or d e s e r t i o n of the aged were, and s t i l l a r e , commonplace i n some s o c i e t i e s . I n d i r e c t means, such as delayed marriage or taboos r e l a t e d to h e a l t h or r e -l i g i o n , have also been used. In a d d i t i o n , there have been attempts to prevent conception i t s e l f - i n c l u d i n g such magical formulae as a n o i n t i n g the n a v e l w i t h s a l v e , s p i t t i n g three 3 times i n t o the mouth of a f r o g , or e a t i n g bees. A r e l a t i v e l y e f f e c t i v e method, withdrawal, has a l s o been used, though . p r a c t i s e has v a r i e d from country to country and from c l a s s to c l a s s . From ancient times, through t r i a l and e r r o r , s e v e r a l i n c r e a s i n g l y e f f i c i e n t means have been developed, but these were known only to the w e l l - t o - d o , and were mainly f o r use "by women. For example, Egyptian p a p y r i , dated about 1 8 5 0 B.C. and l a t e r , describe female methods, such as p e s s a r i e s made from c r o c o d i l e or elephant dung, or douching w i t h a combina-t i o n of honey and sodium carbonate. Tampons of roots or gr a s s , l i n t or sponge soaked w i t h t a n n i c a c i d , gum a r a b i c (a component of modern contraceptive j e l l i e s ) or other s o l u t i o n s were a l s o used.-* Some s o c i e t i e s used potions s a i d to induce s t e r i l i t y , but i n f o r m a t i o n on t h i s t o p i c i s scant. However, one study r e p o r t s forty-two medicines to be taken by women, three to be taken by both men and women, and one to be taken by men on l y . ^ By the mid-sixteenth century a male method, a p r o t o -type of the modern condom (a l i n e n v a r i e t y to p r o t e c t the wearer against s y p h i l i s ) had been added.''' The s k i n condom, from membranous animal t i s s u e , a l s o made i t s appearance about t h i s time. D e s c r i p t i o n s of the device are numerous i n seven-teenth and eighteenth century European l i t e r a t u r e - i n the w r i t i n g s of James Boswell and Casanova, f o r example - but i t was used more o f t e n to prevent venereal disease than conception. I n d u s t r i a l i z a t i o n also played a p a r t . When Charles Goodyear developed h i s method of v u l c a n i z i n g rubber i n 1 8 3 9 > the rubber condom, and new rubber appliances - c e r v i c a l caps and d i a -phragms f o r women became p o s s i b l e . In the meantime, i n the l a t e seventeenth century (c 1 6 7 8 ) the Dutchman, Anthony van Leeuwenhoek, had discovered the nature of spermatazoa, and i n s p i r e d a succession of st u d i e s to f i n d a means of i m m o b i l i z i n g them. This l e d to the i n t r o d u c t i o n of f u r t h e r female methods - v a g i n a l s u p p o s i t o r i e s and the modern j e l l i e s , Q creams and foams. In 1929 the "rhythm" method was added, and given q u a l i f i e d approval by the Roman C a t h o l i c Church. x^ A f t e r World War I I , the population e x p l o s i o n and i t s s o c i a l , economic and p o l i t i c a l i m p l i c a t i o n s added urgency to research; and 'Western f a m i l y planners i n s p i r e d the discovery of the modern o r a l c o n t r a c e p t i v e , and the r e v i v a l and improve-ment of the i n t r a - u t e r i n e contraceptive device (ITJCD, IUD or " l o o p " ) . 1 ' 1 Both male and female s t e r i l i z a t i o n have also become popular, and a t t i t u d e s to induced a b o r t i o n are growing more l i b e r a l . For a l l t h e i r e f f e c t i v e n e s s , a l l these methods have disadvantages, and research i n t o others, such as i n -j e c t i b l e s , implants and a b o r t i f a c i e n t s ( s u i t a b l e f o r mass use,.) continues. There i s l i t t l e doubt that the need i s urgent, and that a more acceptable s o l u t i o n w i l l be found. But, f o r the purposes of t h i s study, the e v o l u t i o n of modern f e r t i l i t y c o n t r o l techniques and t h e i r worldwide use i s onl y of i n t e r e s t f o r i t s r e l a t i o n to the h i s t o r y of the b i r t h con-t r o l "cause" which has developed over the past 170 years. This movement was an attempt to increase the use o f b i r t h c o n t r o l methods i n order to hasten v a r i o u s s o c i a l reforms such as improved working c l a s s wages and .'" st a t u s of women. In each country i t had s i m i l a r c h a r a c t e r i s t i c s , but as f a r as i s known, i t a l l began i n those of European stock. Except f o r "Dr." Marie Stopes (an advocate of b i r t h c o n t r o l i n the United Kingdom from the 1920s u n t i l her death i n 1958), the e a r l y leaders of the movement i n tha t country, the United S t a t e s , and i n Western Europe, were f r e e t h i n k e r s . N e a r l y a l l came from "middle c l a s s " "backgrounds. Many had e g a l i t a r i a n p o l i t i c a l views; some were p a c i f i s t s ; and a l l were convinced, f o r one reason or another, that sex should be brought out from under i t s "cloak of s i n and shame". A s o l u t i o n to poverty, equal r i g h t s f o r women, maternal and c h i l d h e a l t h , and world peace were cumulative g o a l s , and reached t h e i r peak, a f t e r World War I I , i n support of f a m i l y planning as a t o o l of n a t i o n a l and i n t e r n a t i o n a l development, and f i n a l l y , as a means of conserving resources and the environment. Techniques of promotion were adapted to the concerns of the time and p l a c e . Many of the b i r t h c o n t r o l v olunteers i n the West were a l s o a c t i v e i n campaigns f o r compulsory education, f r e e speech, freedom of the p r e s s , u n i v e r s a l a d u l t f r a n c h i s e , land reform, the a b o l i t i o n of c h i l d l a b o r , and other s o c i a l meas-ures which are taken f o r granted today, but were r a d i c a l ideas when introduced i n the nineteenth and e a r l y t w e n t i e t h c e n t u r i e s . B i r t h c o n t r o l r e q u i r e d the longest b a t t l e (not yet completely won), and i t was fought f i r s t i n the United Kingdom and the United States of America. In the beginning, opponents were s c a t t e r e d , but the f a m i l y planners' own peers were among them. Some f r e e t h i n k e r s would not support the i d e a . Some r a d i c a l s , some Trade Union-i s t s , and some C h a r t i s t s opposed i t , and, when the f e m i n i s t movement developed i n the mid-nineteenth century, even these m i l i t a n t s were d i v i d e d on the quest i o n . As the century advanced, and the advocates of b i r t h c o n t r o l became organized, o p p o s i t i o n a l s o began to c r y s t a l l i z e . Hardin suggests that the f o l l o w i n g quotation probably represents a f a i r l y common, i f not conscious, expression of male a t t i t u d e s to women, and hence, to b i r t h c o n t r o l i n 1880. God made hi m s e l f to be born of a woman to s a n c t i f y the v i r t u e of endurance; l o v i n g submission i s an a t t r i b u t e of a woman; men are l o g i c a l , but women, l a c k i n g t h i s q u a l i t y , have an i n t r i c a c y of thought. There are those who t h i n k women can be taught l o g i c ; t h i s i s a mistake. They can never, by any power of education a r r i v e at the same mental s t a t u s as tha t enjoyed by men .... Wifehood i s the crowning g l o r y of a woman. In i t she i s bound f o r a l l time. To her husband she owes the duty of u n q u a l i f i e d obedience. There i s no crime which a man can commit which j u s t i f i e s h i s w i f e i n l e a v i n g him or a p p l y i n g f o r that monstrous t h i n g , d i v o r c e . I t i s her duty to subject her-s e l f to him always, and no crime t h a t he can commit can j u s t i f y her l a c k of obedi-ence. I f he be a bad or wicked man, she may ge n t l y remonstrate w i t h him, but refuse him never.... I am the f a t h e r of many c h i l -dren and there are those who have ventured to p i t y me. "Keep your p i t y f o r y o u r s e l f , " I have r e p l i e d , "they never cost me a s i n g l e pang."15 In a d d i t i o n to the a t t i t u d e of many i n d i v i d u a l s , s e v e r a l mutually dependent i n t e r e s t groups obstructed the movement. CRUDE BIRTHRATES IN SOME INDUSTRIALIZED COUNTRIES Sourcet A.P.K. and Katherine Organski, " C h i l d r e n Become an Economic L i a b i l i t y " , Louise B. Young, ed., P o p u l a t i o n I n P e r s p e c t i v e , Toronto, 1968, pb, p. 11-+. State p o l i c y makers, both b u r e a u c r a t i c and e l e c t e d , had a vested i n t e r e s t i n population growth because of the con-v i c t i o n t h a t i t was synonymous w i t h i n t e r n a t i o n a l p o l i t i c a l muscle. As long as defence, the waging of war and the occu-pat i o n of conquered t e r r i t o r i e s depended on l a r g e numbers of men, i t was n a t u r a l t h a t governments should favor p r o - n a t a l i s t p o l i c i e s . 1 ^ But b i r t h r a t e s i n Europe and the United States began to d e c l i n e : i n France from about 1800, and, i n such co u n t r i e s as B r i t a i n , Denmark, Norway, Sweden and the United S t a t e s , from the 1 8 7 0 s . ^ By the 1930s the d e c l i n e was so p e r s i s t e n t t h a t demographers began t o warn th a t populations might begin to s h r i n k . Fryer r e p o r t s a f r i n g e element who added to the general panic by c l a i m i n g t h a t contraception would undermine the B r i t i s h Empire, a l l o w the y e l l o w and b l a c k races to dominate, cause the degeneration of women and deprive the world of geniuses - an argument r e s u r r e c t e d from time to time by the opponents of b i r t h c o n t r o l , and, l a t e l y , by those who oppose induced a b o r t i o n . Even though t o t a l p opulation was i n c r e a s i n g , laws against contraception were passed i n some c o u n t r i e s , and p r o - n a t a l i s t measures such as f a m i l y allowances and tax b e n e f i t s were introd u c e d . Due to government propa-ganda i n Germany and I t a l y the b i r t h r a t e s i n those c o u n t r i e s responded f o r a short time, but the long term slippage i n Europe and i n many cou n t r i e s of European stock ( i n c l u d i n g 18 Canada) has continued. Another i n t e r e s t group to oppose b i r t h c o n t r o l f o r many years was the business community, and i n t h i s i t r e c e i v e d government support. Commercial e n t e r p r i s e supported pro-n a t a l i s t p o l i c i e s on the b a s i s that "More babies mean more busi n e s s " . This c u l t had i t s r o o t s i n nineteenth century a t t i t u d e s to l a b o r and wages on both side s of the A t l a n t i c . A growing po p u l a t i o n would keep l a b o r costs low and increase the demand f o r goods. Whoever p r o f i t e d from cheap l a b o r was prepared to r e s i s t to the l a s t d i t c h any promotion of b i r t h 1 9 c o n t r o l i n f o r m a t i o n . The t w e n t i e t h century i n d u s t r i a l expansion d i d not d i f f e r i n i t s t e n e t s , even though the " b i o l o g i c a l Cassandras" were warning as e a r l y as the 1 9 3 0 s and kOs that overpopulation was at hand. As per c a p i t a i n -come i n the l i t e r a t e world i n c r e a s e d , the l a t t e r were accused of a t t a c k i n g the " r e l i g i o n of progress", and ho one took time to n o t i c e what was happening elsewhere. Since World War I I the a t t i t u d e has p e r s i s t e d . Nathan K e y f i t z , a Canadian born demographer teaching at the U n i v e r s i t y of C a l i f o r n i a , Berkeley, has i d e n t i f i e d urban developers, landowners, manufacturers, churches, and the a d v e r t i s i n g 2 1 media as the contemporary promoters of the f e r t i l i t y c u l t . Now,in a d d i t i o n to the b i o l o g i s t s and a "reformed" breed of demographers, a number of e c o l o g i s t s , economists, s o c i o l o -g i s t s , and other p r o f e s s i o n a l s i n f i e l d s r e l a t e d to p o p u l a t i o n , have added t h e i r voices to h i s p r o t e s t about u n b r i d l e d popu-l a t i o n i n crease and consumption. Robert S. McNamara, Pr e s i d e n t of the World Bank, also has spoken out against i t , f i r s t i n 1 9 6 9 « 2 2 Confidence i n increased consumption i s d i m i n i s h i n g because of the i n f l u e n c e of l e s s m a t e r i a l i s t i c p h i l o s o p h i e s , questions about the merits of technology, and the f a c t s of environmental damage. Questioning i s now widespread i n o c c i d e n t a l r e l i g i o u s c i r c l e s also, but t h i s d i d not begin to gain s t r e n g t h u n t i l the 1 9 6 0 s . However, r e l i g i o u s o p p o s i t i o n to b i r t h c o n t r o l had i t s o r i g i n s i n ancient times. F e r t i l i t y c u l t s were normal i n p r i m i t i v e s o c i e t i e s , and apparently the major r e l i g i o n s had to s t r u g g l e against the i n f l u e n c e s of f e r t i l i t y gods and god-desses. This produced a c l a s h between the need f o r s u r v i v a l and i n c l i n a t i o n s toward l i c e n s e . The strongest o p p o s i t i o n to b i r t h c o n t r o l had i t s o r i g i n s i n t h i s c o n f l i c t and a s c e t i c i s m became m e r i t o r i o u s . Richard M. Fagley, a demographer, and author of a study on behalf of the World Council of Churches, explained t h a t the Old Testament i n j u n c t i o n , "Be F r u i t f u l and M u l t i p l y " conjured up a p i c t u r e of an abundant s o c i e t y . ^ P r e s e r v a t i o n of the f a m i l y name was another f a c t o r encouraging f e r t i l i t y , and, i f a man died without progeny, i t was h i s brother's duty to marry the widow and beget c h i l d r e n f o r t h i s purpose. Onan would not conform, and used withdrawal to evade Oh, h i s o b l i g a t i o n to impregnate Tamar. A controversy has s i n c e raged (among C h r i s t i a n s ) over whether the Lord slew Onan f o r the act of withdrawal i t s e l f , or f o r r e f u s i n g to perform h i s L e v i r a t e d u t y . 2 ^ Although the o b l i g a t i o n to perpetuate the race remained, contraception must have been p e r m i s s i b l e l a t e r i n Jewish h i s t o r y f o r the Talmud, w r i t t e n between the second and s i x t h century A.D., recommended c o i t u s i n t e r r u p t u s , a v a g i n a l sponge, or a d r i n k s a i d to induce s t e r i l i t y . About 230 A.D. there was an argument over man's duty to ensure per-petuation of the race, so the onus was placed on women to use 27 the sponge, i f d e s i r e d . ' The Jewish Encyclopaedia i n d i c a t e s that u r b a n i z a t i o n induced the adoption of a t w o - c h i l d f a m i l y norm, a p a t t e r n s t i l l observed by many Jews i n Europe, the 28 United States and Canada. In the "Princeton Study", Family  Growth i n Met r o p o l i t a n America, i t was shown t h a t Jews i n the United States today are b e t t e r contraceptors than P r o t e s t a n t s and Roman C a t h o l i c s . 2 ^ Though contraception was permitted at f i r s t i n C h r i s t i a n i t y , Greco-Roman l i c e n s e , i n which the wor-ship of Venus f i g u r e d , was a f a c t o r i n a change of attitude.-^' To prevent moral breakdown, at the end of the f o u r t h century A.D., S t . Augustine held t h a t every conjugal act was f o r the purpose of p r o c r e a t i o n . This teaching was r e i n f o r c e d i n the t h i r t e e n t h century by S t . Thomas Aquinas i n hi s • great work, Summa Theologica. Almost every aspect of A r i s t o t e l i a n philosophy was adopted except the p r i n c i p l e of b i r t h c o n t r o l . S t . Thomas h e l d that b i r t h c o n t r o l was against nature and, i n an age of famine, disease and war, i t was a l o g i c a l r u l i n g . Since that time C h r i s t i a n s have debated whether Aquinas was condemning the common p r a c t i s e of a b o r t i o n and i n f a n t i c i d e , or whether he was r u l i n g out contraceptive practices.-^" I n any event, h i s views have survived and, u n t i l a f t e r World War I , on the ground that s m a l l f a m i l i e s were s e l f i s h and reduced i n d u s t r i a l p r o d u c t i o n , they were upheld by P r o t e s t a n t as w e l l as Roman C a t h o l i c Churches. One of the f i r s t of the P r o t e s t a n t Churches to waver was the Church of England i n 1 9 3 0 and, by the 1 9 6 0 s , overt approval was extended by most of the others as w e l l . Although approving the rhythm method i n 1 9 3 0 , Roman C a t h o l i c p r e l a t e s maintained a more or l e s s u n i t e d o p p o s i t i o n to " a r t i f i c i a l " means u n t i l the 1 9 6 0 s . I t was suggested that b i r t h c o n t r o l would cause grave p h y s i c a l d i s o r d e r s , f i b r o i d tumors, s t e r i l -i t y , i n f i d e l i t y , s eparation and d i v o r c e . A married woman who 3 2 p r a c t i s e d contraception was no b e t t e r than a p r o s t i t u t e . Today Roman C a t h o l i c churchmen are not unanimous, and, not only are many C a t h o l i c s p r a c t i s i n g a r t i f i c i a l b i r t h c o n t r o l , but d i s a p p r o v a l has not been strong enough to prevent the i n t r o d u c t i o n of modern b i r t h c o n t r o l programs i n some C a t h o l i c 33 n a t i o n s . B i r t h c o n t r o l has been introduced a l s o to t r y to combat the unusually h i g h induced a b o r t i o n r a t e s and "uncon-34 s c i o u s i n f a n t i c i d e " , a r e s u l t of p a r e n t a l n e g l e c t . In C h i l e , f o r example, the i l l e g a l a b o r t i o n r a t e i s estimated to be one to two l i v e b i r t h s , and i n Uruguay and Honduras, one to t h r e e , and one to four l i v e b i r t h s , r e s p e c t i v e l y . M a r x i s t s , who were once r i g i d l y opposed to b i r t h c o n t r o l , i n both "West" and "East", have l a t e l y been ambivalent about i t . Some adherents c l a i m t h a t "surplus l a b o r " i s c h a r a c t e r i s -t i c of c a p i t a l i s m and i m p e r i a l i s t e x p l o i t a t i o n , and tha t the i d e a l s t a t e should be able to absorb i n c r e a s i n g population through economic growth i n both a g r i c u l t u r e and i n d u s t r y . To them, a b i g population i s a p o l i t i c a l a s s e t . Nevertheless, a recent assessment of Marxist opinion shows t h a t , i n the USSR, at l e a s t , Marx, Engels, and l e n i n are now considered to have favored b i r t h c o n t r o l when necessary, even i n the " s o c i a l i s t " s t a t e . Government p o l i c i e s are s a i d to be based on the con-cept that women must have the choice regarding maternity, and that contraception i s p r e f e r a b l e to a b o r t i o n . T h e i r labor i n other a c t i v i t i e s i s a l s o needed. B i r t h c o n t r o l i s recommended to-day f o r developing c o u n t r i e s as an a i d to economic growth and to r a i s e the standard of l i v i n g . In f a c t contraception i s a v a i l a b l e i n such Marxist c o u n t r i e s as B u l g a r i a , China, Cuba, Czechoslovakia, Hungary, the USSR, and Yu g o s l a v i a . Induced a b o r t i o n i s a v a i l a b l e i n some. Another group opposing b i r t h c o n t r o l has been the medical p r o f e s s i o n . I d o l i z e d as h e a l e r s , doctors of the nineteenth and tw e n t i e t h c e n t u r i e s i n the West used Hippo-c r a t e s , of the f o u r t h century B.C., as the guide to e t h i c a l p r a c t i c e , and took p r i d e i n the t r a d i t i o n of s e r v i c e estab-l i s h e d by such p h y s i c i a n s as Soranos of Ephesus (second century g y n a e c o l o g i s t ) , and Avicenna, the te n t h century ( i s l a m i c ) doctor whose teachings were i n f l u e n t i a l i n Europe during the Middle Ages and a f t e r . ... I w i l l use treatment to help the s i c k according to my a b i l i t y and judgement, but never w i t h a view to i n j u r y and wrongdoing. I w i l l keep pure and holy both my l i f e and my a r t . In whatsoever houses I en t e r , I w i l l enter to help the s i c k , and I w i l l a b s t a i n from a l l i n t e n t i o n a l wrongdoing and harm... .37 These leaders of the p r o f e s s i o n i n t h e i r times took i t f o r granted t h a t b i r t h c o n t r o l would be p r a c t i s e d , and discussed v a r i o u s methods i n t h e i r w r i t i n g s . However, a f t e r Summa  Theologica, there was d i s c r e e t s i l e n c e among Western t r a i n e d doctors on such matters. With very few exceptions ( i n the 1 9 t h and 2 0 t h c e n t u r i e s ) , the s i l e n c e was maintained f o r seven hundred y e a r s . U n t i l the 1 9 6 0 s l i t t l e or no i n s t r u c t i o n was given i n l e c t u r e s or demonstrations i n medical schools or c o l l e g e s anywhere i n the world, and no i n f o r m a t i o n on the s o c i o l o g i c a l aspects of f e r t i l i t y , human s e x u a l i t y or p o p u l a t i o n dynamics was imparted.-^ Fryer notes t h a t medical men gave the f o l -lowing excuses f o r t h e i r l a c k of i n t e r e s t i n the s u b j e c t : b i r t h c o n t r o l endangers v i r i l i t y , i s conducive to a d u l t e r y , destroys the "glamour" of marriage, i s a danger to h e a l t h , leads to lunacy, has a s t e r i l i z i n g e f f e c t , or i s tantamount 39 to masturbation• ' Another problem was f r a n k l y admitted at a g y n a e c o l o g i c a l conference i n Budapest i n September, 1 9 & 9 , when the doctors agreed t h a t d i f f i c u l t y a l s o arose over t r a d i -t i o n a l r i v a l r y between p r a c t i t i o n e r s of c u r a t i v e medicine and those whose s p e c i a l t y ^ was preventive medicine. The r e l u c t a n c e of the medical p r o f e s s i o n to take a l e a d i n the promotion of b i r t h c o n t r o l was summed up by Dr. Alan Guttmacher, Pr e s i d e n t of the United States v o l u n t a r y o r g a n i -z a t i o n , Planned Parenthood-World P o p u l a t i o n , as f o l l o w s : D e d i c a t i o n to the p r e s e r v a t i o n of l i f e at a l l c o s t s , to "doing no harm", to a d e s i r e f o r p o p u l a r i t y , t o medical p o l i t i c s , t o a r e l u c t a n c e to p l a y God, and l a s t l y , because of a l l b o d i l y systems, the reproductive t r a c t i s unique i n t h a t " i t i s the o n l y one which f a s c i n a t e s State and Church." H o s p i t a l s followed the doctors' lead i n r e f u s i n g to g i v e contraceptive care - i n few York, f o r example, u n t i l Ik 1 9 5 8 . Dr. Guttmacher a t t r i b u t e d the recent s o f t e n i n g of a t -t i t u d e s to the f a c t t h a t , s t i l l h e s i t a n t i n the matter of f a m i l y planning,, the World Health O r g a n i z a t i o n had agreed to define h e a l t h as a human r i g h t , and a s t a t e of "complete p h y s i c a l , mental and s o c i a l w e l l - b e i n g " and not merely the absence of disease or i n f i r m i t y . In 1 9 5 9 i n the" United S t a t e s , the American P u b l i c Health A s s o c i a t i o n passed a r e s o l u t i o n i n favour of f a m i l y p l a n n i n g * The American College of O b s t e t r i c i a n s and Gynaecologists f o l -lowed s u i t i n 1 9 6 3 J and the American Medical A s s o c i a t i o n i t s e l f d i d so i n 1 9 6 4 but, even to-day, few doctors w i l l speak out as  i n d i v i d u a l s i n i t s f s v o r . The l i b e r a l i s e d a t t i t u d e s of the medical a s s o c i a t i o n s to ab o r t i o n and s t e r i l i s a t i o n i n the United Kingdom, the United States and Canada i s of a d d i t i o n a l i n t e r e s t but few doctors as i n d i v i d u a l s w i l l speak out i n •f Besevmatters * Not s u r p r i s i n g l y , education and the law have tended al s o to r e f l e c t the opinions of the o p p o s i t i o n . Prom the 1 8 5 0 s i n the United Kingdom these i n t e r a c t i n g and mutually supporting i n t e r e s t groups t r a n s l a t e d t h e i r o p p o s i t i o n i n t o laws f o r b i d d i n g blasphemy, o b s c e n i t y , and a b o r t i o n , w h i l e , from the 1 8 6 0 s i n the United States the proponents of b i r t h c o n t r o l were prosecuted and j a i l e d f o r "pornography". In the l a s t quarter of the nine t e e n t h century, the United States Federal P o s t a l Regulations were amended t o f o r b i d the d i s -semination of information about c o n t r a c e p t i o n , and many State s f o l l o w e d s u i t w i t h s i m i l a r l e g i s l a t i o n . Laws against b i r t h c o n t r o l were also passed i n Europe, at d i f f e r e n t times. "Malthusian" Leagues, and, l a t e r , Family Planning A s s o c i a t i o n s to promote the idea as a t o o l of s o c i a l reform were formed i n countr i e s of European stock, hut i t was not u n t i l the 1 9 5 0 s that they or p r o f e s s i o n a l s i n the f i e l d had much impact. Then t h e i r governments began to accept i n theory th a t f a m i l y planning was a needed p u b l i c s e r v i c e , but were slow to act at home, and obstructed help f o r developing coun-t r i e s u n t i l the l a t e 1 9 6 0 s . In s p i t e of the o p p o s i t i o n , and perhaps un r e l a t e d to the a c t i v i t i e s of the Family Planning A s s o c i a t i o n s , d e c l i n i n g b i r t h r a t e s showed tha t contraception was being p r a c t i s e d w i d e l y by the middle and upper income groups i n Western co u n t r i e s by i n d i v i d u a l c h oice. What w i l l happen to "Western" b i r t h r a t e s i n f u t u r e i s now thought to depend on education, economic c o n d i t i o n s , c h i l d b e a r i n g i n t e n t i o n s , and the s i z e of the reproductive age group. But most western governments are s t i l l r e l u c t a n t to develop population p o l i c i e s and take p o s i t i v e a c t i o n to i n f l u e n c e knowledge, a t t i t u d e s and prac-t i c e , and the volunteers are s t i l l attempting to persuade them 4 l to do so, but to b u i l d i t on i n d i v i d u a l choice• FOOTNOTES - I n t r o d u c t i o n i R i c h a r d M. Fagley, "Parenthood and World R e l i g i o n s " , The P o p u l a t i o n Explosion and C h r i s t i a n R e s p o n s i b i l i t y " , Oxford, I 9 6 0 , p. 9 5 . 2Norman E. Himes, Medical H i s t o r y of Contraception, B a l t i m o r e , 1 9 6 3 , p. 79. ^Peter F r y e r / The B i r t h C o n t r o l l e r s . London, 1 9 6 5 , pb, p. 2 0 - 1 . The H i s t o r y of Contraceptives", I n t e r n a t i o n a l Planned Parenthood F e d e r a t i o n , London, I 9 6 7 , P» 14. **John P e e l & Malcolm P o t t s , Textbook of Contraceptive  P r a c t i c e . Cambridge, 1 9 6 9 , pb., pp. 4 9 - 5 1 ; Clyde V. K i s e r , ed. "Panel Discussion on the Comparative A c c e p t a b i l i t y of D i f f e r e n t Methods of Contraception", Research i n Family  P l a n n i n g , P r i n c e t o n , 1 9 6 2 , pp. 3 8 0-81; Medical men used to disapprove of t h i s method, but there i s no evidence t h a t i t i s harmful, and i t i s now accepted as f a i r l y r e l i a b l e f o r those s k i l f u l enough to use i t . I t has always been popular i n Europe and the United S t a t e s , and a l s o among educated c l a s s e s i n A s i a . ^Himes, o p . c i t . , pp. 3 , 4 ; IPPF, o p . c i t . , p. 2 . ^K. N d e t i , " A t t i t u d e s of the R u r a l P o p u l a t i o n to the C l i n i c S e r v i c e s , " The Role of Family Planning i n A f r i c a n  Development, London, 1 9 6 8 , pp.4 7 - 8 ; B.E. F i n c h and Hugh Green, Contraception Through the Ages, S p r i n g f i e l d , 1 9 6 4 , pp. 1 0 5-08. 7Himes, Op.Cit., p. 186. 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Spengler, "The Economics of P o p u l a t i o n Growth", S t u a r t Mudd, ed., The P o p u l a t i o n C r i s i s  and the Use of World Resources, Bloomington, 1964, pp. 7 3 - 9 3 ; A.F.K. and Katherine Organski, P o p u l a t i o n and World Power, New York, I 9 6 I , p. 1 7 ; P h i l i p Hauser. P o p u l a t i o n and World  P o l i t i e s . Glencoe, 1958, pp. 193 - 2 1 3 . 17 'A.F.K. and Katherine Organski, "Children Become an., Economic L i a b i l i t y , Louise B. Young, ed., P o p u l a t i o n i n  P e r s p e c t i v e , New York, 1968, p. 114; Kings±ey -uavis, " P o p u l a t i o n " , i b i d , p. 1 1 9 , 127. 18 Peter F r y e r , o p . c i t . , p. 2 9 4 ; Vancouver Sun, 5 J u l y 1 9 6 9 , p. 6 . 19 ^ L i n c o l n H. and A l i c e Taylor Bay, o p . c i t . , pp. 147 - 5 3 ; J . Mayone Stycos, "Problems of F e r t i l i t y C o n t r o l i n Under-Developed Areas" Stuart Mudd, ed., o p . c i t . , p. 9 6 ; Arthur W. Calhoun, A S o c i a l H i s t o r y of the American Family. V o l . 3 , From I863 to 1919, New York, 1919 ( i 9 6 0 ) p. 1 3 6 . 20 G a r r e t t Hardin, "Cassandra Gets a Hearing", G a r r e t t Hardin, ed., o p . c i t . , pp. 39-40. 21 Nathan K e y f i t z , "Population and S o c i e t y " . I n t e r n a t i o n a l J o u r n a l , V o l . x x i v , No. 3 , Summer, 1 9 6 9 , p. 145. S 2 P a u l R. E h r l i c h , The P o p u l a t i o n Bomb. New York, 1 9 6 8 , p. 149; J . J . Spengler, " I m p l i c a t i o n s of P o p u l a t i o n Change f o r Business", Commercial, F i n a n c i a l C h r o n i c l e , Aug. 1 1 , 1966, UBC M i c r o f i l m R 3 0 1 0 , I 9 6 6 - 6 7 , p. 3 , 26-27. " I t i s high time, t h e r e f o r e , t h a t business cease l o o k i n g at the s t o r k as a b i r d of good omen.", p. 27; Robert S. McNamara, Address to the U n i v e r s i t y of Notre Dame, Notre Dame, Indiana, 1 May, 1969, IBRD, Washington, p. 10 - 1 1 . 2 ^ H a r d i n , o p . c i t . , p. 180; Richard M. Fagley, The  P o p u l a t i o n E x p l o s i o n and C h r i s t i a n R e s p o n s i b i l i t y , New York, I960, p. 1 1 5 . 24 Genesis 3 8 . 25Himes, o p . c i t . , pp. 6 9 - 7 0 . By 330 B.C., P a l e s t i n e was overpopulated, and, at the time of the Jewish m i g r a t i o n , l a r g e f a m i l i e s were no longer an a s s e t . Polygamy was abandoned, and a two c h i l d f a m i l y became acceptable. ^ A c c o r d i n g to Marie Stopes, the Roman C a t h o l i c church d e l i b e r a t e l y confused contraception w i t h "Onanism"; and some opponents a l s o i n t e r p r e t e d "Onanism" as masturbation. Marie Stopes, Contraception, London, 1 9 2 3 , p. 6 9 , f n . ' C DPagley, o p . c i t . , p. 1 2 1 . 27 'Himes, o p . c i t . , pp. 7 7 - 7 8 . 2 8 D a v i d M. Peldman, B i r t h C o n t r o l i n Jewish law, New York, 1 9 6 8 , p. 3 0 4 . 2 9 F a g l e y , o p . c i t . , p. 1 2 1 ; Clyde V. K i s e r , "Summary of P o p u l a t i o n Study", o p . c i t . , pp. 1 8 5 - 1 9 2 . 3°Fagley, o p . c i t . , pp. 95-96. 31 H: Imes, o p . c i t . , p p . 9 3 , 9 7 - 9 8 ; F r y e r , o p . c i t . , pp. 2 0 - 2 1 3 2 A l v a h W. Sulloway, " B i r t h C o n t r o l and C a t h o l i c D o c t r i n e " , Hardin, ed., o p . c i t . , p. 238. 3-^1970 World P o p u l a t i o n Data Sheet. P o p u l a t i o n Reference Bureau, Washington, D.C., 1 9 7 0 ; Dorothy Nortman, P o p u l a t i o n  and Family P l a n n i n g Programs: A Factbook, Reports on Popu-l a t i o n / F a m i l y P l a n n i n g , Population C o u n c i l , New York, J u l y 1 9 7 0 . pp. 3 3 - 3 4 . In L a t i n America, since 1 9 6 6 , governments have approved, and sometimes assisted,",, u n i v e r s i t y , or u n i v e r s i t y - o r g a n i z e d s e r v i c e s i n twelve Spanish-speaking c o u n t r i e s where the highest p o p u l a t i o n growth r a t e s i n the world e x i s t - a c o n t i n e n t a l average of 2 . 9 percent per annum and a doubling time of 24 years. J "The S o c i a l Consequences of Pop u l a t i o n Growth", Po p u l a t i o n Reference Bureau, S e l e c t i o n No. 3 0 , Washington, D.C., October, I 9 6 9 . 3-'Family Planning i n Five Continents, IPPF, London, A p r i l , 1970, pp. 15, 21, 18. 3 6 I b i d . , pp. 11-31? USSR: Views on Population/Family  P l a n n i n g , Studies i n Family P l a n n i n g , Population C o u n c i l , New York, January, 1 9 7 0 , p. 4 9 . -^John B a r t l e t t , F a m i l i a r Quotations, Boston, 1955» P» 2 1 . 38christopher T i e t z e et a l , "Teaching of F e r t i l i t y R egulation i n Medical Schools, Survey i n the United States and Canada, 1 9 6 4 . " JAMA. Ap . 4 , 1 9 6 6 , V o l . I 9 6 , pp. 20-24 j Donald T. R i c e , "Asian i v-edical Colleges and F e r t i l i t y C o n t r o l " , JAMA, 6 May, 1 9 6 8 , V o l . 204, #56, p. 1 0 6 ; Dr. Jorge V i l l e r e a l , D i r e c t o r of P o p u l a t i o n , Pan American Federation of A s s o c i a t i o n s of Medical Schools, Bogota, "Medical l e a d e r s h i p : A C o n t r i b u t i o n to a Country's Economic Development", Family P l a n n i n g and N a t i o n a l Devel-opment, Pr o c . SE A s i a and Oceania Region, IPPF, June, 1 9 6 9 , Bandung, London, 19&9, PP» 51-f>7; Dr. Guillermo A d r i a s o l a , School of P u b l i c H e a l t h , U n i v e r s i t y of C h i l e , " I n t e g r a t i o n of Family P l a n n i n g i n t o Medical C u r r i c u l a " , I b i d . , pp. 1 8 5 - 1 9 2 . 3 9 l r y e r , o p . c i t . , pp. 144,2 0 1 , 2 7 4 , 2 7 6 , 2 9 4 ,3*0. ^OAlan Guttmacher, "The R e s p o n s i b i l i t y of the P u b l i c H e a l t h and Medical P r o f e s s i o n s " , P r o c . 8 t h I n t e r n a t i o n a l Conference, IPPF, Santiago, 1 9 6 7 , London, 1967, pp. 208^09. ^ L i n c o l n H. Day, "The American F e r t i l i t y C u l t " , S t u a r t Mudd, ed., Op.Cit., pp. 2 3 1 - 3 8 . CHAPTER I The S o c i a l Reformers: The United Kingdom I t has always needed a devoted band of pioneers to introduce the i d e a , to brave uninformed o p p o s i t i o n , and to e s t a b l i s h the f i r s t s e r v i c e s . T i m i d i t y i s too often the most prominent q u a l i t y of p o l i t i c i a n s and c i v i l s ervants, and the courage of volunteers has had to show them th a t they had no need to f e a r . The demand i s l a t e n t l y present i n every country from the o r d i n a r y people.... The s t o r y of b i r t h c o n t r o l as a t o o l of s o c i a l reform began i n the l a s t decade of the eighteenth century when Marquis de Condorcet, a French p h i l o s o p h e r , wrote of the i d e a l s t a t e i n which a l l passion would e v e n t u a l l y dwindle away; and W i l l i a m Godwin, an E n g l i s h m a t e r i a l i s t , b e l i e v i n g poverty was caused by s o c i a l i n e q u i t i e s , urged man to make 2 greater use of h i s c a p a c i t y f o r s e l f - d e t e r m i n a t i o n and reason. Such views aroused considerable controversy. Among those who attacked them was an A n g l i c a n clergyman, Reverend Thomas Malthus, who l a t e r became professor of p o l i t i c a l economy at the East I n d i a Company's t r a i n i n g college,Haileybury» His Essays on  The P r i n c i p l e of P o p u l a t i o n as I t A f f e c t s the Future Improve- ment of Mankind sought to demonstrate t h a t the achievement of the i d e a l s t a t e would always be obstructed by the tendency of population to press upon the means of subsis t e n c e . Between 1798 and 1826 Malthus r e v i s e d h i s o r i g i n a l essay f i v e times, hut h i s ideas remained the same. They may he summarized as f o l l o w s : P o p u l a t i o n i n c r e a s e s i n a geometric r a t i o , whereas subsistence increases only i n a r i t h m e t i c r a t i o . Were popu-l a t i o n not subject to c e r t a i n checks, i t would expand beyond the means of subsi s t e n c e . In f a c t , given a t o t a l p opulation of one b i l l i o n , i t would m u l t i p l y by 256 i n 200 y e a r s , whereas subsistence would only m u l t i p l y by 9» The long term cheek i s want of food, but short term checks are moral r e s t r a i n t (a degree of a s c e t i c i s m through sexual r e s t r a i n t outside marriage, and l a t e marriage), v i c e ( p r o s t i t u t i o n and other forms of s e l f - g r a t i f i c a t i o n ) , and misery (war, famine and d i s e a s e ) , In s p i t e of these checks, population growth con-'s t i n u e s , and the poor are the c h i e f v i c t i m s . Malthus claimed t h a t , i n s t e a d of h e l p i n g to r e l i e v e poverty, the Poor Laws ( i n s t i t u t e d i n the seventeenth century and since amended) were aggravating i t . Because the low income po p u l a t i o n was encour-aged to increase i n number, " p r o v i s i o n s " per c a p i t a were reduced. Some of those who were not yet on s o c i a l a s s i s t a n c e would be f o r c e d to apply. P r i c e s of p r o v i s i o n s were r i s i n g , but the r e a l p r i c e of l a b o r was d e c l i n i n g . There was a l a c k of f r u g a l i t y , and there was increased spending f o r useless purposes. The French R e v o l u t i o n had indeed improved the c o n d i t i o n of the poor i n that country by g i v i n g them a g r e a t e r share of land and the b e n e f i t s of production, but t h i s had been accompanied by a diminished p r o p o r t i o n of b i r t h s , greater i n d u s t r y , greater s e l f - r e l i a n c e and an i n c l i n a t i o n to save. I f i t be taught t h a t a l l who are born have a r i g h t to support on the l a n d , whatever be t h e i r number, and t h a t there i s no occasion to e x e r c i s e any prudence i n the a f f a i r of marriage so as to check t h i s number, the tempta-t i o n s , according to a l l the known p r i n c i p l e s of human nature, w i l l i n e v i t a b l y be y i e l d e d t o , and more and more w i l l g r a d u a l l y become dependent on p a r i s h a s s i s t a n c e . There cannot t h e r e f o r e be a greater i n c o n s i s t e n c y and c o n t r a d i c t i o n than t h a t those who maintain these do c t r i n e s r e s p e c t i n g the poor should s t i l l complain of the number of paupers. Such d o c t r i n e s and a crowd of paupers are unavoidably u n i t e d ; and i t i s u t t e r l y beyond the power of any r e v o l u t i o n or change of government to separate them.... 0 Malthus s t a t e d a l s o t h a t the only s o l u t i o n was to r a i s e the buying power of the poor by c o n t r o l l i n g p r i c e s and reducing the l a b o r supply, thus b r i n g i n g about a r i s e i n wages. I f the r i c h r e a l l y wanted to see the c o n d i t i o n 7 of the poor improve, they must accept an end to cheap l a b o r . A s t a t i o n a r y population was d e s i r a b l e , f o r i t would b r i n g about a balance between supply and demand. Then, i f growth were needed, i n c e n t i v e s could be introduced. (This must have been the nineteenth century v e r s i o n of Zero P o p u l a t i o n Growth!) By reducing the l a b o r supply, Malthus meant reducing the r a t e of n a t u r a l i n c r e a s e , and s t a t e d that t h i s could o n l y be brought about by moral r e s t r a i n t . He d i d not favor b i r t h c o n t r o l by any other means. When t h i s r e s t r a i n t produces v i c e , the e v i l s which f o l l o w are but too conspicuous. A promiscuous i n t e r -course to such a degree as to prevent the b i r t h of c h i l d r e n seems to lower, i n the most roe rice d manner, the d i g n i t y of human nature. I t cannot be without i t s e f f e c t on men, and nothing can be more obvious than i t s tendency to degrade the female c h a r a c t e r , and to d e s t r o y ' a l l i t s most amiable and d i s t i n g u i s h i n g c h a r a c t e r i s t i c s ...° Malthus i s being re-read to-day w i t h growing i n t e r e s t . In the l i g h t of progress-in food p r o d u c t i o n , technology, and s t u d i e s of the f a c t o r s a f f e c t i n g human f e r t i l i t y , a number of people b e l i e v e he was wrong. On the other hand, perhaps h i s theory has been proven tr u e f o r developing c o u n t r i e s a l r e a d y , and, i f t o t a l resources are l i m i t e d , f o r the r e s t of the world as w e l l . H i s suggestion t h a t poverty could be solved by s e l f - h e l p and l i m i t a t i o n of f e r t i l i t y may have been both r e a l i s t i c and u s e f u l . I t i s being t r i e d to-day i n some p l a c e s . Right or wrong, Malthus d i d p o s t u l a t e a r e l a t i o n s h i p between population and food, and i n s p i r e d c o n t i n u i n g s t u d i e s of popu-l a t i o n change and the development of the science of demography. The essays made enemies i n more than one camp. The Utopians were upset by the argument th a t t h e i r i d e a l was u n a t t a i n a b l e • Business i n t e r e s t s resented Malthus's advocacy of higher wages f o r l a b o r , and used h i s comment tha t there would always be p r o p r i e t o r s and l o b o r e r s to j u s t i f y i n a c t i o n to improve the l o t of the l a t t e r • The U t i l i t a r i a n s , who agreed w i t h many of h i s ideas i n p r i n c i p l e , saw no hope of h e l p i n g the working c l a s s to reduce f e r t i l i t y through as-c e t i c i s m . I t was from the U t i l i t a r i a n group t h a t the f o r e -runners of the f a m i l y planning movement arose, and, when they formed o r g a n i z a t i o n s i n the l a t e nineteenth and e a r l y twen-t i e t h c e n t u r i e s , many of them were so audacious as to c a l l themselves, "Malthusian" or "Neo-Malthusian Leagues". Nothing a s s o c i a t e d population growth w i t h human misery so r e a d i l y , as d i d the name of Malthus, hut, c o n s i d e r i n g h i s views on c o n t r a -c e p t i o n , nothing was a bigger sham. The proponents of U t i l i t a r i a n i s m , Jeremy Bentham, James M i l l and Joseph Townshend, argued t h a t , i f the l o t of the working classes could be improved through a r e d u c t i o n i n t h e i r numbers, they should have c o n t r a c e p t i o n . The f i r s t of the a c t i v e supporters of the i d e a , and a close f r i e n d of M i l l , was F r a n c i s P l a c e , a self-educated t a i l o r who had known poverty but was becoming s u c c e s s f u l i n business and p o l i t i c s . Urging the needs of the working c l a s s e s , and of women w i t h p h y s i c a l weaknesses, Place wrote I l l u s t r a t i o n s and Proofs of the P r i n c i p l e of P o p u l a t i o n , i n which he condemned Malthus's 10 "moral r e s t r a i n t " as i m p r a c t i c a l . H a n d b i l l s were d i s t r i -buted i n 1822 i n working c l a s s d i s t r i c t s i n London and the i n d u s t r i a l n o r t h . They were addressed "to the married of both sexes" i n both "genteel l i f e " and "among the working people", and suggested t h a t , by l i m i t i n g the number of c h i l -dren, the workers would enjoy r i s i n g wages and have more time f o r r e c r e a t i o n and the moral and r e l i g i o u s i n s t r u c t i o n of t h e i r o f f s p r i n g . Through withdrawal and the sponge, workers could make e a r l y marriages, and p r o s t i t u t i o n and debauchery would be reduced. Place's opponents c a l l e d h i s h a n d b i l l s " d i a b o l i c a l " and s a i d they would have the opposite e f f e c t . But no a c t i o n was taken to s i l e n c e Mm, and he had the support of other 11 U t i l i t a r i a n s as w e l l . John Stuart M i l l summed up the case f o r b i r t h c o n t r o l i n 1 8 2 3 , By checking p o p u l a t i o n , no pain i s i n f l i c t e d , no alarm e x c i t e d , no s e c u r i t y i n f r i n g e d . I t cannot t h e r e f o r e , on any p r i n c i p l e s , be termed immoral; and ... i f i t tends to elevate the working people from poverty and ignorance to a f f l u e n c e and i n s t r u c t i o n , I am compelled to -,? regard i t as h i g h l y moral and v i r t u o u s . As an exponent of b i r t h c o n t r o l , P lace was f o l l o w e d by Richard C a r l i l e , a f r e e t h i n k i n g p u b l i s h e r who, besides con-t i n u i n g the campaign f o r contraception f o r the poor, also fought a long b a t t l e f o r the freedom of the p r e s s . Together w i t h medical a r t i c l e s on other t o p i c s , he published Every  Woman's Book, a pamphlet which advocated the sponge, the condom and withdrawal. So f a r as i s known, however, n e i t h e r Place nor C a r l i l e had any e f f e c t on the working c l a s s b i r t h -r a t e ; and overt i n t e r e s t i n b i r t h c o n t r o l waned a f t e r passage of the Reform B i l l and the new Poor Law of 1834 (which placed s o c i a l welfare payments under the s u p e r v i s i o n of the n a t i o n a l government). I t i s d o u b t f u l also i f contraception was used at t h a t time to any great extent by any income group i n B r i t a i n , but i n one very h i g h place there was personal con-cern. In 1841 the young Queen V i c t o r i a wrote to her uncle, the King of the B e l g i a n s , I t h i n k , dearest Uncle, you cannot r e a l l y wish me to be the "Mama d'une nombreuse f a m i l l e " , f o r I t h i n k you w i l l see w i t h me the great inconvenience a large f a m i l y would be to us a l l , and p a r t i c u l a r l y to the country, independent of the hardship and inconvenience to myself; men never t h i n k , at l e a s t seldom t h i n k what a hard ta s k i t i s f o r us^women to go through t h i s very o f t e n . 1 - 5 Nevertheless the Queen became resigned to the "hard t a s k " nine times i n l e s s than seventeen y e a r s . In France, however, where i n t e l l e c t u a l r a d i c a l i s m and s o p h i s t i c a t i o n were already w e l l e s t a b l i s h e d , withdrawal and the sponge were much i n vogue. The b i r t h r a t e had f a l l e n from 38.5 per 1000 i n 1771-75 to 3 1 . 3 i n 1816 (and was to de c l i n e to 25.4 by 1871-1880). What W i l l i a m Ranger c a l l e d "disguised i n f a n t i c i d e " was also very common - babies turned over to ancient crones or f o u n d l i n g h o s p i t a l s , p a c i f i e d w i t h g i n and dying of n e g l e c t , or p e r i s h i n g i n the care of peasant women i n the countr y s i d e . More than one t h i r d of babies died 14 i n t h i s way. From 1846 emigration from Western Europe a l s o reduced the population growth r a t e . A g i t a t i o n f o r b i r t h c o n t r o l i n c r e a s e d , a b o r t i o n became commonplace, the age of marriage r o s e , and, i n p u r s u i t of higher s o c i a l and economic 15 s t a t u s , f a m i l y s i z e shrank. SCANDINAVIA AND JAPANi COMPARISON OP VITAL RATES 1800 1820 1840 1860 1880 1900 1920 1940 1960 Figure 2. Birth and death rates for Denmark, Norway, and Sweden combined (black lines and dales) are compared with Japanese rates (gray lines and dates) of 50 years later. Japan has been passing through a population change similar to that which occurred earlier in Scandinavia."Area between respective birth-rate curves (solid lines) and death-rate curves (broken lines) shows natural increase, or population growth that would have occurred without migration. In past few years both Japanese rates have dropped extremely rapidly. # I l l u s t r a t e s the d i f f e r e n c e between a spontaneous and an induced d e c l i n e i n p o p u l a t i o n growth r a t e s . Source* K i n g s l e y Davis, " P o p u l a t i o n " , Louise B. Young, ed., Po p u l a t i o n i n P e r s p e c t i v e . Toronto, 1968, pb, p. 119. In the United Kingdom, i n 1854, a f t e r a time lapse of twenty y e a r s , the e f f o r t s of Place and C a r l i l e were r e v i v e d when Dr. George Drysdale wrote, anonymously, a hook c a l l e d P h y s i c a l , Sexual and N a t u r a l R e l i g i o n . I t was published by Edward Truelove, a f r e e t h i n k i n g f o l l o w e r of Robert Owen, S c o t t i s h s o c i a l reformer and pioneer i n the co-operative movement. La t e r e d i t i o n s were c a l l e d Elements of S o c i a l  Science, and, i n the Place t r a d i t i o n , favoured contraception and sex education as a means of r a i s i n g wage r a t e s . Drysdale went f u r t h e r , however, i n h o l d i n g t h a t mankind s u f f e r e d from the i n t e r r e l a t e d e v i l s of poverty, p r o s t i t u t i o n and c e l i b a c y , and i n s i s t e d that b i r t h c o n t r o l was the cure f o r a l l t h r e e . Marriage should not be considered the p r e r e q u i s i t e f o r i n t e r -course and, i f women would take the r e s p o n s i b i l i t y f o r a v o i d i n g pregnancy, by using the sponge, men could have f u l l enjoyment of "the ve n e r e a l a c t " . Drysdale a l s o included f r a n k d i s c u s -s i o n of a l l methods of b i r t h r e g u l a t i o n - from prolonged l a c t a t i o n to induced a b o r t i o n - very d o u b t f u l to very c e r t a i n . He wrote a r t i c l e s on Neo-Malthusianism ( b i r t h c o n t r o l ) f o r Charles Bradlaugh's N a t i o n a l Reformer, and, i n the e a r l y 1860s, founded, w i t h Bradlaugh, a s h o r t - l i v e d Malthusian League to promote c o n t r a c e p t i o n . 1 ^ Whether or not Drysdale*s f r e e love philosophy was the cause, the B r i t i s h government passed the Obscene P u b l i c a t i o n s Act i n 1857* I t was not long before another uproar over f a m i l y l i m i t a t i o n occurred. In 1868, Lord Amberley, son of Lord John, and f a t h e r of Bertrand R u s s e l l , at a meeting on over-population and p u b l i c h e a l t h , organized by the London D i a l e c t i c a l S o c i e t y , expressed the hope t h a t b i r t h c o n t r o l methods would improve. The c l e r g y and s o c i e t y promoted over-population, he s a i d , and he was sure t h a t , i f women had a say, they would not f a v o r l a r g e f a m i l i e s . He was attacked from many quarter s , i n c l u d i n g the medical p r e s s , and the f u r o r e l a s t e d f o r more than a year, 17 g i v i n g the i s s u e increased p u b l i c i t y . But, from the days of P l a c e , the campaign was more or l e s s d e s u l t o r y u n t i l a greater p u b l i c row was r a i s e d by Bradlaugh h i m s e l f . Dedicated to promoting f r e e p u b l i c d i s c u s s i o n of any i s s u e , and, s p e c i f i c a l l y , such causes as compulsory education, land reform, the separation of church and s t a t e , r e p u b l i c a n i s m , and the a b o l i t i o n of h e r e d i t a r y peerages - as a f r e e t h i n k e r , Bradlaugh a l s o attacked conventional r e l i g i o n , and, i n p a r t i -c u l a r , the swearing of oaths on the B i b l e . A f t e r a long s t r u g g l e he was e l e c t e d to the House of Commons where he won considerable r e s p e c t , though l i t t l e approbation, f o r h i s r a d i c a l views. V/hen a B r i s t o l b o o k s e l l e r and p u b l i s h e r was prosecuted and j a i l e d f o r s e l l i n g an i l l u s t r a t e d e d i t i o n ( b e l i e v e d to have in c l u d e d drawings of the reproductive organs) of F r u i t s of Philosophy, a book on b i r t h c o n t r o l by Dr. Charles Knowlton of the United S t a t e s , Bradlaugh decided t h a t t h i s was another instance i n which f r e e d i s c u s s i o n of an important subject had been ob s t r u c t e d . The p r i n c i p l e of f r e e speech must be pursued. Forming the Freethought P u b l i s h -i n g Company w i t h Mrs. Annie Besant (another s o c i a l reformer and a f e m i n i s t ) he published the same pamphlet - t h i s time w i t h notes "by Dr. Drysdale. Next, Bradlaugh n o t i f i e d the p o l i c e t h a t he intended to s e l l i t , and where. He. and Mrs. Besant were charged w i t h o b s c e n i t y . Though the book's c i r c u l a t i o n since 1832 had averaged only a thousand copies a year, i n the three months between t h e i r a r r e s t i n 1877 and t h e i r t r i a l , 1 2 5 , 0 0 0 copies were s o l d . The two were convicted of p u b l i s h i n g "an obscene l i b e l c a l c u l a t e d to destroy or c o r -rupt the morals of the people" but t h e i r defense was summed up as f o l l o w s : No b e t t e r book can be p u b l i s h e d , f o r doctors w i l l not w r i t e , and p u b l i s h e r s w i l l not s e l l , a work which may b r i n g them w i t h i n the w a l l s of a g a o l . I t was f o r the sake of f r e e d i s c u s s i o n t h a t we published the a s s a i l e d pamphlet, and to make the way p o s s i b l e f o r others d e a l i n g w i t h the same t o p i c , that we r i s k e d the penalty which has f a l l e n upon us.... Once more a cause has t r i -umphed by the f a l l of i t s defenders ... and has gained a hearing from the dock that i t would never have won from the p l a t f o r m .... ... This b a t t l e w i l l end, as every other such b a t t l e has ended, i n the triumph of a Free Press .... 1 ° On a t e c h n i c a l i t y , Bradlaugh and Mrs. Besant won an appeal, and at once published a new pamphlet, w r i t t e n by Mrs. Besant, The Law of P o p u l a t i o n : I t s Consequences and i t s Bearing Upon  Human Conduct and Morals. In i t she discussed the popu-l a t i o n problem i n I n d i a and i n I r e l a n d , and the humanitarian reasons f o r making b i r t h c o n t r o l knowledge a v a i l a b l e to a l l . She described various methods - rhythm, withdrawal, douche, baudruche (condom) and the sponge, and warned against r e l i a n c e on l a c t a t i o n . She favored a b o r t i o n only i f a b s o l u t e l y neees sary and concluded, Thus has t h e c e f f o r t to obtain s o c i a l reform gone hand i n hand w i t h that f o r p o l i t i c a l and r e l i g i o u s freedom; the v i c t o r s i n the l a t t e r have been the s o l d i e r s i n the former. Di s c u s s i o n on the p o p u l a t i o n question i s not yet s a f e ; l e g a l penalty threatens those who advocate the r e s t r i c t i o n of b i r t h i n -stead of the d e s t r u c t i o n of l i f e ; .... V/e work f o r the redemption of the poor, f o r the s a l v a t i o n of the wretched; the cause of the people i s the sacredest of a l l causes, and i s the one which i s the most c e r t a i n to triumph, however sharp may be the s t r u g g l e f o r the v i c t o r y . x 9 This p u b l i c a t i o n enjoyed phenomenal sa l e s (200,000 copies i n s i x years) even as f a r away as New South Wales; but no f u r t h e r l e g a l a c t i o n was taken to suppress i t i n the United 20 Kingdom. Mrs. Besant and Bradlaugh were f r e q u e n t l y a t -tacked, however, f o r c o n t r i b u t i n g to "sexual o r g i e s and s o c i a l degradation" because i t was assumed th a t f r e e t h i n k e r s who would approve Drysdale's t h e o r i e s of f r e e love must be wholly depraved. But, they had p r a i s e d Drysdale f o r h i s courage, not f o r h i s philosophy. R e a l l y s i g n i f i c a n t was the f a c t that the d i s t r i b u t i o n of b i r t h c o n t r o l knowledge was now more or l e s s unimpeded i n the United Kingdom. In 1877 or 1878 the Malthusian league was r e v i v e d , w i t h Dr. C H . Drysdale, younger brother of the author of Elements, as p r e s i d e n t , and Annie Besant as s e c r e t a r y . The younger Drysdale's w i f e , Dr. A l i c e V i c k e r y , f i r s t woman doctor, and Edward Truelove were among the members. Dr. H.A. A l l b u t t , a dermatologist, f r e e t h i n k e r and r e p u b l i c a n , 21 joined i n 1880. L i k e the U t i l i t a r i a n s , w i t h whom some were a f f i l i a t e d , these "Malthusians" saw themselves as crusaders against poverty. House-to-house canvasses of working c l a s s areas were conducted, and a monthly j o u r n a l i s s u e d . The  Malthusian became very popular and a t t r a c t e d new members. But, due to the i n f l u e n c e of Mme Helena Betrovna B l a v a t s k y , leader of the Theosophist movement, Mrs. Besant l e f t Free-thought and the Malthusian League. Instead of c o n t r a c e p t i o n , she adopted the view th a t the sexual i n s t i n c t must be c o n t r o l -l e d , and t h a t i t s indulgence should be r e s t r i c t e d to the 22 perpetuation of the ra c e . In 1928, however, she attended a dinner h e l d i n London i n honour of the f i f t i e t h anniversary of the famous Bradlaugh-Besant t r i a l , and i n d i c a t e d that she had amended her c o n v i c t i o n s once more. Wow, she s a i d , she f e l t she had been r i g h t to f o l l o w Madame Blavatsky's views, and t h a t s e l f c o n t r o l was e s s e n t i a l ; but b i r t h c o n t r o l must be promoted f o r m a t e r i a l reasons. J By t h i s time o p p o s i t i o n was beginning to c r y s t a l l i z e , but the e f f o r t s of the i n t e r e s t groups to put an end to t h i s t h r e a t were o n l y p a r t i a l l y s u c c e s s f u l . As has been noted, i n the 1870s the B r i t i s h b i r t h r a t e com-menced a more or l e s s steady de c l i n e which has continued to 2k t h i s day. The f i r s t to c o n t r o l t h e i r f e r t i l i t y were business 25 and p r o f e s s i o n a l f a m i l i e s . ^  Methods were improving and w i t h -drawal popular. From the 1870s, the middle c l a s s e s also married l a t e r . I t i s p o s s i b l e , too, that the s m a l l f a m i l y and "lady" w i f e had become a stat u s symbol and means of s o c i a l 26 upgrading. D.V. Glass suggests t h a t working c l a s s couples who wished to upgrade themselves d i d not r e a l l y accept b i r t h c o n t r o l u n t i l i t was obvious that i t had been adopted by the higher income groups; b u t, once the s t y l e was s e t , they f o l -lowed suit. 2''' The i n t e r e s t groups continued t h e i r overt o p p o s i t i o n , however, and, when, i n 1887 1 Dr. A l l b u t t published The Wife's Handbook - which i n c l u d e d hygiene, p r e - n a t a l and baby care,-the medical p r o f e s s i o n forbade him the r i g h t to p r a c t i s e . Apparently the General Medical C o u n c i l was not only confusing 28 contraception w i t h o b s c e n i t y , but a l s o w i t h a b o r t i o n . The movement i t s e l f continued to be accused of immorality and atheism, but i t found new support from another c o n t r o v e r s i a l body, the Eugenics S o c i e t y f o r R a c i a l Q u a l i t y , founded i n 1883 by S i r F r a n c i s G a l t o n . 2 ^ The Fabian S o c i e t y , a S o c i a l i s t o r g a n i z a t i o n l e d by George -Bernard Shaw, Sidney and B e a t r i c e Webb and o t h e r s , also supported i t . By t h i s time, the term, 30 "Neo-Malthusian" had been coined. However, the d e c l i n i n g b i r t h r a t e took on a new aspect. Alarmed by what they considered a t h r e a t of under-p o p u l a t i o n , the Anglican bishops, at the Lambeth Conference of 1908, condemned contraception and c a s t i g a t e d doctors who provided i n f o r m a t i o n or f i t t e d p a t i e n t s w i t h the Dutch cap, otherwise known as the Mensinga diaphragm, ( I t was invented i n the 1870s by Dr. W i l l i a m Mensinga of Flensburg, and, by 31 1908, was a very popular method). But t h e i r warnings went unheeded. I r o n i c a l l y enough, the B r i t i s h Census of 1911 showed th a t clergymen, doctors and teachers had the smallest f a m i l i e s - three o c c u p a t i o n a l groups o v e r t l y opposed to b i r t h 32 c o n t r o l , but, apparently, the most e f f e c t i v e p r a c t i t i o n e r s . In B r i t a i n , i l l e g a l l y induced abortion was p r e v a l e n t , and, not only dangerous a p p l i a n c e s , but dangerous a b o r t i -f a c i e n t s were being promoted by pharmacists, h e r b a l i s t s , 33 barbers, and market t r a d e r s . Misunderstanding and m i s i n f o r -mation about the r e a l nature and purpose of b i r t h c o n t r o l had become so widespread t h a t Dr. C.V. Drysdale, P r e s i d e n t of the Malthusian League, (son of Dr. C.R. Drysdale, an e a r l i e r p resident and nephew of Dr. George Drysdale, author of Elements of S o c i a l Science) decided i n 1913 to h o l d p u b l i c meetings to c l e a r up some of the confusion. He al s o c i r c u -l a t e d l e a f l e t s , p a r t i c u l a r l y i n working c l a s s d i s t r i c t s , which i n c l u d e d i n f o r m a t i o n on contraception and also about i n f e r t i l i t y . Not long afterwards Marie Stopes, a second woman advocate of sex education and contraception appeared on the scene. Her o r i e n t a t i o n , though i n part s o c i a l and eugenic, was mainly humanitarian and pers o n a l . B i r t h c o n t r o l was f o r her a means of f r e e i n g women from the bondage of numerous and unwanted pregnancies; hence her outlook was a l s o f e m i n i s t and l i b e r t a r i a n . 3 ^ Mrs. Stopes, a b o t a n i s t who had earned a PhD. i n a German U n i v e r s i t y , and whose uncomsummated marriage had been annulled i n 1916, decided to p u b l i s h a book on sex and mar-r i a g e so tha t others could be helped to understand t h e i r own problems. P u b l i c a t i o n was financed by H.V. Roe, one of the founders of Avro A i r c r a f t , whom she l a t e r married. Though i t gave few d e t a i l s about the s u b j e c t , Married Love caused an i n t e r n a t i o n a l s e n s a t i o n . Her readers demanded more p r e c i s e i n f o r m a t i o n , so Dr. Stopes o b l i g e d w i t h Wise Parenthood, i n which she described v a r i o u s methods of i n t e r c o u r s e and b i r t h c o n t r o l , i n d i c a t i n g her p a r t i a l i t y f o r the c e r v i c a l cap. The l a t t e r p u b l i c a t i o n was very c o n t r o v e r s i a l , and even supporters of b i r t h c o n t r o l f e l t t h a t i t was too fra n k and too r e a d i l y a v a i l a b l e to school boys and g i r l s . B e l i e v i n g that she had d i v i n e i n s p i r a t i o n , i n 1920, Dr. Stopes attempted to persuade the Lambeth Conference of th a t year to approve c o n t r a c e p t i o n . Her p r i v a t e l e t t e r to each of the bishops was s t u d i o u s l y ignored. But the opposi-t i o n l o s t ground when Lord Dawson of Penn, p h y s i c i a n to King Georve V, e l e c t r i f i e d a l a y congress i n Birmingham the next year by supporting b i r t h c o n t r o l . H i s stand was backed by Dean Inge ("The Gloomy Dean") of S t . Paul's C a t h e d r a l . As there was new concern f o r maternal and c h i l d h e a l t h , and feminism was growing s t r o n g e r , both the c l e r g y and doctors began to r e l e n t . In 1921 Dr. Stopes and her husband opened the " f i r s t b i r t h c o n t r o l c l i n i c i n the B r i t i s h Empire" i n I s l i n g t o n , where a nurse f i t t e d women w i t h c e r v i c a l caps (known also as "check" or " o c c l u s i v e " p e s s a r i e s ) . As the c l i n i c was i n a mobile van, i t could a l s o be c a l l e d the " f i r s t mobile c l i n i c " i n the wo r l d . Acceptance was handicapped by the atheism of most of her predecessors, and by the advocacy of f r e e love by some of her r i v a l s (Havelock E l l i s and H.G. W e l l s , f o r example), so Mrs. Stopes organized the So c i e t y f o r Constructive  B i r t h C o n t r o l and R a c i a l Progress, appealing f o r members on the grounds of s o c i a l betterment, eugenic improvement of the race and as a preventive of war. In her P r e s i d e n t i a l Address to the S o c i e t y , she s t a t e d that o p p o s i t i o n had a r i s e n because people a s s o c i a t e d b i r t h c o n t r o l w i t h the r a d i c a l i s m and f r e e -t h i n k i n g of Charles Bradlaugh and Annie Besant, but tha t her supporters were r e a l l y not r a d i c a l at a l l . In f a c t , t h e i r c h i e f aim was to help space pregnancies, i n the i n t e r e s t s of the i n d i v i d u a l mother, and of the r a c e . D u t i f u l C h r i s t i a n s could now discuss i t , f o r the f a c t s were innocent enough. In her book, Contraception Mrs. Stopes a l s o accused the Roman C a t h o l i c s of d e l i b e r a t e l y confusing "Onanism" w i t h b i r t h c o n t r o l . A few months a f t e r her I s l i n g t o n c l i n i c was opened, the Malthusian league s t a r t e d a c l i n i c at Walworth, using the Dutch cap (diaphragm) - evidence of disagreement between the two over whether the c e r v i c a l cap was s u p e r i o r to the Dutch cap, and, a l s o , whether l a y personnel should be allowed to f i t these devices. There was al s o argument over which type 36 of chemical contraceptive should be used. To encourage s e r v i c e s which would be s t a f f e d by medical p r a c t i t i o n e r s , i n 1924 the Malthusian league organized the S o c i e t y f o r the P r o -v i s i o n of B i r t h C o n t r o l C l i n i c s . As they were able to over-come p a t i e n t shyness more r e a d i l y than men, women doctors were i n great demand, and t r a i n i n g courses f o r both were set 37 up by Dr. Norman R a i r e . As numerous u n r e l i a b l e methods of contraception were s t i l l being s o l d , and, as there was l a c k of s c i e n t i f i c knowledge about the s u b j e c t , the S o c i e t y a l s o supported i n 1927 the o r g a n i z a t i o n of the B i r t h C o n t r o l I n - v e s t i g a t i o n Committee, the membership of which added g r e a t l y 38 t o the p r e s t i g e of the movement. I t became a j o i n t Anglo-American endeavor i n v o l v i n g a l s o the United S t a t e s N a t i o n a l Committee on Maternal Health; and, because of the Comstock Law (see page 47) the work was done i n B r i t a i n . Outgrowths of the B i r t h C o n t r o l I n v e s t i g a t i o n Committee were the Popu-l a t i o n I n v e s t i g a t i o n Committee i n the United Kingdom and the 39 Population C o u n c i l i n the United S t a t e s . In 1927 the Malthusian League decided to d i s s o l v e , paving the way f o r the formation, i n 1 9 3 0 , of the N a t i o n a l  B i r t h C o n t r o l C o u n c i l . S i r Thomas Horder, p h y s i c i a n - i n -o r d i n a r y to H.R.H., the P r i n c e of Wales, p r e s i d e d , and other members i n c l u d e d P.R. Browne, P r o f e s s o r of O b s t e t r i c Medicine, London U n i v e r s i t y ; J . Maynard Keynes; P r o f e s s o r Harold L a s k i ; Bertrand R u s s e l l ; H.G. W e l l s ; C.V. Drysdale and Marie Stopes. (Although she proposed the r e s o l u t i o n which brought the o r g a n i -z a t i o n i n t o b e i n g , she resigned i n 1 9 3 3 ) . In response to the needs of the unemployed, and the pressure of s o c i a l i s t w r i t e r s and t h i n k e r s , i n J u l y , 1 9 3 0 , the M i n i s t r y of Health issued a memorandum a u t h o r i z i n g b i r t h c o n t r o l s e r v i c e s f o r p u r e l y medical reasons (the only government concession to f a m i l y planning u n t i l 1967 when the Family Planning Act was passed). The members of the C o u n c i l were disappointed when l o c a l H e alth A u t h o r i t i e s d i d not take up the challenge. The f o l -lowing year the name of the C o u n c i l was changed to N a t i o n a l  B i r t h C o n t r o l A s s o c i a t i o n , and, i n 1938, the B i r t h C o n t r o l I n v e s t i g a t i o n Committee, the Workers' B i r t h C o n t r o l Group, the S o c i e t y f o r the P r o v i s i o n of B i r t h C o n t r o l C l i n i c s , and the B i r t h C o n t r o l Information Centre (see p. 82 ) amalgamated to form the Family Planning A s s o c i a t i o n . This o r g a n i z a t i o n came i n t o o f f i c i a l existence i n May, 1939» and was loaned 41 premises by the Eugenics S o c i e t y . Opposition to a l l t h i s a c t i v i t y centred mainly i n the League of N a t i o n a l L i f e , organized by Roman and A n g l o - C a t h o l i c s , w i t h a few other r e l i g i o u s elements. Numerous reasons f o r opposing contraception were advanced. Cysts and tumors would r e s u l t , not to mention "Malthusian Uterus" - an ailment of d i r e p r o p o r t i o n s on the i n s i d e , i t was s a i d , which produced 42 "an anxious, drawn expression" on the o u t s i d e . B i r t h r a t e s were low, i n any case, and there were accusations that the f a m i l y planners were encouraging race s u i c i d e . At Marie Stopes's suggestion, the f a m i l y planners decided i t would be wise to in c o r p o r a t e i n t o t h e i r program marriage guidance and p r e - m a r i t a l c o u n s e l l i n g , the diagnosis and treatment of i n f e r t i l i t y as w e l l as c o u n s e l l i n g i n eugenics. The goal of maternal and c h i l d welfare could em-brace t h i s s e r v i c e . In a d d i t i o n , " f a m i l y p l a n n i n g " was adopted as a comprehensive term which would be l e s s contro-43 v e r s i a l and more d e s c r i p t i v e than " b i r t h c o n t r o l " . Some support f o r vo l u n t a r y s t e r i l i z a t i o n was also developing i n the 1 9 3 0 s , hut as was p r e v i o u s l y noted, experiments i n Germany during World War I I made the i d e a unpopular f o r some years afterward. Even f o r o r d i n a r y b i r t h c o n t r o l s e r v i c e s , a problem arose f o r the Family Planning A s s o c i a t i o n because so few doctors knew anything about c o n t r a c e p t i o n . I t was necessary f o r them to r e f e r p a t i e n t s to the v o l u n t a r y c l i n i c s , and, i n cases where p a t i e n t s v i s i t e d the c l i n i c s without r e f e r r a l , the c l i n i c doctors were f o r c e d to break a r u l e of medical e t h i c s - that no-one would t r e a t another doctor's p a t i e n t except i n an emergency, or when he requested such a c t i o n . The problem was p a r t i c u l a r l y d i f f i c u l t f o r women doctors who were i n p r a c t i c e on suffranee i n any case. Inasmuch as the l o c a l B r i t i s h Medical A s s o c i a t i o n branch u s u a l l y disapproved of f a m i l y p l a n n i n g , a l l doctors who worked f o r the v o l u n t a r y c l i n i c s placed themselves i n jeopardy. I f , as sometimes happened, l a y committees set c l i n i c p o l i c i e s without c o n s u l -44 t a t i o n w i t h t h e i r d o c t o r s , f u r t h e r complications arose. The B r i t i s h government would not concede the n e c e s s i t y to i n c l u d e f a m i l y planning s e r v i c e s as a r o u t i n e i n o r d i n a r y maternal and c h i l d h e a l t h u n i t s , but d i d agree to a s s i s t l o c a l Health A u t h o r i t i e s , and the Family Planning A s s o c i a t i o n grew r a p i d l y , using the premises of the l a t t e r . The L o c a l Health A u t h o r i t i e s a l s o provided some f i n a n c i a l h e l p . By I 9 6 7 , when the government accepted more r e s p o n s i b i l i t y , the FPA was op e r a t i n g more than 900 c l i n i c s , over 90 percent housed i n L o c a l Health A u t h o r i t y , Maternal and C h i l d Health Centres, or h o s p i t a l premises. Apart from medical o f f i c e r s and nurses, the c l i n i c s are s t i l l run mainly "by volunteers who serve as r e c e p t i o n i s t s , i n t e r v i e w e r s and supply c l e r k s . The L o c a l Health A u t h o r i t i e s are now allowed to set up f a m i l y planning s e r v i c e s themselves, but, because some of the members of the o l d i n t e r e s t groups i n o p p o s i t i o n are s t i l l i n f l u e n t i a l i n some cases, the government does not push them. The m a j o r i t y of L.H.A.s s t i l l p r e f e r to leave i t to the FPA, and provide f i n a n c i a l support. In a d d i t i o n to making s e r v i c e s a v a i l a b l e to married couples, the FPA now accepts s i n g l e women and, besides conventional methods of c o n t r a c e p t i o n , accepts the usefulness of a b o r t i o n as a back-up f o r accident or ignorance. The Family Planning A s s o c i a t i o n continues to t r a i n medical and 46 paramedical personnel. Increased government s e r v i c e s v i a area h e a l t h a u t h o r i t i e s are being considered, but a c t i o n i s 47 u n l i k e l y f o r s e v e r a l y e a r s . In summary, l e a d e r s h i p i n the f a m i l y planning movement i n the United Kingdom came from the educated c l a s s e s . ' Motives were numerous and v a r i e d , but a l l were d i r e c t e d to s o c i a l r e -form of one s o r t or another. Opposition c r y s t a l l i z e d i n the p o l i t i c a l , commercial, r e l i g i o u s and medical arenas, but ac-ceptance by the general p u b l i c was growing as the needs of the s o c i e t y changed. The volunteers hastened t h i s process through t h e i r p u b l i c promotion, but, to the end of 1969» p o l i t i c a l sup-p o r t was s t i l l h e s i t a n t . The Family Planning A s s o c i a t i o n was very h e l p f u l i n the e a r l y f i n a n c i n g of the I n t e r n a t i o n a l Planned Parenthood Fe d e r a t i o n , but, before c o n s i d e r i n g the o r i g i n and development of th a t o r g a n i z a t i o n , i t i s necessary to look at the p a r a l l e l development of the movement, also as a means of s o c i a l reform, i n the United States of 48 America. FOOTNOTES - Chapter I xG-eorge Cadbury, "The Role of the I n t e r n a t i o n a l Planned Parenthood Federation", Stuart Mudd, ed., The Po p u l a t i o n  C r i s i s and the Use of World Resources, The Hague, 1 9 6 4 , p. 369 2James A l f r e d F i e l d , "Beginning of the B i r t h C o n t r o l Movement," Essays on P o p u l a t i o n . Chicago, 1 9 3 1 , p. 2 5 8 . 3 l b i d » , "The Malthusian Controversy", p. 1 5 . (Malthus's mathematics have since been questioned.) ^Thomas R. Malthus, Essay on the P r i n c i p l e of Po p u l a t i o n  as I t A f f e c t s the Future Improvement of Mankind, 5th ed., V o l . 1 , Book 1 , Chapter 1 , (John Murray) London, 1 8 1 7 , P. 3 ^ . ^ I b i d . , Chapter I I , p. 2 5 . 6 I b i d . , (J.M. Dent) London, 1 8 1 6 , V o l . I I , Chapter V I I , p. 6 9 . 7 I b i d . . (John Murray) London, 1 8 1 7 , V o l . I l l , Chapter I I I , pp. 111-114. 8 I b i d . , V o l . I l l , Chapter IV, pp. 1 15-117 . 9 I b i d . , V o l . 1 , Book 1 , Chapter I I , p. 2 0 . x^John P e e l & Malcolm P o t t s , Textbook of Contraceptive  P r a c t i c e , Cambridge, 1 9 6 9 , P» 2» Place was l a t e r a c t i v e i n the f i g h t to r e p e a l the Combination Laws, and f o r the Reform B i l l of 1 8 3 2I ± xHimes, o p . c i t . , pp. 2 1 3 - 1 7 ; Pryer, o p . c i t . , p. 82. 1 2»A.M." (John S t u a r t M i l l ) i n The Black Dwarf, 27 November 1 8 2 3 ; No. 22^ page 7 5 6 , c i t e d F r y e r , p. 8 9 . l^The L e t t e r s of Queen V i c t o r i a : A S e l e c t i o n of Her  Majesty's Correspondence Between the Years 1837 and 1861, Arthur Christopher Bacon and Viscount Esher, eds. V o l . I , London, 1 9 0 7 , p. 3 2 1 . 14 W i l l i a m L. Langer, "Disguised I n f a n t i c i d e " , G a r r e t t Hardin, ed., P o p u l a t i o n , E v o l u t i o n and B i r t h C o n t r o l , 1 9 6 9 , pb, pp. 1 9 4 - 9 6 . F r y e r , o p . c i t . , pp. 3 ^ - 5 , 41. See also K i n g s l e y Davis, "P o p u l a t i o n " , Louise B. Young, ed., P o p u l a t i o n i n P e r s p e c t i v e , New York, 1968, pb, pp. 1 1 6 - 2 1 . / 1^James A l f r e d F i e l d , o p . c i t . , p. 86, 87; a l s o F r y e r , o p . c i t . , p. 124, 178. • ^ F r y e r , o p . c i t . , pp. 1 3 f - l 4 6 . 18 Charles Bradlaugh, defendant, The Queen V Charles  Bradlaugh and Annie Besant, London, 1877> P« i» ii» -^Annie Besant, The Law of P o p u l a t i o n ; I t s Consequences  and I t s Bearing Upon Human Conduct and i vJora!s, Jj'reetnought P u b l i s h i n g Co., London, n.d., p. 48. 2 0¥alter R. A r n s t e i n , The Bradlaugh Case, Oxford, 1 9 6 5 , p. 22. 21Marie Stopes, E a r l y Days of B i r t h C o n t r o l , London, 1 9 2 3 , p. 2 3 ; Himes, o p . c i t . , p. 2 5 7 . 2 2 A n n i e Besant: An Autobiography, The Theosophical P u b l i s h i n g House, London (1908), pp. 242 - 4 4 . ^ A r t h u r H. Nethercot, The Last Four L j y e s of Annie Besant, London, 1963., p. 3 9 3 . 2**James A l f r e d F i e l d , Op.Cit., p. 2 1 3 ; K i n g s l e y Davis, "P o p u l a t i o n " , S c i e n t i f i c American, September, 1963* 209 ( 3 ) : 6 2 - 7 1 . 25 Frank W. N o t e s t e i n , Dudley K i r k , & Sheldon Segal, "The Problem of P o p u l a t i o n C o n t r o l " , The P o p u l a t i o n Dilemma, P h i l i p M. Hauser, ed., 2nd ed. pb. Englewood C l i f f s , 1 9 6 9 , p. 141. ?6 J.A. & O l i v e Banks, Feminism and Family P l a n n i n g i n V i c t o r i a n England, L i v e r p o o l , 1964, pp. 1, 5 , 1 2 3 ; I r e l a n d was an exception because of l a t e marriage. N o t e s t e i n , K i r k , S egal, o p . c i t . , p. 142. 2^D.V. G l a s s , ed., I n t r o d u c t i o n to Malthus, London, 1 9 5 3 , PP. ^7 - 5 0 . 28 P e e l and P o t t s , o p . c i t . , pp. 7 4 , 7 6 . 2^C.P. B l a c k e r , "Family Planning and Eugenic Movements i n the Mid-Twentieth Century", The Eugenics Review, January, 1 9 5 6 , 4 7 , 4, pp. 2 2 6 - 2 7 . 30 Himes, o p . c i t . , p. 257• 3 1 I b i d . , p. 2 1 1 . P e e l & P o t t s , o p . c i t . , p. 2 1 . 3 3 i b i d . , p. 2 3 . 34c.P. B l a c k e r , o p . c i t . , p. 226. ^^Marie Stopes, o p . c i t . , pp. 20-25; Marie Carmichael Stopes, Contraceptiort, London, 1 9 2 3 , p. 6 9 . 3 6 p e e l & P o t t s , o p . c i t . , p. 75 . 3 7 p r y e r , o p . c i t . , p. 2 7 8 . 3^Among i t s members were Lord B r a i n , S i r Alexander Carr-Saunders, and S i r J u l i a n Huxley. There was one holder of the Order of M e r i t , two Nobel P r i z e winners, two P r e s i -dents of the Royal S o c i e t y , one P r e s i d e n t of the Royal College of P h y s i c i a n s , two Regius P r o f e s s o r s of Medicine, two Oxford and Cambridge c o l l e g e heads, and f o u r other Fellows of the Royal S o c i e t y . Margaret Pyke, "Family P l a n n i n g , An Assessment," The Eugenics Review, J u l y , 1963» P»6. 3 9 P e e l & P o t t s , op. c i t . , p. 3 6 . ^°Blacker, o p . c i t . , p. 2 2 6 ; P e e l & P o t t s , o p . c i t . , p. 13-^ M a r g a r e t Pyke, o p . c i t . , p. 7 . ^ 2 F r y e r , o p . c i t . , p. 2 9 6 . ^3(3.P. B l a c k e r , "The I n t e r n a t i o n a l Planned Parenthood Federation: Aspects of I t s H i s t o r y " , The Eugenics Review, October, 1 9 6 4 , p. 1 3 8 ; a l s o "Family Planning and Eugenic Movements", o p . c i t . , p. 2 2 8 . ^ e e l & P o t t s , o p . c i t . , p. 14. ^ M a r g a r e t Pyke, op. c i t . , p. 8 . ^ " F a m i l y Planning S e r v i c e s , a Guide f o r S o c i a l Workers," The Family P l a n n i n g A s s o c i a t i o n , Nov. 1968 ( l e a f l e t ) ; Family P l a n n i n g on Five Continents, IPPF, London, August, 1 9 6 9 , p. 3 1 . 47 Family P l a n n i n g . J u l y , 1 9 7 0 , pp. 4 5 - 6 . 48 George Cadbury, I n t e r v i e w , O a k v i l l e , O n t a r i o , 7 . 1 2 . 6 9 . > CHAPTER -II The S o c i a l Reformers: The United States of America In the United States the "birth c o n t r o l movement was s t a r t e d by Robert Dale Owen, son of the S c o t t i s h reformer already mentioned. An admirer of Bentham and P l a c e , the younger Owen had emigrated from B r i t a i n i n 1825* He had acquired a copy of Every Woman's Book and was urged to have i t published i n the new country. In s p i t e of h i s r e f u s a l a prospectus was i s s u e d . But he maintained h i s d e c i s i o n u n t i l someone c i r c u l a t e d anonymous.suggestions about h i s m o r a l i t y . Owen then f e l t o b l i g e d to make h i s p o s i t i o n c l e a r . In 1831 he published h i s own 72-page bo o k l e t , Moral Physiology: or a B r i e f and P l a i n T r e a t i s e on the Population Question. In i t he gave s o c i a l and eugenic arguments f o r f a m i l y l i m i t a -t i o n and, d e s c r i b i n g the physiology of reproduction as he understood i t , gave d e t a i l s regarding withdrawal, the condom and the sponge. The book, which was also p r i n t e d and s o l d i n the United Kingdom, earned the p r a i s e of ex-President James Madison and o t h e r s . Owen d i d not make promotion of c o n t r a -ception a l i f e t i m e avocation however. Prom I 8 3 6 he entered p o l i t i c s , promoting education, emancipation, and s p i r i t u a l i s m . He a l s o helped to found the Smithsonian I n s t i t u t i o n i n Washington, D.C.1 Nevertheless, h i s Moral Physiology was the b a s i s on which Dr. Charles Khowlton could b u i l d . Khowlton, the f i r s t of the medical p r o f e s s i o n i n the United States to promote b i r t h c o n t r o l , i n 1832 or 1833 pub-l i s h e d f o r h i s own p a t i e n t s , F r u i t s of Philosophy, ... showing how d e s i r a b l e i t i s , both i n a p o l i t i c a l and a s o c i a l p o i n t of view, f o r mankind to be able to l i m i t , at w i l l , the number of t h e i r o f f s p r i n g , without s a c r i f i c i n g the pleasure that attends the g r a t i f i c a t i o n of the reproductive i n s t i n c t . Knowlton noted that Malthus had suggested no s o l u t i o n but c e l i b a c y , and that the absence of b i r t h c o n t r o l encouraged p r o s t i t u t i o n and intemperance. E a r l y marriages were im-p o s s i b l e . Human nature would not change, and, without b i r t h c o n t r o l , the mind would become u n s e t t l e d and judgment waiver. A l l men had a r i g h t to the knowledge. He discussed v a r i o u s methods, d i s c a r d i n g withdrawal as u n s a t i s f a c t o r y , and condoms because they were r e l a t e d to the prevention of vene-r e a l disease. His v e r s i o n of the rhythm method was i n c o r r e c t , and recommendations of douching were l a t e r proven u n r e l i a b l e , 2 but Knowlton did advocate the sponge. He had been prosecuted and j a i l e d already i n the Massachusetts courts when a student ( f o r i l l e g a l d i s s e c t i o n , and f o r peddling a book on materialism) and was n o t punished f o r the booklet on b i r t h c o n t r o l . Since h i s medical c o l -leagues would give him no support, he decided not to pursue the t o p i c . F r u i t s of Philosophy was r e p r i n t e d i n B r i t a i n , and enjoyed some p o p u l a r i t y among working c l a s s r a d i c a l s and f r e e t h i n k e r s , and i t was destined to become i n t e r n a t i o n a l l y known as the focus of the Bradlaugh-Besant t r i a l already r e -f e r r e d to i n Chapter *T. In the meantime, another f l u r r y of 3 excitement arose i n the State of New York. In 1847 John Noyes founded the c o n t r o v e r s i a l Oneida Community, which f l o u r i s h e d near Syracuse f o r about t h i r t y y e a r s . I t was a r e l i g i o u s " P e r f e c t i o n i s t " and communal s o c i e t y which p r a c t i s e d complex marriage and mating f o r eugenic reasons. As an unorthodox i n t e r p r e t e r of the B i b l e and opponent of mar-ri a g e as a sacrament, and as an advocate of c o i t u s reservatus 4 and the sexual r i g h t s of women, Noyes was f i e r c e l y c r i t i c i z e d . H i s o r g a n i z a t i o n e v e n t u a l l y broke up, and i s remembered to-day mainly f o r i t s business a c t i v i t i e s - c a r r i e d on from 1881 -as a s t e e l t r a p and s i l v e r w a r e manufacturing company - "Oneida" and "Community" being well-known trade names.^ The c i r c u l a t i o n of pornography was i n c r e a s i n g i n New York State and, i n 1868, a f t e r a campaign l e d by the YMCA, the General Assembly made d i s t r i b u t i o n of such m a t e r i a l an off e n s e . Contraception was also forbidden as another form of obsc e n i t y . Other States followed s u i t , and, i n 1873, the Federal P o s t a l Law was amended to f o r b i d the use of the mails f o r obscene m a t e r i a l , i n c l u d i n g i n f o r m a t i o n about b i r t h con-t r o l or contraceptive s u p p l i e s . This e f f e c t i v e l y blocked a c t i o n i n f a v o r of contraception by a l l but the bravest of 6 s o c i a l reformers. Chief enforcer was Anthony Comstock, a drygoods s a l e s -man who i s s a i d to have had a g u i l t complex about h i s y o u t h f u l sexual a b e r r a t i o n s . He also founded the New York S o c i e t y f o r the Suppression of Vice i n 1873• B e l i e v i n g h i m s e l f i n s p i r e d by God and a love of c h i l d r e n , Comstock held the unshakeable c o n v i c t i o n that " i n f i d e l i t y ( i . e . atheism) and obsce n i t y shared the same bed...." Dealers i n contraception were " a b o r t i o n i s t s " , and f o r them he had no p i t y . Dancing, the-i a t r e , a r t and press s e n s a t i o n a l i s m were e q u a l l y r e p r e h e n s i b l e . With the support of Theodore Roosevelt and the YMCA, Comstock was appointed a s p e c i a l i n s p e c t o r of the post o f f i c e , and commenced h i s crusade. Through posing as one seeking i n -formation f o r h i s a i l i n g w i f e , or through h i r e d decoys or f a l s e m a i l i n g addresses, Comstock assembled evidence -a b o r t i f i c i e n t s , contraceptives and obscene p u b l i c a t i o n s -and was r e s p o n s i b l e f o r the a r r e s t of more than 3*600 persons, the m a j o r i t y of whom were convicted and not only f i n e d (up to g $ 5 , 0 0 0 ) , but j a i l e d as w e l l . In order to maintain support, Comstock f r e q u e n t l y i n v i t e d s e l e c t audiences to view choice 9 items of pornography before they were destroyed. So i n f l u -e n t i a l was he that few of the medical p r o f e s s i o n would stand against him. In f a c t , supporting the Comstock view, some of the medical j o u r n a l s even j u s t i f i e d t h e i r p o s i t i o n by ex-p l a i n i n g t h a t , i f the b i r t h r a t e were to d e c l i n e , medical 10 incomes might a l s o d e c l i n e 1 Comstock a l s o wrote Traps  f o r the Young i n which he described how he had lo c a t e d these items, and h i s experiences i n b r i n g i n g the offenders to t r i a l . A l l s o c i a l i l l s were due to " e v i l r e a d i n g " , he s a i d . ± X The f i r s t United States c i t i z e n to run f o u l of the new law (soon to be known as the Comstock Law) was Dr. Edward B l i s s Foote, whose pamphlet, Words i n P e a r l ("Pearl" - a p r i n t e r ' s t y p e s i z e ) s o l d more than 250,000 copies before i t was suppressed i n I876. Dr. Foote advocated contraception f o r the c h r o n i c a l l y i l l , or p h y s i c a l l y or mentally handi-12 capped, f o r f a m i l y w e l f a r e , and to reduce disea s e . In b r i e f , I would, i f p o s s i b l e , so f i x thin g s that none but the healthy people should procreate at a l l . and that wives should procreate only ax w i l l . 1 - 3 A few other proponents of the s o c i a l and eugenic b e n e f i t s of b i r t h c o n t r o l were a l s o e f f e c t i v e l y s i l e n c e d by the Comstock Law and i t s circumvention was a long, slow process, which l a s t e d about f o r t y years. The f i r s t f a v o rable opinion to appear i n any medical j o u r n a l i n the world was p r i n t e d i n the Michigan Medical News i n 1882. Here O.E. H e r r i c k maintained that contraception was a woman's r i g h t , and al s o the only reasonable a l t e r n a t i v e to the widespread scourge of a b o r t i o n . On the grounds of f a m i l y welfare and m a r i t a l harmony, and as an antidote to poverty and delinquency, he re c e i v e d some medical support. Those who agreed w i t h him observed that b i r t h c o n t r o l was e s s e n t i a l to compensate f o r the men who would not r e f r a i n from i n t e r c o u r s e even when t h e i r wives' h e a l t h was at stake. Among the oppo-s i t i o n were some who averred that i t was a woman's " r e l i g i o u s " 14 duty to al l o w a man h i s " r i g h t s " . Around the turn of the century Dr. W i l l i a m J . Robinson, who ed i t e d s e v e r a l medical p e r i o d i c a l s , wrote many a r t i c l e s f e a t u r i n g c o n t r a c e p t i o n . In 1905 he al s o published a l e a f l e t on the subject f o r p h y s i c i a n s . Based on the needs of the poor and of eugenics, Dr. Robinson a l s o persuaded Dr. Abraham Jacob! to i n c l u d e support f o r b i r t h c o n t r o l i n h i s P r e s i d e n t i a l Address to the American Medical A s s o c i a t i o n i n 1 9 1 2 . But the AMA was not ready to pass a r e s o l u t i o n to t h i s e f f e c t f o r more than f i f t y years. About t h i s time, however, the cause was taken up by Margaret Sanger - perhaps the most ene r g e t i c and f e a r l e s s of a l l the b i r t h c o n t r o l p i o n e e r s . Though her d e c i s i o n s were sometimes u n p r e d i c t a b l e , and her personal r e l a t i o n s h i p s some-times unhappy, her determination on t h i s subject was such t h a t she i s recognized as the founder of the b i r t h c o n t r o l movement i n the United S t a t e s , and a l s o of the I n t e r n a t i o n a l Planned Parenthood F e d e r a t i o n . No obstacles were too g r e a t , no c r i t i c i s m too harsh, and no j a i l too f o r b i d d i n g (she was j a i l e d e i g h t times) to shake her d e c i s i o n to make i t accept-able as a h e a l t h s e r v i c e . Using an a b i l i t y to f i n d staunch supporters among wealthy p h i l a n t h r o p i s t s , and considerable s k i l l i n g a i n i n g the maximum news mileage from every s i t u -a t i o n , she worked single-mindedly f o r b i r t h c o n t r o l u n t i l she was over e i g h t y . She died i n 1 9 6 6 , at the age of eighty-seven, having l i v e d to see the 5 0 t h Anniversary of the Planned Parent-hood movement i n the United S t a t e s , and i t s acceptance as a government r e s p o n s i b i l i t y i n many c o u n t r i e s . Because the t a c t i c s of the Women's L i b e r a t i o n and other r a d i c a l movements to-day are s i m i l a r , and because other countries sometimes borrowed her i d e a s , s p e c i a l a t t e n t i o n w i l l be given to her s t o r y . Margaret Higgins Sanger was the s i x t h of eleven c h i l d r e n , and r a i s e d i n Corning, New York. The f a m i l y was always i n s t r a i t e n e d circumstances because her f a t h e r , a stone-c u t t e r , besides being a s o c i a l i s t was als o a v o c a l f r e e t h i n k e r . In consequence, l i t t l e employment came h i s way. Her mother, died i n her f o r t i e s from t u b e r c u l o s i s , exacerbated, Margaret maintained, by too much c h i l d b e a r i n g . As a P u b l i c Health Nurse, she had f i r s t haM experience w i t h New York slum co n d i -t i o n s , and w i t h the ignorance of the women-about t h e i r own bodies, about reproduction and about venereal d i s e a s e ; P o l i -t i c a l l y she became a supporter of the a n a r c h i s t , Emma Goldman, and was a f r i e n d of B i l l Haywood, a leader i n the I n d u s t r i a l Workers of the Worid("The Wobblies"). Emma was als o an advo-cate of b i r t h c o n t r o l , and Margaret, too, saw i t as a weapon i n the s t r u g g l e to gain r e v o l u t i o n a r y muscle f o r the working cl a s s e s against the " c a p i t a l i s t e x p l o i t e r s " . 1 ^ A f t e r ten years of dom e s t i c i t y as the wife of W i l l i a m Sanger, an a r c h i t e c t cum p a i n t e r , she returned to nursing i n 1912. Though they now had two sons and a daughter, and Sanger shared her r a d i c a l p o l i t i c a l views, Margaret was chafing against household r e s p o n s i b i l i t i e s and longing f o r a more a c t i v e part i n the c l a s s struggle she b e l i e v e d was coming. A new i n f l u e n c e on her t h i n k i n g was provided by the works of Havelock E l l i s , a world famous sexual p s y c h o l o g i s t who b e l i e v e d t h a t more honesty about human s e x u a l i t y should be a part of person a l r e l a t i o n s h i p s and that women should have the same sexual freedom and s a t i s f a c t i o n as men. In a d d i t i o n , w i t h depressing r e g u l a r i t y she saw mothers of la r g e f a m i l i e s i n the slums d ie of s e l f - i n d u c e d a b o r t i o n or $5.00 v i s i t s to neighborhood quacks. Doctors would not r i s k g i v i n g them i n -formation about c o n t r a c e p t i o n , and Mrs. Sanger began to see h e r s e l f as the leader of a campaign f o r a l l these g o a l s . She i d e n t i f i e d the death of one Sadie Sachs from i l -l e g a l l y induced a b o r t i o n as the event which t r i g g e r e d her d e c i s i o n to campaign f o r b i r t h c o n t r o l f o r a l l who wanted i t . Though i n f o r m a t i o n on methods e x i s t e d i n s e v e r a l nearby l i -b r a r y sources, and many Americans were already p r a c t i s i n g b i r t h c o n t r o l , Mrs. Sanger claimed t h a t she had to v i s i t France to get i t from the r e v o l u t i o n a r y l a b o r movement t h e r e . I t may be that American doctors would not help her, or t h a t , as David Kennedy suggests, the f a m i l y t r i p to France f o r a year i n 1913 was arranged by her husband i n a l a s t d i t c h attempt to ho l d her a f f e c t i o n and i n t e r e s t . But, whatever the reason, a f t e r a few months i n P a r i s , Margaret and the c h i l d r e n returned to New York ahead of him. From th a t time on they l i v e d separate , . l 6 l i v e s * Back i n the United S t a t e s , she devoted much time to e d i t i n g Woman Rebel, an eight page p e r i o d i c a l which was d e d i -cated to r a d i c a l p o l i t i c s and the advocacy of b i r t h c o n t r o l . Because i t d i d not describe contraception methods, i t only challenged the law f o r b i d d i n g o b s c e n i t y . A f t e r s e v e r a l i s s u e s , Mrs. Sanger was charged w i t h v i o l a t i o n s , but no i n -formation was given as to how the law had been broken. A f t e r arranging w i t h her husband f o r the care of the c h i l d r e n , she adopted an assumed name and f l e d the country. A v a r i e t y of reasons have "been given, none of which i s very c l e a r , but i t appears t h a t she f e l t she had to have time to marshal more support. (She had also w r i t t e n and published 100,000 copies of a pamphlet on methods, which d i d break the law, but Family  L i m i t a t i o n was not yet d i s t r i b u t e d . ) Margaret s a i l e d from Montreal f o r England and, while at sea, sent a message i n s t r u c t i n g her supporters to release the pamphlet. C i r c u l a t i o n was obtained through trade unions and other sympathetic o r g a n i z a t i o n s , and i t was e n t h u s i a s t i c a l l y r e c e i v ed i n working c l a s s d i s t r i c t s . On a r r i v a l i n England she met the C.V. Drysdales, leaders of the Neo-Malthusian League. They applauded her e f f o r t s to challenge the Comstock Law, t o l d her the h i s t o r y of b i r t h c o n t r o l and the law i n t h e i r country, arranged f o r her to do research on the subject at the B r i t i s h Museum, and introduced her to Havelock E l l i s . Of considerable s i g n i f i c a n c e i s the f a c t t h a t the Malthusians and E l l i s urged her to drop her exaggerated stances against c a p i t a l i s m , r e l i g i o n and mar-r i a g e , and to concentrate on one i s s u e only - the p r o v i s i o n of b i r t h c o n t r o l i n f o r m a t i o n and s e r v i c e s . Another s i g n i f i c a n t i n f l u e n c e arose from a v i s i t to The Hague, where Dr. Johannes Rutgers, who had pioneered contraception i n h i s country, urged her to work f o r medical support, and to promote the use of the 17 Mensinga diaphragm. She followed t h i s a d v ice, by and l a r g e , but was never able to overcome her o l d resentments e n t i r e l y or to a l l o w others to l e a d her movement. E a r l y i n 1915 > W i l l i a m Sanger was a r r e s t e d by one of Comstock's spies f o r g i v i n g him a copy of Family L i m i t a t i o n . Rather than pay a f i n e , Sanger e l e c t e d to s t i c k "by the p r i n c i -p l e t h a t the l e a f l e t was not obscene, and chose to serve a t h i r t y - d a y j a i l sentence i n s t e a d . This l e f t the c h i l d r e n without adequate s u p e r v i s i o n , so Margaret had to hurry home. On a r r i v a l she found b i r t h c o n t r o l under p u b l i c d i s c u s s i o n i n the p r e s s , and a group of i n f l u e n t i a l women ready to help her campaign. The nuclear f a m i l y , w i t h i t s r i g h t to independence was an e s t a b l i s h e d c h a r a c t e r i s t i c of urban l i v i n g ; i n t e r e s t i n eugenics was growing; and, i n s p i t e of warnings of population d e c l i n e s and race s u i c i d e , many of the middle and upper income groups were p r a c t i s i n g b i r t h c o n t r o l . The emancipation of women, i n c l u d i n g a s i n g l e standard, was much di s c u s s e d . As E l l i s had al s o convinced her t h a t , besides being a p r o t e c t i o n f o r women, b i r t h c o n t r o l was also a key to race betterment and adjustment of population to world resources, she took up the cause w i t h renewed energy."^ At the same time, she was informed t h a t , i f she would promise to obey the law i n f u t u r e , the charges against her over Woman Rebel would be g r e a t l y reduced. Mrs. Sanger r e f u s e d , and braced h e r s e l f f o r the t r i a l . Her hopes of more p u b l i c i t y f o r her cause were disappointed, however, f o r the charges were suddenly dropped i n February, 1916. Some s a i d the a u t h o r i t i e s d i d not want to make a martyr of her . Whatever the reason, she was then f o r c e d to f i n d a new means of c h a l l e n g i n g the law. In 1916 she organized a b i r t h c o n t r o l c l i n i c i n Browns-v i l l e , a Brooklyn slum. I t was i n s t a n t l y popular; a l e g a l charge under Section 11^2 of the New York State Penal Code was s p e e d i l y l a i d ; and Mrs. Sanger and her s i s t e r , E t h e l Byrne, were a r r e s t e d . E t h e l was t r i e d f i r s t , convicted and given a 30-day sentence. She achieved world fame by going on a hunger s t r i k e - a f a m i l i a r f e m i n i s t technique. Force-feeding l e n t drama to the s i t u a t i o n and Margaret, out on h a i l , issued d a i l y b u l l e t i n s ' on her c o n d i t i o n . F i n a l l y E t h e l ' s h e a l t h was so endangered t h a t Margaret guaranteed to the Governor t h a t E t h e l would take no f u r t h e r p a r t i n the movement whi l e her case was being appealed, and E t h e l was r e l e a s e d . Margaret's own case f o l l o w e d . She was o f f e r e d a l i g h t sentence i f she would obey the law, but refu s e d , s t a t i n g that she could not obey a law f o r which she had no re s p e c t . Her 30-day sojourn i n j a i l provided her w i t h an opportunity to c r i t i c i z e c o n d i t i o n s on the i n s i d e , and, before she was r e l e a s e d , she refused to be f i n g e r p r i n t e d on the ground that she was not a c r i m i n a l . I t was decided to appeal her c o n v i c t i o n , but the case was l o s t . In handing down h i s d e c i s i o n however, the judge re-defined S e c t i o n 11^5 so t h a t , having provided f o r doctors to give contraceptive i n f o r m a t i o n " f o r the cure and prevention of disease" to men (treatment against venereal d i s e a s e ) , he broadened "disease" to mean any sickness or d i s o r d e r - which meant that b i r t h c o n t r o l advice could be given to married women to p r o t e c t t h e i r h e a l t h . B i r t h c o n t r o l c l i n i c s could now be e s t a b l i s h e d l e g a l l y so long as they were run by 19 d o c t o r s . This r u l i n g d i d not allow b i r t h c o n t r o l f o r any and a l l purposes, and there was argument over whether a l l r e -s t r i c t i o n s should be a b o l i s h e d , or whether b i r t h c o n t r o l should be made a v a i l a b l e only by a doctor. Quackery would be p o s s i b l e i f a l l r e s t r i c t i o n s were removed, so Mrs. Sanger favored "doctors o n l y " . Support from the doctors themselves was the n ext chal1eng e. Dr. Robert Latou D i c k i n s o n , a l e a d i n g gynaecologist and head of the N a t i o n a l Committee on Maternal Welfare, wanted t o see h i s colleagues i n v o l v e d i n b i r t h c o n t r o l to prevent damage to p a t i e n t s ' h e a l t h from v i s i t s to quacks. But other doctors feared that quacks might f u n c t i o n j u s t the same, and were r e l u c t a n t to be inv o l v e d i n a f i e l d i n which such a c o n f l i c t could occur. Many of those who favored b i r t h c o n t r o l d i s l i k e d Mrs. Sanger's t a c t i c s and h e s i t a t e d to be ass o c i a t e d w i t h her se n s a t i o n a l i s m . Others argued against b i r t h c o n t r o l f o r non-medical - i . e . eugenic or socio-economic reasons. Most doctors were poorly informed i n any case, and l a c k of a simple, e f -f e c t i v e b i r t h c o n t r o l method also obstructed t h e i r co-operation. To begin to answer t h e i r needs i n a s c i e n t i f i c way, Mrs. Sanger organized a C l i n i c a l Research Bureau i n New York and h i r e d a woman doctor to open i t i n January, 1923* Dr. Dickinson had run a hos p i t a l - b a s e d r e f e r r a l s e r v i c e , but medical e t h i c s had prevented p u b l i c i t y , and the Sanger p r o j e c t , under no such r e s t r a i n t s , was much more s u c c e s s f u l . I t s f i n d i n g s were not e l i g i b l e f o r p u b l i c a t i o n i n reputable medical j o u r n a l s , however, so i t was obvious that there was a need f o r mutual support. Dr. Dickinson t r i e d to arrange f o r a medical r e s e a r c h c o u n c i l to take over the Bureau, but h i s colleagues h e s i t a t e d because of Mrs. Sanger's connection w i t h i t , and Mrs. Sanger refused to give up her predominant p o s i t i o n . In t h i s she was supported by her non-medical board members - noted b i o l o -g i s t s , s o c i o l o g i s t s and the l i k e , and the c o n f l i c t was i n s o l u b l e . At l e a s t part of the r e s p o n s i b i l i t y f o r the tragedy of continuing medical ignorance of contraception had to be l a i d to Margaret Sanger. Had she r e l i n q u i s h e d c o n t r o l of the c l i n i c to Dickinson i n 1925, she would have f a c i l i t a t e d r e s e a r c h , opened up the best medical journals f o r the p u b l i c a t i o n s of t e s t r e s u l t s , and made the c l i n i c much more e f f e c t i v e as a t r a i n i n g centre f o r phy s i c i a n s i n t e r e s t e d i n contraception .... M i l l i o n s of women, f i n d i n g no help w i t h regard to contraception from orthodox medicine, turned to the quacks. And as i n the nineteenth century, the absence of c l e a r l e g a l r e g u l a t i o n s exacerbated the s i t u a t i o n . 2 0 The impasse continued, although by 1930 there were f i f t y - f i v e c l i n i c s i n twenty-three c i t i e s . When Mrs. Sanger f i n a l l y detached the Bureau from the American B i r t h C o n t r o l League and l e f t t h a t o r g a n i z a t i o n terself the same year, a l s o 1930, Dr. Dickinson joined the Board of the Bureau. At the same time Margaret decided to organize a r e p e a l of the Comstock Law and to replace i t w i t h a b i l l to allo w doctors, h o s p i t a l s or dru g g i s t s f r e e use of the m a i l s . A monster lobbying campaign was set i n motion i n Washington, and, by 1931, she was t e s t i f y i n g t h a t b i r t h c o n t r o l would lower i n f a n t and maternal mortality r a t e s and improve f a m i l y w e l f a r e . She also noted i t s eugenic value and relevance to 21 world population problems. There was considerable C a t h o l i c o p p o s i t i o n on the ground t h a t b i r t h c o n t r o l would encourage immorality and weaken f a m i l y r e l a t i o n s h i p s . A d e c l i n i n g popu-l a t i o n would be another consequence, and a g r i c u l t u r e , business and i n d u s t r y would s u f f e r . An executive of the Metropolitan L i f e Insurance Company supported the C a t h o l i c c l a i m . Mrs. Sanger r e p l i e d t h a t b i r t h c o n t r o l would ease poverty and unemployment and reduce t a x e s . Without i t , the lower income groups would continue to m u l t i p l y , whereas middle and upper income l e v e l s would s h r i n k , causing an imbalance i n the age s t r u c t u r e . In the end, i n s p i t e of her campaign, no amendment to the law was passed. I t was being circumvented i n any case by a wider i n t e r p r e t a t i o n of the law, so the matter was no longer urgent. The only remaining obstacle f o r doctors was the r u l e which prevented i m p o r t a t i o n of c o n t r a c e p t i v e s . I t was i n 1936 th a t the Second Federal C i r c u i t Court (New York, Connecticut and Vermont) decided t h a t importation of contraceptives was p e r m i s s i b l e . Increased l e g a l l a t i t u d e and a broader d e f i n i t i o n of h e a l t h as w e l l as Mrs. Sanger's p e r s i s t e n c e , brought American Medical A s s o c i a t i o n approval of b i r t h c o n t r o l f o r other than p a t h o l o g i c a l reasons i n 1937* In the meantime, during the twenty years since Browns-v i l l e , Margaret Sanger had promoted the f e m i n i s t side of her case by w r i t i n g two books, Woman and the New Race, and The  P i v o t of C i v i l i z a t i o n , i n which she urged women to a s s e r t t h e i r r i g h t to v o l u n t a r y motherhood, pleaded f o r p o p u l a t i o n " q u a l i t y -not q u a n t i t y " , and f o r spacing or l i m i t i n g pregnancies to prevent the a r r i v a l of unwanted c h i l d r e n . Marxism, trade unions and the Roman C a t h o l i c Church were attacked f o r t h e i r 22 o p p o s i t i o n . During t h i s p e r i o d a l s o , Mrs. Sanger formed a new group, the American B i r t h C o n t r o l League i n 1921, severing her con-n e c t i o n w i t h the conservative N a t i o n a l B i r t h C o n t r o l League. To honor the new o r g a n i z a t i o n , she scheduled a p u b l i c meeting i n New York's Town H a l l to discuss B i r t h C o n t r o l : I s I t Moral? Two thousand people crowded i n t o the h a l l to hear i t , but when Margaret a r r i v e d with the guest speaker, the p o l i c e were bar-r i n g the door. I t i s s a i d t h e i r presence was i n s p i r e d by Archbishop ( l a t e r C a r d i n a l ) P a t r i c k J . Hayes. An eager press p r i n t e d a c o n t i n u i n g debate between Mrs. Sanger and His Grace, which was more noted f o r i t s heat than i t s reason. But Margaret managed to t u r n the p u b l i c i t y to the advantage of her cause -23 as she was a l s o able to do on many other s i m i l a r occasions. Funds to continue the campaign were always a problem, however. A f t e r a quiet divorce from W i l l i a m Sanger i n 1 9 2 0 , Margaret acquired an ardent admirer i n J . Noah S l e e , P r e s i d e n t of the Three-in-One O i l Company. He followed her wherever she went, seeking to marry her. A f t e r numerous r e f u s a l s , she f i n a l l y agreed to marry him, provided they could l i v e inde-pendent l i v e s and she would be allowed to pursue her b i r t h c o n t r o l campaign under her own name and without i n t e r f e r e n c e . From Slee she got funds f o r the B i r t h C o n t r o l League, and a l s o f o r the C l i n i c a l Research Bureau. He also supported the N a t i o n a l Committee on Federal l e g i s l a t i o n f o r B i r t h C o n t r o l , and c o n t r i b u t e d to i n t e r n a t i o n a l conferences. When she f e l l out w i t h the League (again, over P r e s i d e n t i a l p r e r o g a t i v e s ) Slee withdrew h i s League support as w e l l , g i v i n g her considerable f i n a n c i a l leverage to maintain her l e a d e r s h i p . When the N a t i o n a l Committee d i s s o l v e d there was a move to co-ordinate the work of the ABCL and the C l i n i c a l Research Bureau and, i n l a t e 1937> the B i r t h C o n t r o l C o u n c i l of America was the r e s u l t . A year l a t e r i t was suggested t h a t the P r e s i -dent should be a man, and the C o u n c i l was replaced by the B i r t h C o n t r o l Federation of America, headed by Dr. Richard N. P i e r s o n . "A few years l a t e r , (l9*+2) over Mrs. Sanger's loud p r o t e s t s , the name was changed to Planned Parenthood Federa-2k t i o n of America, and others took over the r e i n s . This coincided w i t h Mr. Slee's s e r i o u s i l l n e s s and Mrs. Sanger's departure f o r A r i z o n a to nurse him. She r e t a i n e d c o n t r o l of the C l i n i c a l Research Bureau, however, u n t i l I 9 6 0 , and she had two more major c o n t r i b u t i o n s to make to the movement i n 25 the United S t a t e s . From 1938 Mrs. Sanger and her supporters had pressed i n c r e a s i n g l y hard f o r b i r t h c o n t r o l f a c i l i t i e s i n the US government h e a l t h s e r v i c e s . I t was not u n t i l her f r i e n d s h i p w i t h Eleanor Roosevelt l e d the l a t t e r to i n t e r v e n e , and White House Conferences were c a l l e d , t h a t the logjam of h e s i t a t i o n was broken. In 19^2 the US P u b l i c H e a l t h Service (USPHS) was able to begin t o o f f e r , both through i t s venereal disease c o n t r o l program and maternal and c h i l d h e a l t h s e r v i c e , the necessary i n f o r m a t i o n and s u p p l i e s . Her second c o n t r i b u t i o n was to arrange some of the i n i t i a l f i n a n c i n g f o r research i n t o hormonal methods of b i r t h c o n t r o l . She had always wanted a simple, r e l i a b l e method, the use of which would not be r e l a t e d to the time of i n t e r c o u r s e , and which would not r e q u i r e any p a r t i c u l a r p r i v a c y . In 1952 she secured a la r g e donation f o r Dr. Gregory Pincus to s t a r t the research which culminated i n 27 "The P i l l " , a combination of progesterone as a suppressant of o v u l a t i o n and estrogen (used by Dr. John Rock i n the treatment of s u b - f e r t i l i t y ) . A f t e r World War I I , the pressures f o r b i r t h c o n t r o l on a la r g e s c a l e , both w i t h i n the United States and i n developing count r i e s brought a considerable change i n p u b l i c a t t i t u d e s i n i t s f a v o r . R e s t r i c t i v e laws began to be repealed and, by 1970, Planned Parenthood was o p e r a t i n g 620 c l i n i c s i n 350 c i t i e s i n 40 s t a t e s , and the D i s t r i c t of Columbia, and had served more than 5°0,000 women. I t s budget was $30 m i l l i o n , and 57 percent of i t s p a t i e n t s had incomes of l e s s than $75*00 a week. A f t e r a slow s t a r t , p u b l i c agencies were al s o s e r v i n g an a d d i t i o n a l 2 0 0 , 0 0 0 , but an estimated 5*3 m i l l i o n low income women i n the United States would use the s e r v i c e i f i t were provided. As an i l l u s t r a t i o n of the change i n p u b l i c a t -t i t u d e s , i n the 1960s P r e s i d e n t s Kennedy, Johnson and M x on, i n v a r y i n g degrees, supported f a m i l y planning, and they were e v e n t u a l l y j o i n e d by former P r e s i d e n t s Eisenhower and Truman as members of a sponsors' c o u n c i l of Planned Parenthood. In summary, as i n the United Kingdom, l e a d e r s h i p i n the f a m i l y planning movement i n the- United States came from the educated c l a s s e s . Motives v a r i e d , "but s o c i a l reform was the u l t i m a t e g o a l . Opposition came from the same i n t e r e s t groups - p o l i t i c a l , commercial, r e l i g i o u s and medical - "but many members of the general p u b l i c were already p r a c t i s i n g b i r t h c o n t r o l . Death c o n t r o l and i n d u s t r i a l i z a t i o n had created the c l i m a t e , the volunteers speeded i t s wider accept-ance but, i n the United S t a t e s , t o o , at the end of 1969, government support was not yet e f f e c t i v e ! . S i m i l a r develop-ments were o c c u r r i n g i n c o n t i n e n t a l Europe and East A s i a . FOOTNOTES - Chapter I I Peter F r y e r , The B i r t h C o n t r o l l e r s , London, 1965, ph., pp. 103-09; See a l s o Norman E. Himes, Medical H i s t o r y  of Contraception, B a l t i m o r e , 1963» P"b •, p. 224. ^Charles Knowlton, M.D., F r u i t s of Philosophy: An Essay  on the P o p u l a t i o n Question, 2nd ed. w i t h notes, Preethought P u b l i s h i n g Company, London, n.d. pp. 12-17» 45; Rhythm was f i r s t e x plained, though i n c o r r e c t l y , by Adam R a c i b o r s k i , a P o l i s h p h y s i o l o g i s t , about 1850. F r y e r , o p . c i t . , p. 124. ^Himes, o p . c i t . , p. 233* 4 B i b l e Communism: A Compilation from the Annual Reports  of the"Oneida A s s o c i a t i o n and i t s Branches', Brooklyn, 1853, pp. 5 - 3 8 . Coitus reservatus - a technique i n which no e j a c u l a t i o n takes p l a c e , and detumescence takes place s l o w l y , over a prolonged p e r i o d . ^ F r y e r , o p . c i t . , p. 154. ^Anthony Comstock, Traps f o r the Young, Robert Bremner, ed., Cambridge, 1967> PP. v i i - x i v . ^ I b i d . , pp. v i i , v i i i , 22; Also F r y e r , o p . c i t . , p. 213. 8Anthony Comstock, o p . c i t . , p. 137; Also F r y e r , o p . c i t . , p. 131. 9Anthony Comstock, o p . c i t . , p. x i i . x 0Himes, o p . c i t . , p. 286. ± xComstock, o p . c i t . , p. x x i i i . 1 2 F r y e r , o p . c i t . , p p . 130-32. 1 3 H i m e s , o p . c i t . , p. 279. ^ I b i d . , pp. 286-87. x^Da.vid M. Kennedy, B i r t h C o n t r o l i n America: The Career  of Margaret Sanger, New Haven, 1970, pp. 1-16. l 6 I b i d . , pp. 4 - 3 5 . 1 7 I b i d . , p. 3 2 . x ^ E m i l y Taft Douglas, Margaret Sanger: Pioneer of the Future, New York, 1970, p. 6 9 . Kennedy, o p . c i t . , pp. 87-8. 20 I b i d . , pp. 211-12. 2 1 I b i d . , p. 233. 22 Margaret Sanger, Women and the Hew Race, New York, 1920. The P i v o t of C i v i l i z a t i o n . New York. 1922. passim. 2 3 p r y e r , o p . c i t . , pp. 236-37. 2^Kennedy, o p . c i t . , pp. 256-57. 25Lawrence Lader and M i l t o n M e l t z e r , Margaret Sanger; Pioneer of B i r t h C o n t r o l , New York, I 9 6 9 , p. 155 . Renamed the Margaret Sanger Research Bureau, i t i s being amalgamated w i t h Columbia U n i v e r s i t y ' s I n t e r n a t i o n a l I n s t i t u t e f o r the Study of Human Reproduction, and w i l l add to i t s education f o r marriage and c l i n i c s e r v i c e s , s u r g i c a l s t e r i l i z a t i o n and research i n s t e r i l i z a t i o n . 2^Kennedy, o p . c i t . , pp. 266-67. 2 ? l b i d . , p. v i i ; Emily Taft Bouglas, op. c i t . , pp. 254-55. . 2 t 5"The Future i s Now", Planned Parenthood - World P o p u l a t i o n , New York, l e a f l e t , 1970. CHAPTER I I I Some Developments i n Europe and East A s i a On the European continent Malthusian leagues were forming - i n the Netherlands, 1881; i n Prance, i n 1885 (though i t was not a c t i v e u n t i l 1898) ; Bohemia, 1901; Spain, 1904; Belgium, 1906; S w i t z e r l a n d , 1908; Sweden, 1911; and I t a l y , 1913; but they were not very vigorous and, w i t h two exceptions, l i t t l e progress was made. The most s u c c e s s f u l among them was the Dutch Nieuw  Malthusiaanschen Bond (1MB), founded to promote the spacing of pregnancies f o r b e t t e r maternal and i n f a n t h e a l t h . One of the l e a d e r s , Dr. A l e t t a Jacobs, saw contraception as a weapon i n the s t r u g g l e f o r women's r i g h t s , and i n 1890 opened the f i r s t b i r t h c o n t r o l c l i n i c i n Europe i n Amsterdam. In her search f o r the best method, she came to p r e f e r the Mensinga diaphragm, and i t s use i n the NMB became so wide-spread that i t was dubbed the "Dutch cap". By 1892 four f r e e c l i n i c s were o p e r a t i n g . Another member of the NMB was Dr. Johannes Rutgers, of The Hague, who opened other c l i n i c s and t r a i n e d midwives and working c l a s s women to f i t the d e v i c e s . His p o l i c y l e d to a s p l i t between the medical and non-medical workers i n the movement, and Dr. Jacobs resigned i n d i s i l l u s i o n m e n t . (By the time Mrs. Sanger v i s i t e d Dr. Rutgers he must have changed h i s mind, f o r i t has been noted t h a t he recommended against u s i n g non-medical personnel to f i t diaphragms. Around the t u r n of the century, r i g h t wing c l e r i c a l p a r t i e s i n the Netherlands became i n f l u e n t i a l enough to ob-s t r u c t the o r g a n i z a t i o n , and i t was not u n t i l the 1930s t h a t i t r e v i v e d and the p o l i c y breach was healed. The p r e s t i g e of the NMB was considerably enhanced when Queen Wilhelmina presented i t w i t h a medal of honour and a c h a r t e r , and p r a i s e d the o r g a n i z a t i o n as a p u b l i c b e n e f a c t i o n . I t now operates f i f t y f a m i l y planning centres i n the Netherlands, and the Dutch government has r e c e n t l y given f i n a n c i a l support to the I n t e r n a t i o n a l Planned Parenthood Federation."'" Another Western European country i n which the b i r t h c o n t r o l movement i s w e l l advanced i s Sweden. As i n other r e l a t e d f i e l d s , Swedish p o l i c y i s o f t e n i n c o r r e c t l y reported and misunderstood. Although the Malthusian league was formed i n 1911» progress was non-existent u n t i l 1933 when Mrs. E l i s e Ottesen-Jensen organized the Swedish N a t i o n a l Union f o r Sexual Information. Advocating sex i n f o r m a t i o n i n the schools and u n i v e r s i t i e s , she was supported by l a b o r and adult education groups. T r a i n i n g was arranged f o r teachers, youth leaders and d o c t o r s , and Mrs. Ottesen-Jensen h e r s e l f gave many of the l e c t u r e s . Among opponents were members of the Lutheran Church. Another negative i n f l u e n c e was a book by Al v a and Cunnar Myrdal, P o p u l a t i o n C r i s i s , i n which a t t e n t i o n was drawn to the d e c l i n e of the Swedish b i r t h r a t e . P r o - n a t a l i s t p o l i c i e s , i n c l u d i n g g l o r i f i c a t i o n of the f a m i l y and s o c i a l r e s p o n s i -b i l i t y , and tax and other i n c e n t i v e s were o f f e r e d by the government. Family P l a n n i n g , which had been a v a i l a b l e through maternal and c h i l d h e a l t h centres, was forb i d d e n . The b i r t h -r a t e continued to d e c l i n e , however, i n d i c a t i n g p r i v a t e use of b i r t h c o n t r o l . As the population a l s o continued to i n c r e a s e , r e s t r i c t i o n s were l i f t e d i n 1938, f a m i l y planning s e r v i c e s were r e s t o r e d , and a b o r t i o n , on socio-medical grounds was l e g a l i z e d . However, contraception continued to be advocated 2 i n preference to a b o r t i o n . Besides her other educational a c t i v i t i e s , Mrs. Ottesen-Jensen opened homes f o r unmarried mothers, and gave l e c t u r e s on f a m i l y planning and prevention of venereal disease to the Swedish army. (Her i n t e r n a t i o n a l a c t i v i t i e s are.described on page 83») In 19^6 sex education i n the schools became compulsory, and Mrs. Ottesen-Jensen a s s i s t e d i n the pr e p a r a t i o n of a teacher's guide. She was honored by the IPPF i n 1965 because, at the age of 80, she, to o , was s t i l l a c t i v e i n the movement. Today, the Swedish Family P l a n n i n g A s s o c i a t i o n operates three f a m i l y planning ce n t r e s , t r a i n s medical and paramedical personnel, i s p r e s s i n g f o r improved f a m i l y planning s e r v i c e s i n r u r a l areas, pro-motes sex education and i s represented on two government commissions on sex education and a b o r t i o n . The Swedish government supports the voluntary o r g a n i z a t i o n , d i r e c t s sex education programs in.the s c h o o l s , t e s t s imported condoms and, at the u r g i n g of Mrs. Ottesen-Jensen, has adopted a p o l i c y of g i v i n g f o r e i g n a i d i n the f a m i l y planning f i e l d . Through the Swedish I n t e r n a t i o n a l Development Agency (SIDA), two of the c h i e f h e n e f i c i a r i e s have been Ceylon and P a k i s t a n . In 1968, f a m i l y planning a s s i s t a n c e amounted to twelve percent of the t o t a l Swedish f o r e i g n a i d budget, and $500,000 of i t 3 was a l l o c a t e d to the IPPP. A f t e r World War I I new a c t i v i t y took place i n some other cou n t r i e s of Western Europe - Denmark, Prance and West Germany, f o r example - but, because of o p p o s i t i o n or imagined opposi-t i o n , i n no country was there an a l l - o u t program e i t h e r by a f a m i l y planning a s s o c i a t i o n or government. In the communist countries of Eastern Europe the German Democratic R e p u b l i c , Poland and Y u g o s l a v i a have f a m i l y planning o r g a n i z a t i o n s a f f i l i a t e d w i t h the IPPP. There i s general c u r i o s i t y about f a m i l y planning i n the People's Republic of China (Mainland), where the population i s estimated to have reached approximately 750 m i l l i o n . Although no o f f i c i a l i n -formation i s a v a i l a b l e , and i t i s not known whether any v o l u n t a r y a c t i v i t y i s present, c e r t a i n trends are evident. Government p o l i c y advocates l a t e marriage and s m a l l f a m i l i e s . B i r t h c o n t r o l i n f o r m a t i o n and a l l methods are provided, p a r t i -c u l a r l y the IUD. O r a l contraceptives are i n use. Abortions and s t e r i l i z a t i o n s are i n c r e a s i n g . How extensive are the f a m i l y p l a n n i n g s e r v i c e s i s not known, but i t would seem t h a t at l e a s t some Maternal and C h i l d Health Centres, h o s p i t a l s and medical schools are i n a c t i o n , and mobile medical teams are being used on an i n c r e a s i n g s c a l e . The postwar world has been f a s c i n a t e d by (but somewhat misinformed on the reasons f o r ) the very r a p i d r e d u c t i o n of n e a r l y 50 percent i n the crude b i r t h r a t e of Japan i n the decade f o l l o w i n g 1949. The Japanese record does not neces-s a r i l y prove th a t a s i m i l a r speedy r e d u c t i o n i n b i r t h r a t e s i s p o s s i b l e i n other Asian c o u n t r i e s j u s t because they, t o o , are A s i a n . The d i f f e r e n c e l i e s i n the f a c t t h a t , to a l l i n t e n t s and purposes, Japan i s a modern i n d u s t r i a l i z e d so-c i e t y l i k e those i n the West, and t h e r e , too, a demographic t r a n s i t i o n has occurred. Irene Taeuber t r a c e s i t s beginning back to 1868, when the M e i j i R e s t o r a t i o n began to open the country to Western i d e a s . As a f e u d a l and a g r a r i a n s o c i e t y of 35 m i l l i o n , Japan had an a r c h a i c s o c i a l and p o l i t i c a l s t r u c t u r e , but i t was u n i t e d and d i s c i p l i n e d . M o r t a l i t y r a t e s were h i g h enough to keep population growth w i t h i n the absorptive c a p a c i t y of the economy. But, from the beginning of the modernizing p e r i o d , m o r t a l i t y began to d e c l i n e . As i t was f o l l o w e d by a f e r t i l i t y d e c l i n e , n a t u r a l increase d i d not reach 2 percent per year u n t i l a f t e r World War I I . But then, a baby boom occurred, s i m i l a r to that i n other i n d u s t r i a l i z e d n a t i o n s . D e a t h r a t e s continued to d e c l i n e , and population growth became a c r u c i a l problem. To counter-act i l l e g a l a b o r t i o n , and f o r eugenic and h e a l t h reasons, s t e r i l i z a t i o n , induced a b o r t i o n , and contraception were l e g a l i z e d under the new Eugenic P r o t e c t i o n Law of 1948. A l -though a b o r t i o n was not provided by the p u b l i c s e c t o r , so many were performed that i t was feared t h a t , not only the h e a l t h , but the l i v e s of many women were threatened. So, i n 1952, the government inaugurated a p o l i c y s t r e s s i n g that v o l u n t a r y contraception was p r e f e r a b l e and f o r both men and women. Through i n d i v i d u a l approaches and mass p u b l i c education 6 i t was very s u c c e s s f u l . In Japan, population pressures on food, space, employment, and education, combined w i t h a t o t a l t r a n sformation of the n a t i o n a l economy to b r i n g about a s i t u -a t i o n p a r a l l e l to European i n d u s t r i a l i z e d s o c i e t i e s . These c o n d i t i o n s , coupled w i t h government encouragement of the use of b i r t h c o n t r o l , brought about a long term, and then a sharp drop i n f e r t i l i t y . Two c h i l d r e n at most, per f a m i l y , became 7 the vogue. In the meantime, concurrent w i t h demographic change i n the t w e n t i e t h century a v o l u n t a r y e f f o r t to promote b i r t h c o n t r o l a l s o developed. The Family P l a n n i n g A s s o c i a t i o n of Japan began i n New York i n 1920, where Baroness Ishimoto, then w i f e of a leader i n the Kaizo (Young Reconstruction League), took a business course under YWCA auspices. I n s t r u c t e d by her engineer husband to f i n d a u s e f u l r o l e f o r h e r s e l f i n s e r v i n g the modernizing needs of her country, Shidzue decided that she would s t a r t a b i r t h c o n t r o l movement - to r e l i e v e maternal and c h i l d h e a l t h problems and to r a i s e the s t a t u s of Japanese women. She met Mrs. Sanger, and, through her h e l p , the Kaizo set up a b i r t h c o n t r o l committee, t r a n s l a t e d Family L i m i t a t i o n , and began a sustained campaign i n Japan. Mrs. Sanger was soon i n v i t e d to v i s i t the country as one of four speakers on Western thought - A l b e r t E i n s t e i n , Bertrand R u s s e l l and H.G. Wells were the o t h e r s . (The Kaizo suggested Mrs. Sanger should speak about the prevalent western concern about the "Yellow P e r i l " and i t s teeming m i l l i o n s as a t h r e a t to peace.) The Japanese government's reluctance to admit her was w e l l p u b l i c i z e d , and, although she was not allowed to give p u b l i c addresses, she gave many to p r i v a t e o r g a n i z a t i o n s , and he l d numerous press i n t e r v i e w s . Baroness Ishimoto went on w i t h her to attend the F i f t h I n t e r n a t i o n a l Malthusian and B i r t h C o n t r o l Conference i n London i n 1922. By 1935» the m i l i t a r i s t f a c t i o n had the upper hand i n Japan and the b i r t h c o n t r o l c l i n i c s were c l o s e d . The Baroness was a r r e s t e d , and then kept under a long s u r v e i l l a n c e . Her husband changed h i s p o l i t i c a l sympathies and there was a d i -vorce. Shidzue then married Kanjo Kato, a la b o r l e a d e r , and i n 19^6 both were e l e c t e d as S o c i a l Democrats to the Japanese Parliament. As an advocate of an end to m i l i t a r i s m and r a i s i n g the s t a t u s of women, Mrs. Kato was able to i n f l u e n c e the w r i t i n g of the new postwar c o n s t i t u t i o n . The b i r t h c o n t r o l c l i n i c s were reopened and run under the d i r e c t i o n of a Dr. Majumi, w i t h the co-operation of the Health M i n i s t r y . In 1951 the Japanese once more i n v i t e d Mrs. Sanger to v i s i t , but t h i s time General Douglas MacArthur, commander of the occupation f o r c e s , refused her a v i s a . An outspoken American f e m i n i s t i n Japan may have been considered undesirable f o r a number of reasons - i n c l u d i n g her advocacy of contraception i n preference to a b o r t i o n - but Mrs. Sanger and the Tokyo press claimed t h a t 73 g m i n o r i t y Roman C a t h o l i c i n t e r e s t s were "behind the d e c i s i o n . She was able to pay her v i s i t i n 195^, however, sponsored "by the M a i n i c h i P r e s s . She spoke to a committee of the Japanese Die t and gave many other t a l k s and i n t e r v i e w s , but the need 9 and means f o r b i r t h c o n t r o l were already e s t a b l i s h e d . In 1952 the Cabinet C o u n c i l announced t h a t b i r t h c o n t r o l s e r v i c e s would be made a v a i l a b l e f r e e f o r a l l through Maternity and C h i l d H e a l t h Centres. Besides a b o r t i o n , the c h i e f methods were condoms and rhythm. (Ora l contraceptives and IUDs are not yet i n c l u d e d i n the o f f i c i a l program.) With the added support of i n d u s t r y and the v o l u n t e e r s , a b o r t i o n r a t e s began to d e c l i n e and the use of conventional contraception to r i s e . In 1955 more than 1 ,100,000 abortions were done. In 1967 t h i s f i g u r e had dropped to 7^0,000. Health Insurance schemes were f i n a n c i n g b i r t h c o n t r o l f o r the employed, and welfare 10 agencies f o r the i n d i g e n t . This a l l - o u t a t t a c k on the population problem had im-proved h e a l t h and welfare aspects and r e l i e v e d the h i g h youth dependency r a t i o which threatened economic recovery. The b i r t h r a t e i s now about 19 per thousand - s t i l l more than double the deathrate of 7> and the r a t e of population increase i s 1.1 percent per year. The population i s approximately 103.5 m i l l i o n ; the doubling time i s estimated to be 63 years; and 25 percent of the population i s under the age of 15 - about 11 the same r a t i o as i n most European i n d u s t r i a l i z e d c o u n t r i e s . But there i s growing concern about the long term e f f e c t of d r a s t i c a l l y lowered f e r t i l i t y r a t e s on the age s t r u c t u r e of the p o p u l a t i o n , and f e a r t h a t , as the r a t e of increase of the l a b o r force has slowed, there w i l l be a labor shortage, and i n c r e a s i n g numbers of middle and o l d e r age Japanese. The i n t e r i m report of the P o p u l a t i o n Problems I n q u i r y C o u n c i l , dated August 5 , 1969, notes t h a t , since 1957, f e r t i l i t y r a t e s have been lower than r e q u i r e d f o r a s t a t i o n a r y p o p u l a t i o n ( 2 . 0 i n s t e a d of 2.13 c h i l d r e n ) . The nuclear f a m i l y , m a t e r i a l v a l u e s , and inadequate housing have con t r i b u t e d to the adoption of the s m a l l f a m i l y norm; and the C o u n c i l recommends that the country should take immediate a c t i o n to r e c t i f y these i n f l u -ences through s o c i a l reforms. But, as the e f f e c t s of any increase i n the f e r t i l i t y r a t e w i l l not be f e l t f o r at l e a s t f i f t e e n y e a r s , other i n t e r i m measures are also e s s e n t i a l : the movement of lab o r must be c o n t r o l l e d , retirement age r e - s t u d i e d , p r o d u c t i v i t y increased and l a b o r - i n t e n s i v e a c t i v i t i e s d i s -couraged. (The C o u n c i l does not take up the question of whether c o n t i n u i n g economic expansion i s the only means of 12. achieving improvements i n the standard of l i v i n g . ) In s p i t e of t h i s new preoccupation w i t h i t s own popu-l a t i o n problems, Ja.pan has announced f o r e i g n a i d i n f a m i l y p l a n n i n g , f o r the IPPF and the United Nations Fund f o r Popu-l a t i o n A c i t i v i t i e s . D i r e c t a i d i s a l s o being given i n Indo-n e s i a . Doctors, v i s u a l a i d s , e d u c a t i o n a l m a t e r i a l s and v e h i c l e s are being provided. In I 9 6 8 the Fa.mily Planning Federation of Japan set up the Japanese Org a n i z a t i o n f o r I n t e r n a t i o n a l Co-operation i n Family P l a n n i n g to r a i s e money from p r i v a t e s e c t o r s and government and to m o b i l i z e Japanese ex p e r t i s e i n the i n t e r n a t i o n a l f i e l d . In summary, the volunteers i n f a m i l y planning i n the i n d u s t r i a l i z e d countries were educated s o c i a l reformers, many were p a c i f i s t , and a l l were of middle c l a s s background. Over the years t h e i r o b j e c t i v e s broadened from improving working c l a s s wages to i n c l u d e women's r i g h t s , maternal and c h i l d h e a l t h , race betterment, f a m i l y w e l f a r e , n a t i o n a l and i n t e r n a t i o n a l w e l l - b e i n g and, f i n a l l y , conservation of r e -sources and the environment. Family planners i n i n d u s t r i a l i z e d c o u n t r i e s were not i n f l u e n t i a l i n reducing b i r t h r a t e s u n t i l other f a c t o r s , p a r t i -c u l a r l y death c o n t r o l and economic c o n d i t i o n s , had induced a downward t r e n d . Their frequent c o n f l i c t s w i t h a u t h o r i t y were w e l l p u b l i c i z e d , however, and increased p u b l i c i n t e r e s t and knowledge of methods was the r e s u l t . Because t h e i r movement was c o n t r o v e r s i a l , and aroused o p p o s i t i o n i n p o l i t i c a l , commercial, c l e r i c a l and medical c i r c l e s , i n p a r t i c u l a r , defensive t a c t i c s were introd u c e d . I t was claimed that b i r t h c o n t r o l was the only s e n s i b l e a l t e r -n a t i v e to a b o r t i o n . I t was a means of spacing pregnancies f o r b e t t e r h e a l t h of both mother and c h i l d . Diagnosis and t r e a t -ment of i n f e r t i l i t y , marriage c o u n s e l l i n g , g e n e t i c c o u n s e l l i n g , and f a m i l y l i f e education were added as time went on. Because there was no background of i n f o r m a t i o n or t r a i n i n g i n t h i s f i e l d , a workable system had to be developed through t r i a l and e r r o r . But the experience of the volunteers was a v a l u a b l e foundation on which government programs could be b u i l t . Much of the f i n a n c i a l support f o r Family Planning A s s o c i a t i o n s i n modernizing c o u n t r i e s has come through the I n t e r n a t i o n a l Planned Parenthood F e d e r a t i o n . FOOTNOTES - Chapter I I I 1 H i s t o r y of Contraceptives, IPPF, London, 196?, pp. 2 3 - 4 . Emily Taft Douglas, Margaret Sanger; Pioneer of the Future, New York, 1970, pp. 82 - 8 3 , 108. 2 Vera Houghton, I n t e r n a t i o n a l Planned Parenthood Federation ( I . P . P . F . ) . I t s H i s t o r y and I n f l u e n c e , IPPF, London, A p r i l , 1962. R e p r i n t from The Eugenics Review, p. 7 . 3 Thorsten S j o v a l l , "Planned Parenthood, Background and Development i n Sweden" paper given at Fourth I n t e r n a t i o n a l Teach-In, Toronto, 27 October 1968; B i r g i t t a L i n n e r , "The Sexual R e v o l u t i o n i n Sweden", Impact, V o l . x v i i i . No. 4 , Oct. D e c , 1968, Sex, Science ana T e c h n o l o g y , UNESCO, pp. 232, 243, 248; Family Planning i n Five Continents, IPPF, London, A p r i l , 1970, pp. 3 0 - 3 7 . 4 I b i d . , pp . 2 5 , 30-37;"Governmental P o l i c y Statements on P o p u l a t i o n : An Inventory," Reports on Population/Family  P l a n n i n g , The P o p u l a t i o n C o u n c i l , February, 1970, pp. 19-20; Dorothy Nortman, Po p u l a t i o n and Family Planning Programs: A Factbook, Population C o u n c i l , Reports on Population/Family P l a n n i n g , J u l y , 1970, p. 355 Leo A. Orleans, "Evidence from Chinese Medical Journals on Current P o p u l a t i o n P o l i c y " , The China Q u a r t e r l y , 0 c t . - D e c , 1969. PP. 137-1^6, c i t e d , Current P u b l i c a t i o n s i n Population/Family P l a n n i n g , No. 7, A p r i l , 1970, Population C o u n c i l , p. 4 . ^ P h i l i p M. Hauser, "World P o p u l a t i o n Growth", P h i l i p M. Hauser, ed., The P o p u l a t i o n Dilemma, Englewood C l i f f s , 1969, p. 17; P o p u l a t i o n was about 25 m i l l i o n i n 1800, about 37 m i l l i o n i n 1880, 50 m i l l i o n i n 1910, and 73 m i l l i o n i n 1940 - a s t e a d i l y i n c r e a s i n g r a t e of growth. "Governmental P o l i c y Statements", o p . c i t . , p. 19* ^Irene B. Taeuber, "Population Growth i n Less Developed Countries," Hauser, ed., o p . c i t . , pp. 47-50. g Emily T a f t Douglas, o p . c i t . , p. 247. 9 I b i d . , p. 251; "Margaret Sanger and the IPPF," P r o c 7th Conference of the I n t e r n a t i o n a l Planned Parenthood F e d e r a t i o n , Amsterdam, 196^, p. 7. •^Family Planning i n Five Continents, p. 27• EWorld Population Data Sheet, P o p u l a t i o n Reference Bureau, Washington, D.C., A p r i l , 1970. x 2 " J a p a n : I n t e r i m Report of the Population Problems I n q u i r y C o u n c i l " , Studies i n -Family P l a n n i n g , No. 56 , The P o p u l a t i o n C o u n c i l , New Xork, August, 1970, pp. 1-4. PART TWO CHAPTER IV I n t e r n a t i o n a l C r o s s - F e r t i l i z a t i o n and Expansion Nor knowest thou what argument Thy l i f e to thy neighbor's creed has l e n t . A l l are needed by each one; ^ Nothing i s f a i r or good alone. I n t e r n a t i o n a l a c t i v i t y i n the f a m i l y p lanning f i e l d began w i t h the F i r s t I n t e r n a t i o n a l Neo-Malthusian Conference h e l d i n P a r i s i n 1900 under the chairmanship of Dr. C.R. Drysdale, brother of the author of The Elements of S o c i a l Science. Suc-ceeding meetings took place i n other European c i t i e s - 1905 i n Lieg e , 1910 i n The Hague, and 1911 i n Dresden. These sessions were spa r s e l y attended underground a f f a i r s -u s u a l l y taken up w i t h tedious debates about the r e l a t i o n of Malthusian p r i n c i p l e s to Marxism. By 1922 however the t o p i c had gained enough i n r e s p e c t a b i l i t y t h a t such a reputable speaker as John Maynard Keynes graced the London program, and over one hundred p h y s i c i a n s attended a se s s i o n devoted to contraceptive t e c h n i q u e s . 2 The F i f t h I n t e r n a t i o n a l Neo-Malthusian and B i r t h C o n t r o l Con-ference i n London i n 1922 was notable f o r the presence of Margaret Sanger, f r e s h from an Asian tour i n which she had been shocked by the c o n d i t i o n of women and c h i l d r e n , and had become convinced that population pressures lead to war. In confirmation of her b e l i e f , Keynes warned that population would become both an economic and a p o l i t i c a l problem. The Conference urged the league of Nations to warn i t s members. Press coverage was e x t e n s i v e . Because she f e l t the message should have an equal impact i n the United S t a t e s , Mrs. Sanger persuaded the American B i r t h C o n t r o l league to i n v i t e the next conference to meet i n New York i n 1925, and financed i t from donations from s u b s c r i b e r s to the B i r t h C o n t r o l Review. More than 1,000 persons from a v a r i e t y of professions, ( i n c l u d i n g medicine), from eighteen count r i e s attended. Two p r a c t i c a l innovations were i n c l u d e d , the delegates heard e v a l u a t i o n s of e x i s t i n g methods of b i r t h c o n t r o l (prepared by Americans) and r e p o r t s of Doctor Stone's work at the Margaret Sanger Research Bureau. As a r e s u l t , the use of the diaphragm and j e l l y was confirmed as the most r e -l i a b l e method to date, and Dr. Dickinson arranged f o r the d e t a i l s to be published i n The Medical J o u r n a l and Record -the f i r s t time such research i n f o r m a t i o n was i n c l u d e d i n a p r o f e s s i o n a l j o u r n a l . This must have been the beginning of world-wide acceptance of the "d & j " method by f a m i l y planners -a p o l i c y to be c r i t i c i s e d l a t e r as a "middle c l a s s " s o l u t i o n unsuited to the p o v e r t y - s t r i c k e n masses of South A s i a . (See Chapter V ) ? Demographers were now assessing the r a t e of population growth and the estimated time r e q u i r e d to add more b i l l i o n s . In the hope of j o l t i n g the League of Nations i n t o r e a l i z i n g how i n e x o r a b l e t h i s increase would be, Mrs. Sanger organized a World Conference on Population i n Geneva i n 1927. Mr. Slee financed the g a t h e r i n g , and Mrs. Stanley McCormick, daughter-i n - l a w of the founder of the I n t e r n a t i o n a l Harvester Company, commenced her i n t e r e s t i n the movement at t h i s time. A s s i s t e d by an able committee which i n c l u d e d J u l i a n Huxley, Mrs. Sanger arranged f o r p a r t i c i p a t i o n by many famous a u t h o r i t i e s . At the l a s t minute, however, the chairman, S i r Bernard M a l l e t t , was warned by the S e c r e t a r y -General of the League, S i r E r i c Drummond, that Europeans would boycott the meeting i f they thought a woman had organ-i z e d i t . There was a l s o r e l i g i o u s o p p o s i t i o n because her name was a s s o c i a t e d w i t h b i r t h c o n t r o l . Mrs. E d i t h How-Martyn, another f e m i n i s t , was a l s o working on the conference. S i r Bernard i n d i c a t e d that the names of a l l women as s o c i a t e d w i t h the program should be removed. The e n t i r e s t a f f r e s i g n e d , but Margaret persuaded them to r e t u r n to t h e i r t a s k s . The meeting was h e l d , and the f a c t s on population became b e t t e r known but the League remained u n a l t e r a b l y opposed to recog-n i t i o n of the problem. Two worthwhile developments d i d , how-ever, emerge w i t h the formation of a continuing Medical Committee (which e v e n t u a l l y became the medical committee of the IPPF) and the I n t e r n a t i o n a l Union f o r the S c i e n t i f i c Study of P o p u l a t i o n , a p r e s t i g i o u s o r g a n i z a t i o n which subse-quently sponsored two f u r t h e r Y/orld Population Conferences, one i n 195^ i n Rome, and another i n 19&5 a ^ Belgrade. That there should he no mistake about i t , i n 1930, the Seventh I n t e r n a t i o n a l B i r t h C o n t r o l Conference was h e l d i n Z u r i c h , and many new goals were de f i n e d . B i r t h c o n t r o l was declared the best way to reduce a b o r t i o n . I t should be part of the p u b l i c h e a l t h s e r v i c e s and of preventive medicine and i n s t r u c t i o n should'ibe included i n the c u r r i c u l a of a l l medical schools and c o l l e g e s . The conference also agreed that no doctor would p r e s c r i b e any chemical contraceptive unless the formula was known to him. S t e r i l i z a t i o n was al s o 5 approved, p a r t i c u l a r l y f o r eugenic reasons. In the same year a B i r t h C o n t r o l I n t e r n a t i o n a l Inform-a t i o n Centre was organized i n London, w i t h Mrs. How-Martyn as Honorary D i r e c t o r and Mrs. Sanger as P r e s i d e n t . This centre made many contacts i n A s i a , and had many v i s i t o r s , i n c l u d i n g J a w a h a r l a l Nehru, then chairman of the Planning Committee of the Indian N a t i o n a l Congress, and Smt. Dhanvanthi Rama Rau, a leader i n the A l l I n d i a Women's Conference, and, l a t e r , founder of the Family Planning A s s o c i a t i o n of I n d i a . A Conference on B i r t h C o n t r o l i n A s i a ( I n d i a , China, Japan) was h e l d i n London i n 1933 to i d e n t i f y o b s t a c l e s to b i r t h c o n t r o l and p o s s i b l e s o l u t i o n s and i t was affirmed t h a t b i r t h c o n t r o l was a necessary c o n d i t i o n of economic develop-ment . As described i n Chapter I I I , i n d i v i d u a l Indians had already s t a r t e d some b i r t h c o n t r o l s e r v i c e s i n t h e i r country, and i n 1934 Mrs. How-Martyn was i n v i t e d to the A l l - I n d i a Women's Conference (AIWC). Mrs. Sanger was i n v i t e d to t h e i r s e s s i o n i n Travancore i n the winter of 1935-36, and Mrs. How-Martyn r e v i s i t e d I n d i a i n 1936-37 and 1937-38. When the work of the Centre was combined wi t h other b i r t h c o n t r o l o r g a n i z a t i o n s i n the United Kingdom i n 1938, Mrs. Rene D a t t a , E n g l i s h wife of an I n d i a n , served as 7 organizer i n I n d i a u n t i l 19^5. Up to World War I I , then, f a m i l y planners i n the United Kingdom and the United States had developed the move-ment to a s t a t e of some, i f not t o t a l , p u b l i c acceptance -as a means of r e l i e v i n g poverty and promoting the welfare of the f a m i l y . Though no n a t i o n a l government programs were i n existence i n e i t h e r country, the Family P l a n n i n g A s s o c i -a t i o n had been organized i n B r i t a i n , and the Planned Parent-hood Federation was soon to emerge from u n i f i c a t i o n i n the United S t a t e s . Comparable groups had developed i n some European c o u n t r i e s and Japan, and some s e r v i c e s and d i s c u s -s i o n had been s t a r t e d by i n d i v i d u a l s i n I n d i a . I n t e r n a t i o n a l conferences were now commonplace, and c r o s s - f e r t i l i z a t i o n among the pioneers and t h e i r o r g a n i z a t i o n s had developed on a d i r e c t b a s i s and under the auspices of the I n t e r n a t i o n a l Information Centre. At t h i s point another r e l a t i v e l y strong i n f l u e n c e entered the i n t e r n a t i o n a l p i c t u r e - from Sweden. A f t e r World War I I Mrs. Ottesen-Jensen r a l l i e d former f a m i l y planning workers i n Europe, and l a i d the foundation f o r a new i n t e r n a t i o n a l v o l u n t a r y o r g a n i z a t i o n . In 19^6, a f r e s h s e r i e s of conferences was inaugurated i n Stockholm, w i t h r e p r e s e n t a t i v e s from B r i t a i n , Denmark, F i n l a n d , Nether-lands, Sweden and the United S t a t e s . I t was agreed t h a t , as the term " b i r t h c o n t r o l " had been dropped i n the United Sta t e s i n favor of "Planned Parenthood" or "Family P l a n n i n g " i n the U.K. and other c o u n t r i e s , i t should also be dropped i n t e r -n a t i o n a l l y . The newer terms more adequately conveyed the broader concept of "spacing" and the treatment of i n f e r t i l i t y Q would be encompassed. As the t h r e a t of over-population was not yet evident to many world l e a d e r s , and as the horror s of H i t l e r ' s s t e r i l i z a t i o n s and genocide were s t i l l f r e s h i n a l l minds, t h i s was the onl y p o l i c y under which an i n t e r -n a t i o n a l v o l u n t a r y o r g a n i z a t i o n of t h i s type could hope to encourage new n a t i o n a l o r g a n i z a t i o n s to serve the h e a l t h and 9 welfare of the masses. I t was agreed to set up an i n t e r i m committee to l a y plans f o r a permanent o r g a n i z a t i o n , and to hold another con-ference i n Cheltenham, England, i n 1948. The Secretary of t h i s committee was Mrs. Dorothy Brush ( l a t e r Walmsley), a p h i l a n t h r o p i s t f r i e n d of Margaret Sanger, whose personal and f i n a n c i a l c o n t r i b u t i o n s were s u b s t a n t i a l . As the B r i t i s h were r e l u c t a n t to play hosts because of war damage, the second conference was organized and financed by Mrs. Sanger v i a Mrs. McGormick's largesse and the B r i t i s h Family Planning A s s o c i a t i o n co-operated. The t o p i c chosen was P o p u l a t i o n and  World Resources i n R e l a t i o n to the Family. l o r d Horder presided and volunte rs from twenty-three coun t r i e s attended. Another I n t e r i m Committee on Planned Parenthood, w i t h two r e p r e s e n t a t i v e s each from B r i t a i n , the Netherlands and Sweden, and three from the United S t a t e s , was set up, and a grant of $5,000 to a s s i s t i n f i n a n c i n g an o f f i c e i n London was given by the Brush Foundation f o r Race Betterment of Cleveland, Ohio. The Eugenics S o c i e t y gave r e n t - f r e e accommodation to the new group as w e l l . From 1949 to 1951 the ICPP met an-n u a l l y i n London, e s t a b l i s h e d contact w i t h groups and support-ers i n some twenty c o u n t r i e s , and made plans f o r r e g i o n a l • committees. The need f o r a simple, cheap, e f f e c t i v e b i r t h 11 c o n t r o l method was also agreed. As i n t e r e s t i n b i r t h c o n t r o l was growing i n I n d i a , and as the question of population growth i n r e l a t i o n to economic needs was beginning to be recognized (John Maynard Keynes had p r e d i c t e d the problem i n 1922 and i t had been con-firmed i n 1951 "by K i n g s l e y D a v i s ) , an economic focus f o r f a m i l y 12 planning a c t i v i t i e s presented i t s e l f . I t was decided to hold the T h i r d I n t e r n a t i o n a l Conference i n Bombay i n 1952. With f i n a n c i a l help from Mrs. Sanger's f r i e n d s , the newly formed Family Planning A s s o c i a t i o n of I n d i a (FPAI), headed by Smt. Rama Rau, undertook to organize i t . The then V i c e - P r e s i d e n t of I n d i a , Dr. S a r v e p a l l i Radhakrishnan, inaugurated the ses-s i o n s . Here i t was agreed to form the I n t e r n a t i o n a l Planned Parenthood Federation, w i t h headquarters i n London. The Family Planning A s s o c i a t i o n s of Hong Kong, I n d i a , the Netherlands, Singapore, Sweden, the United Kingdom, the United States and West Germany were the charter members. Mrs. Sanger and Smt. Rama Rau became j o i n t Honorary P r e s i d e n t s . The former had fought f o r f a m i l y planning f o r n e a r l y f o r t y y e a r s , had seen the movement begin to f l o u r i s h i n the United S t a t e s , and was now i n d u c i n g the b i r t h of an i n t e r n a t i o n a l o r g a n i z a t i o n as w e l l . Smt. Rama Rau symbolized non-Western l e a d e r s h i p , and represented the f i r s t of the developing areas i n which the program could expand. Mrs. Ottesen-Jensen, who had fought f o r f a m i l y planning i n Sweden and had taken the i n i t i a t i v e which l e d to the formation of the new o r g a n i z a t i o n , was e l e c t e d Chairman of the Governing Body. Mrs. Vera Houghton, wi f e of a B r i t i s h Labour M.P., was s e c r e t a r y from 1953 to 1959. A new C o n s t i t u t i o n f o r the Federation was to be drafted, and i t was decided to p u b l i s h a monthly b u l l e t i n , Around the World News of Population and B i r t h C o n t r o l (the t i t l e was e v e n t u a l l y changed to I n t e r n a t i o n a l Planned Parenthood News). The e a r l y issues were financed by the Brush Foundation and e d i t e d by Mrs. Brush, from 1952 to 1957* In i t s f i r s t ten years, i t s c i r c u l a t i o n climbed from 5,000 to 1 3 , 5 0 0 , and i t i s now published i n E n g l i s h , French 13 and German. The h i s t o r y of the Indian Family Planning movement w i l l be given i n the next chapter, but i t i s of i n t e r e s t to note t h a t , s h o r t l y a f t e r the Bombay meeting, Prime M i n i s t e r Nehru recommended to the Indian parliament t h a t f a m i l y planning be included i n the F i r s t Five-Year P l a n . Rs. 6 ,500,000 (-c U.S. $1 ,625,000) were e v e n t u a l l y a l l o t t e d ,14 to the M i n i s t r y of H e a l t h f o r t h i s purpose. In 1953 the Fourth I n t e r n a t i o n a l Conference on Planned Parenthood, h e l d once again i n Stockholm to commemorate the t w e n t i e t h anniversary of the Swedish N a t i o n a l league f o r Sex Education, adopted a new c o n s t i t u t i o n , to ... advance through education and s c i e n t i f i c r e s e a r c h the u n i v e r s a l acceptance of f a m i l y planning and r e s p o n s i b l e parenthood i n the i n t e r e s t s of f a m i l y w e l f a r e , community we l l - b e i n g and i n t e r n a t i o n a l g o o d w i l l . Membership would be o f f e r e d i r r e s p e c t i v e of r a c e , creed or c o l o r ; and commercial i n t e r e s t s would be excluded from as-15 s o c i a t i o n w i t h the new o r g a n i z a t i o n . When the F i f t h I n t e r n a t i o n a l Conference on Planned Parenthood was held i n Tokyo i n 1955» Mrs. Sanger, now 76 and s u f f e r i n g from a coronary a i l m e n t , b u r s i t i s , s a c r o - i l i a c s t r a i n and lumbago, took the opportunity to l e c t u r e world heads of s t a t e f o r t r y i n g to use "stop gap" s o l u t i o n s to world problems when, i n r e a l i t y , p opulation was "the b a s i c i s s u e " . She r e g r e t t e d t h a t the question had not been d i s -cussed at the recent Summit Conference i n Geneva. 1^ In a d d i t i o n to doctors, s o c i o l o g i s t s , demographers and other r e l a t e d p r o f e s s i o n s , f o r the f i r s t time anatomists, b i o l o g i s t s , biochemists, and other s c i e n t i s t s were gathered to compare notes i n the search f o r a b i o l o g i c a l means of c o n t r a c e p t i o n . As has been noted, t h i s was a g o a l long advo-cated by Mrs. Sanger because of the world wide need f o r a simple, cheap and r e l i a b l e method, the use of which would be 17 u n r e l a t e d to the time of i n t e r c o u r s e . I t had been p a r t l y through her i n t e r e s t t h a t Dr. Pincus had received a grant to begin the study of progesterone as a means of suppressing o v u l a t i o n . In the meantime, i t was agreed that abortion should not be considered a primary s o l u t i o n to population problems. The S i x t h I n t e r n a t i o n a l Conference was h e l d i n New D e l h i i n 1959 > and was memorable f o r a number of reasons: I t was p a r t l y financed by a grant of Rs. 50,000 from the government of I n d i a , and inaugurated by Prime M i n i s t e r Nehru^ 800 delegates and observers from twenty-nine n a t i o n s - i n c l u d i n g f i f t e e n Asian c o u n t r i e s - were present, and an observer from the USSR was on hand. Margaret Sanger, at 80, made her l a s t v i s i t to the IPPP. The theme of the conference was, Pamily  Planning: Motivations and Methods, and the m o t i v a t i o n of governments, too, was not neglected. As has been noted, some Indians were already aware t h a t population growth was h i n d e r i n g economic development. Keynes and Davis had pointed the way, and Ansley J . Coale and Edgar M. Hoover had r e c e n t l y published t h e i r study of India's prospects. (See also Chapter V.) The Asian f a m i l y planners took up the chorus, p r e s s i n g t h e i r governments to do something e f f e c t i v e i n the United Nations through WHO, PA0, EC0S0C, and the Human Rights Commission to support p o p u l a t i o n c o n t r o l programs. Countries planning to attend the forthcoming ECAPE (Economic Commission f o r A s i a and the Par East) conference, were urged to give the question 19 s e r i o u s a t t e n t i o n when i t was taken up.  7 A study group on population problems under the chairmanship of Dr. W i l l i a m Vogt, N a t i o n a l D i r e c t o r of The Planned Parenthood Federation of America, s t a t e d t h a t h i s country was an example of "over-development" and warned that i t , t o o , had a po p u l a t i o n problem - an ide a warmed over by P a u l E h r l i c h i n 1968 i n The P o p u l a t i o n Bomb. The group recommended t h a t , i n a d d i t i o n to a medical committee, another on economic and s o c i a l prob-lems be appointed, but, by the Seventh Conference, i n 19^7» only a committee on b a s i c science had been added. On f a m i l y planning p o l i c y , the S i x t h Conference how f o r m a l l y approved the p r i n c i p l e of spacing pregnancies f o r b e t t e r h e a l t h , and urged members to provi d e , wherever pos-s i b l e , diagnosis and treatment of i n f e r t i l i t y . Though i t had been acceptable i n 1930, a r e s o l u t i o n f o r m a l l y supporting s t e r i l i z a t i o n was r e j e c t e d - not because the i d e a of s t e r i l i -z a t i o n was abhorrent to a l l members, but because i t was to some, and, sin c e 1955 and the r e s o l u t i o n i n Tokyo on a b o r t i o n , i t had become IPPP p o l i c y to avoid t a k i n g a stand f o r or against any s p e c i f i c b i r t h c o n t r o l method. (Chapter V, p. 129») Research i n a l l aspects of human f e r t i l i t y was urged, however. Since 195^, Dr. Pincus had had the P i l l under a c c e p t a b i l i t y t r i a l s i n the United States and Puerto R i c o , and he was i n t e r e s t e d i n f u r t h e r t r i a l s i n A s i a . I t i s reported that Indian a u t h o r i t i e s would not agree, reputedly because of the cost of s u p e r v i s i o n , the f e e l i n g that i l l i t e r a t e women would not be able to manage i t , and f e a r s of s i d e - e f f e c t s . Ceylon, however, was more r e c e p t i v e . (Chapter V I , p. 190.) George Cadbury, who had spent the preceding ten years as head of the United Nations T e c h n i c a l A s s i s t a n c e Admini-s t r a t i o n , had r e c e n t l y joined the IPPP as Honorary P i e l d D i r e c t o r and S p e c i a l Representative. In p u r s u i t of h i s new r e s p o n s i b i l i t i e s , Mr. Cadbury and h i s w i f e , Barbara, v i s i t e d eleven Asian countries advocating f a m i l y planning as part o f maternal and c h i l d h e a l t h s e r v i c e s , and al s o urging United Nations a c t i o n . Mrs. Cadbury's r e p o r t included t h i s statement: We expected t h a t we should be concentrating on ways of educating Asian people to use f a m i l y planning s e r v i c e s ; we expected that r e l i g i o n , s u p e r s t i t i o n , myth and ancient custom would make i t d i f f i c u l t f o r the ordinary people of A s i a to accept b i r t h c o n t r o l . On the whole we were wrong. The problem i s to provide the s e r v i c e , not to educate people to use i t . I t i s not O r i e n t a l r e l i g i o n s and c u l t u r e s which are a bar to i t s widespread use, but O c c i d e n t a l Roman C a t h o l i c i s m , and the wariness of p o l i t i c i a n s of the Roman C a t h o l i c voter i n the O c c i d e n t a l democracies. To a s s i s t the volunteers i n these c o u n t r i e s the IPPF needed g r e a t l y increased funds. These were r a i s e d by the combined e f f o r t s of the Cadburys and Mr. Cass C a n f i e l d (a leader of Planned Parenthood i n the United S t a t e s ) , and from 2? $ 7 0 , 0 0 0 i n I 9 6 0 the IPPF budget rose to $935 ,000 i n 1965. L i a i s o n was e s t a b l i s h e d w i t h the P o p u l a t i o n C o u n c i l i n New York; C o n s u l t a t i v e Status w i t h the United Nations was achieved; the IPPF became a member of the I n t e r n a t i o n a l Conference of S o c i a l Work; and, i n 1 9 6 3 , the I n t e r n a t i o n a l C o u n c i l of Women passed a r e s o l u t i o n recommending world-wide education i n f a m i l y p l a n n i n g . Mrs. Margaret Pyke, wife of a noted B r i t i s h s c h o o l master, was appointed General Secretary a f t e r Mrs. Houghton. I t i s of i n t e r e s t that i n March, I 9 6 2 i n Tokyo, ECAFE set up a team of demographers to advise and a s s i s t Asian 23 governments i n developing f a m i l y planning a c t i o n programs. The Seventh I n t e r n a t i o n a l Conference on Planned Parent-hood, held i n Singapore i n 19&3, w a s attended by four hundred delegates from t h i r t y - e i g h t c o u n t r i e s . S c i e n t i f i c , medical and demographic papers were read on the theme, Changing P a t -t e r n s i n F e r t i l i t y t S o c i a l and C u l t u r a l F a c t o r s . Sessions were he l d on current research and a workshop was conducted on pro-motion and p u b l i c i t y . R e s o l utions urging a balance between p o p u l a t i o n , p r o d u c t i v i t y and resources were passed. Aims were r e - s t a t e d : to promote r e s p o n s i b l e parenthood f o r f a m i l y w e l f a r e , community w e l l - b e i n g and i n t e r n a t i o n a l g o o d w i l l . Education, t r a i n i n g and conferences would be continued. Members should consider o f f e r i n g sex education and marriage c o u n s e l l i n g . Previous r e s o l u t i o n s r e q u i r i n g i m p a r t i a l i t y regarding r a c e , creed and c o l o r , were broadened to in c l u d e " p o l i t i c s " . In response to c r i t i c i s m s about motives, Mrs. Ottesen-Jensen, r e t i r i n g p r e s i d e n t , noted t h a t , while they were not the f i r s t , women had jo i n e d the movement because i t was devoted to f a m i l y w e l f a r e . Men had joine d f o r the same reasons, and r e c e n t l y a l s o because of the economic and s c i e n t i f i c s i g n i -f i c a n c e of f a m i l y p l a n n i n g . Smt. Rama Rau was e l e c t e d president of the IPPF, and Cass C a n f i e l d and George Cadbury, Chairman and Vice-Chairman, r e s p e c t i v e l y , of the Governing Body. A former B r i t i s h c i v i l servant w i t h wide experience i n the Caribbean area, S i r C o l v i l l e D e v e r e l l , was appointed S e c r e t a r y -General, succeeding Mrs. Pyke. In a d d i t i o n to i t s world conferences, the IPPF had -"been developing r e g i o n a l conferences and seminars. Eighteen of these had "been h e l d from 1955 "to 19&3. A l l of i t s meetings were now a t t r a c t i n g h i g h l y q u a l i f i e d personnel from many p a r t s of the world and IPPP p u b l i c a t i o n s , f i l m s and s p e c i a l s t u d i e s had achieved equal p r e s t i g e . I t was the only i n t e r n a t i o n a l body s t i m u l a t i n g both v o l u n t a r y f a m i l y planning o r g a n i z a t i o n s and government a c t i o n , and there were now t h i r t y - f i v e member countri e s i n f i v e c o n t i n e n t s . Help was being given to more than s i x t y non-member n a t i o n s . The IPPP would continue to f u n c t i o n i n f a m i l y planning promotion at l e a s t u n t i l the 24 World Health Organization was ready to do so. 1964 was notable f o r a new focus - t h i s time on A f r i c a and l a t i n America. In the former, the o r g a n i z a t i o n of Family Planning A s s o c i a t i o n s by the IPPF was welcomed, not so much f o r p o p u l a t i o n c o n t r o l (though t h i s would soon be a need) as f o r maternal and c h i l d h e a l t h . In the l a t t e r c o n t i n e n t , governments were s t i l l h e s i t a n t , but u n i v e r s i t i e s were f r e e r to act and accepted h e l p . The j u s t i f i c a t i o n was the need to reduce the a p p a l l i n g l y h i g h a b o r t i o n r a t e s evident from h o s p i t a l admissions and maternal death s t a t i s t i c s . Coupled w i t h these a c t i v i t i e s , a dramatic development i n b i r t h c o n t r o l methods, was the confirmation by the Popu-l a t i o n C o u n c i l i n New York of exhaustive t e s t s and accept-a b i l i t y t r i a l s of the polythene IUD, on which work had been done by Japanese as w e l l as American doctors. As a r e s u l t of i n s e r t i o n s i n Taiwan and Korea, the C o u n c i l recommended th a t the ITJD be adopted f o r general use throughout the world, and many b e l i e v e d t h a t here, at l a s t , was the method best s u i t e d 25 to mass use. (See Chapter T f o r f u r t h e r comment.) L i a i s o n was set up w i t h the United States Agency f o r I n t e r n a t i o n a l Development (AID), the government of the United Kingdom, and Oxfam. C o n s u l t a t i v e s t a t u s was e s t a b l i s h e d w i t h UNESCO, the United Nations Children's Fund, the World Health O r g a n i z a t i o n , the Pood and A g r i c u l t u r e O r g a n i z a t i o n , and the I n t e r n a t i o n a l Labor O r g a n i z a t i o n . The IPPP Medical Committee was s e t t i n g standards of c l i n i c a l procedure and t r a i n i n g , as w e l l as the medical aspects of c o n t r a c e p t i o n . I t was conduct-i n g e v a l u a t i o n and other research, and had access to labo-r a t o r y f a c i l i t i e s i n England, I n d i a , Poland, the Netherlands and the United S t a t e s . The E i g h t h I n t e r n a t i o n a l Conference, h e l d i n A p r i l I 9 6 7 i n Santiago, C h i l e , was inaugurated by P r e s i d e n t P r e i , and attended by more than 1,500 delegates from eighty-seven c o u n t r i e s . These in c l u d e d not only v o l u n t a r y o r g a n i z a t i o n s , but government agencies, r e l i g i o u s o r d e r s , and u n i v e r s i t y s t a f f members. A s p e c i a l session f o r youth a t t r a c t e d more than 1,000 people. On the theme, Planned Parenthood: A Duty  and a Human Right papers were given on population growth i n r e l a t i o n to economic and s o c i a l development i n L a t i n America, world food problems, education, housing, and maternal and c h i l d h e a l t h . The widespread, problem of i l l e g a l a b o r t i o n , e s p e c i a l l y i n L a t i n America, the need f o r both medical promotion and increased f a m i l y planning s e r v i c e s was discussed. B a s i c science and medical sessions were also h e l d , and, once again, the proceedings subsequently p u b l i s h e d . This conference was financed by government grants from Denmark, The Netherlands^: Norway, Sweden, the United States (AID), the Brush Foundation, and the Ford and R o c k e f e l l e r Foundations. In the opening s e s s i o n , Lord Caradon, then United Kingdom Permanent Repre-s e n t a t i v e to the United Nations, urged that the U.N. take concerted a c t i o n i n the coming Human Rights Year (1968) and announced th a t h i s government would make an annual grant of ?6 $140 ,000 to the IPPF f o r f i v e years. A s p e c i a l d r i v e f o r funds to support expanded a c t i v i t i e s by the IPPF was undertaken i n the United States by Planned Parenthood, and headed by General W i l l i a m S. Draper, J r . Known as the Victor-Bostrom Fund, i t achieved i t s i n i t i a l t a r g e t of $3 m i l l i o n by the f a l l of 1968. A f u r t h e r t a r g e t of $3 m i l l i o n to a s s i s t the IPPF through 1971 was o v e r s u b s c r i b -ed, and was increased to $6 m i l l i o n . From i t s p r e v i o u s l y modest t o t a l of j u s t under $1 m i l l i o n i n I 9 6 5 , the 1970 budget of the IPPF t o t a l l e d $13 m i l l i o n , and, f o r 1971, $20 m i l l i o n . A f a r cry from the handful of enthusiasts from s i x c o u n t r i e s who met i n Sweden i n 1946, Family P l a n n i n g Asso-c i a t i o n s i n s i x t y - f o u r countries had a f f i l i a t e d w i t h the IPPF by the end of 1969, as had s e v e r a l i n d i v i d u a l governments. Si x r e g i o n a l o f f i c e s (Singapore, Rawalpindi, Tokyo, N a i r o b i , London, New York) had been e s t a b l i s h e d ; and another, i n B e i r u t , was opened i n March, 1970 to serve the Middle East and North A f r i c a . The IPPF was a s s i s t i n g i n more than 70 other coun-t r i e s , and i t s government support was swelled "by a grant from Japan. IPPF st a t u s i n UNESCO had been r a i s e d to "Category,B., informa t i o n and c o n s u l t a t i v e " , and Mr. ( l a t e r S i r ) David Owen, former co-administrator of the United Nations Development P l a n , was appointed Secretary-General of the IPPF, succeeding S i r C o l v i l l e D e v e r e l l . In November, 19&9, Mr. George Cadbury succeeded Mr. C a n f i e l d as Chairman of the Governing Body, and Dr. Agnete Braestrup of Denmark, succeeded Smt. Rama Rau as P r e s i d e n t . D i r e c t government a s s i s t a n c e to the IPPF was now an e s t a b l i s h e d procedure - a r e c o g n i t i o n of the usefulness of a non-government, n o n - p o l i t i c a l , i n t e r n a t i o n a l agency i n the f r e q u e n t l y d e l i c a t e promotion of a needed program. The work of the Federation, always keyed to h e a l t h and welfare on a worldwide b a s i s , was s t i l l ... based on the b e l i e f t h a t knowledge of planned parenthood i s a fundamental human r i g h t and t h a t a balance between the population of the world and i t s n a t u r a l resources and p r o d u c t i v i t y i s a necessary c o n d i t i o n of human happiness, p r o s p e r i t y and peace.2o In summary, the volunteers from the United Kingdom, the United States and some European countries h e l d a s e r i e s of i n t e r n a t i o n a l gatherings from 1900 to 1939 which l a i d a foundation f o r i n t e r n a t i o n a l o r g a n i z a t i o n to promote the spread of the f a m i l y planning movement. Though these gatherings issued warnings of the danger to peace of popu-l a t i o n pressures, no one l i s t e n e d . Meetings were renewed i n 19^8, and the I n t e r n a t i o n a l Planned Parenthood F e d e r a t i o n , w i t h headquarters i n London, England, wa.s organized i n Bombay i n 1952. The member a s s o c i a t i o n s have always i n s i s t e d that b i r t h c o n t r o l be v o l u n t a r y , and that i t should be o f f e r e d w i t h no d i s t i n c t i o n as to race, c o l o r , creed or p o l i t i c s . Though some methods, such as the diaphragm and j e l l y , and s t e r i l i -z a t i o n , were -recommended before 1939» i t was decided a f t e r 1955 that the IPPP would not s i n g l e out any p a r t i c u l a r one i n preference to any ot h e r . In 1964 the main focus of the i n t e r n a t i o n a l o r g a n i -z a t i o n turned from A s i a to A f r i c a and L a t i n America, where i t could continue to f i l l i t s t r a d i t i o n a l r o l e of h e l p i n g v o l u n t a r y o r g a n i z a t i o n s to s t a r t , and to be the c a t a l y s t s of government a c t i o n . In t h i s , the IPPP was g r e a t l y a s s i s t e d by increased income from both v o l u n t a r y donations and d i r e c t grants by governments. By 1969 there were 64 member c o u n t r i e s . The U t i l i t a r i a n and humanitarian philosophy i n which the Family Planning movement had had i t s o r i g i n s , appealed to the Western-educated l e a d e r s h i p i n South A s i a when they were pl a n n i n g , not only f o r independence, but al s o f o r s o c i a l and economic progress f o r t h e i r people. FOOTNOTES - Chapter IV •J-Ralph Waldo Emerson, "Each and A l l " , Stanza I , B a r t l e t t ' s F a m i l i a r Quotations, Boston, 1955, P« 503 . 2 D a v i d M. Kennedy, B i r t h C o n t r o l i n America, The  Career of Margaret Sanger, New Haven", 1970, p. 101 , f . n . ^Vera Houghton, The I n t e r n a t i o n a l Planned Parenthood  Federation, (I.P.P.j? 1.), i t s H i s t o r y and i n f l u e n c e , 1-bTi?1, London, 1962, pp. 1 - 3 . ^ I b i d . , p. 3 ; Also Emily Taft Douglas, Margaret Sanger: Pioneer of the Future, New York, 1970, pp. 196 - 9 8 . 5" "The Story of Margaret Sanger and the IPPF" Proc. Seventh Conference of the I n t e r n a t i o n a l Planned Parenthood  Federation, Singapore, Amsterdam, 1963. P. 6. °Vera Houghton, o p . c i t . , p. 3» 7"The Story of Margaret Sanger and The IPPF", o p . c i t . , p.8 . 8 I b i d . ^ F r e d e r i c k S. J a f f e , Steven P o l g a r , " E p i d e m i o l o g i c a l I n d i c a t i o n s f o r F e r t i l i t y C o n t r o l : P r e l i m i n a r y Formulation" J o u r n a l of the C e n t r a l Medical A s s o c i a t i o n of I n d i a , Family Planning P r o j e c t Supplement, September, 1967, p. 12 . x 0 A B r i t i s h doctor agreed but took no a c t i o n . A s s i s t a n c e was given by J u l i a n Huxley and S i r John Boyd O r r . Mrs. Sanger bought co-operation v i a Mrs. Stanley McCormick's pocketbook. Emily Taft Douglas, Pioneer of the Future, Margaret Sanger, New York, 1970, pp. 244-45. x l N i n t h Report, I n t e r n a t i o n a l Planned Parenthood Fe d e r a t i o n , 1967-68, London, p. 15; Vera Houghton, "Report of a Meeting of the I n t e r i m Committee on Planned Parenthood", Eugenics Review, V o l . x l i i i , No. 3 , Ap., 1951 - Jan., 1952, p. 142. 1? c K i n g s l e y Davis, A Study of the Population of I n d i a  and P a k i s t a n , P r i n c e t o n , 1951> P» 222. 1 3 P r o c . Seventh Conference, o p . c i t . , p. 9« l^Program, Seventh Conference of the I n t e r n a t i o n a l Planned Parenthood Federation, Singapore, 1963, P« 8 . 1 5 P r o c . Seventh Conference, o p . c i t . , p. 7. •^Proc. F i f t h International Conference on Planned  Parenthood, Tokyo, 1955, P» 6 . 1 "^Program, Seventh Conference, o p . c i t . , p. 9 . 1 8 • L OAnsley J . Coale and Edgar M. Hoover, Population  Growth and Economic -Development i n Low Income Countries: India's Prospects, Princeton, 1958, passim. 1 9 I n 1962 ECAFE (Economic Commission for Asia and the Par East) adopted a program of research into population problems and began to give advice to governments on economic and s o c i a l planning. O A ^"George .Cadbury, Interview, Oakv i l l e , Ontario, 7 . 1 2 . 6 9 . ^Barbara Cadbury, "Eastern Advance" i n Marian Maury, ed., Birthrate and B i r t h r i g h t , New York, 1963, p. 130. Substantiated i n person by Cadburys, Oakville, 7 . 1 2 . 6 9 . c^The V i c t o r Fund f o r the I.P.P.P., Report No. 7, F a l l , 1967, i^ ew lork, p. 29 . ' 2-^Program, Seventh Conference, op.ci t . , p. 9 . 24 1955 - Puerto Rico 1 9 6 I - Barbados 1957 - West B e r l i n I962 - Dacca, Warsaw 1958 - Jamaica 1963 - Ceylon 1960 - The Hague 1964 - Puerto Rico, Hong Kong, Nepal, London. S c i e n t i f i c Seminars 1955 - Bombay I962 - Bombay, Singapore 1959 - Lahore 1963 - Ceylon 1961 - Hyderabad Sixth Report, International Planned Parenthood Federation, London, I 9 6 3 , pp. 1-2; also Program, Seventh Conference, op.cit., p. 9? Tenth Annual Report, Family Planning Association of Ceylon, Colombo, I 9 6 3 , p. 12 . 25"Secretary-General's Survey", Seventh Report, I.P.P.F., London, 1964, pp. 1-2. 26 Proc. Eighth International Conference of the I.P.P.F., Santiago, 1967, pp. 11-16. 2 7 V i c t o r Fund f o r the I.P.P.F. Reports P a l l 1 9 6 7 , S p r i n g , 1969, Spring, 1970, Mew *ork and Washington, IPP News, No. 191, January, 1970. 2 8 N i n t h Report. IPPP, o p . c i t . , p. 3; IPP News, March, 1970; Population Program A s s i s t a n c e . USAID, Washington, October, 1969, p. 53. J'00 noQ 1910 I9Z0 1920 1940 i?S0 I960 l$70 1980 \ 990 '20O0 A-- REPLACEMENT LEVEL FERTILITY REACHEO BY 198^ 8* REPLACEri£NT LEVEL FERTILITY PEACHED BY /99S~ C • PEPL*C£M£A/T LEVEL FERTILITY REACHES BY SOURCE-. INTERNATIONAL PEMOGRAPhjIC ST/\TIST<CS CENTRE "US. BUREAU OF THE PART THREE S o c i a l Reformers and Government i n South A s i a CHAPTER V I n d i a ... I b e l i e v e that to wait u n t i l the moral sense of man becomes a great deal more powerful than i t i s now, and t i l l then to a l l o w countless generations of c h i l d r e n to s u f f e r p r i v a t i o n s and u l t i m a t e l y death f o r no f a u l t of t h e i r own i s a great s o c i a l i n j u s t i c e which should not be t o l e r a t e d . 1 As i n the Western context, concern over population growth i n South A s i a began w i t h Malthus. Although he d i d not v i s i t the country, he noted i n the 1803 v e r s i o n of h i s Essay that I n d i a was a c l a s s i c example of h i s theory. Such p o s i t i v e checks on population growth as a s c e t i c i s m and taboos against widow remarriage, were o f f s e t by the compulsion f o r male h e i r s and e a r l y and u n i v e r s a l marriage. Consequently, the "lower c l a s s e s " were so numerous that they were reduced to f r u g a l i t y , and, t h e r e f o r e , very vulnerable to any dete-r i o r a t i o n i n the food supply. Abbe' Dubois, a contemporary of Malthus, who d i d v i s i t the country, described the Indian scene south of the K i s t n a R i v e r , and noted p a r t i c u l a r l y the i n f e r i o r s t a t u s of women: The o p i n i o n i s f i r m l y e s t a b l i s h e d throughout the whole of I n d i a , t h a t women were only created f o r the propagation of the s p e c i e s , and to s a t i s f y men's d e s i r e s . A l l women are o b l i g e d to marry .... Only courtesans are allowed an education. P a r a l l e l l i n g the nineteenth century i n t e r e s t i n population growth and i t s s o c i a l and economic consequences i n European c o u n t r i e s , there was growing d i s c u s s i o n of the t o p i c by B r i t i s h a d m i n i s t r a t o r s and Indians reformers i n the Indian sub-continent. In 1888, the V i c e r o y , l o r d P u f f e r i n , commented w i t h some a s p e r i t y that the re c e n t l y - o r g a n i z e d Indian N a t i o n a l Congress would be b e t t e r advised to worry over the e f f e c t s of over-population than over t h e i r e x c l u s i o n from p a r t i c i -p a t i o n i n government. No one can pass even a few months i n I n d i a without being aware th a t we are s i t t i n g under the shadow of an enormous danger - overpopulation of the country, or at a l l events of l a r g e d i s t r i c t s and t e r r i t o r i e s , whose i n h a b i t a n t s are y e a r l y , nay monthly and weekly, m u l t i -p l y i n g beyond the numbers the s o i l i s capable of s u s t a i n i n g - yet during the four years I have been here t h i s most important subject has not a t t r a c t e d the a t t e n t i o n of a s i n g l e Native news-paper a s t i l l l e s s of any Native p u b l i c body By 1929 the B r i t i s h p o s i t i o n i n I n d i a had become u n c e r t a i n , and, although a f t e r 1921 the population growth r a t e had begun to s p i r a l upward, no a d m i n i s t r a t i o n wanted to i n t e r f e r e . Nothing would end B r i t i s h r u l e more q u i c k l y than any attempt to introduce j u s t those reforms which would do the most to improve the w e l l - b e i n g of the masses. A we l l - p r o p o r t i o n e d decrease i n the b i r t h r a t e would unquestionably r e s u l t i n an increase i n income per head .... Where i s the Indian Malthus who w i l l i n v e i g h against the devastating t o r r e n t of Indian c h i l d r e n ? ^ Major-General S i r John Megaw, former P u b l i c Health Commissioner w i t h the Government of I n d i a , and subsequently President of the Medical Board at the I n d i a O f f i c e i n London, knew what was needed. The t r u t h i s that the i n h i b i t i o n s connected w i t h the study of the popu-l a t i o n problem have been c h i e f l y on our s i d e : we have been accustomed to plan our own l i v e s i n such a way as to secure a comfortable e x i s t e n c e , but we have assumed, qu i t e wrongly, t h a t education i n l i f e , p l a n n i n g i s in a d m i s s i b l e i n I n d i a . 0 Some Indians of the educated c l a s s e s had been developing a growing i n t e r e s t i n s o c i a l improvement and one of the obvious avenues was h e a l t h and w e l f a r e . A n a t u r a l extension was i n -t e r e s t i n c o n t r a c e p t i o n , and, by the time of Megaw's comment i n 1 9 3 4 , some were prepared to promote f a m i l y planning as a form of n a t i o n a l s e r v i c e . One of the i n f l u e n c e s which l a i d the groundwork f o r t h i s i n t e r e s t was the founding - i n 1828 - of the Brahmo Samaj, a Hindu reform movement, s t a r t e d i n Bengal by Ram Mohun Roy, a f r i e n d of Jeremy Bentham and an advocate, among other t h i n g s , of u n i v e r s a l a d u l t s u f f r a g e . At the end of the n i n e -t e e n t h century, the teachings of the sage Ramakrishna and h i s d i s c i p l e , Swami Vivekananda added impetus to the i d e a of s e r v i c e . By the end of the century, the Moderates of the Indian N a t i o n a l Congress were urging t h e i r countrymen to borrow from the West whatever measures would b e n e f i t t h e i r people. " S o c i a l s e r v i c e " became popular among the educated middle and upper c l a s s e s . Gandhi used s e r v i c e to the st a t e as a r a l l y i n g cry f o r the Independence Movement, advocating equal r i g h t s f o r women on the b a s i s of ancient Hindu t r a d i -t i o n . I t was n a t u r a l , t h e r e f o r e , f o r " s o c i a l workers" (as the v olunteers were c a l l e d ) to p a r t i c i p a t e i n v o l u n t a r y o r -g a n i z a t i o n s dedicated to s o c i a l improvement, and that t h e i r western education would induce them to adopt models of western o r i g i n such as the Boy Scouts, G i r l Guides, Red Cross and the A l l - I n d i a Women's Conference. In 1916 S r i Pyare W i t t a l , w r i t i n g The P o p u l a t i o n Prob-lem i n I n d i a , urged Indians to plan t h e i r f a m i l i e s i n accord-7 ance w i t h t h e i r s o c i a l , economic and h e a l t h needs. What was more n a t u r a l than to press f o r b i r t h c o n t r o l s e r v i c e s as a means of s o c i a l reform? Who were the f i r s t to do so? l i k e the "European" f a m i l y planners, the leaders of the movement i n I n d i a before World War I I were men, but they were joined l a t e r by women. Advocates of f a m i l y planning appeared f i r s t i n C a l c u t t a , Bombay, and Madras, the three c i t i e s where contacts w i t h the West had been most prolonged. In 1911 Babu Nilambura M u k e r j i , as Pre s i d e n t of the C a l c u t t a o M u n i c i p a l C o u n c i l , s t r o n g l y advocated c o n t r a c e p t i o n . 0 Pro-f e s s o r Raghunath Dhondo Karve, a teacher i n the C h r i s t i a n missionary-supported W i l l s o n C o l l e g e , opened the f i r s t b i r t h c o n t r o l c l i n i c i n I n d i a i n 1 9 1 5 i n Bombay. Though B r i t i s h o f f i c i a l d o m was i n d i f f e r e n t , so much l o c a l c r i t i c i s m was aroused by the c l i n i c and by P r o f e s s o r Karve's speeches and w r i t i n g s on the s u b j e c t , that he was asked to r e s i g n from the c o l l e g e . This he d i d , but, w i t h h i s w i f e , he spent the remaining twenty-eight years of h i s l i f e working f o r the 9 f a m i l y planning movement. Another development was the o r -g a n i z a t i o n i n 1 9 2 9 i n Madras of a Neo-Malthusian league, headed by two d i s t i n g u i s h e d c i t i z e n s - a j u s t i c e of the High Court, who had ten c h i l d r e n , and a member of the Governor's Executive C o u n c i l , who was c h i l d l e s s . The League published a r e g u l a r b u l l e t i n on b i r t h c o n t r o l and s o l d rubber sponges and j e l l i e s . 1 0 In June 1 9 3 0 , the p r i n c e l y s t a t e of Mysore opened the f i r s t state-supported c l i n i c i n the world i n Bangalore, and the B r i t i s h province of Madras s h o r t l y a f t e r f o l l o w e d s u i t . 1 1 In 1 9 3 2 , i n s p i t e of o p p o s i t i o n from some of i t s members, the A l l - I n d i a Women's Conference, a c o - o r d i n a t i n g body of women's v o l u n t a r y o r g a n i z a t i o n s , passed an unprece-dented r e s o l u t i o n supporting b i r t h c o n t r o l c l i n i c s f o r both men and women. This was the f i r s t time the subject was d i s -cussed openly at t h e i r meetings, and there was much enthusiasm. But the P r e s i d e n t , Smt. Lakshmi N. Menon, observed that a l -though i t was a humanitarian program, the B r i t i s h government would not want to introduce i t " f o r f e a r of o f f e n d i n g the 1 2 r e l i g i o u s sentiments of the people." Also i n 1932, The Senate of Madras U n i v e r s i t y passed a r e s o l u t i o n f a v o r i n g i n c l u s i o n i n the curriculum of i n s t r u c -t i o n i n f a m i l y planning. Two years l a t e r a new f a m i l y planning o r g a n i z a t i o n was s t a r t e d i n Bombay. I t began to p u b l i s h a j o u r n a l , Marriage Hygiene, edited by Dr. A.P. P i l l a i , and, f o r the f i r s t time i n the world, included marriage coun-s e l l i n g i n i t s program. In 1 9 3 5 Snit Cowasji Jehangir founded the S o c i e t y f o r the Study and Promotion of Family Hygiene, a l s o i n Bombay, and a f r e e c l i n i c f o r women was opened i n a 13 l o c a l cotton m i l l . In 1 9 3 5 the Indian N a t i o n a l Congress set up a N a t i o n a l Planning Committee, headed by Ja w a h a r l a l Nehru. This body supported b i r t h c o n t r o l on socio-economic grounds, both f o r the sake of,the i n d i v i d u a l and f o r s o c i e t y . I t would improve the h e a l t h of the mother and i n f a n t , increase f a m i l y happi-ness, and help to combat induced a b o r t i o n . The planning committee was the f i r s t a l s o to discus s the question of population growth i n the context of economic planning and n a t u r a l resources, but there was disagreement both as to p r i o r i t i e s and methods. Both s e l f - r e s t r a i n t and cont r a -c e p t i v e s were approved, as was eugenic s t e r i l i z a t i o n - a popular cause i n some Western c o u n t r i e s at the t i m e . ^ In h i s P r e s i d e n t i a l Address to the Congress at i t s f o r t y - n i n t h s e s s i o n i n 1 9 3 6 , Nehru urged the middle c l a s s e s to renew t h e i r e f f o r t s f o r the cause of Indian independence, and to work more c l o s e l y w i t h the "people at l a r g e " - an e x h o r t a t i o n to greater involvement i n s o l v i n g n a t i o n a l problems. 1-' In the meantime, Mrs. How-Martyn had v i s i t e d I n d i a i n 1935 on behalf of the B i r t h C o n t r o l Information Centre; as a r e s u l t , the A l l - I n d i a Women's Conference i n v i t e d Margaret Sanger to speak at t h e i r meeting i n Travancore at the end of 1 9 3 5 ^ Though a r e s o l u t i o n supporting b i r t h c o n t r o l was opposed by Eurasian Roman C a t h o l i c members, and the chairman, the Maharani of Travancore was hard pressed to keep the meeting 17 on an even k e e l , the vote was passed by a 3 to 1 margin. ' In r e c a l l i n g those days, Smt. Bhanvanthi Rama Rau, who l a t e r founded the Family P l a n n i n g A s s o c i a t i o n of I n d i a , noted t h a t the educated people i n I n d i a concerned w i t h p o p u l a t i o n prob-lems wondered why Americans considered Miss ( s i c ) Sanger 18 immoral when she t a l k e d about the l i m i t a t i o n of f a m i l y s i z e . Paramount i n Mrs. Sanger's appeal was the need to reduce i n f a n t m o r t a l i t y and the importance of spacing pregnancies f o r b e t t e r 19 h e a l t h of both mothers and c h i l d r e n . Mrs. Sanger t r a v e l l e d 1 0 , 0 0 0 m i l e s , v i s i t e d eighteen c i t i e s and towns, gave s i x t y - f o u r l e c t u r e s , saw scores of government o f f i c i a l s , and met many leaders of Indian o p i n i o n . Mrs. How-Martyn, on her 1 9 3 5 v i s i t and a subsequent one i n 1 9 3 7 - 3 8 , t r a v e l l e d 6 , 5 0 0 miles and addressed forty-one meet-i n g s , i n c l u d i n g the A l l - I n d i a Medical Conference; the I n s t i t u t e of P o p u l a t i o n Research, Lucknow; the Marriage Welfare and C h i l d Guidance A s s o c i a t i o n of C a l c u t t a ; and the Bombay Women's Work G u i l d . Taken together, these two women spoke to 3 2 medi-c a l a s s o c i a t i o n s . I t i s not known whether the vote was unanimous, but the A l l - I n d i a Medical Conference r e s o l v e d that i n s t r u c t i o n i n c ontraception should he included i n a l l medical c u r r i c u l a . The r e s o l u t i o n had l i t t l e impact, but a B i r t h C o n t r o l Inform-a t i o n Centre, already opened i n C a l i c u t , was strengthened,, and i n a d d i t i o n to the c l i n i c at Bangalore c l i n i c s were oper-a t i n g i n D e l h i , Nagpur, A k o l a , S a t a r a , Indore, C a l c u t t a , Poona and Mysore C i t y . The Bombay M o f u s s i l M a t e r n i t y , C h i l d Welfare, and Health C o u n c i l adopted a. b i r t h c o n t r o l p o l i c y and arranged 2 1 f o r i t s medical s t a f f to take t r a i n i n g . The f i r s t organized step toward the s c i e n t i f i c study of p o p u l a t i o n i n I n d i a was taken mil 1 9 3 6 when Dr. Radhakamal Mukerjee convened the f i r s t of a succession of Indian popu-l a t i o n conferences at the U n i v e r s i t y of Lucknow. Papers on demography, n u t r i t i o n , h e a l t h , economics, f a m i l y hygiene, and 22 eugenics were presented and di s c u s s e d . In the same year Dr. A.P. P i l l a i set up t r a i n i n g courses i n Bombay, and toured South I n d i a to promote the p r o v i s i o n of b i r t h c o n t r o l s e r v i c e s but doctors there showed l i t t l e i n t e r e s t . 2 ^ B i r t h C o n t r o l World Wide opened c l i n i c s i n what are now U t t a r Pradesh and Madhya Pradesh; and C o l . B.L. Raina, l a t e r D i r e c t o r of Family Planning i n the C e n t r a l Government, and e v e n t u a l l y D i r e c t o r of the C e n t r a l Family P l a n n i n g I n s t i -t u t e i n New D e l h i , s t a r t e d a c l i n i c at U j j a i n , a l s o i n Madhya Pradesh. In 1938 the Second A l l - I n d i a P o p u l a t i o n and F i r s t Family Hygiene Conference was held i n Bombay, and the N a t i o n a l Pl a n n i n g Committee of the Indian N a t i o n a l Congress once again warned of the need f o r f e r t i l i t y c o n s t r a i n t . In 19^0 S r i . P.N. Sapru " s u c c e s s f u l l y moved" a r e s o l u t i o n i n the C o u n c i l of States f o r the establishment of b i r t h c o n t r o l c l i n i c s - a much broader p l a n . That year a l s o , the Family Planning A s s o c i a t i o n of London sent Mrs. Rena Dutta, S c o t t i s h w i fe of the Indian head of a missionary c o l l e g e i n Lahore, on an extensive tour of the sub-continent, where she met w i t h . 2 6 v a r y i n g success m o r g a n i z i n g s e r v i c e s . Thus, the i n i t i a t i v e i n s e t t i n g up f a m i l y planning c l i n i c s i n the 1930s came from a few o r g a n i z a t i o n s , but t h e i r a c t i v i t i e s were i n t e r r u p t e d by the war. No data on t h e i r achieve-ments are a v a i l a b l e , but i t seems th a t only a few middle c l a s s , educated, urban dwellers who were motivated towards f a m i l y planning made use of the f a c i l i t i e s provided; the general population remained untouched.27 Between 1921 and 1941, 6 7 . 3 m i l l i o n people were added to the Indian population and i n 1943 the government took o f f i c i a l cognizance of the problem and appointed a Health Survey and Development Committee, headed by S i r Joseph Bhore. For the f i r s t time, b i r t h c o n t r o l was discussed as a question of p u b l i c p o l i c y . Although the Committee was d i v i d e d on whether to introduce f a m i l y planning to the poor on economic grounds, i t d i d agree t h a t i t should be provided on h e a l t h grounds and through o f f i c i a l medical sources. Contraceptives should be f r e e to women who needed them and the s t a t e should c o n t r o l t h e i r manufacture and s a l e . An i n f o r m a t i o n program 28 should be s t a r t e d . The f i n d i n g s of the Bhore Committee were s u b s t a n t i a t e d by the Bengal Famine Enquiry Commission i n 1946, which recommended a c t i v e government p a r t i c i p a t i o n i n a f a m i l y planning program. But, when the p r o v i n c i a l governments were consulted, the idea was not favored because of the f e a r of r e l i g i o u s o p p o s i t i o n . The number of b e n e f i c -i a r i e s would have been low, i n any case, because the pro-p o r t i o n of doctors to population was 1 : 6 , 3 0 0 and 7 5 percent were located i n urban areas. The r a t i o of Health V i s i t o r s to population was 1 : 4 0 0 , 0 0 0 , and h e a l t h s e r v i c e s were few. Even i n States l i k e Madras where the suggestions of the Bhore Committee were supported, the number of people who were given advice must have been very limited.2° Nonetheless, the p r e l i m i n a r y groundwork was l a i d . The Bhore Committee recommendations were shelved u n t i l a f t e r Independence i n 1 9 4 7 , when the e f f e c t s of wartime s h o r t -ages and i n f l a t i o n were exacerbated by the a r r i v a l of eight 30 m i l l i o n refugees from P a k i s t a n as a r e s u l t of P a r t i t i o n . I t was seen th a t a "population problem", w i t h s o c i a l , economic, p o l i t i c a l and i n t e r n a t i o n a l aspects, was one of the challenges which the Indian people would have to f a c e . In t h i s they were not alone.... I t was at such a time t h a t , as a r e s u l t of the p e r s i s t e n t demand by a group of men and women i n t e r e s t e d i n the h e a l t h and welfare of women and c h i l d r e n , two fr e e f a m i l y planning c l i n i c s were s t a r t e d under the Bombay Municipal Health S e r v i c e s . Two years l a t e r , some of these workers found that these c l i n i c s were not being put to f u l l use because many needy mothers i n the c i t y were not even aware of t h e i r e x i s t e n c e . In J u l y , 1 9 4 9 , t h e r e f o r e , a handful of women s o c i a l workers formed a. Committee to b r i n g t h i s f a c i l i t y to the n o t i c e of f a m i l i e s l i v i n g i n Bombay c i t y . 3 1 I l l P u b l i c i t y brought i n t e r e s t e d men and women to meetings i n d i f f e r e n t p a r t s of Bombay. This Family Planning Committee, headed by Smt. Rama Rau, ap p l i e d f o r and was granted a l i c e n s e to import and s e l l c o ntraceptives at cost to the Mun i c i p a l and other bona f i d e c l i n i c s . This would f i l l the gap between the Bhore Committee recommendations and t h e i r implementation. By March, 1 9 5 0 , the Family P l a n n i n g Committee had become a f u l l - f l e d g e d Family Planning A s s o c i a t i o n , i n -12 c o r p o r a t i n g s e v e r a l of the i n t e r e s t e d groups. O b j e c t i v e s included education of the general p u b l i c on the n e c e s s i t y of f a m i l y planning; and centres f o r advice on spacing pregnancies, f o r treatment of i n f e r t i l i t y and f o r marriage c o u n s e l l i n g . Contraceptive appliances would be provided f o r married couples as cheaply as p o s s i b l e , so t h a t low and middle income groups might b e n e f i t . Other o b j e c t i v e s were research and "to f o s t e r and develop contacts w i t h organ-i z a t i o n s engaged i n a s i m i l a r type of work i n I n d i a and abroad."33 To achieve these aims re p r e s e n t a t i o n s were made to the newly-appointed Indian Government Planning Commission "to i nclude f a m i l y planning as one of the measures f o r econo-mic development". An i n t e g r a t e d scheme f o r propaganda, c l i n i c s , t r a i n i n g , f i e l d s t u d i e s , r e s e a r c h , g u i d e l i n e s f o r a l l v o l u n t a r y agencies and standards f o r a l l c l i n i c s was 34 suggested. y The leaders of the Family P l a n n i n g A s s o c i a t i o n (FPAl) have been accused of being "middle c l a s s women, b a t t l i n g simultaneously against the shackles of pu r i t a n i s m and the tyranny of men."35 i n the f i r s t p l a c e , they were not a l l women. Men were a c t i v e l y i n v o l v e d i n the o r g a n i z a t i o n from 1953 when a C o l . R.N. Khosla of the Family P l a n n i n g A s s o c i a -t i o n of the Punjab, and P r o f e s s o r S r i p a t i Chandrasekhar (who became M i n i s t e r of State f o r Family Planning from 196? to 1970) were members of the A s s o c i a t i o n ' s d e l e g a t i o n to the IPPP conference i n Stockholm. P r o f e s s o r Chandrasekhar was a l s o the f i r s t e d i t o r of Planned Parenthood, a f o u r page b u l l e t i n s t i l l published monthly by the A s s o c i a t i o n . Other men have been members of the A l l - I n d i a c o u n c i l end i n 1969» two of the three "Vice-Presidents were men* Male doctors headed the c l i n i c s e r v i c e s from the beginning. Male p a r t i -c i p a t i o n has been prominent i n each of the b i e n n i a l A l l - I n d i a Conferences on Family P l a n n i n g , and the s e v e r a l i n t e r n a t i o n a l conferences sponsored by the A s s o c i a t i o n ; and they represented a cross s e c t i o n of u n i v e r s i t y f a c u l t y , m i l i t a r y and govern-ment i n s t i t u t i o n s . The President of I n d i a , the V i c e - P r e s i d e n t , the l a t e Prime M i n i s t e r Nehru, and M i n i s t e r s of r e l e v a n t de-partments of the c e n t r a l and s t a t e governments have inaugurated meetings and given keynote addresses. The volunteers have been represented on high l e v e l government c o u n c i l s and com-mittees and have been urged by government to undertake s p e c i f i c t a s k s . B a t t l i n g women would hardly l i k e l y have been accorded such courtesies.37 j n the second p l a c e , i n a s o c i e t y where sexual freedom was r a r e , and male domination s t i l l s o l i d l y entrenched, i t i s not l i k e l y t h a t , whatever t h e i r aims, FPAI lea d e r s expected to change these c o n d i t i o n s over n i g h t . Feminism i n the Western sense was not t h e i r i n s p i r a t i o n . There was a s p e c i f i c and urgent need i n the f i e l d s of mater-n a l and c h i l d health. At least two thirds of the deaths of women in the reproductive age group were from causes connected with pregnancy and c h i l d b i r t h . The maternal deathrate was 2 5 per 1 , 0 0 0 population and infant mortality was as high as 2 0 0 per 1 , 0 0 0 . 3 9 Indian Family planning leaders welcomed outside con-t a c t s . Their attitudes were expressed very well i n 1 9 5 9 , i n the 1PAI report of work over a ten-year period, The countries of Western Europe have an .experience of several decades i n the management and control of human f e r t i l i t y , and l a t e l y , Japan has made s i g n i f i c a n t strides i n t h i s d i r e c t i o n . The movement in India, although d i r -ected by Indians on l i n e s suited to t h e i r own country and culture, has had the great advantage i n that i t s leaders are able to study and analyse factors which have influenced Western and Far Eastern population trends. Also, the exchange of information by way of cor-respondence and personal meetings and conferences between Indian and Overseas workers through the IPPF and i t s member organizations, the Population Council, Inc., the UN Population Commission and other expert bodies, have helped con-siderably i n placing the Indian move-ment on a sound b a s i s . ^ But, as f a r as a t t r a c t i n g prospective users of b i r t h control was concerned, there were b u i l t - i n obstacles - just as in Western countries. Some were the same, o t h e r 3 d i f f e r e d . The difference was not so much organized opposition as a combination of nationalism, inadequate s o c i a l and medical s e r v i c e s , c u l t u r a l t r a d i t i o n , poor communications and p o l i t i c a l c a u t i o n . Before Independence, to many educated n a t i o n a l i s t s , the cause of Indian poverty was not pop u l a t i o n growth, hut B r i t i s h e x p l o i t a t i o n of the sub-continent. In s p i t e of high b i r t h -r a t e s , Japan had made progress a f t e r her v i c t o r y over the Russians i n 1905• Her i n d u s t r i a l expansion had been impres-s i v e and I n d i a could f o l l o w the same course, they s a i d . Even i f her population growth was too r a p i d , a r t i f i c i a l b i r t h con-t r o l was b a r b a r i c . S e l f - r e g u l a t i o n should be the only means, and would help to i n s p i r e people to r e t u r n to Aryan t r a d i t i o n s of s e l f - r e l i a n c e and reason. Both the progress of i n d u s t r y and the more conscious l i m i t a t i o n of f a m i l i e s w i l l f o l l o w i n s t r i c t measure the r e a l i z a t i o n of pro-gressiveness and purposeful a c t i o n i n our conduct. 1 S i m i l a r o b j e c t i o n s were heard a f t e r Independence, and supported a l s o by Marxist argument that over-population could be cured by b r i n g i n g c a p i t a l i s m to an end. As f o r c u l t u r a l obstacles i n diverse I n d i a , a few g e n e r a l i z a t i o n s are p o s s i b l e . Indian c u l t u r a l t r a d i t i o n was s t i l l male-centred. Sons were v i t a l - to share the work i n the f i e l d s and to support parents i n t h e i r o l d age. They ensured f a m i l y c o n t i n u i t y and f i l l e d an important r o l e i n p a t e r n a l f u n e r a l r i t e s by p r o p i -t i a t i n g the dangerous s p i r i t s which might impede the path to r e i n c a r n a t i o n . At l e a s t two sons were d e s i r e d , i n hopes t h a t one would l i v e to ma t u r i t y . Therefore, the number and b i r t h order of sons i n f l u e n c e d the degree of m a r i t a l f e r t i l i t y . Shyness, and ignorance of the physiology of reproduction a l s o played a p a r t - f o r example, i n the cases where the "safe p e r i o d " was known, i t was f r e q u e n t l y b e l i e v e d t h a t the f i f t e e n days of mid-cycle were the safe days. The f a c t t h a t c o n t r a -ception was p o s s i b l e at a l l was unknown to the m a j o r i t y and l e d to the commonly asserted phrase, " I t ' s God's w i l l " -meaning t h a t nothing could be done to avert a pregnancy i f i t was going to occur. On the other hand, t r a d i t i o n a lso provided some f e r -t i l i t y r e g u l a t i o n . In some parts of I n d i a , i n t e r c o u r s e i s forbidden on more than one hundred f e s t i v a l days a year. Some people b e l i e v e t h a t c o i t u s by the parents i s i n a u s p i c i o u s f o r a baby who i s being breast fed (an almost u n i v e r s a l p r a c t i c e ) , and that the period of s e l f - r e s t r a i n t should be shortened only by i t s death or premature weaning. When t h i s taboo i s observed, i t tends to lengthen the p e r i o d between p r e g n a n c i e s . ^ P r a c t i t i o n e r s of indigenous medicine also b e l i e v e t h a t semen, when r e t a i n e d , produces energy (ojas) which i s d i f f u s e d over the body v i a the h e a r t . This i d e a 43 has been used to support the case f o r vasectomy. Related to the idea, of energy through r e s t r a i n t , among middle and upper income groups, at l e a s t , there i s the Hindu t r a d i t i o n of a s c e t i c i s m during the f i r s t , t h i r d and f o u r t h stages of l i f e (the asramas). Gandhi was a very i n f l u -e n t i a l proponent of t h i s r u l e , b e l i e v i n g that s e l f - c o n t r o l was a very important i n g r e d i e n t f o r s o c i a l and economic progress, and, as a leader of the Independence movement (and, having f a t h e r e d three l i v i n g c h i l d r e n ) he decided i n 1899 to l i v e a continent l i f e . In 1906 he took a formal vow of c e l i b a c y (Brahmacharya). Thus, when Margaret Sanger paid him a v i s i t i n 1935» he agreed that women should have c o n t r o l over t h e i r own bodies and that f a m i l y s i z e should he l i m i t e d , hut was adamant that continence was the only acceptable method of b i r t h c o n t r o l . Women must say "No" to t h e i r husbands; and, a f t e r three or four c h i l d r e n , couples should l i v e a p a r t . Otherwise they would never l e a r n the v i r t u e of s e l f - r e s t r a i n t . ^ 5 Gandhi was a l s o convinced t h a t , i f each person labored only f o r s u f f i c i e n t to s a t i s f y h i s i n d i v i d u a l need, a l l would have enough, and there would be an end to the cry of over-population. On the other hand, an e q u a l l y noted I n d i a n , Br. S a r v e p a l l i Radhakrishnan, former president of I n d i a , and a sch o l a r of repute, always maintained t h a t b i r t h c o n t r o l i s necessary, and there i s no s p e c i f i c o p p o s i t i o n i n Hinduism to cont r a -4 7 c e p t i o n . I f r e l i g i o n was not a seriou s o b s t a c l e , other c o n d i t i o n s impeded f a m i l y planning. Welfare programs and medical s e r v i c e s were scant. In a d d i t i o n , l a c k of t r a i n i n g f o r doctors and others i n b i r t h c o n t r o l s e r v i c e s a l s o obstructed the program. Western t r a i n e d p h y s i c i a n s had acquired Western a t t i t u d e s to co n t r a c e p t i o n , and w i t h the few i n d i v i d u a l exceptions noted, the r e s u l t was medical i n e r t i a . Resolutions might be passed at medical meetings i n support of f a m i l y planning and i n r e -sponse to such leaders as Margaret Sanger and Mrs. How-Martyn, but that v/as the end of i t . Although by 1966 some Asian countries were reported to be g i v i n g f i v e times as many hours of i n s t r u c t i o n i n f a m i l y planning i n t h e i r medical courses as were the United S t a t e s , the United Kingdom, and Canada, i n 1967 Dr. Chandrasekhar was s t i l l e x h o rting Indian medical 48 schools and co l l e g e s to greater e f f o r t . But, as a r e s u l t of these o b s t a c l e s , and because there was no way of estimating the p o l i t i c a l consequences, the Union government v/as slow to put i n t o e f f e c t a f u l l y supported fam-i l y planning program, and State governments were even slower. Not only were p o l i t i c a l ; : p i t f a l l s f e a r e d , but the st a t e s were r e l u c t a n t to spend money on a program f o r which n e c e s s i t y had not been proven. Furthermore, the f i r s t M i n i s t e r of Health i n the C e n t r a l government, an Indian princess named Raj Kumari Amrit Kaur (a P r o t e s t a n t , but a devotee of the Mahatma), stood 49 i n the way of any method but rhythm f o r ten yea r s . Nevertheless, as a t e n t a t i v e h e a l t h and welfare measure, the Union government was prepared to s u b s i d i z e the FPAI i n i n c r e a s i n g amounts to ca r r y out an a c t i o n program of b i r t h c o n t r o l s e r v i c e s , and to have i t s r e p r e s e n t a t i v e s s i t on planning b o d i e s , These funds were never enough to do an e f f e c t i v e job, however. Vast amounts were r e q u i r e d f o r t r a i n i n g , f o r research, f o r propaganda, and the extension of s e r v i c e s , and, though the FPAI knew i t , they were never given carte blanche. On the other hand, o f f i c i a l s i n the f i e l d of population p o l i c y d i d not h e s i t a t e to t a k e advantage of o p p o r t u n i t i e s a v a i l a b l e through the FPAI to t r a v e l , to p a r t i c i p a t e i n conferences and. to l e a r n what they could. Un-f o r t u n a t e l y , because of reluctance f o r the f i r s t ten years, population pressures have g r e a t l y i n c r e a s e d , and now that the government i s s e r i o u s l y promoting b i r t h c o n t r o l , p o l i t i -c a l l y l e d communalism - both r a c i a l and r e l i g i o u s - has posed a new t h r e a t to the program. The Jan Sangh, a r i g h t wing Hindu extremist p a r t y , has attacked the f a m i l y planning program as a t h r e a t to Hindu numerical supremacy, and Dr. Chandrasekhar, as M i n i s t e r , was f o r c e d to counter w i t h the i n f o r m a t i o n that ... Muslims, C h r i s t i a n s (both P r o t e s t a n t and C a t h o l i c ) and other m i n o r i t y r e l i g i o u s communities are a l l coming to government c l i n i c s , and the communal r a t i o of the Indian population shows no signs of changing. A l l evidence shows that these Hindu extremist f e a r s are groundless and t h a t educated and motivated husbands and wives r e s o r t to f a m i l y planning w h i l e the very poor, the ignorant and the un-motivated do not - among a l l r e l i g i o u s groups. He observed that Muslims, i n theory, had the p r i v i l e g e of four wives, but t h a t , i n p r a c t i c e , 9 5 percent had only one, and f u r t h e r reform must o r i g i n a t e w i t h the Muslims, them-s e l v e s , p a r t i c u l a r l y the Muslim w o m e n . I n d i a n and Foreign  News A noted that the Papal E n c y c l i c a l of J u l y , 1 9 & 8 , against a r t i f i c i a l means of c o n t r a c e p t i o n , had provoked a c r i s i s of conscience f o r the Roman C a t h o l i c s of I n d i a (there are only 1 0 . 5 m i l l i o n C h r i s t i a n s a l t o g e t h e r ) and speculated whether they would i n i t i a t e a campaign against government p o l i c y and thus create f u r t h e r communal t e n s i o n s , but no a c t i o n of t h i s s o r t i s apparent, the p r e l a t e s on the spot being r e a l i s t s . But what of the i n d i v i d u a l s who used b i r t h c o n t r o l ? As f a r as they were concerned, f o r the i n t e l l e c t u a l l y motivated, there was continence. The more p r o s a i c middle and upper cl a s s e s p r a c t i s e d c o i t u s i n t e r r u p t u s or used the d i a -phragm or other a r t i f i c i a l methods. Coitus i n t e r r u p t u s was p r a c t i s e d by some v i l l a g e people as w e l l , but induced a b o r t i o n or "unconscious" or d e l i b e r a t e i n f a n t i c i d e (of g i r l s , i n p a r t i -52 c u l a r ) v/as t h e i r main a l t e r n a t i v e to u n l i m i t e d f e r t i l i t y . In p r o p o r t i o n to the population of I n d i a , those who used contraception were very few, and motivation to accept the s e r v i c e s o f f e r e d by the FPAI and, l a t e r , by government, de-pended l a r g e l y on the i n f l u e n c e of the obstacles already d i s -cussed. The r o l e performed by the FPAI was i n p r o v i d i n g a forum f o r d i s c u s s i o n and exchange of information among i n f l u -e n t i a l I n d i a n s , and i n t e s t i n g p u b l i c r e a c t i o n to both pro-motion and p r o v i s i o n of s e r v i c e s . I t also marshalled evidence to persuade the government th a t a c t i o n should and could be taken w i t h s a f e t y , and developed the prototypes f o r promotion and the d e l i v e r y of s e r v i c e s . Co-operation between the government and the PPAI was close from 1 9 5 0 °n, when the vo l u n t a r y o r g a n i z a t i o n was i n -v i t e d to send r e p r e s e n t a t i v e s to the advisory panels on h e a l t h and welfare of the Plan n i n g Commission. Smt. Rama Rau jo i n e d the former and Smt. Wadia the l a t t e r . Family planning was incl u d e d i n the F i r s t F i v e Year P l a n , and Rs. 6 , 5 0 0 , 0 0 a l l o -cated f o r the program.53 i n -the meantime, the FPAI inaugurated the f i r s t i n a s e r i e s of i n c r e a s i n g l y p r e s t i g i o u s p e r i o d i c A l l - I n d i a conferences on f a m i l y p lanning which have had an important e d u c a t i o n a l f u n c t i o n , and i n which the i n t e r a c t i o n between the FPAI and the p r o f e s s i o n a l s i s of i n t e r e s t . I t was held i n Bombay i n December of 1 9 5 1 • Dr. Chandrasekhar, then D i r e c t o r of the Indian I n s t i t u t e of P o p u l a t i o n S t u d i e s , U n i v e r s i t y of Baroda, and a Board member of the PPAI, gave the i n a u g u r a l address. The presence of 1 1 0 delegates, i n -c l u d i n g many doctors, i n d i c a t e d wider i n t e r e s t i n the i d e a of f a m i l y p lanning than had been a n t i c i p a t e d . Instead of the " b i r t h c o n t r o l " concept of former y e a r s , the theme was, "Conscious and Responsible Parenthood". Resolutions advo-c a t i n g a n a t i o n a l i n s t i t u t e of population r e s e a r c h , demographic, s o c i o l o g i c a l , h e a l t h , and other s t u d i e s were adopted. Education f o r medical and para-medical personnel was urged, and i t was agreed that treatment of i n f e r t i l i t y and marriage guidance should be g i v e n . As had been recommended by the Bhore Commit-te e , a. wide choice of contraceptives should be manufactured i n I n d i a , and d i s t r i b u t e d f r e e to a l l . B e t t e r p u b l i c education, t r a i n i n g , data c o l l e c t i o n , and e v a l u a t i o n were e s s e n t i a l . ^ In 1 9 5 2 the o r g a n i z a t i o n of the T h i r d I n t e r n a t i o n a l Conference on Planned Parenthood i n Bombay and the formation of the IPPP, drew more a t t e n t i o n to the movement. Eighty delegates from t h i r t e e n f o r e i g n c o u n t r i e s , and f o u r hundred from I n d i a ( i n c l u d i n g the Union M i n i s t r y of H e a l t h , some State governments and the Indian Army) attended. As has been noted, i n 1 9 5 3 the PPAI commenced p u b l i c a t i o n of the four-page monthly news b u l l e t i n , Planned Parenthood', In 1 9 5 k Dr. P i l l a i s t a r t e d the J o u r n a l of Family Welfare, a source of in f o r m a t i o n and re p o r t s both of which are s t i l l published by the A s s o c i a t i o n , and s u b s i d i z e d by government gr a n t s . P o s t e r s , f i l m s and other v i s u a l aids were also undertaken. In the meantime, the Union M i n i s t r y of Health had made a t e n t a t i v e s t a r t on a government program by approving s t e r i -l i z a t i o n and advice on contraception f o r medical reasons, but only i f doctors had time! Furthermore, contraceptives were not to be given to the poor as "they might not use them". Studies were to be allowed, but no a c t i o n was to be taken. The M i n i s t e r of Health, Raj Kumari Amrit Kaur, agreed to an experimental research p r o j e c t on the "safe p e r i o d " i n which, a f t e r considerable n e g o t i a t i o n , the World Health O r g a n i z a t i o n was persuaded to a s s i s t . Under WHO auspices, Dr. Abraham Stone, of the Margaret Sanger C l i n i c a l Research Bureau i n New York, was loaned to conduct experiments i n C a l c u t t a , Madras, Mysore and the D e l h i area. These t r i a l s began i n May 1 9 5 2 , l a s t e d f o r n e a r l y three years, and s u f f e r e d many v i c i s s i t u d e s . The women were given charts on which to record d e t a i l s of t h e i r menstrual c y c l e s , but they proved unable to do so. I t was concluded t h a t they were too poorly educated, so an a l t e r -n a t i v e was devised. They were given s t r i n g s of coloured beads - orange f o r the days of menstruation, green f o r safe days, and red f o r f e r t i l e days. S p e c i a l adjustments had to be made f o r the women whose cycles v a r i e d i n l e n g t h , and, because the c o l o r was i n d i s t i n g u i s h a b l e at n i g h t , the shape of the beads had to be changed. Some women d i s l i k e d the beads because they caused gossip i n the neighborhood; others (applying the commonly accepted taboos about menstruation) would not touch the beads on the days of t h e i r p e r i o d s ; s t i l l others forgot to move a bead a day, or assumed th a t the mere moving of the bead provided p r o t e c t i o n against pregnancy. In the end, only a few were able to use the meth-od, and the p r o j e c t was judged a f a i l u r e . Because Roman C a t h o l i c i n f l u e n c e was strong i n WHO, no f u r t h e r experiments 56 were permitted by that agency f o r another ten yea r s . The Second A l l - I n d i a Conference on Family Planning was held at Lucknow U n i v e r s i t y i n January, 1955* Srat. Rama Rau reviewed progress i n the government program to date• L i t t l e of the money a l l o c a t e d i n the F i r s t Five-Year P l a n had been spent. T r a i n i n g had been neglected, e s p e c i a l l y i n the medi-c a l c o l l e g e s . No plan had been devised to spread knowledge of f a m i l y planning among the people, or to manufacture con-t r a c e p t i v e s i n I n d i a . No research had been done on simple methods. A c e n t r a l i z e d i n s t i t u t i o n f o r research was needed and an i n t e r - d i s c i p l i n a r y approach was r e q u i r e d . Marriage c o u n s e l l i n g and help f o r the i n f e r t i l e was a l s o a must. Spacing or l i m i t i n g pregnancies f o r h e a l t h or economic reasons was the best approach. Because they were " n o n - p o l i t i c a l " , v o l u n t a r y s o c i a l workers could p l a y a v i t a l r o l e x-/ith government, and w i t h o r g a n i s a t i o n s i n other countries." 5 Dr. Radhakaraal Mukerjee, V i c e - C h a n c e l l o r o f Lucknow U n i v e r s i t y , urged a s t a b l e p o p u l a t i o n , a t h r e e - c h i l d f a m i l y i d e a l , and, to encourage the p r a c t i c e of f a m i l y p l a n n i n g , a program f o r s o c i a l s e c u r i t y . B i r t h c o n t r o l would not cause immorality, but a mass campaign was necessary to create new v a l u e s . I n d i s c r i m i n a t e increase would only increase the dependency r a t i o and place an unneces-sary dram on resources. Dr. K.C.K.E. Raja , of the M i n i s t r y of H e a l t h , where Gandhism s t i l l p r e v a i l e d , warned th a t w i t h r e d u c t i o n i n morta-l i t y , the population would increase i n any case, and that the r e s t of the world should share i t s resources w i t h I n d i a . Spacing was not a u s e f u l theme, as there was already an average of four years between pregnancies. Women i n s t i n c t i v e l y r e -s i s t e d a r t i f i c i a l b i r t h c o n t r o l , and those who used i t would create p s y c h o l o g i c a l problems f o r themselves. Semen had a b e n e f i c i a l e f f e c t on them, s t i m u l a t i n g t h e i r generative powers. Cancer could r e s u l t . I f the middle and upper c l a s s e s were en-couraged i n f e r t i l i t y c o n t r o l , the o v e r a l l i n t e l l i g e n c e l e v e l of the population would be reduced. Abortion and s t e r i l i z a t i o n were also un t h i n k a b l e . Rhythm was the most s u i t a b l e method, and would be s u c c e s s f u l i f the husbands were educated to i t s use. Other speakers favored c o n t r a c e p t i o n , however, and the u s u a l r e s o l u t i o n s urging research and medical t r a i n i n g were passed. Dr. Chandrasekhar's arguments i n favor of b i r t h c o n t r o l were published the same year. I t was an a l t e r n a t i v e to a b o r t i o n . Because people wanted to l i m i t t h e i r f e r t i l i t y , i t should be an i n t e g r a l part of the development program. Conservation of human resources through improved h e a l t h was e s s e n t i a l . V i l l a g e women were emerging from t h e i r apathy, and t h e i r a t t i t u d e s to c h i l d b i r t h should be guided along these l i n e s . Sex education f o r women and f o r a l l students i n schools and c o l l e g e s was e s s e n t i a l , and b i r t h c o n t r o l should be f r e e . "Whether i t i s moral or immoral i s not a matter of o b j e c t i v e f a c t but one of s u b j e c t i v e a t t i t u d e " , he s a i d ; and the Gandhian view, which favored f r e e i n g women through ab-sti n e n c e , ignored the f a c t that women might enjoy i n t e r c o u r s e . ^ ' The T h i r d I l l - I n d i a Conference on Family Planning was held i n C a l c u t t a i n January, 1 9 5 7 * Guests from Egypt, Indo-n e s i a , P a k i s t a n , China (Peking), Singapore, the United Kingdom, the United S t a t e s , the P a t h f i n d e r Fund (Mrs. Margaret R o o t s ) , and U.K. Sarkar, a demographer from Ceylon, attended. Nineteen papers were read, followed by a seminar on marriage c o u n s e l l i n g and sex education, conducted by an American, Dr. David Mace. Dr. J.C. Gosh of the Plan n i n g Commission p r a i s e d the FPAI f o r i t s crusade, and urged i t to persuade the S o c i a l Welfare Board (a c o - o r d i n a t i n g agency f o r women's volun t a r y o r g a n i z a t i o n s ) to support the cause. Smt. Rama Rau's p r e s i d e n t i a l address noted that government support of f a m i l y planning was i n c r e a s -i n g , but there were s t i l l many shortcomings i n the o f f i c i a l program. Less than h a l f the money appropriated had been spent, there was no c e n t r a l i n s t i t u t e f o r c l i n i c a l work, t r a i n i n g , t r i a l s , f e r t i l i t y and i n f e r t i l i t y s t u d i e s , and nothing at the st a t e l e v e l . No s p e c i a l courses were being given i n schools of medicine, n u r s i n g , or s o c i a l work. Some research had been done i n g e n e t i c s , economics, and demography, but progress was uneven. Volunteers were s t i l l needed to pioneer where the government was unable to do so, and the FPAI could a s s i s t i n s t a n d a r d i z i n g p o l i c y and procedures. Family P l a n n i n g was not a plan to l i m i t f e r t i l i t y , but one to space pregnancies f o r health, and happiness. L t . C o l . B.L. Raina, Secretary of the C e n t r a l Family Planning Board, and D i r e c t o r of Family P l a n n i n g , assured the audience t h a t b e t t e r o r g a n i z a t i o n was on the way and that more help would be given the s t a t e s , l o c a l bodies and v o l u n t a r y o r g a n i z a t i o n s . Dr. K.C.K.E. Raja, now c o - o r d i n a t i n g o f f i c e r of the Demographic T r a i n i n g and Research Centre (to be opened l a t e r t h a t year under Indian and UN sponsorship), spoke once more. This time he was more e n t h u s i a s t i c about the program. He was s t i l l opposed to a b o r t i o n , but approved s t e r i l i z a t i o n by mutual consent of parents w i t h completed f a m i l i e s . There was an acute shortage of doctors, so teams and camps f o r b i r t h c o n t r o l were a good i d e a . Mass education was a l s o needed. Genetic study of i n t e l l i g e n c e and h e r i t a b l e defects should be c a r r i e d out (there was ample m a t e r i a l i n the caste system and endogamous marriages). Dr. C. Chandrasekharan, Professor of S t a t i s t i c s , A l l - I n d i a I n s t i t u t e of Hygiene and P u b l i c H e a l t h , C a l c u t t a , doubted t h a t r a i s i n g the age of marriage would succeed. I n -stead, r u r a l people should be motivated to change t h e i r a t -t i t u d e s , and economic development should be prompted to help them do s o . ^ 1 I t should be noted here that s t u d i e s of the economic aspects of p o p u l a t i o n growth had already been done by Indians and o u t s i d e r s . In 1 9 4 6 D. Ghosh had published Pressure of  P o p u l a t i o n and Economic E f f i c i e n c y i n I n d i a , i n which he urged a population c o n t r o l program. J . M. Keynes had suggested i t i n the 1 9 2 0 s , and K i n g s l e y Davis had recommended i t i n 1 9 5 1 and 1 9 5 k . c At the C a l c u t t a conference i t s e l f , Dr. M.C. B a l f o u r of the R o c k e f e l l e r Foundation, gave a summary of a 1 9 5 6 p r e l i m -i n a r y d r a f t of a book by Ansley J . Coale and Edgar M. Hoover, showing the negative e f f e c t of population growth on economic progress. In i t s published form i t s message was, High f e r t i l i t y i s a n e c e s s i t y f o r human s u r v i v a l when m o r t a l i t y r i s k s are g r e a t . When m o r t a l i t y r i s k s are reduced, h i g h f e r t i l i t y becomes a burden - by i n c r e a s i n g the dependency r a t i o , by d i v e r t i n g c a p i t a l from uses t h a t would r a i s e per c a p i t a out-put, and i n the long run by overwhelming any f i n i t e resources. I f b e t t e r h e a l t h and longer l i f e are valued, h i g h f e r t i l i t y must be considered an extravagance. A population w i t h h i g h incomes and ample resources may be able to a f f o r d i t f o r a p e r i o d , perhaps f o r many decades. But a low-income area w i t h h i g h f e r t i l i t y t h a t chooses the luxury of sustained b i r t h s i n e v i t a b l y chooses to forego a much more r a p i d expansion of per c a p i t a incomes. Reduced f e r t i l i t y permits higher per c a p i t a incomes i n the short run and i n the intermediate f u t u r e ; i n the d i s t a n t f u t u r e i t can avert the otherwise i n e v i t a b l e r e t u r n of poverty and h i g h death rates.63 In the same year Robert C. Cook gave I n d i a only a generation to f i n d a s o l u t i o n , and urged i n c e n t i v e s to speed the process 64 and avoid catastrophe. The C a l c u t t a conference urged once more that medical t r a i n i n g i n methods of b i r t h c o n t r o l be g i v e n , and pressed the government to introduce the program i n the p l a n t a t i o n areas and i n i n d u s t r i a l e n t e r p r i s e s . About the only progress made had been i n slogans: b i r t h c o n t r o l i n the F i r s t Five-Year P l a n had been f o r "f a m i l y w e l f a r e " . In the Second ( 1 9 5 6 - 6 I ) i t became a "key f a c t o r i n development", but a c t i o n was s t i l l h e s i t a n t and t e n t a t i v e . The f r u s t r a t i o n of the FPAI was summed up by Warren S. Thompson, a pioneer observer since the 1 9 2 0 s : The Planned Parenthood movement i n I n d i a i s w e l l organized and quite v i g o r o u s , but i t s leaders would be the f i r s t to recognize that i t does not reach many people and that i t i s having only a n e g l i g i b l e e f f e c t on the b i r t h r a t e at present. Handicapped by inadequate funds and by l a c k of t r a i n e d workers, i t cannot c a r r y on any la r g e campaign.... Most of the c l i n i c s now i n operation are i n the la r g e c i t i e s , and some of these are not yet being used to c a p a c i t y , probably because of inadequate propaganda. To say the l e a s t , t h i s s i t u a t i o n i s pro-foundly discouraging to those people who are the most deeply convinced of I n d i a ' s need f o r f a m i l y planning and who are g i v i n g generously both of t h e i r time and money. 65 The FPAI's own summary of ten years of propaganda contained the urgent recommendation that s e r v i c e s be extended through a "country-wide network of c l i n i c s supported by a massive and sustained e d u c a t i o n a l programme which must be implemented w i t h patience and f a i t h , " but a dynamic s t a r t was s t i l l f i v e 66 years away. The S i x t h I n t e r n a t i o n a l Conference on Planned Parent-hood was h e l d by the IPPF i n New D e l h i i n February, 1 9 5 9 . The theme was, "Motivation and Methods". I t has already been described i n part i n Chapter IV, but items about I n d i a should be noted here. S i r J u l i a n Huxley, a famous b i o l o g i s t , the former D i r e c t o r General of UNESCO, summed up India's m o t i v a t i o n a l problems as conformity, i l l i t e r a c y , under-n u t r i t i o n , pressure on space, u r b a n i z a t i o n , s p e c i a l problems because of migration and unemployment, d e f o r e s t a t i o n , and e r o s i o n , water shortage, s p o l i a t i o n of r e c r e a t i o n areas, and l a c k of conservation p o l i c y , l i k e Robert Cook, he, too, recommended i n c e n t i v e s to reduce f e r t i l i t y - a r e d u c t i o n i n f a m i l y allowances a f t e r two c h i l d r e n , and a modified tax s y s -tem p e n a l i z i n g those w i t h l a r g e f a m i l i e s . A paper by Dudley K i r k , then Demographic D i r e c t o r of the P o p u l a t i o n C o u n c i l , urged more motivation f o r men and the promotion of more male methods of c o n t r a c e p t i o n . In any case, a wider choice of methods, e s p e c i a l l y those which d i d not r e q u i r e a doctor's a s s i s t a n c e , should be used. There should be l e s s " c l i n i c " o r i e n t a t i o n , more p u b l i c i t y , and more research i n knowledge, a t t i t u d e s and p r a c t i c e . People were i n t e r e s t e d however, motivation i n urban areas was h i g h e r , but, i n both cases, s e r v i c e s must be w e l l organized and a l l must be warned th a t methods could f a i l . P r o f e s s o r S. Chandraskhar, by t h i s time D i r e c t o r of the Indian I n s t i t u t e f o r Population Studies i n Madras, reported on the Kaufman Foundation C l i n i c at Mangadu (Madras S t a t e ) . This p r o j e c t had been financed f o r f o u r years from 1 9 5 5 * "by Mr. A.S. Kaufman, P r e s i d e n t , Parents' Information Bureau, l t d . , K i t c h e n e r , O n t a r i o , to f i n d out whether the average mother wanted to space those she had with a minimum i n t e r v a l of two years, what were the b a r r i e r s to acceptance, and what methods would be w e l l r e c e i v e d . I t was found t h a t most would l i k e to l i m i t f a m i l y s i z e , but t h a t the need f o r sons took precedence. There was the need to emphasize spacing, c h i l d care and general h e a l t h . The women were not aware th a t the government had approved the experiment^ so b e t t e r i n f o r m a t i o n s e r v i c e s were needed. In two-and-one-half years there were 1 , 2 0 0 acceptors but 192 f a i l u r e s because the method chosen was not used. The reasons f o r f a i l u r e were reported as: l a c t a t i o n , aversion to handling the g e n i t a l s , or the method was too messy. Dr. Chandrasekhar 1s American w i f e had done most of the work and i t was concluded that an o u t s i d e r could promote f a m i l y planning. Most of the p a t i e n t s wanted i t f o r economic and h e a l t h reasons, but motivation was not strong enough to induce long term use. As diaphragm and j e l l y was unsuited to a r u r a l s e t t i n g , simpler methods had been t r i e d . Tampons and o i l or s a l t s o l u t i o n were unpopular. The sponge and foam powder were acceptable. An i d e a l method was needed -an i n j e c t i o n , a p i l l or the l i k e - and vasectomy should be pushed because i t made an end of f e a r and encouraged b e t t e r c h i l d care. The government of Madras was undertaking such a 68 campaign. A study group on s t e r i l i z a t i o n , presided over by Dr. C P . B l a c k e r , and w i t h Dr. G.M. Phadke as rapporteur, appears to have produced some c o n f l i c t . In the meeting there was no o p p o s i t i o n i n p r i n c i p l e to the method, and a r e s o l u t i o n u r g i n g support was passed unanimously. I t was a s a f e , accept-able and e f f e c t i v e method, and r e v e r s i b l e by Dr. V.N. Shirodkar's technique; and more inf o r m a t i o n should be given to the medical p r o f e s s i o n and the p u b l i c . The necessary f a c i l i t i e s "should be made a v a i l a b l e f r e e of charge to persons who seek them v o l u n t a r i l y . " Though i t was l e g a l , doctors seemed to f e e l the need f o r p r o t e c t i o n , and governments should make sure t h i s was provided. The motion was proposed by S r i R.A. Gopalaswami of Madras, and seconded by a "Dr. A.M. Mehta" who appears to have been n e i t h e r a delegate nor a speaker,'and, judging from h i s name, was from the Bombay area. When i t was considered by the Governing Body of the IPPP the f o l l o w i n g r e s o l u t i o n was passed: The Governing Body n o t i n g the recom-mendation... and r e a l i z i n g f u l l y the value of s t e r i l i z a t i o n i n many s i t u a t i o n s , hereby r e s o l v e s t h a t , i n the present s t a t e of knowledge, i t would be premature f o r the IPPP to take a p o s i t i o n i n t h i s matter at t h i s time. I t was decided to leave the question to the member countries 6 9 to d e a l w i t h as they saw f i t . y Dr. C. Chandra.se kharan, another Indian demographer now I n t e r r e g i o n a l Adviser on Population at the United Nations, l i k e Thompson, noted t h a t people were i n t e r e s t e d i n f a m i l y planning but r u r a l motivation was weak. Mot i v a t i o n i n urban areas was h i g h e r , but, i n both cases, s e r v i c e s must be w e l l 70 organized, and a l l must be warned t h a t methods could f a i l . In a p r i v a t e b r i e f to the C e n t r a l Government i n October, 1959j the PPAI expressed i t s impatience w i t h the l a c k of pro-g r e s s . I t pointed out tha t the C e n t r a l Family P l a n n i n g Board (of which Smt. Rama Rau was a member) had not met f o r a year. State e f f o r t s were inadequate, and c o - o r d i n a t i o n and i n s p e c t i o n were r e q u i r e d . More money was needed by the v o l u n t a r y o r g a n i -z a t i o n s . Cheap c o n t r a c e p t i v e s , manufactured i n I n d i a , were e s s e n t i a l ; and a b e t t e r plan should be made to e n l i s t support of the medical p r o f e s s i o n , labor departments and trade unions. The FPAI urged more research i n I n d i a ( i n preference to w a i t i n g u n t i l the West d i d i t ) ; and, once more, the need of i n s t r u c -t i o n i n medical c o l l e g e s , nursing s c h o o l s , and schools of s o c i a l work, was s t r e s s e d . The government program was good, so f a r as i t went, but there was danger that i t would slow down ro u t i n e h e a l t h s e r v i c e s , that i t would be subject to the usual b u r e a u c r a t i c c o n v o l u t i o n s , and that the sense of urgency would be l o s t . Economic i n c e n t i v e s were recommended and a 71 s p e c i a l m i n i s t r y was r e q u i r e d to c a r r y out the whole concept. No doubt as a r e s u l t of t h i s challenge, Smt. Rama Rau was appointed chairman of the C e n t r a l Family P l a n n i n g Board's committee on the T h i r d Five-Year P l a n , to survey progress and formulate proposals. She and Mrs. Wadia sat a l s o on the Advisory H e a l t h Panel of the Planning Commission while d i s -cussions of f a m i l y planning were i n progress. But s t i l l the program lagged. At a conference on research i n f a m i l y p l a n n i n g , held the same year i n New York, P r o f e s s o r J . Mayone Stycos, a s o c i o l o g i s t , now of C o r n e l l U n i v e r s i t y , who was also concerned about the delay i n e f f e c t i v e a c t i o n i n developing c o u n t r i e s , blamed the " T r a d i t i o n a l Planned Parenthood Approach" f o r the problems. He repeated the c r i t i c i s m three years l a t e r i n a s l i g h t l y d i f f e r e n t form, and many of h i s points were w e l l taken. But the had as w e l l as the good have si n c e "been en-shrined i n two hooks which are f r e q u e n t l y read hy students of pop u l a t i o n problems; and the impression has been created, by i n f e r e n c e , t h a t the volu n t e e r s were behind the times, i l l -informed and i n f l e x i b l e . Because i t has a bearin g on current and f u t u r e r e l a t i o n s between p r o f e s s i o n a l s and v o l u n t e e r s , the a i r should be c l e a r e d . Stycos s a i d t h a t , because i t was derived from American and B r i t i s h experience, the t r a d i t i o n a l planned parenthood approach should not be used i n developing c o u n t r i e s . But, as noted e a r l i e r , other countries a l s o i n f l u e n c e d the " t r a d i -t i o n a l " approach and, from these c o n t a c t s , I n d i a introduced her own a c t i o n program. So long as the b a s i c IPPP tenets were observed, the member o r g a n i z a t i o n could make i t f i t l o c a l c i r -cumstances and needs. As there was no other background of experience than that of the volunteers i n the i n d u s t r i a l i z e d c o u n t r i e s , i t was n a t u r a l t h a t some a t t i t u d e s would be t r a n s -f e r r e d . But the r e s u l t was not a l l bad. S p e c i f i c a l l y , Stycos s a i d t h a t the " t r a d i t i o n a l " approach had three b i a s e s - a l l unsuited to Asian c u l t u r e s . I t was too med i c a l l y o r i e n t e d , too middle c l a s s , and too f e m i n i s t . In the f i r s t i n s t a n c e , i t was dominated by doctors, the most conservative of p r o f e s s i o n s , so the h e a l t h of the mother and c h i l d took precedence over other c o n s i d e r a t i o n s , and s e r v i c e s were c l i n i c - b o u n d . Even though i t was not n e c e s s a r i l y s u i t e d to a l l Asian users, the diaphragm-and-jelly was advocated before other methods. Though s t e r i l i z a t i o n and ab o r t i o n might be s o c i a l l y t h e r a p e u t i c , these procedures were f o r b i d d e n , and, regardless of t h e i r value i n population c o n t r o l , the IPPF had refused to support e i t h e r at i t s 1 9 5 9 conference. The id e a of spacing pregnancies as a means of b i r t h c o n t r o l was incomprehensible to parents i n a developing country who spaced them by 3 to 4 years anyway, and the treatment of i n f e r t i l i t y had been b u i l t i n t o the program to give i t a c c e p t a b i l i t y w i t h the establishment. Second, he sa i d the program was middle c l a s s and, hence, m o r a l i s t i c i n i t s approach. I t refused to serve the unmarried, and was based on. unfounded e l i t e t h e o r i e s of the f e r t i l i t y of the "lower c l a s s e s " . I t was f r e q u e n t l y s a i d , f o r example, tha t r u r a l e l e c t r i f i c a t i o n would slow t h e i r reprodtictive a c t i -v i t i e s . T h i r d , i t was f e m i n i s t . S e r vices were run by women, f o r women, to f r e e them from male e x p l o i t a t i o n , and probably even to help them dominate. On the grounds that males were i r -r e s p o n s i b l e , male methods such as condoms and withdrawal were not taught. Stycos approved contraception f o r maternal and c h i l d h e a l t h , but suggested that an e f f e c t i v e appeal could a l s o be made to men on economic grounds. I f home v i s i t i n g or promotion through v i l l a g e leaders were b u i l t up, motivation would be more sus t a i n e d . Simple methods should be d i s t r i b u t e d through commercial channels and withdrawal taught. More men should be employed i n promotion w i t h men. F i n a l l y , govern-ment should take over a l l p o l i c y c o n t r o l , and replace medical i n f l u e n c e w i t h tha.t of s o c i a l s c i e n t i s t s , community develop-ment and communications s p e c i a l i s t s . The amateurs should he replaced hy p r o f e s s i o n a l s . 7 2 Dr. W i l l i a m Vogt of Planned Parenthood, George Cadbury of the IPPP, and P r o f . D.V. Gla s s , of the I n s t i t u t e f o r Popu-l a t i o n Studies i n England, explained the reason behind some of the " t r a d i t i o n a l " p o l i c i e s , and c e r t a i n p o i n t s should be made 7 3 here. Medical support was needed f o r acceptance of a contro^ v e r s i a l s e r v i c e , and also f o r the d e l i v e r y of "medical" methods. I t was also necessary i n order to have f a m i l y p l a n -n i n g i n c l u d e d i n o r d i n a r y h e a l t h s e r v i c e s , one of the most obvious routes to multiparous women. C l i n i c s were u s e f u l as demonstration p r o j e c t s and f o r t r a i n i n g . But the need f o r home v i s i t i n g was also recognized, and, l i m i t e d though t h e i r e f f o r t was, the PPAI, had pioneered the i d e a . They had a l s o pioneered the use of the mass media, and, i n a d d i t i o n , had s t a r t e d f a m i l y planning s e r v i c e s i n i n d u s t r y . Because t h e i r funds were l i m i t e d , and personnel few, t h e i r work d i d not extend f a r i n t o the r u r a l areas. The diaphragm was favored by the volunteers i n South A s i a , too, because i t was the most r e l i a b l e method. While low income women might not have the p r i v a c y of bathrooms, some found a way to use i t , e s p e c i a l l y as i n t e r c o u r s e often takes place without p r e l i m i n a r i e s , and, f o r example, when they take lunch to t h e i r husbands when the 7k crops are h i g h . In a d d i t i o n to the diaphragm - sponge and j e l l y , and foam t a b l e t s were also d i s t r i b u t e d . The condom was as s o c i a t e d i n the medical mind w i t h p r o s t i t u t i o n and the need f o r p r o t e c t i o n against venereal disease, so i t was not popular at f i r s t w i t h the f a m i l y planners e i t h e r . Withdrawal was opposed because i t was then b e l i e v e d to be emotionally u n s a t i s f a c t o r y , and al s o because i t sometimes f a i l e d . Female s t e r i l i z a t i o n had been performed i n I n d i a as e a r l y as 195^, and vasectomy was also o f f e r e d by the FPAI. The l a t t e r was not popular f o r some years, however, because men thought i t was c a s t r a t i o n . Doctors were also cautious because of imagined l e g a l l i a b i l i t y . P r o f e s s o r Chandrasekhar, as a member of the FPAI, had been advocating s t e r i l i z a t i o n since 1 9 5 5 * I n f e r -t i l i t y s e r v i c e s were indeed defensive i n both, the West and i n South A s i a , and f o r good reason; but, i n the l a t t e r , they had an added a t t r a c t i o n . I n f e r t i l i t y was such a s o c i a l t r a g -edy f o r women that the diagnosis of both husband and wife and treatment f o r whichever was r e s p o n s i b l e , could sometimes r e l i e v e women of the seriou s stigma of being " i n a u s p i c i o u s " . 7 ^ The " t r a d i t i o n a l " approach to induced a b o r t i o n had s e v e r a l bases: i t was i l l e g a l , and, before the advent of a n t i b i o t i c s , induced a b o r t i o n , even i n the best circumstances, was s t i l l r e l a t i v e l y dangerous. I t would also r e q u i r e massive investment i n f a c i -l i t i e s and t r a i n i n g ; and, a f t e r a l l , Margaret Sanger and her contemporaries had used the dangers of abortion as j u s t i f i -c a t i o n f o r contraception as an a l t e r n a t i v e . The movement was indeed middle c l a s s , but most reforms o r i g i n a t e w i t h the middle c l a s s . T h e i r a t t i t u d e s to b i r t h c o n t r o l f o r the unmarried v a r i e d from country to country, b u t, from the po i n t of view of p u b l i c r e l a t i o n s , i t was the best to emphasize t h a t i t was f o r the married. In I n d i a and P a k i -stan the formal statement uses the term "married couples". In Ceylon, i t i s "couples", and i n Nepal, the married s t a t e could he i n f e r r e d , as the s e r v i c e i s f o r maternal and c h i l d 77 w e l f a r e , and i t , too, i s a t r a d i t i o n a l s o c i e t y . In p r a c t i c e i n South A s i a , exceptions were made, no doubt. As f o r i n v i -dious opinions of "lower c l a s s " f e r t i l i t y , i t would he s u r -p r i s i n g i f some f a m i l y planners had not had them; hut, from personal experience, I b e l i e v e they were few. In any case, i n I n d i a the FPAI set out to serve "middle" income groups as w e l l as the "low". In Asian countries " c l a s s " was i r r e l e v a n t and caste d i s t i n c t i o n s too complex f o r easy d e f i n i t i o n . Those who stiggested to me t h a t e l e c t r i f i c -a t i o n would reduce f e r t i l i t y , were not a c t i v e i n the f a m i l y planning movement. As f o r f e m i n i s t b i a s - a few f e m i n i s t s were a c t i v e i n Western co u n t r i e s and Japan, but i t has been shown i n t h i s paper that nowhere was the movement run e x c l u s i v e l y by women, f o r women. The need f o r maternal and c h i l d h e a l t h i n A s i a has already been noted. (See p. 1 1 3 • ) Because b i r t h c o n t r o l s e r v i c e s were u s u a l l y open i n the daytime onl y , i t was n a t u r a l that most of the workers and c l i e n t e l e would be women. From 1 9 5 2 the FPAI had o f f e r e d male s t e r i l i z a t i o n , and, from 1 9 5 ^ » condoms were prescribed.'' 7^ More men were c e r t a i n l y needed i n the t a s k of g e t t i n g male support, and also i n d e l i v e r i n g the s e r v i c e s , but men were running the government program, and most doctors were men. Their s h i f t s i n p o l i c y and emphasis over the years show that i n f l e x i b i l i t y was not a character-i s t i c of the v o l u n t e e r s . There were weaknesses i n the system, to be sure, but no background of experience had e x i s t e d , there was l i t t l e or no dynamic p o l i t i c a l support, and socio-economic and l o g i s t i -c a l problems had not been solved. I t was s t i l l a c o n t r o v e r s i a l and v u l n e r a b l e program, and needed a few safeguards. There was no doubt that medical i n f l u e n c e was s t r o n g , and should have been leavened by other p r o f e s s i o n s , i n c l u d i n g s o c i a l s c i e n t i s t s , community development v/orkers and communications s p e c i a l i s t s . But i n I960 these were r e l a t i v e l y new p r o f e s -s i o n s . Demographers and economists were already a c t i v e , t r a i n e d s o c i a l workers were beginning to enter the f i e l d , and the volunteer f a m i l y planners were prepared to welcome an t h r o p o l o g i s t s and s o c i o l o g i s t s as w e l l . For example, t h e i r sponsorship of conferences was a d i r e c t means of encouraging i n t e r d i s c i p l i n a r y communication. By the time the FPAI organized the A l l - I n d i a Family Planning Conference i n Hyderabad e a r l y i n 1 9 6 1 , the Indian government was beginning to r e a l i z e that the economic conse-quences of population growth were s e r i o u s , that Independence by i t s e l f had not provided the s o l u t i o n , and t h a t b i r t h con-t r o l was an urgent n e c e s s i t y . But t h e i r approach was very " t r a d i t i o n a l " j u s t the same. The P l a n n i n g Commission had s a i d that f a m i l y planning was the "key programme f o r the T h i r d and Fourth Five-Year P l a n s " . D.P. Karmarkar, Union M i n i s t e r f o r Health, explained t h a t f a m i l y planning i n the f i r s t two plan-periods had been "preparatory" phases f o r the T h i r d P l a n . L i m i t e d s e r v i c e s were now being o f f e r e d , but they should be taken to the masses, e s p e c i a l l y those i n r u r a l areas. More r u r a l leaders should be i n v o l v e d , and the help of the v o l u n t a r y o r g a n i z a t i o n s was s t i l l needed. The Family Planning Commissioner, L t . C o l . B.L. Raina described i n glow-i n g terms a f o u r f o l d plan f o r the r e o r g a n i z a t i o n and expansion of government s e r v i c e s , t r a i n i n g , education and research. O r i e n t a t i o n camps f o r l o c a l l e a d e r s , and e x h i b i t i o n s were now proving s u c c e s s f u l , and Honorary Family Planning Education Leaders to promote l o c a l v o l u n t a r y groups were a l s o e f f e c t i v e . Considerable progress had been made to date, both by govern-ment and by the v o l u n t e e r s , and t a r g e t s f o r the f u t u r e were e s t a b l i s h e d . I t was agreed t h a t more e f f o r t should be made to e n l i s t male support (Dudley K i r k had suggested i t at the S i x t h IPPF conference i n 1959). A r e s o l u t i o n to the WHO Assembly (soon to meet i n De l h i ) pointed out t h a t saving l i v e s was admirable, but people a l s o needed i n f o r m a t i o n to . 79 plan t h e i r f a m i l i e s , and thereby improve t h e i r l o t . By the end of 1 9 & 3 , some 28 Knowledge, A t t i t u d e and P r a c t i c e (KAP) studi e s had been done by p r o f e s s i o n a l s i n I n d i a , and the government published the r e s u l t s . In g e n e r a l , people were r e c e p t i v e to the id e a of f a m i l y p l a n n i n g , but methods and p r o v i s i o n of s e r v i c e s were weak, and motivation depended on i n d i v i d u a l circumstances. Three or four c h i l d r e n was the d e s i r e d f a m i l y s i z e . There was l i t t l e or no com-munication between husbands and wives on the subject of b i r t h c o n t r o l and methods s u i t e d to v i l l a g e l i f e were needed. Par e n t s - i n - l a w , and the demands of r e l i g i o n were s a i d to have l i t t l e i n f l u e n c e i n decision-making, hut i n view of t r a d i t i o n , of the need f o r o l d age s e c u r i t y , and f o r sons to p a r t i c i p a t e i n r e l i g i o u s r i t e s , t h i s l a s t p o i n t i s questionable. When the F i f t h A l l - I n d i a Conference on Family P l a n n i n g was he l d i n Patna i n January, 1 9 6 4 , 3 0 0 r e p r e s e n t a t i v e s of both government and v o l u n t a r y agencies heard S r i Asoka Mehta, Deputy Chairman of the Planning Commission, repeat what they already knew - that a t t i t u d e surveys had i n d i c a t e d r e c e p t i v i t y . There were 9 , 0 0 0 c l i n i c s and s e r v i c e centres, of which 7 , 0 0 0 were r u r a l . S t e r i l i z a t i o n had proven to be acceptable i n Madras and Maharashtra; some t r a i n i n g was given i n some u n i -v e r s i t y undergraduate courses, but the help of i n d u s t r y , trade unions, and v i l l a g e teachers should also be e n l i s t e d . Above a l l , to co-ordinate and improve the work, each s t a t e and d i s -t r i c t must set up a f i r m program. In confirmation of the f a i l u r e of the f a m i l y planning scheme to get o f f the ground so f a r , Dr. C. Chandrasekharan, then D i r e c t o r of the Demo-graphic T r a i n i n g and Research Centre i n Bombay, noted that although I n d i a was i n the midst of her Th i r d Five-Year P l a n , no d e c l i n e i n the b i r t h r a t e was ev i d e n t . Induced abortion should be l e g a l i z e d , he s a i d . A b o r t i o n and s t e r i l i z a t i o n could be promoted i n r u r a l areas as more e f f e c t i v e than o r d i n a r y c o n t r a c e p t i v e s . Improvements i n the government program were made grad-u a l l y , and more dynamism was i n j e c t e d , but i t continued to lumber s l o w l y on, s u f f e r i n g from l a c k of p o l i t i c a l courage, s c a t t e r e d s t a t e co-operation, and inadequate promotion and 81 s e r v i c e s . In 19^5, at India's request, the United Nations T e c h n i c a l Assistance Program sent a team of a d v i s e r s , headed by S i r C o l v i l l e D e v e r e l l , former Secretary-General of the IPPP, to study the Indian f a m i l y planning program and make recom-mendations f o r i t s improvement. Their report concluded t h a t , i n s p i t e of continued improvement and a r e o r g a n i z a t i o n i n 1963» l i t t l e progress had been made i n reducing the b i r t h -r a t e . Some of t h e i r suggestions were already being imple-mented (nor were they a l l o r i g i n a l ) , but i t was recommended th a t the IUD, s t e r i l i z a t i o n , a.nd condoms be the main methods o f f e r e d , and tha t i n c e n t i v e s be given both the acceptors and the m o t i v a t o r s . These s e r v i c e s should be o f f e r e d i n i t i a l l y through h o s p i t a l s , urban c l i n i c s and h e a l t h centres where personnel were a v a i l a b l e , then taken to the r u r a l areas through IUD and vasectomy camps. A post partum IUD program should be inc l u d e d as w e l l . Condoms should be fre e or at very low c o s t , and d i s t r i b u t e d through h e a l t h c e n t r e s , t e a shops, general s t o r e s , and chemists' shops. Long term plans to provide many more t r a i n e d people should be made, and, i n the meantime, short courses should be o f f e r e d . Refresher courses should become permanent fe a t u r e s of the t r a i n i n g program. I n c e n t i v e s f o r doctors to give t h e i r s e r v i c e s i n t h i s f i e l d , and to a t -t r a c t them to r u r a l areas should a l s o be given. Health edu-cators and mid-wives should be t r a i n e d , and teachers should be e n l i s t e d . Instead of emphasizing the burden of a b i g f a m i l y , the b e n e f i t s of a small one should be s t r e s s e d . Com-munity development and l o c a l panchayat personnel should be e n r o l l e d . I n d u s t r i a l f i r m s , p l a n t a t i o n s , government o f f i c e s and armed f o r c e s could e a s i l y be reached. Constant r e s e a r c h , review and e v a l u a t i o n should be undertaken. The e n t i r e C e n t r a l and State government apparatus should be i n v o l v e d , v o l u n t a r y  agencies { i t a l i c s minej r e l i g i o u s , and other p r o f e s s i o n s , f a c t o r y workers, trade unions and co-operatives as w e l l . Above a l l , the e n t i r e program should be given autonomous s t a t u s , much more f i n a n c i a l support, and be upgraded to s e n i o r cabinet rank, both at the Centre and State l e v e l . P o s i t i v e l e a d e r s h i p should be given by a l l persons i n p o s i t i o n s of a u t h o r i t y at every l e v e l . With these c o n d i t i o n s , i t should be p o s s i b l e to reduce the b i r t h r a t e by about one t h i r d i n ten years, and the growth r a t e to 1 percent per annum by 1 9 8 5 . Without such true p r i o r i t y to f a m i l y p l a n n i n g , which i n e v i t a b l y means the d i v e r s i o n of e f f o r t and resources from other d e s i r a b l e o b j e c t i v e s , the pro-gramme w i l l not succeed. With i t , there i s great hope that i t will.°2 I n d i a now had g u i d e l i n e s f o r the program she had long needed. In I 9 6 6 the new plan began to take shape. To speed i t , the government o f f e r e d to pay a l l s t a t e and l o c a l costs - an i n v i t a t i o n which d i d much to remove a serious roadblock which had e x i s t e d i n the past.^3 The Union Department of Pamily P l a n n i n g was set up, 6 r e g i o n a l centres f o r l i a i s o n w i t h the s t a t e s and r e p r e s e n t a t i v e s t a t e , d i s t r i c t and l o c a l bureaux were e s t a b l i s h e d . The vo l u n t a r y o r g a n i z a t i o n s were given f u l l support. A mass communications program was put i n t o a c t i o n using a l l media - i n c l u d i n g p r e s s , radio and TV, f i l m s , f i l m s t r i p s , songs, dramas, push c a r t s and posters - w i t h a symbol c o n s i s t i n g of an i n v e r t e d red t r i a n g l e , and cartoon f i g u r e s of a man and wife and two c h i l d r e n w i t h the slogan: "Two or Three Ch i l d r e n ... Enough!"^ In m i d - 1 9 6 7 Dr. Chandrasekhar was appointed M i n i s t e r f o r Health and Family P l a n n i n g , r e p o r t i n g d i r e c t to a Cabinet Committee c o n s i s t i n g of the Prime M i n i s t e r , the M i n i s t e r s of Pl a n n i n g , Finance, H e a l t h , and Food and A g r i c u l t u r e . His C e n t r a l Family Planning C o u n c i l was comprised of States Min-i s t e r s f o r Health and Family P l a n n i n g , Health e x p e r t s , and r e p r e s e n t a t i v e s of v o l u n t a r y f a m i l y planning o r g a n i z a t i o n s ! On the s e r v i c e s s i d e , was a S e c r e t a r y , Department of Family P l a n n i n g , a Commissioner f o r Family P l a n n i n g , and s i x Regional Family P l a n n i n g O f f i c e r s . Their t a s k was set out i n a very concise l i t t l e handbook, backed up w i t h a set of f r i g h t e n i n g s t a t i s t i c s ; In a d d i t i o n to the fundamental problems of 14 major languages, more than 2 0 0 d i a l e c t s , low l i t e r a c y and non communication, there was a net increase a n n u a l l y of 1 3 m i l l i o n I n d i a n s , and each year they would r e q u i r e Although food production ha.d increased from 5 5 m i l l i o n tons i n 1 9 5 1 to 7 2 m i l l i o n tons i n 1 9 6 5 , per c a p i t a food consumption had decreased from 1 2 . 8 ounces to 1 2 . 4 ounces per day. Unem-ployment i n 1 9 5 - L - 5 2 was 3 « 5 m i l l i o n , but, by I 9 6 I , i n s p i t e of 1 2 6 , 5 0 0 schools 3 7 2 , 5 0 0 school teachers 2 , 5 0 9 , 0 0 0 hous.es 4,000,000 jobs 3 1 m i l l i o n new jobs, i t had reached 10 m i l l i o n . In 1 9 5 0 / 5 1 2 3 . 4 9 m i l l i o n c h i l d r e n were i n s c h o o l . F a c i l i t i e s had i n -creased by 3 0 0 percent, and, i n mid-1967, there were 76.5 m i l l i o n i n s c h o o l , but 6 3 . 8 m i l l i o n were not yet accommodated'. A d e t a i l e d plan of a c t i o n was included and t a r g e t s s e t : 1 7 m i l l i o n loops to be i n s e r t e d , 6 m i l l i o n s t e r i l i z a t i o n s done, 86 and 400 m i l l i o n condoms d i s t r i b u t e d by 1970/71. In the meantime, i n s t e a d of the usual p e r i o d i c conference, the amateurs took charge of the o r g a n i z a t i o n of the Seventeenth I n t e r n a t i o n a l Conference on the Family, which was h e l d i n December, 1966, i n New D e l h i . The meeting was sponsored by the I n t e r n a t i o n a l Union of Family O r g a n i z a t i o n s , and the theme was, Changing Family P a t t e r n s i n A s i a . FPAI p a r t i c i p a t i o n i n d i -cated i t s growing i n t e r e s t i n f a m i l y l i f e education. 27 coun-t r i e s were represented by 773 p a r t i c i p a n t s . P o p u l a t i o n prob-lems, marriage, f a m i l y l i v i n g , s o c i a l s e r v i c e s , and research were among t o p i c s discussed. The FPAI reverted to i t s u s u a l p a t t e r n i n 1968, however, h o l d i n g i t s S i x t h A l l - I n d i a Conference at Chandigarh i n November. Nine f o r e i g n countries were represented. For the f i r s t time i n the h i s t o r y of f a m i l y p l a n n i n g , r e p r e s e n t a t i v e s of the World Health O r g a n i z a t i o n (TOO), and the United Nations E d u c a t i o n a l , S c i e n t i f i c and C u l t u r a l O r g a n i z a t i o n (UNESCO) were present, and addressed the meetings. The blockage at the UN had been, at l e a s t p a r t i a l l y , c l e a r e d by the D e c l a r a t i o n of Human Rights and the World Leaders* D e c l a r a t i o n on Po p u l a t i o n i n I 9 6 6 and I 9 6 7 . ." - 450 a d m i n i s t r a t o r s , s c i e n t i s t s , doctors, volunteer s o c i a l workers and others had gathered to " h i g h l i g h t progress so f a r and i d e n t i f y needs" i n order to achieve a b i r t h r a t e i n I n d i a of 23 hy 1978. News was good and had. The r a t e of s t e r i l i z a t i o n s had more than doubled s i n c e 19&6, and was s t i l l i n c r e a s i n g , but the govern-ment IUD program had run dnto s e r i o u s problems ( o u t l i n e d on page 1 5 1 ) . Condom d i s t r i b u t i o n was j u s t beginning to b u i l d up. The government r e p r e s e n t a t i v e s urged the vo l u n -t e e r s to continue t h e i r e f f o r t s , and to m o b i l i z e support among the people. Family L i f e Education i n the schools 87 was a new challenge i n which they were needed. In September, 19&9, the PPAI met f o r a s p e c i a l three day conference to analyse i t s a c t i v i t i e s and consider i t s f u t u r e r o l e . I t was agreed to continue to comment and recom-mend regarding government p o l i c y and program, to continue PPAI a c t i o n programs, to increase to the utmost i t s promotion-a l work, to carry out p i l o t p r o j e c t s , to forge l i n k s among r e l a t e d d i s c i p l i n e s , and to promote contacts w i t h f a m i l y planning or s i m i l a r o r g a n i z a t i o n s abroad. The PPAI would continue to organize congresses to promote an exchange of info r m a t i o n n a t i o n a l l y and i n t e r n a t i o n a l l y . P o p u l a t i o n and 88 f a m i l y l i f e education i n the schools would be a new p u r s u i t . In other words, there was s t i l l a c a t a l y t i c r o l e f o r the vo l u n t e e r s . A f t e r more than two years of i n t e n s i v e work on In d i a ' s population problems, Dr. Chandrasekhar, as M i n i s t e r of State f o r H ealth and Family P l a n n i n g , s t a t e d i n October, 19&9 t h a t the three most important remaining needs were communication to more than 5°0,000 v i l l a g e s , an i d e a l c o n t r a c e p t i v e , and the means to motivate the poor to use i t . ^ 9 The f o l l o w i n g month, the C e n t r a l Family Planning C o u n c i l met at Bhopal. Many aspects of the work were considered i n d e t a i l , i n c l u d i n g education, a d m i n i s t r a t i o n , the r o l e of the v o l u n t a r y o r g a n i -s a t i o n s , p r i v a t e medical p r a c t i t i o n e r s , and recruitment of l o c a l o p i n i o n l e a d e r s . I t was agreed t h a t t a r g e t s should he more r e a l i s t i c and geared to c a p a b i l i t y , but the o b j e c t i v e should s t i l l be to reduce the b i r t h r a t e , b e l i e v e d to be 3 9 per 1,000, to 3 2 by 1 9 7 4 , and to 2 5 by 1 9 7 9 . T*ie need to f u l f i l t r a i n i n g t a r g e t s was s t r e s s e d . Mass education and extension t r a i n i n g , i n c l u d i n g i n f o r m a t i o n on methods, should be f u r t h e r expanded. Po p u l a t i o n education i n schools and c o l l e g e s should be promoted, and involvement of p r i v a t e doctors and homeopathic p r a c t i t i o n e r s sought. The p r i v a t e p r a c t i t i o n e r s could be o f f e r e d i n c e n t i v e s comparable to government s t a f f members. I f homeopathic personnel were given b a s i c courses i n anatomy and physiology, they could become motivators and act also as depot holders f o r conven-t i o n a l c o n t r a c e p t i v e s . The p a r t i c i p a t i o n of newly-weds and young couples w i t h one or two c h i l d r e n should be promoted, using the theme, "Next C h i l d Not Now ... A f t e r Three, Never." I t was agreed a l s o to e s t a b l i s h primary h e a l t h centres i n 400 remote B l o c k s . Immunization against c h i l d r e n ' s diseases should provide another inducement to the small f a m i l y norm everywhere i n I n d i a and a u s e f u l contact w i t h multiparous women. Assessment of the vo l u n t a r y o r g a n i z a t i o n s should he "based on the performance of other " e s t a b l i s h e d and reputed l o c a l centres".9° i n resear c h , t r a i n i n g and s e r v i c e s , govern-ment programs were improving. While d e t a i l s are scarce, the vo l u n t e e r s , on paper at any r a t e , a l s o had a c r e d i t a b l e r e c o r d . Prom the beginning the PPAI r e a l i z e d t h a t accurate data were important, not only f o r research purposes, but f o r e v a l -u a t i o n and pl a n n i n g . And i t would seem t h a t , to some exte n t , the aim was achieved. Unfortunately the published r e p o r t s made a v a i l a b l e to me do not give much s t a t i s t i c a l i n f o r m a t i o n or a c l e a r p i c t u r e of the performance of the volunteers i n the country as a whole. A good deal of comment on a c t i v i t i e s at Headquarters i n Bombay, and i n the Bombay area i s i n c l u d e d ; and a few branches ( f o r example, New D e l h i , (Old) D e l h i , C a l c u t t a , and Hyderabad), have been s e l e c t e d from time to time f o r s p e c i a l mention.-.But comprehensive f i g u r e s on the whole o r g a n i z a t i o n and i t s f i n a n c i n g , are l a c k i n g . The PPAI d i d pioneer work i n i n f e r t i l i t y s e r v i c e s , marriage guidance and sex education. I t also pioneered mobile vans, and male moti v a t i o n through i n d u s t r i a l and commercial e n t e r p r i s e s . Home v i s i t i n g was undertaken on a l i m i t e d s c a l e , but whether these ventures can be cl a s s e d as research i s not known. However, while a s s o c i a t e d w i t h the Kutumb Sudhar Kendra, Dr. G-.M. Phadke d i d do considerable research i n vasectomy; and s p e c i a l s t u d i e s on g e n i t a l t u b e r c u l o s i s , o v u l a t i o n d e t e c t i o n , the e f f e c t of s c r o t a l suspenders on male f e r t i l i t y , and the e f f e c t of testosterone were also made. Tests of foam t a b l e t s were conducted f o r Dr. Clarence Gamble, founder of the Path-f i n d e r Fund. In the past few years, s t u d i e s financed by the V i c t o r Fund (a vo l u n t a r y o r g a n i z a t i o n to r a i s e money i n the United States of America f o r the IPPP) i n the Bombay area have in c l u d e d motivation through mobile teams, promotion through l a b o r unions and other o r g a n i z a t i o n s , and propaganda through v i l l a g e school t e a c h e r s . Female s t e r i l i z a t i o n i n Indore was a l s o surveyed. In 1969 work was being done on a follow-up of 9 0 0 s t e r i l i z e d male i n d u s t r i a l workers i n Bombay, the f a m i l y planning s t a t u s of 2 , 5 0 0 married A i r I n d i a employees, and Knowledge and A t t i t u d e s of 2 8 0 teachers of adult l i t e r a c y c l a s s e s , and of 3 ^ 0 of t h e i r p u p i l s . 9 1 In government resea r c h , besides the KAP s t u d i e s , i t was shown t h a t , where s p e c i a l programs had been i n t r o d u c e d , b i r t h r a t e s had d e c l i n e d . At Gandhigram (Madras) the b i r t h r a t e had been reduced from 40 i n 1 9 5 2 to 3 6 . 3 i n I 9 6 5 . In another p r o j e c t , the Demographic T r a i n i n g and Research Centre at Bombay had induced a d e c l i n e i n f e r t i l i t y of 1 2 percent between 1 9 6 4 and 1 9 6 6 . At Singur, the A l l - I n d i a I n s t i t u t e of Hygiene and P u b l i c Health i n C a l c u t t a had achieved a reduction from 42 i n 1 9 5 8 to 3 4 . 2 i n 1 9 6 6 . In C h o t l a , the ra t e had been 2 9 i n 1 9 6 1 , but was reduced to 24 i n 1 9 6 6 . The C e n t r a l Family Planning I n s t i t u t e , i n New D e l h i had reduced the r a t e at Mehrauli from 5 2 i n 1 9 6 4 to 48 i n 1 9 6 6 . 9 2 These p r o j e c t s demonstrated th a t i t could be done. One of the r e -quirements, of course, was t r a i n i n g , and i n t r a i n i n g , the FPAI f i l l e d a v i t a l role". In s p i t e of repeated urging by the volunteers, f o r the f i r s t ten years of the government program i n I n d i a a l l t r a i n i n g was l e f t to the Family P l a n n i n g A s s o c i a t i o n . S t a t i c courses were given i n Bombay, and t o u r i n g t r a i n i n g teams gave seven to ten-day courses i n other areas. For example, between 1 9 5 1 and 1 9 6 1 , more than 2 5 0 doctors and about 6 5 0 other per-sonnel were given i n s t r u c t i o n . The need was so massive, how-ever, t h a t a f t e r the 1 9 6 3 r e o r g a n i z a t i o n of the government program, w i t h the exception of a few courses run on contract w i t h the Union government i n such c i t i e s as Hyderabad, the »93 work was done by the tax-supported program. y j By m i d - 1 9 6 7 the government had set up f i v e C e n t r a l T r a i n i n g Centres, and 2 8 more i n S t a t e s , w i t h 3 3 5 D i s t r i c t c e l l s . By the end of I 9 6 9 , 1 3 , 0 0 0 doctors, 1 2 5 , 0 0 0 f i e l d workers, and 3 7 5 » 0 0 0 p a r t time f i e l d workers had been t r a i n e d . The A s s o c i a t i o n was s t i l l able to hold seminars and symposia on such s p e c i a l subjects as s t e r i l i z a t i o n , sex and f a m i l y l i f e , and the physiology of re p r o d u c t i o n , which f i l l e d a u s e f u l purpose i n support of the government. There were s i m i l a r developments i n the f i e l d o f c l i n i c s e r v i c e s . These were s t a r t e d by the FPAI i n Bombay i n 1 9 5 2 , and, by 1 9 5 7 > twelve branches were organized. By 1 9 5 9 there were eighteen - i n Agra, Ajmer, Andhra Pradesh, Bombay, Bengal, D e l h i , Indore, J a l p a i g u r i , K a l c h i n i , South Kanara, Madras, Manipur, Mysore, Punjab, T i r u c h i r a p a l l i , Trivandrum and "Vidarbha. By the end of 1 9 6 9 * the FPAI had 3 5 branches and was running 1 7 5 c l i n i c s . Figures were a v a i l a b l e f o r 5 2 of these, and, i n the year ending March 3 1 , I 9 6 9 , 123 ,973 new p a t i e n t s had "been served, i n c l u d i n g 14 ,000 s t e r i l i z a t i o n s and 11,476 ITJD i n s e r t i o n s . Most of the p a t i e n t s i n the FPAI c l i n i c s had incomes of l e s s than Rs. 100 per month, were between 20 and 35 years of age, and those w i t h the most c h i l d r e n were the most frequent v i s i t o r s . I t was recommended tha t c l i n i c s remain open at night so that men could v i s i t as w e l l . A mobile van was d i s t r i b u t i n g simple contraceptives and p r o v i d i n g f a c i l i t i e s f o r vasectomy on a r e g u l a r b a s i s . The Indian Tea A s s o c i a t i o n ( i n Bengal and Assam) had had the se r v i c e s of an o r g a n i z e r , and some s t a t e and l o c a l governments had been a s s i s t e d . In a d d i t i o n , the Associated Cement Company, t e x t i l e m i l l s , and the Reserve Bank of Bombay were now spon-s o r i n g f a m i l y planning s e r v i c e s organized w i t h FPAI h e l p . Their numbers grew u n t i l , by November, 1968, 56 i n d u s t r i a l and commercial firms had introduced t h e i r own programs, covering 111,700 people. The government program had increased g r e a t l y , and, by the end of I 9 6 9 , 1,779 urban and 29,675 r u r a l h o s p i t a l , c l i n i c and h e a l t h center f a m i l y planning programs, and 256 mobile teams were also i n action.9 5 Contraceptives were not made i n I n d i a u n t i l r e c e n t l y . In 1952 the FPAI was given a l i c e n s e to import them f o r d i s t r i -b u t i o n to recognized agencies. From the beginning, the Asso-c i a t i o n urged as wide a choice as p o s s i b l e , on the ground t h a t any method, used r e g u l a r l y , i s b e t t e r than no method at a l l . I t a l so advocated that contraceptives be made i n I n d i a and d i s t r i b u t e d f r e e . Diaphragms w i t h j e l l y were known to be the most r e l i a b l e method, and some women used them very success-f u l l y , hut there was general agreement th a t an e q u a l l y r e l i a b l e method was needed which would be simple, cheap and e a s i l y a v a i l a b l e without the need f o r a doctor's s e r v i c e s . Rice powder and s a l t mixtures w i t h v a g i n a l sponge or pad were found to be messy and u n s a t i s f a c t o r y f o r a e s t h e t i c reasons. Foam t a b l e t s came c l o s e r to the need, but i n v o l v e d problems of storage i n damp weather. S t e r i l i z a t i o n had always been approved, and many had been done both by the PPAI and some government personnel, but a l l were e q u i v o c a l about i n -duced a b o r t i o n . Some people f e l t i t was a problem of e t h i c s ; others that common sense made i t a poor s u b s t i t u t e f o r con-t r a c e p t i o n ; s t i l l o t h e r s , that medical f a c i l i t i e s were inade-quate. The law f o r b i d d i n g a b o r t i o n had been introduced 160 years b e f o r e , and amendment seemed f a r i n the f u t u r e . When the P i l l was made a v a i l a b l e i n I 9 6 0 , there were r e s e r v a t i o n s about i t t o o . R e c a l l i n g the rhythm f i a s c o , the p o s s i b i l i t y of c o s t l y confusion, and r e a l i z i n g the need f o r medical s u p e r v i s i o n , l i t t l e i n t e r e s t was shown by e i t h e r government or PPAI. P r i c e was another f a c t o r . By the end of I 9 6 9 , however, 119,000 women (mostly IUD drop-outs) were e n r o l l e d i n government approved t e s t programs, but the Indian C o u n c i l f o r Medical Research had not yet re l e a s e d the p i l l f o r wide-spread use. I t was claimed that s i d e - e f f e c t s were s e r i o u s , the most l i k e l y being r e d u c t i o n i n br e a s t m i l k f o r nu r s i n g mothers. IUDs were introduced i n mid-1965, and s t e r i l i z a t i o n had been provided since 1 9 5 6 i n some s t a t e s . A l l - I n d i a cumulative t o t a l s i n thousands at the end of I 9 6 9 were: IUDs, 2 , 9 8 9 , and s t e r i l i z a t i o n 5 , 5 1 3 . (See Table I , page 1 5 2 ) . The reduction i n the rat e of IUD acceptors from 1 9 6 7 was due to a combination of unfortunate f a c t o r s . Doctors were not given s u f f i c i e n t i n s t r u c t i o n i n i n s e r t i n g them, and p a t i e n t s were not o f t e n warned that the IUD might cause i r r e g u l a r b l e e d i n g , p a i n , and, i n some cases, might be e x p e l l e d . The f a i l u r e r a t e , though s m a l l , was al s o overlooked. Of these problems, b l e e d i n g was the most s e r i o u s . Most low income Indian women are anaemic and can i l l a f f o r d the e x t r a l o s s of blood. There are a l s o taboos r e l a t i n g to menstruation which r e q u i r e t h a t a woman be i s o l a t e d . In a d d i t i o n , i t i s rumored that one of the pharma-c e u t i c a l houses, hoping to promote the use of the p i l l , c i r -c u l a t e d a rumor t h a t , during i n t e r c o u r s e , a man became entrapped i n the nylon threads attached to h i s wife's IUD, and, to f r e e him, her l i f e had to be s a c r i f i c e d ! As improved v a r i e t i e s are now a v a i l a b l e and doctors are b e t t e r t r a i n e d , there i s hope that i t w i l l recover i t s i n i t i a l p o p u l a r i t y , but known i n I n d i a as the "loop", the IUD may a l s o have to be re-named. S t e r i l i z a t i o n s have a l s o f a l l e n o f f , p a r t l y because some st a t e s are not pr e s s i n g the program, p a r t l y because the ma j o r i t y of the most r e c e p t i v e p a t i e n t s (men w i t h an average of 4 . 5 l i v i n g c h i l d r e n ) have now been operated on, and, a l s o , because, i n a few cases, the operation has f a i l e d . In other cases of pregnancy, i t has been found that the wife strayed 96 from the path of r e c t i t u d e . TABLE I Data on Indian Government Family P l a n n i n g Program ( i n thousands) Year A l l Methods IUD O r a l S t e r i l i z a t i o n Other Cumulative 1 9 6 4 u 0 0 u u 1 , 0 0 0 1 9 6 5 u 3 1 8 0 u u u 1 9 6 6 u 9 7 1 0 7 7 8 u u 1 9 6 7 u 7 2 8 0 1 , 5 ^ 5 u u 1 9 6 8 u 5 4 7 0 1,821 u u 1 9 6 9 u 4 2 5 0 1 , 3 6 9 u u Estimated cumulative acceptors through 1 9 6 9 as percent of e v e r - e l i g i b l e women = 7 « 5 Estimated Percentage of Married Women Users, 1 5 - 4 4 years: January, 1 9 7 0  1 2 1 - 2 0 . 1 9 1 . 1 Estimated Current Users (Male and Female): January, 1 9 7 0 1 1 , 2 0 0 1 , 3 3 0 1 1 9 8 , 7 1 1 1 , 0 2 9 Source: Dorothy Nortman, Population and Family Planning Programs: A Factbook. Reports on Population/Family P l a n n i n g , P o p u l a t i o n C o u n c i l , New York, J u l y , 1 9 7 0 , PP• 4 7 , 5 1 , 68. (Sub-categories do not add to t o t a l s because of rounding.) The number of condoms (Nirodh) d i s t r i b u t e d i s not known, but, at the end of 1 9 6 9 , the IPPF estimated that . 7 m i l l i o n couples were using them. They were being manufactured i n I n d i a and d i s t r i b u t e d e i t h e r f r e e through h e a l t h s e r v i c e s , or 3 f o r a f r a c t i o n of a cent through commercial channels. Federal c i v i l servants were even g e t t i n g a package of 3 each 9 7 month wits, t h e i r pay checks. Antidotes f o r pregnancy had been sought i n indigenous medicine. Government research had f a i l e d to t u r n up anything r e l i a b l e except, p o s s i b l y , the seeds of the w i l d papaw; but r e s u l t s of the research were not yet f i n a l . By the end of 1 9 6 8 , o r g a n i z a t i o n , t r a i n i n g and f a c i l i t i e s f o r d e l i v e r y of f a m i l y planning s e r v i c e s had been g r e a t l y im-proved and the s t r u c t u r e f o r f u r t h e r development e x i s t e d . Though i t was so w e l l organized and so many had accepted a method, the ITJD-Sterilization-Condom plan of the government had not yet made any s i g n i f i c a n t d i f f e r e n c e i n the b i r t h r a t e . More d r a s t i c measures were needed. The c a l l went out to the UN f o r a second Advisory M i s s i o n . Led t h i s time by Leo Mates of Belgrade, the group v i s i t e d I n d i a i n the f i r s t quarter of 1 9 6 9 . Again, some of the sug-gestions had already been put i n t o e f f e c t . While the Commission d i d not doubt t h a t the program would succeed i n time, i t was p e s s i m i s t i c about e a r l y r e s u l t s . The continuing problem was to e s t a b l i s h f a m i l y planning as a p r i o r i t y , a permanent program, from Union cabinet and other C e n t r a l government l e v e l s through s t a t e and on to l o c a l a d m i n i s t r a t i o n s . F a c i l i t i e s , p ersonnel, v e h i c l e s , equipment, s u p p l i e s and t r a i n i n g were s t i l l i n short supply. A b o r t i o n should he l e g a l i z e d , and the teaching of population dynamics and f a m i l y l i f e education should he 98 u n i v e r s a l i n the school system. But p o l i t i c a l t r o u b l e s i n I n d i a were i n c r e a s i n g , and the Congress pa r t y became d i v i d e d i n t o a conservative and a more s o c i a l i s t group - the l a t t e r l e d by Mrs. Gandhi. The Jan Sangh p a r t y attacked the f a m i l y planning program as a t h r e a t to the numerical s u p e r i o r i t y of Hindus, t r a d i n g on the p o s s i b i l i t y t h a t , i f Muslims continued to be allowed four wives, they would soon outbreed them. Other p o l i t i c a l op-p o r t u n i s t s climbed on the bandwagon, so the p u b l i c i t y was s o f t - p e d a l l e d , although the work went on. Of the 9 0 - 1 0 0 m i l l i o n couples i n the reproductive age group, a t o t a l of 11.2 m i l l i o n had been e n l i s t e d i n the f a m i l y planning program, and the female component represented 1 2 percent of married women aged 1 5 - 4 4 . ^ The t o t a l popu-l a t i o n of I n d i a i s estimated to be 5 ^ 7 m i l l i o n , i n c r e a s i n g by 18 m i l l i o n a. year. The o v e r a l l annual growth r a t e i s 2 . 5 percent, and, i f t h i s r a t e continues, the p o p u l a t i o n w i l l double i n 2 7 years. 41 percent are now under the age of 1 5 years, and, when t h i s youth group moves i n t o the reproductive years, the population increase w i l l be s t a g g e r i n g . ^ ^ ^ The b i r t h r a t e may be as low as 3 9 per thousand now, but i t i s u n l i k e l y t h a t i t w i l l reach 2 5 by I 9 8 O - the l a t e s t scheduled t a r g e t - unless a monumental e f f o r t goes i n t o the promotion from now on. Dr. Chandrasekhar, who b e l i e v e s that there are 9 m i l l i o n i l l e g a l a bortions a year i n I n d i a , persuaded the Cabinet to approve a d r a f t b i l l to l e g a l i z e t h i s procedure. I t has been approved by the C o u n c i l of S t a t e s , but a c t i o n i n the Lok Sabha has not yet been taken. The load on medical f a c i l i t i e s would be i n c r e a s e d , but i t i s an e s s e n t i a l adjunct to popu-l a t i o n c o n t r o l , and techniques and being s i m p l i f i e d . Chandrasekhar ha.s also appealed f o r a higher l e g a l marriage age - 18 f o r women and 2 1 f o r men. (Average age at marriage at present i s 14.5 years f o r g i r l s and 2 0 . 0 f o r men. I f the age at marriage could be r a i s e d , reproductive years would be shortened.) He b e l i e v e s that i n c e n t i v e s f o r s t e r i l i z a t i o n should be i n c r e a s e d . Tata I n d u s t r i e s , one of the l a r g e s t i n d u s t r i a l complexes i n I n d i a , i s now paying i t s employees Rs. 2 5 0 each to be s t e r i l i z e d , and he has suggested to Mrs. Gandhi th a t government inducements of Rs. 1 0 - 40, depending on the S t a t e , are too s m a l l to entice younger people i n t o the program. S t e r i l i z a t i o n a f t e r two c h i l d r e n would be d e s i r a b l e , and Mrs. Gandhi should use the $ 1 0 0 m i l l i o n i n United States counterpart funds i n I n d i a to o f f e r as much as Rs. 5 0 0 as an i n c e n t i v e . To supplement t h i s pro-gram, Chandrasekhar suggests a g r e a t e r e f f o r t to improve n u t r i t i o n , to do away w i t h the parents' f e a r t h a t c h i l d r e n w i l l d i e , l e a v i n g them without s e c u r i t y . He has also sug-gested that r e l i g i o u s leaders promote the i d e a t h a t once a man has f a t h e r e d one son he has done h i s duty by h i s ancestors and the r a c e . The t a r g e t of reducing the b i r t h r a t e to 2 5 by 1 9 8 0 has been amended to read "as soon as p o s s i b l e " . He, t o o , says that a t o t a l e f f o r t must be put i n t o the b i r t h c o n t r o l p r o g r a m . ( S e e Table X I , Appendix, f o r supplementary data on I n d i a ) . R e a l i z i n g the c r i t i c a l s t a t e of India's population problem, " A l l the king's horses and a l l the king's men" are working hard to help India, stem the f l o o d of babies -the I n t e r n a t i o n a l Planned Parenthood Federation i s h e l p i n g the FPAI; the P a t h f i n d e r Fund, the Pop u l a t i o n C o u n c i l , the Ford Foundation, the R o c k e f e l l e r Foundation, Church World S e r v i c e , C h r i s t i a n Medical A s s o c i a t i o n of I n d i a , World Neighbors, Oxfam, Lutheran World R e l i e f , CARE, the Swedish I n t e r n a t i o n a l Development Agency (SIDA), Denmark, the United Kingdom, Canada and the United S t a t e s , and the United Nations 1 0 ? Fund f o r Pop u l a t i o n A c t i v i t i e s are a l s o h e l p i n g I n d i a . I n d i a ' s own expenditures to help h e r s e l f have m u l t i p l i e d 3 , 0 0 0 times since the s t a r t of the program i n 1 9 5 1 , and represent an e v e r - i n c r e a s i n g percentage of the n a t i o n a l budget. TABLE I I Family Planning Component of N a t i o n a l Budget ( i n m i l l i o n s ) A l l o c a t e d Expended Percentage 1 9 5 1 - 5 6 P l a n Rs. 1 * ($U.S. 2 0 0 , 0 0 0 ) e 0 . 0 0 5 1 9 5 6 - 6 1 P l a n Rs. 2 2 e 0 . 0 5 1 9 6 1 - 6 6 P l a n Rs. 249 ** ($U.S. 3 1 m) e 1 . 0 1 9 6 6 - 7 1 P l a n Rs. 3 1 5 0 ($U.S. 3 9 4 m) - 2 . 0 1 9 6 6 - 6 9 Rs. 6 9 4 e * R = $U.S. . 2 1 ** R = $U.S. . 1 3 Annual | e r c a p i t a budget, a l l sources, i n U.S. cents = 7 * 7 2 Source: Dorothy Nortman, Po p u l a t i o n and Family Planning Programs: A Factbook. Reports on r o p u l a t i o n / V a m i l y P l a n n i n g , P o p u l a t i o n C o u n c i l , New York, J u l y , 1 9 7 0 , pp. 7 1 , 7 5 . In the meantime, the FPAI remains part of the whole program, r e c e i v i n g i t s subsidy from the government and the IPPF f o r i n n o v a t i v e p r o j e c t s . I t s branches run 1 7 5 v o l u n t a r y c l i n i c s , and i t promotes s e r v i c e s through business and i n d u s t r y . I t i s pursuing the question of population and f a m i l y l i f e education f o r c h i l d r e n and a d u l t s , and i t s mem-bers continue to attend Indian Ocean Region and IPPF general meetings. The FPAI r e a l i z e s the urgency of the population program, but u n i v e r s a l support i s not yet a f a c t i n the country. Much has been accomplished - f i r s t by the FPAI and l a t e r much more by government - but whether i t w i l l be e f f e c t i v e i s a question only time can answer. To sum up, as i n the more i n d u s t r i a l i z e d c o u n t r i e s , the leaders of the f a m i l y planning movement i n I n d i a were educated s o c i a l reformers, but they had the s p e c i a l a d d i t i o n a l motivation of s e r v i c e to t h e i r newly independent country. They r e a l i z e d from the beginning t h a t population growth was a t h r e a t to i t s chances of s o c i a l , economic and p o l i t i c a l progress, but they knew al s o t h a t , i n a country where conser-v a t i v e t r a d i t i o n was the r u l e , the only p o s s i b l e approach was through "spacing". I f the time between pregnancies could be lengthened, f e r t i l i t y and i n f a n t and maternal m o r t a l i t y would be reduced. Because i n f e r t i l i t y was al s o a tragedy, they o f f e r e d treatment f o r t h i s problem as w e l l . In a d d i t i o n to adopting an o f f i c i a l program, the govern-ment supported the FPAI f i n a n c i a l l y almost from the beginning, but the e f f e c t i v e n e s s of both bodies was complicated by the enormity of the challenge, the l a c k of r e a l l y dynamic p o l i -t i c a l l e a d e r s h i p , l a c k of previous experience, l a c k of i n -centives f o r mass acceptance, and the l o g i s t i c a l problems of communication, t r a i n i n g , p h y s i c a l f a c i l i t i e s , and s u i t a b l e methods of b i r t h c o n t r o l f o r those who wanted them. Knowing the dimensions of the t a s k , the volunteers were f r u s t r a t e d , from the s t a r t , w i t h government l e t h a r g y and red tape£> L i t t l e r e a l progress was made u n t i l the mid-1960s. Because i t was always a r e l a t i v e l y s m all o r g a n i z a t i o n , i t i s u n l i k e l y that the FPAI made any impact on the Indian f e r t i l i t y r a t e , but i t s e f f o r t s d i d t e s t the climate and l a y the foundations f o r dynamic government a c t i o n . The FPAI branches proved that a f a m i l y planning program was acceptable and f e a s i b l e , and t h e i r e f f o r t s i n o r g a n i z a t i o n , t r a i n i n g , research and s e r v i c e s provided some background on which govern-ment a c t i v i t y could be b u i l t . Through p u b l i c a t i o n s and con-ferences, they provided information and a forum f o r informed d i s c u s s i o n i n which a growing number of p r o f e s s i o n a l s were pleased to p a r t i c i p a t e and the careers of s e v e r a l people l a t e r prominent i n the population f i e l d were a s s i s t e d by membership i n the FPAI. The vo l u n t a r y o r g a n i z a t i o n s t i l l has a u s e f u l r o l e i n s p e c i a l s t u d i e s , p u b l i c i t y and promotion of f a m i l y l i f e education, and continues to o f f e r informed c r i t i c i s m of o f f i c i a l a c t i v i t i e s . The i n t r o d u c t i o n of b i r t h c o n t r o l pro-grams i n the other c o u n t r i e s of South A s i a f o l l o w e d s i m i l a r , though not i d e n t i c a l l i n e s . In Ceylon, l e a d e r s h i p came f i r s t from a Canadian who became a Ceylonese by adoption. t FOOTNOTES - Chapter V "''Rahindranath Tagore, c i t e d Family Planning i n I n d i a , D i r e c t o r a t e General of Health S e r v i c e s , u-overnment of I n d i a , New D e l h i , Ap. 1 9 5 6 - Nov. 1 9 5 8 , I n s i d e hack cover. 2 Thos. R. Malthus, An Essay on the P r i n c i p l e of  P o p u l a t i o n , Bk. i , Ch. x i , 1803, Homewood, 1963, p. 92. Abbe Dubois, Hindu Manners, Customs and Ceremonies, 2nd ed., Oxford, 1899, PP. 210, 340. 4 Lord D u f f e r i n , "Minute on the Congress", Nov. 1888, i n C.H. P h i l i p s , ed. S e l e c t Documents of the H i s t o r y of I n d i a  and P a k i s t a n , IV: The E v o l u t i o n of India and Pakistan, 1858-1947, London, 1962. p. 144. 5 Vera Anstey, The Economic Development of I n d i a , 3rd ( r e v i s e d ) e d i t i o n , London, 1942, pp. 4 7 4 - 7 5 . 12 . 9 m i l l i o n were added to the p o p u l a t i o n , 1 9 0 1 - 1 9 2 1 and 27.6 m i l l i o n added 1 9 2 1 - 1 9 3 1 ; also Facts About Population  and Family Planning i n I n d i a , Government of I n d i a , New D e l h i , 1967, P. 2. ^Man. Gen. S i r John Megaw, M.S. (Retd), "Population and Health i n I n d i a " , A s i a t i c Review, A p r i l , 1934, pp. 2 4 3 - 6 5 , (Paper read before East I n d i a A s s o c i a t i o n , c i t e d D.G. Karve, Poverty and P o p u l a t i o n i n I n d i a , Oxford, I 9 3 6 , pp. 3 4 - 5 • B. L. Raina, D i r e c t o r , C e n t r a l Family P l a n n i n g I n s t i t u t e , New D e l h i , " I n d i a " , i n Bernard B e r e l s o h , ed., P o p u l a t i o n and  Family P l a n n i n g Programs, Chicago, 1 9 6 6 , p. 112. o K i n g s l e y Davis, The Population of I n d i a and P a k i s t a n , P r i n c e t o n , 1 9 5 1 , p. 227. Q Report of "Work, 1949-1959< Family Planning A s s o c i a t i o n o f I n d i a , Bombay, 1 9 5 9 , p. 1 3 -•^S. Chandrasekhar, ed., Asia's Population Problems, New York, 1 9 6 7 , p. 92. ^"C. B. Mamoria, P o p u l a t i o n and Family P l a n n i n g i n  I n d i a , Allahabad, 1 9 6 3 , p. 217. I b i d . . p. 2 1 7 ; a l s o S. Chandrasekhar, op. c i t . , p. 92. 1 3 c . B. Mamoria, op. c i t . , p. 2 1 7 . 14 N a t i o n a l Planning S e r i e s , P o p u l a t i o n , 1947, p. 145, c i t e d , S a v i t r i Thapar, "Family Planning i n I n d i a " , P o p u l a t i o n  S t u d i e s , V o l . x v i i , 1963-64, Part I , J u l y , I 9 6 3 , pp. 4 - 1 9 . 1 5 l n d i a n N a t i o n a l Congress, Proceedings, M i c r o f i l m , UBC L i b r a r y , R 5 8 2 : 6 , p. 1 7 . 16 Vera Houghton, " I n t e r n a t i o n a l Planned Parenthood Federation (I.P.P.F.): I t s H i s t o r y and I n f l u e n c e " , Eugenics Review, October, 1 9 6 1 , January 1 9 6 2 , r e p r i n t , IPPF, A p r i l , 1 9 6 2 , p. 5 . l 7 E m i l y Taft Douglas, Margaret Sanger: Pioneer of the  Future, New York, 1 9 7 0 , p. 2 3 4 . 18 Smt. Rama Rau was one of the f i r s t women i n I n d i a to earn a U n i v e r s i t y degree and to teach i n a u n i v e r s i t y i n I n d i a . She was a l e c t u r e r i n E n g l i s h , Queen Mary's C o l l e g e , U n i v e r s i t y of Madras, and an advocate of women's s u f f r a g e . Kamala Rau to Mary Bishop, 2 4 . 1 2 . 6 9 ; a l s o Dhanvanthi Rama Rau, "The Need and Promise of Planned Parenthood", Together, Methodist P u b l i s h i n g House, N a s h v i l l e , January 1 9 6 5 , P« 1 6 . ^ K i n g s l e y Davis, op. c i t . , pp. 227-28. 90 . ^ VC. B. Mamoria, op. c i t . , p. 1 5 0 . 21 K i n g s l e y Davis, op. c i t . , p. 228. 2 2 c . B. Mamoria, op. c i t . , p. 2 1 7 . 2 3 I b i d . 2^B. L. Raina, op. c i t . , p. 1 1 3 • 2 ^ 0 . B. Mamoria, op. c i t . , p. 218. 2 6 B. L. Raina, l o c . c i t . ; also Family Planning i n I n d i a , D i r e c t o r a t e General of Health S e r v i c e s , Government of I n d i a , New D e l h i , Ap. 1 9 5 6 - Nov. 1 9 5 8 , p. 2. 27 S a v i t r i Thapar, op. c i t . , p. 6 . 28 I b i d . , p. 6 ; also C. Chandrasekharan and Katherine Kuder, Family Planning Through C l i n i c s , Bombay, 1 9 6 5 > P» 7 « 2 9 s a v i t r i Thapar, l o c . c i t . 3°Ibid.; a l s o C. B. Mamoria, op. c i t . , p. 1 5 1 . 31 Report of Work. 1 9 4 9 - 1 9 5 9 , op. c i t . , p. 3 . 3 2 r b i d . 3 3 p r o c . 2 n d A l l - I n d i a Conference on Family P l a n n i n g , Bombay, 1 9 5 5 ? P» i v . 34 J Report of Work, op. c i t . , pp. 5 - 6 J . Mayone Stycos, "Problems of F e r t i l i t y C o n t r o l i n Underdeveloped Areas", Marriage and Family L i v i n g , Feb. 1 9 6 4 , r e p r i n t e d i n Stewart Mudd, ed., The Population C r i s i s and  the Use of World Resources, Bloomington, 1966, p. 1 0 2 ; a l s o G-unnar Myrdal, Asian Drama, V o l . I l l , New York, 1 9 6 8 , pp. 2 1 5 6-2160. 16 Report of Work, op. c i t . , i n s i d e back cover. 3 7 P r o c . F i f t h A l l - I n d i a Conference on Family P l a n n i n g , Patna, FPAI, Bombay, 1964, pp. 168-76. From a budget of Rs. 5 0 / - i n 1 9 4 9 , the budget i n I 9 6 3 was Rs. 3 6 3 , 6 1 2 / - . 38"Women's M e e t i n g . . . 2 2 n d March 1968", 15th Annual  Report, Family Planning A s s o c i a t i o n of Ceylon, Colombo, 1968, p. 16; Questionnaires to Ceylon and Nepal; Conversation w i t h George and Barbara Cadbury, Toronto, 6 . 1 2 . 6 8 . 39 Report on the Family Planning Program of I n d i a , TAO/LND/48, 2 0 February, 1 9 6 8 , Item 44, p. 14; a l s o S. Chandrasekhar, P o p u l a t i o n and Planned Parenthood i n I n d i a , London, 1 9 5 5 , P» 1" 2 T ^°Report of Work, op. c i t . , pp. 2 0 - 2 1 . ^D. G. Karve, Poverty and P o p u l a t i o n i n I n d i a , London, I 9 3 6 , pp. 1 1 2 - 1 3 , 1 2 2 - 2 3 . Karve could not foresee Japan's population problem a f t e r World War I I , or her d e c i s i o n i n 1 9 4 8 to c o n t r o l i t through the Eugenic P r o t e c t i o n A c t . ^ B a l j i t Singh, "Family Planning Work i n U t t a r Pradesh", Proc. Second A l l - I n d i a Conference, FPAI, Bombay, 1 9 5 5 , P» 5 9 . ^A. L. Basham, op. c i t . , p. 5 0 1 ; a l s o Joseph L e l y v e l d , New York Times, 1 4 . 1 . 6 8 , p. 7 1 . ^ " A c c o r d i n g to Hindu d o c t r i n e s , the i d e a l l i f e c o n s i s t s of four asramas ( s t a g e s ) : brahmacarya, the p e r i o d of d i s c i p l i n e and education, garhasthya, the l i f e of the householder and a c t i v e worker, ya.naparasth.ya, r e t r e a t f o r the loosening of bonds, and f i n a l l y sannyasa, the l i f e of a hermit." K. M. Sen, Hinduism, B a l t i m o r e , I 9 6 I , pb. p. 2 2 . ^ B . S. Nanda, Mahatma Gandhi: A Biography, Boston, 1 9 5 8 , p. 82; also Emily Taft Douglas, Margaret Sanger, Pioneer of the Future, New York, 1 9 7 0 , p. 2 3 2 . ^ 6Gunnar Myrdal, Asian Drama, V o l . I I , New York, I 9 6 8 , pb., pp. 1 4 8 4 - 1 4 8 5 . 47 'CP. B l a c k e r , "Family Planning and Eugenic Movements" The Eugenics Review, January, 1 9 5 6 , p. 229. Donald T. R i c e , "Asian Medical Colleges and F e r t i l i t y C o n t r o l " , JAMA, 3 May, 1968, V o l . 204, #6, pp. 106-09; al s o S. Chandrasekhar, Inaugural Address, Conference of Deans and P r i n c i p a l s of Medical Schools and Col l e g e s , New D e l h i , 1967, pp. 4-5. 4 9 S. Chandrasekhar, Asi a ' s P o p u l a t i o n Problems, New York, I 9 6 7 , P« 88; al s o l e c t u r e , U n i v e r s i t y of B r i t i s h Columbia, 24 March 1971. 5°S. Chandrasekhar, "How I n d i a i s T a c k l i n g Her Pop u l a t i o n Problem", Foreign A f f a i r s , October, I968, p. 146. 51pndia and Foreign News, 1 September I968, pp. 5-6. 5 2 J o h n P e e l & Malcolm P o t t s , Textbook of Contraceptive  P r a c t i c e , London, I969, pp. 50-1; a l s o Dr. Marian J t i a l l , Richmond, B . C . , s e v e r a l conversations, I969; a l s o S. Chandrasekhar, P o p u l a t i o n and Planned Parenthood i n  I n d i a , London, 1955» P« 21. eport of Work, op. c i t . , p. 4. 5 ^ I b i d . , pp. 4-5. 5 5 s a v i t r i Thapar, op. c i t . , pp. 8-9. Chandrasekhar, Population and Planned Parenthood, p. 83, f . n . ; also C . H. Rolph, ed., The Human Sum, London, 1957, PP. 27-8. 57Proc. Second A l l - I n d i a Conference, op. c i t . , pp. 16-18. 5 8 i P j d . . pp. 6-10. 5 9 K . C . K . E . Raja "Family Planning i n R e l a t i o n to the Popu l a t i o n and Community Welfare," Proc. Second Conference, op. c i t . , pp. 19-37. 60 S. Chandrasekhar, P o p u l a t i o n and Planned Parenthood, pp. 37-89. 61 Proc. T h i r d A l l - I n d i a Conference on Family P l a n n i n g , FPAI, Bombay, 1957, passim. D. Ghosh, Pressure of Pop u l a t i o n and Economic E f f i c i e n c y  i n I n d i a , Bombay, 19^6. PP. 102-09; also K i n g s l e y Davis, The  Po p u l a t i o n of I n d i a and P a k i s t a n , P r i n c e t o n , 1951* PP» 222-29; a l s o K i n g s l e y Davis, "The Demographic Foundations of N a t i o n a l Power", M. Berger, T. A b e l , and C. H. Page, eds. Freedom and  C o n t r o l i n Modern S o c i e t y , New York, 195^, r e p r i n t e d , G a r r e t t Hardin, ed. P o p u l a t i o n , E v o l u t i o n and B i r t h C o n t r o l , 2nd ed. San F r a n c i s c o , 1969, PP. 71-4. Davis warned th a t resources were f i n i t e , economic expansion could not f o r e v e r absorb p o p u l a t i o n growth, and emigration was no longer a p r a c t i c a l a l t e r n a t i v e . J A n s l e y J . Coale and Edgar M. Hoover, P o p u l a t i o n Growth  and Economic Development i n Low Income Countries; India's  Prospects, P r i n c e t o n , 1958, p. 3 3 1 . 6k Robert C. Cook, Po p u l a t i o n Reference Bureau B u l l e t i n , XIV, No. 8, December, 1958. ^Warren S. Thompson, "I n d i a : P o p u l a t i o n " , P o pulation  and Progress i n the Par East, Chicago, 1 9 5 9 , pp. 141-48. 66 Report of Work, op. c i t . , p. 2 5 . ^ D u d l e y K i r k , " P o s s i b l e Lessons from H i s t o r i c a l Experience f o r Family P l a n n i n g Programmes i n A s i a " , Proc. S i x t h I n t e r n a t i o n a l Conference on Planned Parenthood, IPPP, London, 1 9 5 9 , p. 65. 6 8 S. Chandrasekhar, "Family P l a n n i n g i n an Indian V i l l a g e : M otivations and Methods", i b i d . , pp. 101-08. A. S. Kaufman to Mary Bishop, 1 5 October 1<?68. Mr. Kaufman t o l d me t h a t the experiment proved to him that home v i s i t i n g or the mobile team, was the most e f f e c t i v e means of d e l i v e r ! f a m i l y p l a n n i n g . 6 9 " S t u d y Group IV: S t e r i l i z a t i o n " , Proc. S i x t h I n t . Conf pp. 3 4 1 - 2 . 7 0 C . Chandrasekharan, " C u l t u r a l Factors and the Pro-pagation of Family Planning i n the Indian S e t t i n g , " i b i d . , pp. 6 7 - 7 2 . Dr. Pincus's i n t e r e s t i n Asian accept-a b i l i t y t r i a l s of the P i l l was noted i n Chapter IV, p. 8 9 . 7 1 F P A I B r i e f , dated 2 3-10.59, mimeographed. 7 2 J . Mayone Stycos, "The T r a d i t i o n a l Planned Parenthood Approach i n Underdeveloped Areas". Clyde V. K i s e r , ed., Research i n Family P l a n n i n g , P r i n c e t o n , I 9 6 2 , pp. 4 7 7 - 5 0 1 ; a l s o "Problems of F e r t i l i t y C o n t r o l i n Underdeveloped Areas" r e p r i n t e d from Marriage and Family L i v i n g , February, 1 9 6 3 ; a l s o Stuart Mudd, ed.. The P o p u l a t i o n C r i s i s and the Use  of World Resources, The Hague, 1964, pp. 94-108. 7 3 "Summary of Conference", Clyde V. K i s e r , op. c i t . , pp. 6 2 2 - 2 6 . 7^Ketayun H. Gould, "Sex and Contraception i n Sherupur", Economic and P o l i t i c a l Weekly, V o l . 4, No. 49, Dec. 6, I 9 6 9 , p. 1890. The author suggests that the diaphragm i s im-p r a c t i c a l f o r v i l l a g e women, but Dr. Marian H a l l s t a t e s t h a t some women i n Rajasthan used i t s u c c e s s f u l l y ; and some low income women i n Ceylon were s i m i l a r l y motivated; see a l s o Report of Work, op. c i t . , p. 81. I b i d . , p. 1 1 . 76 -n Planned Parenthood i n the United S t a t e s , and Family Planning i n the United Kingdom and Canada make no d i s t i n c t i o n today. ^"Aims and Objects", F i f t h A l l - I n d i a Conference on  Family P l a n n i n g , FPAI, Bombay, 1964, i n s i d e f r o n t cover; also "What i s Family Planning?" i n 10 Years of Family P l a n n i n g  i n Ceylon, 1 9 5 3 - 1 9 6 3 , i n s i d e back cover; Annual Report, The Family P l a n n i n g A s s o c i a t i o n of P a k i s t a n , Lahore, (1964;, f l y l e a f . C o n s t i t u t i o n of Nepal Family Planning A s s o c i a t i o n , Kathmandu, A r t i c l e 2, mimeographed. ^ R e p o r t of Work, op. c i t . , pp. 3 0 , 81. 7 9"Resolution Passed Unanimously at the P l e n a r y Session Held on 3 r d February I 9 6 I " , Fourth A l l - I n d i a Conference on  Family P l a n n i n g , Bombay, l § 6 l , p. 181. SQReport of Indian Parliamentary and S c i e n t i f i c Committee, Government of I n d i a , New D e l h i , May, 1964, p. 5 1 , pp. 14 - 1 5 . 8 1 S h r i Ashoka Mehta, "Inaugural Address" F i f t h A l l - I n d i a  Conference on Family P l a n n i n g , op. c i t . , pp. 8-10, 18-24. 8 2 I n d i a : Report of UN Advisory M i s s i o n , P o p u l a t i o n C o u n c i l , s t u d i e s i n f a m i l y P l a n n i n g , New l o r k , June, I 9 6 6 , pp. 1 - 6 . 83 B. L. Raina, op. c i t . , pp. 114 - 2 1 . 8 ^ h e Quiet R e v o l u t i o n : Family Planning i n I n d i a , Embassy of I n d i a , Economic Wing, Washington, D.C., 1 9 6 7 , P« 6 . 8 ^ F a c t s about Po p u l a t i o n and Family Planning i n I n d i a , M i n i s t r y of Health and Family P l a n n i n g , Department of Family P l a n n i n g , Government of I n d i a , New D e l h i , 1967> P« 8. 86 0 The Quiet R e v o l u t i o n , op. c i t . , p. 5« 8 7 j o u r n a l of Family Welfare, S p e c i a l Conference Number, V o l . XV, No. 3 , i V Jarch 1969, passim. 8 8 " F P A I A l l - I n d i a C o u n c i l Meeting", Planned Parenthood, V o l . XVII, No. 4, October, I 9 6 9 , p. 1 . 89 "Three Problems", I b i d . . p. 1 . ^ " C e n t r a l Family Planning C o u n c i l Meets", Planned  Parenthood, V o l . XVII, No. 5 , November, I 9 6 9 , P. 1 . ^ S i t u a t i o n Report, I n d i a , IPPP, London, November, 1 9 6 9 , P. 3 . 9 2S. Chandrasekhar, "India's Family Planning Programme: What We Have Accomplished So Far", The J o u r n a l of Family  Welfare, March, 1 9 6 9 , P« 14: a l s o , S i t u a t i o n Report, op. c i t . , p. 5« 93 7^Programmes and A c t i v i t i e s , FPAI, Bombay, I 9 6 8 (recent undated l e a f l e t ) , pp. 8 - 9 • 94 Dorothy Nortman, Population and Family P l a n n i n g  Programs: A Factbook, Reports on Population/Family P l a n n i n g , P o p u l a t i o n C o u n c i l , New York, J u l y , 1970, p. 3 8 . 95 I b i d . ; a lso S i t u a t i o n Report, op. c i t . , p. 2; also Report of Work, op. c i t . , pp. 27 - 3 0 . ^°Alan F. Guttmacher, P r e s i d e n t ' s l e t t e r , No. 5 2 , Planned Parenthood-World P o p u l a t i o n , New York, 14 March, 1 9 7 1 , and supplement. 97 S i t u a t i o n Report, op. c i t . , p. 5 ; also Canada I n d i a  Times, 4.12.69* 9 8 I P P News, No. 1 8 9 , IPPF, london, November, 1 9 6 9 . 99norothy Nortman, op. c i t . , p. 6 8 . ^°°"Census i n I n d i a " , Indian and Foreign Review, 1 May 1 9 7 1 , p. 2 3 ; also World Po p u l a t i o n Data Sheet, Pop u l a t i o n Reference Bureau, Washington, A p r i l , 1970; also S. Chandrasekhar, "Population Problems and P o l i c i e s i n I n d i a " , l e c t u r e , U n i v e r s i t y of B r i t i s h Columbia, 24 March 1 9 7 1 . l O l s . Chandrasekhar, l e c t u r e , op. c i t . 1 A O ^Population Program A s s i s t a n c e , United States Agency f o r I n t e r n a t i o n a l Development, Washington, October, 1 9 7 0 , pp. 1 5 3 - 5 8 . FIGURE U I THREE PROTECTIONS OF CEYLON'S POPULATION GROWTH i r IQOJ }9)l 1921 1921 1946 /9S3 1963 I97J I9&3 1993 CENSUS YEARS SOURCES: STATISTICAL ABSTRACT OF CEVLON, I9(S~ DEPARTMENT OF C£NSUS AND STATISTICS COLOMBO. >96S TABLE. I6-P.Z6; STATISTICAL POCft.£TB00K OF CEYLON, 1966, DEPARTMENT OF CENSUS AND STATISTICS, rru r>MGf\ lot A -T-AOI c e> >a CHAPTER VI Ceylon Though the leaders from the s t a r t of the f a m i l y p l a n -n i n g movement i n I n d i a were I n d i a n , the f i r s t known f a m i l y planner i n Ceylon was a determined l i t t l e Canadian, Dr. Mary (Irwin) Rutnam, a graduate of T r i n i t y Medical School i n Toronto, who a r r i v e d i n the I s l a n d under American Methodist auspices as a medical missionary i n 1898. Some-how the job she had expected to f i l l i n J a f f n a was not a v a i l a b l e , so Dr. Irw i n found work i n a government h o s p i t a l i n Colombo. Por some obscure reason, the B r i t i s h admini-s t r a t o r s decided that her q u a l i f i c a t i o n s were not s a t i s -f a c t o r y ; so she became the f i r s t woman doctor i n p r i v a t e p r a c t i c e i n Ceylon. At f i r s t , most of her p a t i e n t s were Muslim women i n purdah who would not accept the s e r v i c e s of a male doctor and Dr. I r w i n acquired considerable ex-perience i n o b s t e t r i c s and the r e a l i t i e s of maternal and c h i l d h e a l t h . Much against the wishes of her parents i n C l i n t o n , O n t a r i o , she married a Tamil school p r i n c i p a l i n Colombo and by him she had f i v e c h i l d r e n . The combination of B r i t i s h d i s a p p r o v a l of her medical q u a l i f i c a t i o n s , the misery of her Muslim woman p a t i e n t s , and f a m i l y d i s a p p r o v a l , must have been the c a t a l y s t s which l e d her to devote the r e s t of her l i f e to improving the stat u s of women i n her adopted country, to encouraging middle and upper income Ceylonese women to give time to " s o c i a l s e r v i c e " , and to improving maternal and c h i l d welfare s e r v i c e s . Mary Rutnam founded no l e s s than s i x women's o r g a n i z a t i o n s , i n c l u d i n g a tran s p l a n t e d v e r s i o n of the Women's I n s t i t u t e s - the Laroka  Mahila S a m i t i - a Women's C h r i s t i a n Temperance Union, and the Family Planning A s s o c i a t i o n . In a d d i t i o n she was an a c t i v e member of ten other s o c i a l welfare o r g a n i z a t i o n s . Dr. Rutnam was Ceylon's f i r s t woman c i t y c o u n c i l l o r , s i t t i n g f o r a short time as a member of the Colombo M u n i c i p a l Coun-c i l . She a l s o wrote pamphlets on h e a l t h , homecraft, and n u t r i t i o n f o r Ceylon s c h o o l s . Members of the Donoughmore Commission, who dr a f t e d the 1931 C o n s t i t u t i o n of Ceylon, encouraged Dr. Rutnam to promote women's p o l i t i c a l a c t i v i t y . She organized the Women's P o l i t i c a l Union, and, through i t , brought pressure on the Ceylon Medical C o u n c i l to introduce b i r t h c o n t r o l and eugenics i n the curricul u m of the Ceylon Medical C o l l e g e . The request was refu s e d , but Dr. Rutnam was not defeated. When Mrs. E d i t h How-Martyn v i s i t e d Ceylon i n 1935, on behalf of the B i r t h C o n t r o l I n t e r n a t i o n a l Information Centre i n London, Dr. Rutnam supported her l e c t u r e s to doctors and s o c i a l workers. In 1937, w i t h the approval of the Ceylon S o c i a l Service League, Dr. Rutnam opened a b i r t h c o n t r o l c l i n i c known as the "Family Welfare S o c i e t y " . Through a donation of £ 100 from S i r J u l i a n Kahn, a v i s i t i n g c r i c k -e t e r from England, she was able to finance imports of d i a -phragms and j e l l i e s ; but, as overt propaganda to promote b i r t h c o n t r o l was r i s k y , p a t i e n t s were r e f e r r e d by word of mouth. 1 There was o p p o s i t i o n to Dr. Rutnam's a c t i v i t i e s not only medical but on r e l i g i o u s grounds. Indigenous f a i t h s had l i t t l e i n f l u e n c e on the government i n Ceylon before World War I I , and, i n any case, i n c l u d e d no p r o h i b i t i o n s against b i r t h c o n t r o l ; but C h r i s t i a n o p p o s i t i o n i n s p i r e d someone to break i n t o her surgery, and destroy her f u r n i t u r e and eq/uip-2 ment. She p e r s i s t e d w i t h the work, but, when World War I I s t a r t e d , was forced to discontinue as imports of sup p l i e s were cut o f f . A f t e r World War I I , w i t h the as s i s t a n c e of two other Ceylonese doctors who o f f e r e d both s e r v i c e s and o f f i c e ac-commodation, Dr. Rutnam renewed her f a m i l y planning a c t i v i -t i e s . The cause was f u r t h e r advanced by the o r g a n i z a t i o n i n Bombay of the IPPP i n 1952, and a v i s i t to Ceylon by Margaret Sanger, Dr. Abraham Stone, and Mrs. Dorothy Brush, a l l of Planned Parenthood i n the United S t a t e s . They were f o l l o w e d soon a f t e r by Dr. Clarence Gamble, a l s o of the USA, rep r e s -e n t i n g the American N a t i o n a l Committee on Maternal Health, but soon to found h i s own o r g a n i z a t i o n , the P a t h f i n d e r Pund. The Family P l a n n i n g A s s o c i a t i o n i n Ceylon (FPAC) was organized i n January, 1953> "by s i x t e e n charter members. Nine were doctors, i n c l u d i n g f o u r women, and seven of the s i x t e e n were men. Dr. Rutnam was e l e c t e d p r e s i d e n t , but, as she was now eighty years of age, meetings were l e d by Dr. (Mrs.) 1 . 0 . Abeyratne, as V i c e - P r e s i d e n t . Two of the founders, P r o f . G.C. de S i l v a , a p a e d i a t r i c i a n , at the U n i v e r s i t y of Ceylon, and Mrs. E. C. Fernando, are s t i l l a c t i v e . The group was soon jo i n e d by Dr. (Miss) S i v a Chinnatamby, now Honorary Medical D i r e c t o r of the FPA, and a V i c e - P r e s i d e n t . This group was r e p r e s e n t a t i v e of the western-educated Ceylonese p r o f e s s i o n a l c l a s s , anxious to share i n the work of modernization i n newly independent Ceylon, and p a r t i c u l a r l y concerned f o r maternal and c h i l d h e a l t h and f a m i l y w e l f a r e . Dr. Rutnam may have been a f e m i n i s t , but her successors were not. Nor d i d Pro-f e s s o r Stycos's other c r i t i c i s m s , discussed i n Chapter V, apply - u n l e s s , perhaps, they too could be f a u l t e d f o r pre-s c r i b i n g the diaphragm i n the 1950s i n preference to l e s s r e l i a b l e methods. The o n l y f i n a n c i n g a v a i l a b l e was the s m a l l amount of money l e f t from the c r i c k e t e r ' s pre-war g i f t , and from t h e i r own pockets but the FPAC also r e c e i v e d the support of Mr. M. Rajanavagam, then Commissioner of l a b o u r . He was i n t e r e s t e d i n promoting f a m i l y planning i n the p l a n t a t i o n areas because i t was becoming d i f f i c u l t to absorb the o f f -s p r i n g of the Indian Tamil workers i n the estate economy. As the problem was urgent, Mr. Rajanayagam wanted cheap, simple methods which could be e a s i l y and q u i c k l y introduced. Support of trade union l e a d e r s h i p i n the p l a n t a t i o n s was a l s o forthcoming as was that of estate management. In I 9 5 k the P l a n t e r s ' A s s o c i a t i o n set up a program to dispense foam t a b l e t s and the sponge. In 1953 the World Bank ( I n t e r n a t i o n a l Bank f o r Re-c o n s t r u c t i o n and Development) published a study of the Ceylon economy, i n which f a m i l y planning was urged because the e x t r a acreage which was a v a i l a b l e f o r food production would not accommodate the expected population i n c r e a s e . A western-s t y l e demographic t r a n s i t i o n would be i m p o s s i b l e , f o r there were n e i t h e r new t e r r i t o r i e s to e x p l o i t , nor s u f f i c i e n t n a t u r a l resources w i t h i n Ceylon to a s s i s t economic develop-ment on a l a r g e enough s c a l e . Family Planning should be o f f e r e d i n e x i s t i n g h e a l t h f a c i l i t i e s ; and v o l u n t a r y o r g a n i -z a t i o n s , such as the Red Cross, Lanka Mahila S a m i t i , CNAPT (Ceylon N a t i o n a l A s s o c i a t i o n f o r the Prevention of Tuber-c u l o s i s ) should be funded through government g r a n t s - i n - a i d , to a s s i s t the program. Dudley Senanayake, then Prime M i n i -s t e r f o r the f i r s t of three terms, supported the i d e a because he had been M i n i s t e r of A g r i c u l t u r e and knew any problem of food s u p p l i e s would be s e r i o u s . But no o f f i c i a l a c t i o n was taken as he was forced out of o f f i c e f o r accepting another 5 of t h e i r recommendations, a r e d u c t i o n i n the r i c e subsidy. About t h i s time a l s o , Dr. Gamble decided to send h i s own f i e l d r e p r e s e n t a t i v e to Ceylon, another Canadian, Mrs. Margaret Roots. She a r r i v e d i n 195^ and remained f o r two years. During t h i s time she t r a v e l l e d to many of the o u t l y i n g centres and r u r a l areas, e x p l a i n i n g f a m i l y planning to h e a l t h o f f i c e r s and v i l l a g e l e a d e r s , and g i v i n g i n s t r u c -t i o n i n the use of salt-and-sponge or foam t a b l e t s , two simple methods s u p p l i e d hy Dr. Gamble. Toward the end of her s t a y , Mrs. Roots was working c l o s e l y w i t h the Executive Committee of the Family Planning A s s o c i a t i o n , who assigned a Ceylonese woman a s s i s t a n t to accompany and a s s i s t her. She was also sending r e g u l a r r e p o r t s to Smt. Rama Rau as P r e s i d e n t of the IPPF.^ Though there has been no open c r i t i c i s m , i t appears t h a t , f o r a l l t h e i r good work, Dr. Gamble's program was not popular w i t h the FPAC at tha t time because i t d i d not at f i r s t seek t h e i r support, appeared to r i v a l t h e i r o r g a n i z a t i o n and was funded generously from abroad, while they were s t r u g g l i n g to develop t h e i r own program. As t h e i r r e a c t i o n was s i m i l a r to tha t of the FPAI, i t seems to have induced a s h i f t i n P a t h f i n d e r Fund p o l i c y toward working i n countri e s where no f a m i l y planning program e x i s t e d a,nd merely supplying c o n t r a c e p t i v e s i n co u n t r i e s i n which there was an FPA. 7 Also i n I 9 5 k , Mrs. Barbara Cadbury v i s i t e d Ceylon, on behalf of the IPPF, and, at a meeting of p o l i t i c a l leaders arranged by the FPAC and Mr. F. H. Jayawardene, then M.P. f o r Colombo South, suggested a government-to-government p i l o t p r o j e c t might be set up. Through Dr. Hanna Rydh and Mrs. Ottesen-Jensen, of Sweden, Mrs. Fernando of the FPAC made p r e l i m i n a r y i n q u i r i e s of the government of Sweden. Sweden approved the i d e a , provided t h a t the request came from the government of Ceylon; and S i r John Kotelawala, then Prime M i n i s t e r , set the plan i n motion. Arrangements were made through Mrs. A l v a Myrdal, Swedish Ambassador, and f i n a l l y , i n 1958, the Sweden-Ceylon P i l o t P r o j e c t went i n t o operation under the j o i n t s u p e r v i s i o n of the then D i r e c t o r of Health S e r v i c e s , Ceylon; Dr. Chinnatamby, re p r e s e n t i n g the FPAC; and the Swedish p r o j e c t s u p e r v i s o r (then Dr. Jan Asplund, l a t e r , Dr. Arne K i n c h ) . This p r o j e c t w i l l be described i n d e t a i l on page 188. To a s s i s t i t s own a c t i v i t i e s , the PPAC was given a government grant of Rs. 2,000 i n 1954. By 1963 t h i s was r a i s e d to Rs. 75,000 and i n I969 remained at t h i s l e v e l . Though somewhat sotto voce, every Prime M i n i s t e r since has supported the movement, and supplementary a s s i s t a n c e has been given by the Health M i n i s t r y . Government doctors and nurses who wished to take PPAC t r a i n i n g were a s s i s t e d i n doing so, and allowed to d i s t r i b u t e FPA-supplied c o n t r a c e p t i v e s . Some h o s p i t a l s , P u b l i c Health U n i t s and h e a l t h centres gave space f o r c l i n i c s , and Health Department educators a s s i s t e d w i t h d i s p l a y s . The government also financed the p u b l i c a t i o n of l e a f l e t s on methods i n S i n h a l a , Tamil and E n g l i s h . The IPPP has continued to support the o r g a n i z a t i o n w i t h funds, as has Oxfam, the P o p u l a t i o n C o u n c i l and the United States Agency f o r I n t e r n a t i o n a l Development (A.I.D.). Further economic s t u d i e s by experts i n v i t e d from abroad were published i n 1959 by the Planning S e c r e t a r i a t of the government of Ceylon. They confirmed the IBRD warning of 1953• V i s i t i n g economist Joan Robinson s a i d t h a t population growth would absorb any advances i n economic p r o d u c t i v i t y , and that the welfare of the people would dete-r i o r a t e . Gunnar Myrdal urged that a P o pulation Commission be set up to promote b i r t h c o n t r o l , s t a t i n g t h a t , even i f the task were undertaken at once, no impact on the work f o r c e would be evident f o r twenty years, and p o l i t i c a l unrest 9 would r e s u l t . But, l i k e governments elsewhere, the govern-ment of Ceylon t r o d s o f t l y i n the matter, hoping, no doubt, th a t by some miracle the economy might expand s u f f i c i e n t l y without i t . I t d i d not adopt a p u b l i c f a m i l y planning p o l i c y u n t i l 1965 when unemployment had reached c r i s i s p r o p o r t i o n s . In I960/6I George and Barbara Cadbury v i s i t e d Ceylon as s p e c i a l r e p r e s e n t a t i v e s of the IPPP on the t o u r mentioned i n Chapter IV. Vera Houghton, former s e c r e t a r y of the IPPP i n London, spent two months i n the I s l a n d h e l p i n g to set up an o f f i c e o r g a n i z a t i o n commensurate w i t h the FPAC's growing needs. IPPP grants were also forthcoming to a s s i s t i n f i l m p r o d uction, to finance a f i l m p r o j e c t o r , tape r e c o r d e r , and a t r a v e l l i n g van f o r promotional work, and to provide t r a v e l funds to a s s i s t Ceylonese delegates to attend i n t e r n a t i o n a l conferences. The Government of I n d i a donated a f a m i l y p l a n -n i n g f i l m i n the Tamil language, and Tamil language pro-motional l i t e r a t u r e . The f a m i l y planning movement was f u r t h e r a s s i s t e d when a r e g i o n a l conference and medical seminar was held i n Colombo i n I963 i n honour of the PPAC's t e n t h an-n i v e r s a r y . In speaking to the delegates, Hon. P. B. K a l u g a l l e , M i n i s t e r of Education i n Mrs. Bandaranaike's cabinet ( i960 -1964) p r a i s e d the PPAC f o r i t s years of hard work i n s p i t e of unkind c r i t i c i s m and l a c k of p u b l i c understanding of what f a m i l y planning could c o n t r i b u t e to h e a l t h and happiness. By the time the A s s o c i a t i o n achieved c h a r i t a b l e s t a t u s i n May, 1965, i t could boast 150 r e g u l a r members, two branches and l l 6 c l i n i c s , many of them i n government h e a l t h premises. P o l i c y f o l l o w e d much the same d i r e c t i o n as that of f a m i l y planning a s s o c i a t i o n s i n Western co u n t r i e s and I n d i a . A l l methods were o f f e r e d on the b a s i s t h a t any method used r e g u l a r l y was b e t t e r than none at a l l . The main o b j e c t i v e was spacing of c h i l d r e n f o r b e t t e r h e a l t h and f a m i l y hap-piness or l i m i t i n g the number i f d e s i r e d f a m i l y s i z e had been achieved. An i n f e r t i l i t y s e r v i c e was a l s o b u i l t i n . As i n I n d i a , - B r i t i s h law had made induced a b o r t i o n i l l e g a l i n Ceylon, and, as i t was f r e q u e n t l y confused w i t h b i r t h c o n t r o l the PPA opposed i t as an undesirable a l t e r n a t i v e to c o n t r a c e p t i o n . Only i f i t was f o r urgent medical reasons, and performed by a recognized doctor, was a b o r t i o n approved. I f adequate support f o r f a m i l y planning were forthcoming, they s a i d , a b o r t i o n would d e c l i n e . The slogan "Every C h i l d a Wanted C h i l d " was the accepted motto. As over-population i n c r e a s e d , the PPA began to introduce the i d e a of a s m a l l f a m i l y norm by i n c o r p o r a t i n g from I963 on the cover of the annual r e p o r t , a sketch showing a t h r e e -c h i l d f a m i l y group and i n c l u d i n g a r t i c l e s on p o p u l a t i o n growth and economic development. By 1965, p o p u l a t i o n growth and unemployment - the l a t t e r o f f i c i a l l y 200,000 but estimated to be nearer 500,000 -f o r c e d the newly e l e c t e d Senanayake government to adopt f a m i l y planning as a n a t i o n a l p o l i c y , and as an e s s e n t i a l element i n planning f o r development. As i n I n d i a , a n a t i o n a l a d v i s o r y committee was set up by the M i n i s t e r of Health. The D i r e c t o r of Health S e r v i c e s was to be chairman, and other members were r e p r e s e n t a t i v e s of the FPAC, the Sweden-Ceylon P r o j e c t , the P l a n t e r s * A s s o c i a t i o n , the Plan n i n g S e c r e t a r i a t and the Department of Health S e r v i c e s . As t r a i n -i n g was one of the most urgent requirements, the task was shared among the PPA, the Sweden-Ceylon p r o j e c t , and the government. I t was agreed that PPA c l i n i c s would be handed over to the Department of Health S e r v i c e s as soon as p o s s i b l e , but that the A s s o c i a t i o n should keep some of i t s c l i n i c a l operations i n being f o r research, t r a i n i n g , and i n n o v a t i o n . I t s major r o l e i n fu t u r e would be education and promotion. Although there was no time l a g comparable to that which occurred i n I n d i a between adoption of the p o l i c y and i t s implementation, the need f o r t r a i n i n g and o r g a n i z a t i o n h e l d up e f f e c t i v e s e r v i c e s u n t i l 1968, and the PPA phase-out was not complete even i n 19&9. The volunteers s t i l l r e t a i n e d 20 c l i n i c s i n the Colombo area and one i n Kandy, but the road ahead seemed f a i r l y smooth. C u l t u r a l a t t i t u d e s toward c h i l d r e n and c o n t r o l of the passions are s i m i l a r i n Ceylon to those i n I n d i a , but, as i n I n d i a , there i s no organized o p p o s i t i o n to f a m i l y planning and no law against i t . U n t i l r e c e n t l y , o b s t r u c t i o n was s o l e l y 10 of western medical and r e l i g i o u s o r i g i n . Dr. Rutnam made a second attempt i n 19^9 to persuade the medical profession to include i n s t r u c t i o n i n b i r t h control i n the medical college curriculum, but was defeated, though only narrowly, by the Ceylon Branch of the B r i t i s h Medical Association (forerunner of the Ceylon Medical Association)."^ However, the Family Planning Association continued to grow under the auspices of prominent physicians and, innovative ( from the beginning, i t began to pioneer the use of the P i l l , the IUD, a,nd vasectomy. C r i t i c s i n the profession were not lacking though each venture progressed s a t i s f a c t o r i l y under FPA auspices. With government p a r t i c i p a t i n g too, a c t i v i t y through the FPAC and through private medical practice greatly increased a f t e r 1965* Some r e l i g i o u s opposition has persisted, but by 1969 i t s basis had shifted from Christian to Buddhist, and from r e l i g i o n to racism. Although Mrs. Roots t o l d me that i n her travels i n Ceylon i n the 1950s she met no r e l i g i o u s op-position i f she took time to " v i s i t the l o c a l p r i e s t and explain" what she was doing, FPAC members have t o l d me that 12 undercover Christian obstruction did exist for a time. Dr. Chinnatamby r e c a l l e d recently that, i n addition to damage to Dr. Rutnam's o f f i c e , handbills were cir c u l a t e d i n which the FPAC was pictured as a witch destroying babies i n t h e i r cots, or a wolf i n sheep's clothing, murdering the unborn. It was also accused of being the agent of genocide, but, a f t e r the 19&5 government announcement of i t s family planning p o l i c y , a "Catholic leader" i n Ceylon instructed Catholic doctors not to defy i t . When the Papal E n c y c l i c a l against f a m i l y planning was is s u e d i n 19&8, the Secretary of the 13 C a t h o l i c Doctors' G u i l d attacked i t p u b l i c l y . From the s t a r t of the A s s o c i a t i o n c r i t i c i s m has been o f f s e t by the f a c t that a c t i v e l e a d e r s h i p has been represent-a t i v e of Buddhist, Hindu and C h r i s t i a n elements of the popu-l a t i o n . While Muslim p a r t i c i p a t i o n has been r a r e , Muslims themselves have not c r i t i c i z e d the FPA, and Muslim attendance at FPA c l i n i c s has always been i n pr o p o r t i o n to population s i z e . The o r g a n i z a t i o n has, t h e r e f o r e , always been able to withstand medical or r e l i g i o u s a t t a c k . U n f o r t u n a t e l y , com-munal r i v a l r i e s have created another source of c r i t i c i s m , and an example of Family Planning A s s o c i a t i o n defence i s of i n t e r e s t : A l l r a c i a l groups are represented i n our c l i n i c s and we f e e l sure t h a t the i n d i v i d u a l i s much l e s s concerned w i t h whether h i s race may be decimated than whether he w i l l have enough money to feed, c l o t h e , and house u n l i m i t e d c h i l d r e n or whether h i s wife w i l l grow o l d and s i c k before her time. He i s more i n t e r e s t e d i n h i s own f u t u r e happiness and i n t r y i n g to save a l i t t l e money f o r a few of the amenities of l i f e . The i r o n y i s th a t the Indian estate labourer leads the r e s t of the country i n l i m i t i n g h i s family.1** Reference to the Indian Tamil arose out of the f a c t that many of t h i s group - approximately 1.5 m i l l i o n strong and sur-v i v o r s of the days of indentured l a b o r - were deprived of t h e i r c i t i z e n s h i p by the f i r s t government of independent Ceylon, but s t i l l are thought to represent an economic t h r e a t as a closed community h o l d i n g jobs which might be given to Ceylonese c i t i z e n s . Next, communal c r i t i c i s m of family planning was taken up, not by one of the minorities, but, as with the Jan Sangh in India, by a few representatives of the r e l i g i o u s majority. Yen. Madihe Pannaseeha, Mahanayake Thero, a senior Buddhist monk, warned several times i n a r t i c l e s i n the press, that i f Sinhalese f e r t i l i t y continued to decline, and the Tamil and "Moor"(Muslim) birthrates did not follow s u i t , i n 141 years, the Sinhalese proportion of the population would have dropped from 71 to 49 percent, and the combined Tamil and Moor element would be 50 percent. Therefore Buddhism was r i s k i n g extinction . 1 5 Responding to t h i s type of propa-ganda, the a g r i c u l t u r a l colonists at Elahera, whose families were reported to be from ten to f i f t e e n strong, refused to take anti-malaria p i l l s i n fear that they were b i r t h control p i l l s and the Municipal Council of a Colombo suburb condemned the government Health Department for collaborating with "the Americans" to decimate the Sinhalese."^ I t did not help matters when a cabinet minister, Hon. I.M.R.A. Iryagolle, Minister of Education i n the Senanayake cabinet, was quoted i n a Sinhala language paper as saying that family planning . was "murder"."*"''7 In reply to a questionnaire sent by the writer an a d d i t i o n a l problem was noted by the FPAC. There i s some b e l i e f among Buddhists that family planning might 18 in t e r f e r e with the process of r e b i r t h . But t h i s must be based on the misconception that "family planning" i s abortion. On the other hand, there i s also Buddhist opinion favorable to the idea. Dr. G. P. Malalasekera, President of the A l l Ceylon Buddhist Congress, stated that, while children were welcomed fo r the t r a d i t i o n a l reasons, popu-l a t i o n pressures were creating problems. Contraception was a new idea to Buddhists; but, as i t was the Buddhist view that l i f e does not exist before conception ( s i c ) , they 19 would accept i t . Some degree of feminine self-determination i s also involved i n acceptance of family planning, f o r , while I was i n Ceylon, there were wives who adopted the P i l l or had an IUD inserted without t h e i r husband's knowledge. The 1973 Census should show how c r i t i c a l i s the need for b i r t h control i n Ceylon, but the government of Mrs. Sirima Bandaranaike, elected once more i n May 1970 a f t e r a term i n opposition, continued the policy introduced by her predeces-sor, and announced that i t would push the program i n urban, r u r a l and estate a r e a s . ^ Except for the "Moors", the b i r t h r a t e i n Ceylon declined s t e a d i l y from 1961 to 1967 and, because the start of the decline coincided roughly with the founding of the Family Planning Association, i t was easy to assume that b i r t h control was having some e f f e c t . TABLE I I I B i r t h r a t e s per 1 , 0 0 0 hy "Race", 1951-61 and Percentage of P o p u l a t i o n , I 9 6 3 Races Annual Average 1951-60 i 9 6 0 I96I 1963 $ Sinhalese Ceylon Tamil Indian Tamil Ceylon "Moor Others 3 7 - 7 3 8 . 2 3 6 . 1 " 41 . 5 3 0 . 3 3 6 . 5 3 8 . 8 3 3 . 1 42 . 7 25.4 3 5 . 7 36.4 31.4 42 . 9 22.4 71 11 1 0 . 6 5 . 9 1 .5 A l l Races 3 7 . 6 3 6 . 6 3 5 . 8 Sources: 1 1 t h Annual Report, FPAC Colombo, 1 9 6 4 , p. 9 ; a l s o S t a t i s t i c a l Pocketbook of Ceylon, Department of Census and S t a t i s t i c s , Colombo, 1 9 6 8 , p. 2 4 . Influences toward spontaneous f e r t i l i t y d e c l i n e s must have been s i m i l a r to those i n I n d i a - continence, a b o r t i o n , or "unconscious" i n f a n t i c i d e , and the l i m i t e d use of c o i t u s i n t e r r u p t u s and other b i r t h c o n t r o l methods. In a d d i t i o n , there was growing attendance at Family Planning C l i n i c s ^ ; as shown by p a t i e n t v i s i t s f o r the years ending June 3 0 t h , 1963 - 1 9 6 5 : TABLE IV Attendance at PPAC C l i n i c s Year No. of C l i n i c s New Patients R e - v i s i t s Total 1963 63 — — 12,387 1964 78 — — 17 , 13^ 1965 97 ^5,157 19,098 64 ,255 1966 116 14,634 29,408 44,042 1967 93 12,166 30 ,474 42,640 1968 54 8 ,291 25 ,53^ 31,825 1969 20 6 ,996 17,091 24,087 Total 116 ,765 119,605 236,370 * Beginning of phase-out to government program. Sources: Annual Reports. FPAC, Colombo, I 9 6 3 - 1969, pp. 28-9, 28 -9 , 26-7 , 26-7 , 22-3 , 8 - 9 , 11 respectively. In the early years of the Association's a c t i v i t i e s , most patients coming to the c l i n i c s had an average of 8 or 9 children, and incomes of Rs. 100 per month or l e s s . By 1963 the majority v/ere coming after 3 or 4 children and the 21 largest age group was between 25 and 35 years. By June 3 0 , I 9 6 9 , i n four Colombo area c l i n i c s , of 1,908 cases, more than 1,100 patients were from both uns k i l l e d and s k i l l e d labor groups, more than 70.0 were under 30 years of age, the largest number were i n the 25-29 year age group, and had come after second and t h i r d pregnancies. It was noted, how-ever, that the sample v/as small, and the patients were urban area d w e l l e r s . Abhayaratne and Jayewardene conducted d e t a i l e d s t u d i e s , from I 9 6 3 to I 9 6 6 , of knowledge, a t t i t u d e s and p r a c t i c e of f a m i l y planning i n 78 v i l l a g e s , and concluded t h a t , ... those who were f u t u r e o r i e n t e d , who planned f o r the fu t u r e of t h e i r c h i l d r e n , were the people who had the lowest f e r t i l -i t y and had used contraceptives to achieve t h i s end. These people do not come mainly from the upper cl a s s e s nor do they come mainly from the lower. They are u s u a l l y educated people w i t h a l i m i t e d income, i n p u b l i c s e r v i c e doing c l e r i c a l j o bs. Their wives are also educated and em-ployed g a i n f u l l y " o u t s i d e the home. They are perhaps people v/ho have r e a l -i z e d that though the good things of l i f e are apparently beyond t h e i r reach they need not be beyond the reach of t h e i r c h i l d r e n . 23 F e r t i l i t y was i n f l u e n c e d by the average age at marriage -which had increased from 2 1 . 0 years i n 1900 to 2 3 . 1 i n i 9 6 0 f o r females, and from 2 7 . 3 f o r males to 2 8 . 3 . This was not only an o l d e r age range than i n I n d i a but had the e f f e c t of 24 shortening the number of reproductive years f o r females. Also c o n t r i b u t i n g to f e r t i l i t y d e c l i n e were the r e l a t i v e l y s m aller numbers i n the reproductive age group, but t h i s percentage was i n c r e a s i n g i n the 1960s because of the sharp d e c l i n e i n the death r a t e between 1945 and 1950 due to ma l a r i a c o n t r o l and other h e a l t h measures. 25 (See Appendix f o r d e t a i l e d d i s c u s s i o n ) . The Government f a m i l y planning program, announced i n I 9 6 5 , began to d e l i v e r f a m i l y planning s e r v i c e s the f o l l o w i n g year and the cumulative t o t a l f o r I 9 6 6 - I 9 6 9 was 1 6 0 , 0 0 0 DEMOGRAPHIC PATTERNSi CEYLON AND SWEDEN 1840 - I960 1840 1860 1880 1900 1920 1940 1960 Figure 5, New demographic pattern is appearing in the nonindustrial nations. The birth rate (solid line) has not been falling significantly, whereas the death rate (broken line) has dropped precipitously, as illustrated by Ceylon (gray). The spread between the two rates has widened. In nations such as Sweden (black), however, the birth rate dropped during development long before the death rate was as low as in most under-developed countries today. / Source* Kingsley Davis, "Population", Population  i n Perspective. Louise B. Young, ed., Toronto, 1968, pb, p. 12? patients, many of which represented patients already enrolled or attracted by the Family Planning Association, at least up to I966 and 1967. The t o t a l number of women i n the reproduc-t i v e age group (15-44) for 1963 was 2 ,151 ,000, and for 1967, 2 , 3 9 2 , 0 0 0 , an increase of approximately 11 percent. This was a formidable threat to the target of a b i r t h rate of 25 per 1,000 by 1975-1976. 2^ The combination of the FPAC program and the government's e f f o r t s have increased the practice of b i r t h control, however, and, considering the r e l a t i v e l y high l i t e r a c y and good communications, could achieve the target i f i t were given maximum promotion. The s o c i a l , economic and p o l i t i c a l consequences of over-population for the country as a. whole are better under-stood by the majority of Ceylonese, than i n India, but, as in India, the FPAC has found that an approach based on in d i v i d u a l and family needs i s the most e f f e c t i v e . In other words, the spacing of pregnancies and smaller family size w i l l improve maternal and c h i l d health, family happiness, 27 and make possible a higher standard of l i v i n g . The FPAC has been fortunate not only i n i t s widely representative leadership, but also i n having had the c o l -laboration of both government and private doctors, nurses and s o c i a l workers to promote family planning. Pre-natal c l i n i c s , t a l k s with mothers i n h o s p i t a l (where 60-65 percent of Ceylonese babies are delivered), well-baby c l i n i c s , and milk and cod l i v e r o i l d i s t r i b u t i o n centres have been used. Home v i s i t i n g has been another means of contact by female employees, and s p e c i a l l y trained Public Health Inspectors have "been able to influence male attitudes as w e l l . Pro-motion of b i r t h control among government employees and trade union leaders has been another route and, of l a t e , an e f f o r t has been made by the PPAC to urge family planning i n business and i n d u s t r i a l establishments. The FPAC has also introduced family l i f e education techniques to teacher t r a i n i n g colleges and lectures on human sexuality have been given to groups of students when requested. I t has also sponsored open seminars on a l l aspects of family welfare, including family planning. In addition, considerable p u b l i c i t y has resulted from Indian Ocean Region (IPPF) Seminars and Conferences i n Ceylon i n 1963 and 1 9 6 8 . An information and p u b l i c i t y unit has been organized for press, radio and f i l m p u b l i c i t y . By 1968 the FPA was employing two f u l l time education o f f i c e r s fluent i n Sinhala, and one fluent i n Tamil. Unfortunately, although such or-ganizations as the YWCA, the Lanka Mahila Samiti, and the CHAPT agreed to promote family planning i n t h e i r programs, and a few lectures were given, up to the end of 19^9, 28 e f f e c t i v e programs by these agencies were s t i l l to come. The Association r e a l i z e s that family planning i s not the only solution to s o c i a l , economic and p o l i t i c a l problems in Ceylon, and that even i f a l l couples adopted a small family norm at once, the fact of over-population would s t i l l remain. I t does believe, however, that any progress to im-prove the standard of l i v i n g of Ceylonese must include a vigorous campaign f o r b i r t h , c o n t r o l . I t would be harder to " s e l l " were i t not f o r other supporting f a c t o r s which char-a c t e r i z e the Ceylon scene - good communications, hig h l i t e r a c y , p o pulation m o b i l i t y , modernizing i n t e n t i o n s and r i s i n g expec-t a t i o n s . The j o i n t f a m i l y system i s disappearing, the marriage age i s r i s i n g , female employment outside the home i s i n c r e a s -i n g , and b i r t h c o n t r o l i s becoming b e t t e r known and understood. Serious unemployment may be another f a c t o r . By agreement w i t h the government the FPAC w i l l continue to operate a few c l i n i c s f o r s p e c i a l s e r v i c e s and research, but i t s main r o l e w i l l be i n p u b l i c education and i n promotion of more in f o r m a t i o n through the school system. The burden of d e l i v e r y of b i r t h c o n t r o l s e r v i c e s r e s t s w i t h the government but i t i s worth n o t i n g e s p e c i a l l y that two research p r o j e c t s of importance -the Sweden-Ceylon p i l o t p r o j e c t , and a c c e p t a b i l i t y t r i a l s of the P i l l - provided e s s e n t i a l i n f o r m a t i o n and were FPA i n s p i r e d . As was noted e a r l i e r , at the request of the FPAC and the government of Ceylon, Sweden agreed to set up a p i l o t p r o j e c t to study a t t i t u d e s to f a m i l y planning and the pros-pects f o r i t s adoption, to provide l i m i t e d s e r v i c e s and to a s s i s t i n t r a i n i n g p u b l i c h e a l t h personnel. This was the f i r s t such p r o j e c t i n the world, and was s t a r t e d i n 1958 among the Sinhalese p o p u l a t i o n of a Colombo suburb, and on a t e a estate where the population was wholly T a m i l . In 19&3 the p r o j e c t was expanded to i n c l u d e government h o s p i t a l s at P o i n t Pedro and V e l v e t t i t u r a i i n the n o r t h , u s i n g medical s t a f f and a female s o c i a l worker. Tea estates i n Mousakelle were also included, as well as another project i n the Polonnaruwa-Matale d i s t r i c t . Training was given to midwives, nurses and Inspectors concerned i n the ordinary health services i n those areas, and to dispensers and midwives on the estates. But soon a f t e r the f i r s t projects were set up, r e l a t i o n s between the project s t a f f and the o r i g i n a l sponsors, the PPAC, cooled over lack of communication, and i t was rumored that contacis with the Director of Health Services were also strained. A subsequent Swedish c r i t i q u e of the program undertaken by the Demographic I n s t i t u t e , University of Goteborg, at the request of the Swedish International Development Agency (SIDA), i d e n t i f i e d other weaknesses as wel l : The choice of Bandaragama and Diyagama by Ceylonese authorities had not been wise as neither location r e a l l y was a representative of the Sinhalese or Tamil population. No control areas were set up, profes-s i o n a l advice i n s t a t i s t i c s and sociology promised by the government of Ceylon were not provided, and other help was not requested u n t i l almost the end of the project. The reports of the Swedish Director that a decline i n the b i r t h -29 rate due to family planning had occurred, were misleading. F e r t i l i t y was reduced i n the f i r s t of the two project areas, but t h i s was more l i k e l y because the mean age of marriage rose from 17.2 to 19.2. In the other area, the project had 30 no effect whatever. After the Ceylon government adopted family planning as national p o l i c y i n mid-1965, the Swedish program was reorganized and assistance hecame much more e f f e c t i v e . Prom the end of 1965 to the close of the entire p i l o t project i n August, I 9 6 8 , 400 c l i n i c s were equipped, 3,000 doctors, nurses, midwives, public health inspectors and health educators were trained, and contraceptives, vehicles and educational materials were provided. The Swedish project o f f i c e i n Colombo was turned over to the Ministry of Health, and became the Family Planning Bureau, headed by Dr. Terence Perera, Assistant Director of Health (Maternal and Child Health). Under a further arrangement between SIDA and the Ceylon government, to run from 1968 to 1970, one Swedish consultant i n t r a i n i n g and communications was to be financed, further c l i n i c s equipped and contraceptives (condoms) provided.3"'' Dr. Gosta Nycander, an educational psychologist was to f i l l the advisory r o l e . P a r a l l e l i n g t h i s program was research on the accept-a b i l i t y of the P i l l . In 1961, with the assistance of the late Dr. Gregory Pincus, Dr. Siva Chinnatamby undertook t r i a l s of several v a r i e t i e s of o r a l contraceptives. The p i l l s were supplied by the drug houses concerned. Tests had already been made in the United States and Puerto Rico f o r about f i v e years, but there was also the question whether Ceylonese women could manage to take the P i l l s u ccessfully. As conventional contra-ceptives were not widely used, i t was considered to be worth the experiment. Most of the research was done i n the Colombo area, and three approaches were used: one through c l i n i c s , where r o u t i n e p e l v i c examinations were made, c e r v i c a l smears taken, and c a r e f u l i n s t r u c t i o n s given by the doctor; the second was the issuance of the p i l l s by a s o c i a l worker through a suburban c l i n i c attended by a doctor only when problems arose; the t h i r d was d i s t r i b u t i o n through home v i s i t i n g , w i t h the doctor's s e r v i c e s o n l y a v a i l a b l e when a d i f f i c u l t y occurred. Of 2,528 women p a t i e n t s i n the four-year study to June 30 , 1965, 67.7 percent used i t r e g u l a r l y . Headaches, nausea, d i z z i n e s s and other symptoms disappeared w i t h i n a few weeks, so reassurance about side e f f e c t s helped a high pro-p o r t i o n of the women to continue. A p i l l w i t h a smaller pro-gestagen content produced fewer side e f f e c t s . There was no evidence of thrombosis or embolism, but 30 percent of the p a t i e n t s found l a c t a t i o n reduced. A few abandoned i t e i t h e r because they found i t d i f f i c u l t to come f o r replacement s u p p l i e s , because they decided to use another method, or because they were f r i g h t e n e d by rumors. I t was concluded that r o u t i n e p e l v i c examinations should be performed p e r i o d i -c a l l y . The suburban c l i n i c and house-to-house d i s t r i b u t i o n were s a t i s f a c t o r y routes as w e l l , provided medical assistance was a v a i l a b l e when needed. A 2 8 - p i l l regimen was p r e f e r r e d , and i t was expected t h a t decreasing costs would make i t a very popular b i r t h c o n t r o l method. The h i g h a c c e p t a b i l i t y r a t e seems to have been due to higher l i t e r a c y than i n other coun-t r i e s , the care taken by the doctor i n reassurance, and system-a t i c checking of s i d e - e f f e c t s . The t r i a l s also proved that women with l i t t l e or noteducation could take the P i l l successfully, provided they were s u f f i c i e n t l y motivated. Motivation was highest among those with the largest f a m i l i e s . Dr. Chinnatamhy hoped that she would he able to follow up 32 these cases aft er a. suitable i n t e r v a l . She also conducted research for the Pathfinder Fund, on the IUD, and confirmed the need for reassurance, e s p e c i a l l y during the f i r s t 2k hours aft e r i n s e r t i o n . Retention was approximately 70 to 76 percent. 5 percent had the IUD removed, mostly due to excessive bleeding. The f a i l u r e rate was 2.8 percent. A subsequent report showed that continuation a f t e r k2 months was 63.2 percent of f i r s t i n s e r t i o n s , and 65 33 percent of f i r s t expulsions reinserted. Dr. Chinnatamhy also undertook investigation of long-acting i n j e c t a b l e s , but when the 16th Annual Report (1968-69) was published, she con-3k sidered i t too early to analyse the r e s u l t s . The FPA also undertook other research. Through Dr. Christopher Tjetze of the Population Council, a year's t r i a l of foam table t s delivered through home v i s i t i n g was conducted. Of 306 women, only 125 practised the method re g u l a r l y , i n d i -eating that i t was not p a r t i c u l a r l y popular. J J Eight FPA c l i n i c s were used for a study i n motivation conducted by the University of Ceylon and financed by the Population Council. This was part of the study of f e r t i l i t y trends undertaken by Professor CHS Jayewardene. V i l l a g e s o r i g i n a l l y studied for the book written i n collaboration with Professor O.E.R. Abhayaratne, F e r t i l i t y Trends i n Ceylon, were re-surveyed and the evaluation and follow-up done by Family Planning Bureau (government) personnel. A number of other studies have "been carried out by other agencies, the new Family Planning Bureau and the Population Council, and a f e r t i l i t y survey and evaluation by a United Nations Population Fund team was r e -quested by the government for 1970. As i n India t r a i n i n g of doctors, nurses, midwives and s o c i a l workers was done by the Family Planning Association exclusively u n t i l 1958, when the Sweden-Ceylon project under-took a share of the task with paramedical personnel. This work continued u n t i l raid-1967 when the government of Ceylon began to take increasing r e s p o n s i b i l i t y . Up to June 3 0 , 1967, the FPA, in co-operation with SIDA, had trained 279 doctors, 169 nurses, 1,125 midwives, 479 Public Health Inspectors and 24 Health Educators, 324 Estate Medical Assistants and 60 estate midwives. Two thirds were trained by the FPA; one t h i r d by the Sweden-Ceylon project. Since August, I968 and the end of the Swedish project the FPA, i n collaboration with government, 37 has conducted t r a i n i n g where needed. The United Nations International Children's Emergency Fund (UNICEF) has financed a r e - t r a i n i n g program f o r 700 nurses per year i n c h i l d welfare, n u t r i t i o n and family planning, and has also provided equipment 38 and transport. I t i s of interest that family planning i s now part of the routine t r a i n i n g of a l l health personnel i n Ceylon - medical students, student nurses, p r a c t i s i n g doctors, nurses, public health inspectors, midwives and Health Educators. The delivery of b i r t h control services followed a p a r a l l e l course. In 1953 the newly organized FPA had no money f o r premises, so, as has been noted, two doctors who had helped Mary Rutnam to organize f a m i l y planning s e r v i c e s before World War I I o f -fer e d t h e i r s u r g e r i e s . A p o s t - n a t a l c l i n i c run at De Soysa Maternity H o s p i t a l i n Colombo by Dr. (Mrs.) F.K. Ram A l u v i h a r e , was also pressed i n t o s e r v i c e f o r f a m i l y p l a n n i n g . In a d d i t i o n , because a c h i l d l e s s woman i s scorned i n Asian c o u n t r i e s , diagnosis and treatment of both i n f e r t i l e husbands and wives were also provided. A s s i s t a n c e i n b o t h f a m i l y planning and i n f e r t i l i t y was also given by Dr. Chinnatamhy. This c l i n i c was dubbed the Mothers' Welfare C l i n i c . I t s u f f e r e d from the beginning from l a c k of p r i v a c y f o r male p a t i e n t s . Hormone treatment was found to be too expensive an item, and b e t t e r f a c i l i t i e s , more time f o r the work, and a means of keeping costs low were other challenges. More such f a c i l i t i e s i n other parts of Ceylon were also needed. Up to June 1967» 228 couples were interviewed but o n l y 32 allowed i n v e s t i g a -t i o n s to be completed. Many of the men were r e l u c t a n t to undergo sperm t e s t s . Nonetheless, 25 percent success was achieved w i t h those couples who d i d take treatment. I t was found that the r a t e of i n f e r t i l i t y i n Ceylon - 10 percent of married couples - was the same as i n other c o u n t r i e s , and that the more or l e s s equal r a t i o of male to female problems a l s o p e r t a i n e d . Family planning s e r v i c e s were increased g r a d u a l l y i n p u b l i c h e a l t h u n i t s , h o s p i t a l s and h e a l t h centres, where government doctors who had taken FPA t r a i n i n g were permitted to provide them i f they wished. Contraceptives were supplied by the Family Planning Association. After the Association acquired i t s own premises i n 1959, marriage and premarital counselling for men and women were introduced on a regular weekly basis at the Headquarters C l i n i c , some sessions being devoted to men only, with male doctors. Support from TB hospitals was also forthcoming, and the Colombo and Kandy Municipal Councils ran t h e i r own ser-vices with supplies provided by the FPAC. By the tenth anniversary of the FPAC i n I963, the organization had 57 c l i n i c s and 9 centres. By 1966 there were 116 c l i n i c s and centres. Only two doctors were being paid, but these were serving f u l l time. Headquarters s t a f f numbered 10 i n I963 - 5 c l e r i c a l help and 5 s o c i a l workers, including two home v i s i t o r s for low income areas. Government sponsor-ship began i n I965 a n d Family Planning Association services began to be phased out. By September, 1969, the government was running 415 c l i n i c s , including many of the former FPAC locations, and expected to add 50 more within a year. The FPAC retained twenty c l i n i c s for services and research, and a cytologist was added to the Headquarters s t a f f . A mobile c l i n i c donated to the FPAC by the people of Scotland was given to the government, and was operating i n the Gal Oya Valley, a r u r a l development area. A special program was also started i n the Eastern Province where the Muslim popu-l a t i o n i s numerous and the birthrate high. In 1969 a c l i n i c was also opened i n the Ayurvedic (indigenous medicine) Hospital i n a Colombo suburb. Special note must be taken of the pro-gram ;mounted by the Planters' Association of Beylon. Pamily planning services were started i n tea and rubber estates by the medical o f f i c e r of the Planters' Association i n 1954, using the sponge and foam t a b l e t s . The l a t t e r were supplied by the Commissioner of Labour. Prom 1958 these e f f o r t s were increased, and, from 1963-1964 condoms were added. The following year o r a l contraceptives were introduced, and, from I 9 6 5 , IUDs were inserted with the co-operation of nearby government c l i n i c s . In return for a fee of Rs. 25 from each of more than 450 estates, the PPAC employes a f u l l time propa-ganda worker who v i s i t s 80-90 estates a year, holding 3 to 4 meetings a day, with two days at each estate, l e c t u r i n g to the labor force and minor s t a f f . Selected men and women are en-r o l l e d to d i s t r i b u t e l i t e r a t u r e , and the estate medical attendants d i s t r i b u t e methods. Medical o f f i c e r s , dispensers and midwives have been given t r a i n i n g by the PPAC and Sweden-Ceylon project. The Indian Tamil population of the Estates has shown a steady decline i n b i r t h r a t e from the inception of the pro-gram, and has consistently maintained a lower b i r t h r a t e than the rest of the country. TABLE V Births per 1,000 population, Ceylon A l l Races Indian Tamil 1953 38.7 38.8 195^ 35.7 38.1 1955 37.3 3^.7 1956 36.3 35.3 1957 3 6 . 4 3 6 . 7 1958 35.8 36.0 1959 37.0 36.6 I960 36.6 35.9 196I 35.8 34 .7 1962 35.5 3 3 . 2 1963 34.1 29.8 1964 33.2 3 0 . 9 1965 33.1 2 9 . 4 1966 32.2 * 28.5 1967 31.6 * 28 .3 27.4 * P r o v i s i o n a l Sources: "Planters' Association Health Scheme", 1 0 t h , 1 5 t h , 1 6 t h , Annual Reports. F.P.A.C. Colombo, 1963, 196b, 1969, PP.. 1"9, 5, 12 respectively; S t a t i s t i c a l Abstract of Ceylon, I965, and S t a t i s t i c a l -focketbook of Ceylon, 1968, Department of Census and S t a t i s t i c s , Colombo, pp. 45 , 29, respectively. Whether t h i s decline has been a genuine one as a r e s u l t of good administration of the family planning program, the growing i n a b i l i t y of the estates to absorb the children into t h e i r own labor forces, and male desire for the income earned by t h e i r wives (who do the tea plucking), or whether - as the Department of Census and S t a t i s t i c s suggested - there has been some f a l s e r e g i s t r a t i o n i n order to q u a l i f y the c h i l d r e n 4o as Ceylon c i t i z e n s , was s t i l l unresolved at the end of 1969. The Ceylon Tamil b i r t h r a t e i n northern Ceylon i s h i gher, but the FPA s t a t e s that t h i s i s because many there have been i n -fluenced by "doctors who profess a c e r t a i n r e l i g i o u s f a i t h " and that the b i r t h r a t e of Sinhalese l a b o r i n comparable types 41 of work has also d e c l i n e d . I t i s c e r t a i n t h a t the h i g h a c c e p t a b i l i t y of IUDs and o r a l contraceptives from I965 42 I966 must have had some e f f e c t i n any case. The e v o l u t i o n of methods fol l o w e d a course s i m i l a r to that i n I n d i a except t h a t the P i l l was used at an e a r l i e r date. In the e a r l y days of the movement, the diaphragm-and-j e l l y was the most r e l i a b l e method, and many p a t i e n t s , es-p e c i a l l y those i n urban centres, were equipped w i t h i t . Foam t a b l e t s and the sponge were also d i s t r i b u t e d , but the l a t t e r was abandoned as a messy procedure. As has been noted, from I 9 6 I the p i l l was d i s t r i b u t e d - at f i r s t on,a s t r i c t l y c o n t r o l -l e d b a s i s i n two Colombo c l i n i c s f o r research on a c c e p t a b i l i t y and side e f f e c t s , but l a t e r on the tv/o other bases already described. O r a l contraceptives were also given out i n out-s t a t i o n c l i n i c s . Condoms were d i s t r i b u t e d i n i n c r e a s i n g numbers. The rhythm method was taught whenever i t was r e -quested. IUDs were added from 1964. Female s t e r i l i z a t i o n v/as also done, but not o f t e n unless the woman had at l e a s t f i v e l i v i n g c h i l d r e n . Male s t e r i l i z a t i o n was urged, and a few operations performed by the PPA from 1966 on men who had fathered four l i v i n g children, hut vasectomy i s not yet a popular method with the government. Among sources of equip-ment and contraceptives were Dr. Gamble's Pathfinder Fund, the Brush Foundation, the IPPF and various pharmaceutical firms. A l l methods have always been given out according to a s l i d i n g scale of charges - depending on the patient's a b i l i t y to pay - and free i f necessary. Acceptors under the FPA program have already been l i s t e d , but the government program i s also of i n t e r e s t : TABLE 71 Family Planning Data on Ceylon Government Program (in thousands) A l l S t e r i l i -Year Methods IUDs Orals zations Other Cumulative 1966 15 9 2 3 1 15 1967 36.7 18.5 8.9 3.6 5 .7 52 1968 48 .1 20.6 16.0 5-2 6.3 100 1969 60.3 20.2 28.0 6.1 6.0 160 Cumulative acceptors through I 9 6 9 as percent of e v e r - e l i g i b l e women •» 6.7 Estimated Percentage of Married Women Users, 15-44 Years of Age: January, 1970 8.2 3.3 Personnel and F a c i l i t i e s S p e c i f i c a l l y Allocated, Current Doctors 112 Other medical personnel 727 F i e l d Workers . 1,935 Government F a c i l i t i e s 437 (Hospitals, c l i n i c s , centres) Mobile teams 1 Source: Dorothy Nortman, Population and Family Planning Programs: A Factbook. Reports on Population/Family Planning, Population Council, New York, July, 1970, pp. 47, 68, 5 0 , 38. (For supplementary data on Ceylon, see Table XI,Appendix). F i n a n c i a l a s s i s t a n c e f o r the Family P l a n n i n g A s s o c i a t i o n has been given r e g u l a r l y by the IPPF f o r general purposes, and f o r s p e c i a l p r o j e c t s . In a d d i t i o n to the P a t h f i n d e r Fund, Oxfam has a l s o a s s i s t e d . For the government, the Po p u l a t i o n C o u n c i l has provided a d v i s e r s , and the Ford Foundation sub-s t a n t i a l g r a n t s . SIDA had also a s s i s t e d . The UN Fund f o r Pop u l a t i o n A c t i v i t i e s and the I n t e r n a t i o n a l Labor O r g a n i z a t i o n have also given s p e c i a l g r a n t s . In 1969 the government a l -l o c a t e d Rs. 242 m i l l i o n ($U.S. 40 m i l l i o n ) which represented 43 .01 percent of the n a t i o n a l budget. In summary, u n l i k e I n d i a , f a m i l y planning was introduced i n Ceylon by a f e m i n i s t from abroad; but, from the beginning, Dr. Mary Rutnam had the support of educated Ceylonese men and women. Although the f a m i l y planners were concerned about over-population, l i k e t h e i r Indian counterparts, they focussed on maternal and c h i l d h e a l t h , and f a m i l y w e l f a r e . They strove to have the s e r v i c e accepted as an o r d i n a r y f u n c t i o n of govern-ment h e a l t h s e r v i c e s , and were fo r t u n a t e i n having the co-operation of the Health Department almost from the f i r s t . O pposition was mainly centred i n Western-induced medical and r e l i g i o u s p r e j u d i c e , but t h i s faded and by 19&9? w i t h un-employment reaching emergency p r o p o r t i o n s , communalism provided the l a s t remaining o b s t a c l e to a l l - o u t e f f o r t . Attendance at FPAC c l i n i c s from 19&3 to 19&9 compared very f a v o r a b l y w i t h l a t e r government performance, and i t i s p o s s i b l e that FPAC e f f o r t s had some s l i g h t e f f e c t i n hastening the d e c l i n e i n the b i r t h r a t e . Other f a c t o r s such as the r i s i n g age of mar-r i a g e , the changing r o l e of women and high l i t e r a c y were more i n f l u e n t i a l however. The f a m i l y planners d i d make more Ceylon-ese aware of the p o s s i b i l i t y of b i r t h c o n t r o l , and t h e i r pro-paganda defused o p p o s i t i o n so t h a t , by 19c$5, the government was able to introduce an o f f i c i a l program w i t h r e l a t i v e ease. In Ceylon, t o o , the experience of the volunteers was a u s e f u l foundation, p a r t i c u l a r l y as much of the t r a i n i n g and c l i n i c s e r v i c e had been c a r r i e d out from the beginning i n close co-operation w i t h government. However, as i n I n d i a , the secret of long term and e f f e c t i v e b i r t h c o n t r o l i n Ceylon i s to be found i n the f o l l o w i n g remark by a v i l l a g e woman to a f a m i l y planning speaker: Lady, you are quite r i g h t , and we agree w i t h you, but ... do you t h i n k you could t a l k to the MEN about i t . This question was even more p e r t i n e n t i n the s t o r y of f a m i l y planning i n P a k i s t a n . FOOTNOTES - Chapter VI •^Although f r e e h e a l t h s e r v i c e s were introduced i n 1900 the B r i t i s h government d i d l i t t l e to improve them u n t i l 1926 when prominent Ceylonese became p o l i t i c a l l y a c t i v e , hut Dr. Rutna,m kept h e r s e l f up to date i n medical knowledge on o c c a s i o n a l t r i p s home; N.K. Sarkar, The  Demography of Ceylon, Government P r e s s , 1957, P« 152; Mrs. W i l f r e d Graham, s i s t e r of Dr. Rutnam, conversations i n October, 19^9» Vancouver. Dr. Rutnam 1s papers, now i n the care of her daughter i n Colombo, may contain some re l e v a n t i n f o r m a t i o n , but, f o r the present, at l e a s t , they are i n a c c e s s i b l e . 2C.C. de S i l v a to Mary Bishop, 2 0 . 2 . 6 8 . 3 " 1 0 years of growth i n Ceylon", 10th Annual Report, Family P l a n n i n g A s s o c i a t i o n of Ceylon (FPAC), Colombo, 1963, P. 14. 4 M. Rajanayagam, "Family Planning Problems i n the P l a n t a t i o n s " , Proc. F i f t h I n t e r n a t i o n a l Conference, IPPF, (Tokyo), London, 1955, PP. 87-89. e I n t e r n a t i o n a l Bank f o r Reconstruction and Development, The Economic Development of Ceylon, B a l t i m o r e , 1953, PP» 65 , 710-11; see a l s o Mary F. Bishop, Ceylon: The Quiet  B a t t l e , Canadian I n s t i t u t e of I n t e r n a t i o n a l A f f a i r s , Toronto, 1966, p. 5 . Margaret Roots to Mary Bishop, 18 . 1 1 . 6 8 . 7The P a t h f i n d e r Fund, Boston, I 9 6 6 , pp. 2 - 3 . o Barbara Cadbury to Mary Bishop, 6 . 1 2 . 6 8 ; C.C. de S i l v a , op c i t . ; a l s o 10th Annual Report, FPAC, Colombo, op. c i t . , p. 1 5 . Q Papers by V i s i t i n g Economists, Planning S e c r e t a r i a t , Colombo, 1959, p. 39 . "^Mary Bishop Questionnaire, 21 .5 .69 "^"C.C. de S i l v a , op. c i t . 12 Margaret Roots, op. c i t . 1 3 l 5 t h Annual Report, FPAC, Colombo, 1968, p. 15; also Ceylon News, 2 2 . 8 . 6 8 . 14 "A Promotional Scheme f o r Planned Parenthood", 11th Annual Report, FPAC, Colombo, I964, p. 3 9 . 1 ^ C e y l o n News, 28.8 .69; also S t a t i s t i c a l Pocket Book  of Ceylon, Department of Census and S t a t i s t i c s , Colombo, 1968, p. 24. 16 Ceylon News, 11.9 . 6 9 ; 15.10.69. l 7 D i n a m i n a , 29«3'68. 18 Mary Bishop, Questionnaire, op. c i t . 1 9 1 5 t h Annual Report, PPAC, Colombo, 1968, p. 18. PO Ceylon News, I 3 . 7 . 7 0 . 21 " C l i n i c s and Centres", 10th Annual Report, PPAC, op. c i t . , p. 3 5 . 22 16th Annual Report, PPAC, pp. 18 - 1 9 , Tables I , l a . 2 3O.E.R. Abhayaratne & C.H.S. Jayewardene, F e r t i l i t y  Trends i n Ceylon, Colombo, 1967, p. 341. 2 ^ l b j d . , p. 116. i c h o l a s H. Wright, "Ceylon: The R e l a t i o n s h i p of Demographic Factors and M a r i t a l F e r t i l i t y to the Recent F e r t i l i t y D e c l i n e " , Studies i n Family P l a n n i n g , The P o p u l a t i o n C o u n c i l , New York, November, 1970, p. 17, f . n . 5 ; also S t a t i s t i c a l A b stract of Ceylon, Department of Census and S t a t i s t i c s , Colombo, 1965, p. 5 0 . S t a t i s t i c a l Pocket Book, op. c i t . , p. 22. 27 Mary Bishop, Questionnaire, op. c i t . S y l v i a Fernando to Mary Bishop, I 7 . 4 . 6 9 . 2 9 A r n e Kinch, "Ceylon", i n Bernard Berelson et a l , eds., Family Planning and P o p u l a t i o n Programs, Chicago, I966, p. 1 0 9 . -^Hannes Hyrenius & U l l a Aas, The Sweden-CeylonrFamily  Planning P i l o t Pro.ject, Goteborg, 1968, passim. 3-^-Radio i n t e r v i e w by Mrs. Nanda. Jayemanne, w i t h Dr. Gosta Nycander, "The Swedish Role i n Family Planning Work", 16th Annual Report. FPAC, 196?, p. 25 . 3 2 S i v a Chinnatamhy, "Acceptance of O r a l Contraceptives by Ceylonese Women", 12th Annual Report, PPAC, pp. 12 -19; a l s o 15th Annual Report, FPAC, op. c i t . , p. 1 5 . 3 3 S i v a Chinnatamhy, " I n t r a u t e r i n e Contraceptive Device", 14th Annual Report, FPAC, 1967. PP» 26-27J S i t u a t i o n Report, IPPF, London, February 1970, p. 5 . S i v a Chinnatamby, "Research i n Control of Conception", 16th Annual Report, FPAC, 1969, pp. 7-9; due to r e -o r g a n i z a t i o n problems, a l ? t h Annual Report was not pu b l i s h e d . 3 ^ S i v a Chinnatamby, "Simple Method A c c e p t a b i l i t y Study", Proc. 7th Conference of the IPPF, (Singapore), Amsterdam, 1963, pp. 600-04. 36 J S i t u a t i o n Report, l o c . c i t . 3 7 s i t u a t i o n Report, IPPF, London, March, 1968, p. 3; a l s o 16th Annual Report, FPAC, Colombo, 1969, p. 2. 3 8 I P P J e w s , #183, May, 1969. 39s i v a Chinnatamby, " I n f e r t i l i t y " , 14th Annual Report, FPAC, 1967, PP. 28-30. 4o H o s p i t a l s and r e g i s t r a r s of v i t a l s t a t i s t i c s were not i n the h a b i t of checking whether parents were Ceylon c i t i z e n s or s t a t e l e s s . ^ C e y l o n Hews. 8.8.68. ^ITJD: I965, 35; 1966, 858 (831 r e t a i n e d ) : ORAL: I965, 1,485; 1966, 12,078, S i t u a t i o n Report. March, 1968, p. 3. ^ P o p u l a t i o n Program A s s i s t a n c e , Agency f o r I n t e r n a t i o n a l Development, Washington, D.C., 1970, pp. 152-53. ^ a y Blaze to Mary Bishop, 19.12.68. 1900 1910 1920 1930 1940 1950 I960 1970 1980 1990 2000 Sourcei P o p u l a t i o n Reference Bureau, Inc. ton, D.C.,April, 1965. CHAPTER V I I Pa k i s t a n I f there were attempts to promote f a m i l y planning among Indian Muslims before Independence, they are d i f f i c u l t to t r a c e . A f t e r P a r t i t i o n , however, a group of educated women set up elementary f a m i l y planning s e r v i c e s i n r e l i e f programs f o r refugees from I n d i a . 1 By 1952 these s e r v i c e s were being given i n K a r a c h i , Lahore, and Dacca; and, the f o l l o w i n g year, Pamily Planning A s s o c i a t i o n s were o f f i c i a l l y formed i n each of these centres. In 1953 they were u n i t e d as the Pamily Planning A s s o c i a t i o n of P a k i s t a n , (PPAP) and i n the f o l l o w i n g year, t h i s n a t i o n a l o r g a n i z a t i o n was i n t u r n a f f i l i a t e d w i t h the I n t e r n a t i o n a l Planned Parenthood Feder-2 a t i o n . The new movement was also a s s i s t e d by such o r g a n i z -a t i o n s as the N a t i o n a l C o u n c i l on S o c i a l Welfare, the Red Cross S o c i e t y , the Rotary Club of Karachi and, i n 1957 i n East P a k i s t a n , by the P a t h f i n d e r Fund i n the person of Mrs. Margaret Roots. The o b j e c t i v e s were "to encourage a system of f a m i l y planning which s a t i s f i e s the n a t u r a l d e s i r e f o r parenthood and ensures reasonable prospects of h e a l t h and u s e f u l l i v e s f o r the c h i l d r e n so t h a t they become an asset to the N a t i o n " . Spacing f o r "good upbringing" and f o r p r o t e c t i o n of the h e a l t h of the mother was e s s e n t i a l . As i n I n d i a and Ceylon, i n a d d i t i o n to con t r a c e p t i o n , diagnosis and treatment of s t e r i l i t y was also provided. T r a i n i n g , r e s e a r c h , p u b l i c i n f o r m a t i o n , and the gat h e r i n g of r e l i a b l e s t a t i s t i c s were other aims; and i t was al s o p o l i c y to b u i l d contacts w i t h other o r g a n i z a t i o n s w i t h s i m i l a r goals i n P a k i s t a n and abroad. Po p u l a t i o n c o n t r o l was not a primary o b j e c t i v e at the time, 3 nor was the i n i t i a l e f f o r t supported by the government. Conforming to the pat t e r n i n other c o u n t r i e s , i n 1957 the Pamily P l a n n i n g A s s o c i a t i o n forwarded to the government a plan to provide f a m i l y planning s e r v i c e s i n government h o s p i t a l s , maternal and c h i l d h e a l t h centres (MDH), and d i s -p e n s a r i e s . I t was accepted and i n the budgets f o r 1957-1958 and 1 9 5 8 - 1 9 5 9 the government approved p r o v i s i o n of Rs. 5°0»000 ($U.S. 1 0 0 , 0 0 0 ) f o r the purpose. In February, 1 9 5 8 , w i t h the support of Pr e s i d e n t Mohammed Ayub Khan, the D i r e c t o r - G e n e r a l of Health c a l l e d a two day meeting which set up the N a t i o n a l Family Planning Board. Membership comprised the D i r e c t o r -General, the D i r e c t o r s of Health S e r v i c e s of East and West P a k i s t a n , r e p r e s e n t a t i v e s of M i l i t a r y Headquarters, the N a t i o n a l S o c i a l Welfare C o u n c i l , the A l l - P a k i s t a n Women's A s s o c i a t i o n , and three r e p r e s e n t a t i v e s of the Family Planning A s s o c i a t i o n . S i m i l a r P r o v i n c i a l Family Planning Boards were set up i n each province, and D i s t r i c t Boards f o l l o w e d . In the meantime, as i n I n d i a , the d r a f t e r s of the F i r s t Five Year P l a n ( 1 9 5 5 - I 9 6 O ) , using the 1950 census r e p o r t s , had fo r e c a s t an annual population growth rate of 1 . 4 percent. I t was thought the increase could he absorbed i n economic ex-pansion, so f a m i l y planning remained a h e a l t h and welfare s e r v i c e w i t h no s p e c i a l agency i n charge and i t was f i n a l l y decided to leave a c t i v e work to the v o l u n t e e r s . The Family Planning A s s o c i a t i o n was given Rs. 85,000 ($U.S. 15,000) and s o l e r e s p o n s i b i l i t y f o r implementing a more e f f e c t i v e program through i t s own urban c l i n i c s , and through the m i l i t a r y and West P a k i s t a n r a i l w a y h o s p i t a l s , and, subject to the approval of the p r o v i n c i a l Board, Rs. 130,000 ($U.S. 26,000) to support i t s p r o j e c t s i n each pr o v i n c e . The r u r a l p opulation was to be approached through the V i l l a g e A i d A d m i n i s t r a t i o n . The PPAP p r o j e c t s i n Lahore, K a r a c h i , Dacca and Ghittagong received a share of the grants. In a d d i t i o n , through a model c l i n i c i n Lahore, the PPAP was to conduct research and t r a i n i n g . Equipment was donated, and the PPAP imported the necessary c o n t r a c e p t i v e s . The PPAP of East P a k i s t a n opened 30 r u r a l c l i n i c s , s e t t i n g up D i s t r i c t Pamily Planning A s s o c i a t i o n s to support them and r e c r u i t i n g motiva-t i o n o f f i c e r s to i n t e r e s t the low income l i t e r a t e s l i v i n g i n , or w i t h r o o t s i n the v i l l a g e s . The F i r s t N a t i o n a l Conference on Family P l a n n i n g was h e l d i n Lahore i n March, 1958» and, f o r the b e n e f i t of both volunteers and government, the agenda was o r i e n t e d toward h e a l t h and w e l f a r e . The volunteers seemed to be o f f and running. Subsequent demographic s t u d i e s i n d i c a t e d a r e a l popu-l a t i o n growth r a t e of 2.3 percent, and t h i s exceeded the 2.1 percent annual increase i n per c a p i t a income. Po p u l a t i o n i t s e l f was now recognized as a s e r i o u s threat to economic progress, and the Second Five Year P l a n (196O-I965) set aside Rs. 30.5 m i l l i o n f o r f a m i l y planning and s h i f t e d the main burden from the v o l u n t a r y o r g a n i z a t i o n s to government h e a l t h s e r v i c e s . I t was proposed to set up 4 ,000 c l i n i c s , and to t r a i n d octors, nurses, Lady Health V i s i t o r s ( P u b l i c Health Nurses), and dais (midwives) to s t a f f them. As the government f a c i l i -t i e s became equipped to take over the t a s k , FPAP c l i n i c s , and s a t e l l i t e f a m i l y planning s e r v i c e s organized through the other v o l u n t a r y o r g a n i z a t i o n s would be phased out.*' Approxi-mately 1 ,700 medical and paramedical s t a f f were t r a i n e d , but, as e x i s t i n g h e a l t h personnel were already overburdened, sup-p l i e s and f i e l d workers were inadequate, and too much r e l i a n c e was placed on conventional c o n t r a c e p t i v e s . A c c o r d i n g l y , government performance f e l l f a r short of the g o a l . U s e f u l research i n communication and b i r t h c o n t r o l methods was accomplished, however, and, i n order to provide b e t t e r sources of v i t a l s t a t i s t i c s , demographic t r a i n i n g was i n t r o d u c e d . The P o p u l a t i o n C o u n c i l , the U n i v e r s i t y of C a l i -f o r n i a , Johns Hopkins U n i v e r s i t y , SIDA and the Pord Foundation began to give a s s i s t a n c e . ^ The N a t i o n a l Research I n s t i t u t e of Family Planning was e s t a b l i s h e d , and f i v e T r a i n i n g cum Research I n s t i t u t e s were organized. The P a k i s t a n Academy f o r R u r a l Development (PARD) at C o m i l l a , undertook s p e c i a l s t u d i e s i n such f i e l d s as home v i s i t i n g and s m a l l group 7 t e a c h i n g . V i l l a g e wives, school teachers, midwives and p r a c t i t i o n e r s of indigenous medicine were e n r o l l e d i n a pro-gram to d i s t r i b u t e condoms and foam t a b l e t s through home v i s i t i n g . But purdah, low female l i t e r a c y , the problem of record-keeping and personnel shortages s e r i o u s l y handicapped the experiment. I t was decided then to t r y to motivate men, using singers and shows i n the market p l a c e s , and other means of a d v e r t i s i n g , and to use commercial o u t l e t s f o r d i s t r i b u t i o n of conventional contraceptives such as condoms. This scheme 8 was more s u c c e s s f u l . The FPAP was having i t s v i c i s s i t u d e s as w e l l . Though i t s work had expanded, p a r t i c u l a r l y i n research, m o t i v a t i o n , and p u b l i c i t y , a d m i n i s t r a t i v e problems had a r i s e n and l o c a l branches were not p u l l i n g t h e i r weight. I t has become the f a s h i o n f o r p r a c t i c a l l y everyone, t e c h n i c a l and n o n - t e c h n i c a l to express t h e i r keen i n t e r e s t i n Pamily Planning without the s l i g h t e s t e f f o r t t o acquiant ( s i c ) themselves w i t h the accepted plans and proceedures ( s i c ) i n Pamily P l a n n i n g . A l l the above observations go to prove our emphasis on education at the three l e v e l s ... Cmedical and paramedical, education f o r the educated, education f o r the massesj.9 Finances were a l s o a problem. Though i t had r e g i s t e r e d as a v o l u n t a r y s o c i a l welfare agency i n 1961, and was s t i l l r e c e i v i n g some government support through a grant of Rs. 125,000, Greater a c t i v i t y has u n f o r t u n a t e l y not been rewarded by government w i t h g r e a t e r funds. Our working c a p a c i t y i s more due to the high achievement motivation of the workers, and our programmes are s e r i o u s l y hampered due to the l a c k of -,Q r e g u l a r , t i m e l y and adequate grantte-in-aid. Nevertheless, at the Family Planning A s s o c i a t i o n Model C l i n i c i n Lahore, f o r example, b i r t h c o n t r o l and s t e r i l i t y s e r v i c e s were provided, and t r a i n i n g wa.s given medical person-n e l . Vasectomy was becoming i n c r e a s i n g l y popular, as was the IUD, and a t r i a l was a l s o s t a r t e d w i t h o r a l c o n t r a c e p t i v e s . Well-baby s e r v i c e s completed the p i c t u r e , and the Model C l i n i c at Dacca had a s i m i l a r r e c o r d . 7,112 p a t i e n t s were served i n 1964. Family Planning A s s o c i a t i o n r e p r e s e n t a t i v e s were able to attend the Indian Ocean Regional Conference, IPPF, i n Colombo, 1963, the 7 th Conference of the IPPF at Singapore the same year, and a medical conference i n Kathmandu, i n Nepal. They a l s o attended conferences of r e l a t e d o r g a n i z a -t i o n s i n P a k i s t a n . At a n a t i o n a l seminar, Pakistan's P o p u l a t i o n Quake, organized by the FPAP i n March, 1964 (see p.226), President Ayub Khan warned again of the danger of over-population. I f nothing i s done to check the r a t e of £ population]] growth, I shudder to t h i n k what w i l l happen a f t e r a few decades. My only c o n s o l a t i o n i s t h a t I s h a l l not be there to face that s i t u a t i o n . But my country and my people would be faced w i t h i t . And the coming generations would not f o r g i v e us f o r landing them i n such a bad mess. In f a c t , at a food conference soon a f t e r , the P r e s i d e n t sug-gested t h a t i n ten years cannibalism could occur."^ Mr. Enver A d i l was appointed Commissioner of Family Planning f o r the P a k i s t a n government i n September, 1964, and a Pakistan-Sweden-United States Advisory Co-ordinating group of p r o f e s s i o n a l s was given the t a s k of s e t t i n g up a r e v i s e d government f a m i l y planning scheme. The P r e s i d e n t of the PPAP, Karachi continued to s i t on the Pamily Planning Advisory C o u n c i l , and the Executive D i r e c t o r became one of a team to t r a i n f a m i l y planning s u p e r v i s o r s , but, e v i d e n t l y , wider p a r t i c i p a t i o n of the n a t i o n a l FPA was not sought. The A s s o c i a t i o n i n keeping w i t h i t s t r a d i t i o n s stepped out to a s s i s t the government as f a r as p o s s i b l e . . . . We presented Memorandums, attended Meetings, and sub-committee Meetings through the various stages and phases i n the p r e p a r a t i o n of the T h i r d Five Year Plan Scheme.13 In the end the N a t i o n a l Family P l a n n i n g Advisory Board of which they were members, was replaced by a C e n t r a l Family Planning C o u n c i l charged w i t h the implementation of a 14 vigorous o f f i c i a l government scheme. A d e t a i l e d , massive plan was published i n which person-n e l t r a i n i n g and d e l i v e r y of s e r v i c e s i n both provinces was d e l i n e a t e d , but i t i n v o l v e d only government employed personnel. Targets aiming to reduce the b i r t h r a t e from 50 Per 1,000 population to 40 by e n r o l l i n g 25 percent of the 20 m i l l i o n f e r t i l e couples by 1970 were e s t a b l i s h e d . Rs. 284 m i l l i o n (#U.S. 60 m i l l i o n ) were a l l o c a t e d , r e p r e s e n t i n g 3.6 percent of the t o t a l plan budget. B a s i c Democracy and Thana leaders as w e l l as 1,000 f a m i l y planning o f f i c e r s would a s s i s t i n m o t i v a t i n g males, and 35,000 dais (most of whom were un-t r a i n e d , i l l i t e r a t e midwives) would be used f o r IUD r e f e r r a l s and i n s e r t i o n s i n the r u r a l areas. A r e p o r t i n g system, and e v a l u a t i o n teams, would he set up to f u n c t i o n continuously, and monetary i n c e n t i v e s i n IUD and vasectomy cases would he given to d o c t o r s , paramedical workers, motivators and p a t i e n t s . P a t i e n t s would re c e i v e some remuneration f o r t r a n s p o r t a t i o n 15 and wages l o s t . Mass media would he used f o r " d i s c u s s i o n " of f a m i l y p l a n n i n g , and would inc l u d e bus panels, brochures, t e l e v i s i o n , p o s t e r s , f i l m s , and f i l m s t r i p s , newspaper adver-t i s i n g , pamphlets, hoardings, r a d i o , cinema s l i d e s , f l a s h cards, k i o s k s , e x h i b i t i o n s , and f a m i l y planning weeks. The Family Pl a n n i n g A s s o c i a t i o n became resigned to i t s reduced r o l e and agreed w i t h government to undertake p r o j e c t s i n r e s e a r c h , h e a l t h education, adult education and mass . . . 16 communication. We b e l i e v e t h a t one of the primary f u n c t i o n s of a v o l u n t a r y A s s o c i a t i o n which i s working i n an area where the problem can only be t a c k l e d by a l a r g e -scale Government programme, i s to advise d i r e c t and inform Government; to comple-ment and supplement t h e i r e f f o r t s ; to support them and get support i n r e t u r n ; f o r no Government can administer success-f u l l y a programme so personal as the f a m i l y planning campaign without u s i n g the v o l u n t a r y movement as i t s handle and mouthpiece.... We wish the Govern-ment a l l success i n i t s T h i r d Five Year Pla n and assure i t of the continued support of the A s s o c i a t i o n . We are but a drop i n the ocean; our finances a.nd resources are the l i m i t i n g f a c t o r , moreover we do not wish to overstep ourselves; v/e have a r o l e to p l a y , but a small one. ? In J u l y , I 9 6 5 , at a press conference organized by the Family Pl a n n i n g A s s o c i a t i o n of East P a k i s t a n i n Dacca, the new Family Planning Commissioner, Enver A d i l , announced the new scheme. L i p s e r v i c e was paid to the work of the volun-t e e r s . P r e s i d e n t Ayuh Khan, and the Governor of East P a k i s t a n would become Patrons i n Chief of the FPA of P a k i s t a n and East P a k i s t a n , r e s p e c t i v e l y ; f i n a n c i a l support (a g r a n t - i n - a i d of Rs. 250,000) would be g i v e n , and the FPAs would be asked to devote t h e i r main e f f o r t to running model c l i n i c s and mobile van c l i n i c s , to motivation and communication, in f o r m a t i o n and p u b l i c i t y , and to r e s e a r c h . A f t e r deducting headquarters expenses, each branch r e c e i v e d Rs. 1 0 3 , 0 0 0 . In a d d i t i o n , IPPF support was maintained through a g i f t of $161,500 i n 1967, i n f e r t i l i t y equipment was provided, a r i v e r boat inform a t i o n and c l i n i c s e r v i c e was s t a r t e d i n East P a k i s t a n , two mobile vans were put i n t o s e r v i c e i n West P a k i s t a n , and a s p e c i a l study of d a i s undertaken. T r a v e l of f o r e i g n delegates to the P o p u l a t i o n Quake conference was reimbursed, and t r a v e l costs f o r FPA delegates to the Indian Ocean Regional Confer-ence i n Kathmandu were provided. Volunteer noses might w e l l have been out of j o i n t when, speaking to t h e i r E i g h t h I n t e r n a t i o n a l Conference on Planned Parenthood i n Santiago, C h i l e , i n 1967» Mr. A d i l gave a l l the c r e d i t f o r s t a r t i n g f a m i l y planning s e r v i c e s to President Ayub Khan, and even borrowed the volunteer terminology: the government program was a "movement" f o r " q u a l i t y , not q u a n t i t y " ! In her r e p o r t f o r the Indian Ocean Region, Mrs. S y l v i a Fernando noted that the government program was the " d i r e c t r e s u l t of the pioneering work of the Family Planning A s s o c i a t i o n of P a k i s t a n , and the P r e s i d e n t of Pakistan's personal i n t e r e s t i n P a k i s t a n ' s p o p u l a t i o n ex-p l o s i o n , " "but she did not deny the magnitude of the problem 19 or the need f o r massive o f f i c i a l o r g a n i z a t i o n and a c t i o n . P r o f e s s o r Prank N o t e s t e i n of the P o p u l a t i o n C o u n c i l reminded government, f a m i l y planning a d m i n i s t r a t o r s and v o l u n t a r y groups that they needed each other, and that the l a t t e r had a c o n t i n u i n g r o l e i n moulding p u b l i c opinion even when i t s 20 c l i n i c a c t i v i t i e s were taken over. P o l i t i c a l s t r e s s e s between the East and West Wings of P a k i s t a n were becoming more acute. Economic problems were so seri o u s and the two provinces were so d i f f e r e n t i n t h e i r economic bases and i n r a c i a l c h a r a c t e r i s t i c s , t h a t the u n i -f y i n g force of Islam was i n s u f f i c i e n t to maintain e q u i l i b r i u m . These s t r e s s e s were evident i n the Pamily Planning A s s o c i a t i o n as w e l l , f o r a Second N a t i o n a l (PPAP) O f f i c e was set up i n Dacca to provide f o r "expansion on a more autonomous b a s i s and f o r b e t t e r o r i e n t a t i o n to the needs of the government program," i n that Wing. Because p o l i t i c a l d i f f i c u l t i e s were threatening the f a m i l y planning program, i t was decided to t r y to b u i l d non-governmental support i n both p r o v i n c e s . Leaders of p u b l i c o p i n i o n , p a r t i c u l a r l y w r i t e r s , u n i v e r s i t y f a c u l t y and students, were i n v i t e d to "Seminars f o r I n t e l l e c t u a l s " i n both Lahore and Dacca i n 1968. The volunteer f a m i l y planners were i n c l u d e d . In h i s keynote address at the Lahore meetings, Mr. A d i l p r a i s e d the volun-t e e r s f o r t h e i r determination i n s p i t e of o p p o s i t i o n , and urged them to continue t h e i r e f f o r t s . However, he h i n t e d 21 r a t h e r "broadly t h a t t h e i r work could "be improved. The C e n t r a l government o r g a n i z a t i o n , and the p r o v i n c i a l and d i s t r i c t f a m i l y planning boards were expanded once more to i n c l u d e "non-2 2 o f f i c i a l s " . The FPA r e a f f i r m e d i t s support of the government program and the attempts to b u i l d p u b l i c approval,, and noted t h a t , I t i s f i r m l y convinced the greater the p u b l i c p a r t i c i p a t i o n and backing f o r the Family Planning Programme, the greater w i l l be i t s s u c c e s s . 2 3 As i n I n d i a i n 1 9 6 5 and 1 9 6 9 , a United Nations Team of e x p e r t s , i n c l u d i n g three from the IPPF, was i n v i t e d to make a d e t a i l e d e v a l u a t i o n of the f a m i l y planning program, and, as i n I n d i a , i t recommended greater s t a t u s f o r i t s leaders and budget i n government, and t h a t the d e l i v e r y of f a m i l y planning s e r v i c e s should be i n t e g r a t e d more e f f e c t i v e l y w i t h h e a l t h s e r v i c e s . Among s p e c i f i c ideas, i t suggested the i n s t a l l a t i o n of Chief Male Organizers f o r each Union C o u n c i l to improve the work of the d a i s , to keep sales records.and to a s s i s t i n m o t i v a t i o n a l work. Education and t r a i n i n g should be given to teachers, s o c i a l workers and a g r i c u l t u r a l extension workers; and r e -f r e s h e r courses should also be part of the program. F i e l d personnel should be given b i c y c l e s , motor b i k e s and jeeps t o improve t h e i r m o b i l i t y . D i s t r i b u t i o n of s u p p l i e s should be improved, and the o b j e c t i v i t y of m u l t i l a t e r a l and other agencies should be used to a greater extent. The Family Planning A s s o c i a t i o n should be given more money and encouraged to work more i n the p u b l i c education and welfare f i e l d , p a r t i c u l a r l y , and w i t h r u r a l women's o r g a n i z a t i o n s . The FPAP decided to continue i t s e x i s t i n g s e r v i c e s where p r a c t i c a l , hut to concentrate on education and promotion "throughpprivate and p u b l i c d i s c u s s i o n . " In a d d i t i o n , i t began to see i t s e l f i n the r o l e of "ombudsman", i n which " d e f i c i e n c i e s i n the s e r v i c e of t h i s vast Government Organ-i z a t i o n " could be i d e n t i f i e d , and brought to the a t t e n t i o n of the a u t h o r i t i e s . The members' experience would equip them to keep the o f f i c i a l program under constant review. But, at the same time, they would maintain t h e i r support. Through the IPPP t h e i r contacts w i t h other PPAs would be a source of valuable i n f o r m a t i o n which they could pass on to government, and they could report to other c o u n t r i e s the successes of the P a k i s t a n government program. They were pleased t h a t such f i n a n c i a l support as the government had given them i n the past would continue. 25 To m o b i l i z e f u r t h e r support, an I n t e r n a t i o n a l confer-ence on P a k i s t a n ' s f a m i l y planning program was h e l d i n Dacca from 2 8 January to h February, 1 9 6 9 . 400 delegates, i n c l u d i n g r e p r e s e n t a t i v e s from i n t e r n a t i o n a l agencies, as w e l l as PPAP members, were i n c l u d e d . The PPA c o n t r i b u t e d a s p e c i a l e x h i b i t showing t h e i r work i n p u b l i c education and m o t i v a t i o n . Two outside e x p e r t s , P h i l i p Hauser of the U n i v e r s i t y of Chicago and Dr. Malcolm P o t t s of the IPPP, recommended the l i b e r a l -i z a t i o n of a b o r t i o n to supplement other methods of b i r t h c o n t r o l . However, i n A p r i l p o l i t i c a l unrest f o r c e d the r e s i g n a t i o n of President Ayub Khan. Though i t continued the program, the M a r t i a l lav/ a d m i n i s t r a t i o n of General Yahya Khan s o f t - p e d a l l e d f a m i l y planning p u b l i c i t y . The UN study was published i n June, and on J u l y 1, 1969, Dr. A.M. M a l i k was appointed M i n i s t e r of H e a l t h , Labour, S o c i a l Welfare and Pamily P l a n n i n g . Enver A d i l was replaced as Secretary and Commissioner of Pamily Planning by Wajiuddin- Ahmad, and, i n October, a r e v i s e d proposal f o r f a m i l y planning i n the Fourth Five Year Plan was submitted to the P l a n n i n g Commission. Rs. 606 m i l l i o n ($11.S. 121 m i l l i o n ) were a l l o c a t e d to prevent 9.6 m i l l i o n b i r t h s during the p e r i o d and reduce the b i r t h r a t e 26 to kO per thousand i n 197^-75* I l l i t e r a t e d a i s were to be g r a d u a l l y replaced by l i t e r a t e male and female f i e l d workers who would provide any d e s i r e d method and conti n u i n g f o l l o w -up and reassurance. These workers v/ould be supervised by one f a m i l y planning a s s i s t a n t f o r each three Union C o u n c i l s . D i s t r i c t l e v e l t r a i n i n g would be improved. Group sessions on a g r i c u l t u r e , h e a l t h , education, and n u t r i t i o n could i n c l u d e f a m i l y p l a n n i n g , and more education i n population problems was to be given to students i n medicine and the s o c i a l s c i e n c e s . T r a i n i n g , research, and e v a l u a t i o n were to be combined and located i n one centre i n each p r o v i n c i a l c a p i t a l and be known as "TRECS". These were to be d i r e c t e d by r e p r e s e n t a t i v e s of the Family P l a n n i n g C o u n c i l and of the P r o v i n c i a l Boards. From an e x c l u s i v e l y p r o f e s s i o n a l group, the Family Planning C o u n c i l v/as once more to be broadened to in c l u d e not only o f f i c i a l r e p r e s e n t a t i v e s of the M i n i s t r i e s of Health and Finance, hut also of the Medical A s s o c i a t i o n , Family P l a n n i n g A s s o c i a t i o n , the A l l - P a k i s t a n Women's A s s o c i a -t i o n , Red Cross and other o r g a n i z a t i o n s , and the U n i v e r s i t i e s . The wheel of sponsorship had come f u l l c i r c l e ' . The l o g i s t i c s of the program were to he r e v i s e d , hut, hy the end of 19&9? few d e t a i l s were known, other than the f a c t t h a t n o n - o f f i c i a l s were to he i n charge of the D i s t r i c t s , and a greater emphasis 27 was to he l a i d on f i e l d work. The FPAP held a conference on p u b l i c p a r t i c i p a t i o n at C o m i l l a i n East P a k i s t a n i n December, I 9 6 9 . 'Dr» A t t i y a I n a y a t u l l a h , V i c e - P r e s i d e n t could not r e s i s t h i n t i n g t h a t the e x c l u s i v e l y governmental program had been b u r e a u c t r a t i z e d and t a r g e t - o r i e n t e d , and tha t i n c l u s i o n of non-governmental agencies might have prevented t h i s from happening. The new Commissioner of Family P l a n n i n g , Mr. Wajiuddin Ahmad, urged the Family Planning A s s o c i a t i o n to help to overcome the dichotomy by b u i l d i n g communication w i t h e l i t e s i n r e l a t e d p r o f e s s i o n s and w i t h l o c a l opinion l e a d e r s . By b u i l d i n g p o l i t i c a l support, the FPA could help prepare f o r the day when a u t h o r i t a r i a n government would be replaced by a demo-c r a t i c system. He s a i d t h a t the FPA could also act as a watchdog over the government program and pioneer new ideas - 28 , and models which could be adopted by the l a t t e r . As 1969 c l o s e d , o f f i c i a l statements by General Yahya Khan and others urged large s c a l e v o l u n t a r y p a r t i c i p a t i o n i n the huge task of s o c i a l u p l i f t . As s o c i a l s e r v i c e was an e s s e n t i a l element i n the s p i r i t of Islam, the Fourth Five Year P l a n would i n -elude l a r g e r a l l o c a t i o n s f o r h e a l t h , education, and housing and s o c i a l welfare - a 250 percent a c c e l e r a t i o n i n t h i s s e c t o r . At the same time the Family Pl a n n i n g A s s o c i a t i o n an-nounced i t s i n t e n t i o n , i n a d d i t i o n to promoting p u b l i c education and p u b l i c p a r t i c i p a t i o n i n the n a t i o n a l program, to s p e c i a l i z e i n p o p u lation education f o r the youth of the country - a new 30 and p o t e n t i a l l y c o n t r o v e r s i a l f a m i l y planning a c t i v i t y . I t s annual grant from government was s l i g h t l y reduced to Rs. 190,000 ($U.S. 38,000) but, f o r 1970, the IPPP was sup-p o r t i n g i t w i t h $162,000 f o r s p e c i a l p r o j e c t s to be described 31 l a t e r . I t was expected t h a t once f a m i l y planning was acceptable to the p u b l i c g e n e r a l l y , the PPA would be able to confine i t s e f f o r t s to f a m i l y l i f e education. As i n other "developing" s o c i e t i e s , i n i t i a l acceptance of f a m i l y planning i n P a k i s t a n was hampered by t r a d i t i o n s f a v o r i n g f e r t i l i t y , supported by r e l i g i o u s precepts, and by the absence of o l d age s e c u r i t y measures. Resistance was founded i n many generations of h i g h i n f a n t m o r t a l i t y , a t r a d i -t i o n of e a r l y marriage, low s t a t u s and low l i t e r a c y of women, and f a t a l i s m - " A l l t h i n g s come from God - i n c l u d i n g n a t u r a l d i s a s t e r s and c h i l d r e n . " Taboos against the d i s c u s s i o n of b i r t h c o n t r o l , even between husband and w i f e , and a b e l i e f t h a t i t i s forbidden i n Islam, were also f a c t o r s i n d e c i s i o n -32 making. They are s t i l l i n f l u e n t i a l . Overt o p p o s i t i o n took the form of pamphlets and speeches 33 against f a m i l y planning at F r i d a y prayer s e r v i c e s . But volunteers and the government thought i t was u s e f u l . ... i t has given our programme even greater p u b l i c i t y , u n r a v e l l e d i t s mysterious image wherever t h a t e x i s t e d among the i g n o r a n t , and debunked the c r e d i b i l i t y of those who chose f a n t a s t i c rumours to scare away the adopters . 3 4 The P a k i s t a n government sought support from "enlightened" theologians i n P a k i s t a n and other Muslim c o u n t r i e s , and these declared themselves i n favor of f a m i l y planning. Books and pamphlets answering the c r i t i c s were i s s u e d . A review of I s l a m i c A t t i t u d e s Toward Family P l a n n i n g , published by the I s l a m i c Research I n s t i t u t e , Rawalpindi, s t a t e d t h a t Family s i z e should harmonise w i t h economic cond i t i o n s and a f a m i l y may seek pro-t e c t i o n against too many. B i r t h c o n t r o l reduces c h i l d n e g l e c t , maternal exhaustion, i l l e g i t i m a c y , a b o r t i o n s , crowding, i n f a n t m o r t a l i t y , and deformity. I t helps prevent d i v o r c e , mental i l l n e s s , poverty, d e l i n -quency and even war.35 Akhter Hameed Khan, another a u t h o r i t y on I s l a m i c theology and c u l t u r e , wrote a pamphlet on the I s l a m i c Opinion of Contra-c e p t i o n , which included favorable opinions by two Muslim j u r i s t s . Other experts r e c a l l e d t h a t Ibn Sina (Avicenna 980 - 1037 A.D.), the famous Muslim p h y s i c i a n , described various methods of b i r t h c o n t r o l and, from time to time, d i f f e r e n t Muslim a u t h o r i t i e s , i n c l u d i n g the Prophet h i m s e l f , had approved c o i t u s i n t e r r u p t u s , s u p p o s i t o r i e s , p e s s a r i e s , and a b o r t i o n of a foetus up to f o u r months a f t e r conception. Though not unanimous on a l l p o i n t s , these opinions have been confirmed by fatwas (pronouncements on canonical law) by Muslim theologians (ulema) i n such countries as the United Arab R e p u b l i c , Turkey and I r a n , P a k i s t a n and Indonesia.-^ Begum Selim Khan, a c t i v e i n the Family Planning A s s o c i a t i o n , noted that times were changing: i n P a k i s t a n i t i s now customary f o r a Muslim to take only one w i f e : i t i s agreed th a t divorce should not be pronounced without good reason: and the dowry system i s on the way out - a l l t r a d i t i o n s 37 which support the i d e a of lar g e f a m i l i e s . Yet, i n p r a c t i c e i t was not always so s i m p l i f i e d . In Ten Years Against the Stream, the Karachi Branch of the Family P l a n n i n g A s s o c i a t i o n observed that i t had been a constant s t r u g g l e against the " s o - c a l l e d r e l i g i o u s t h i n k i n g " o f i n f l u -o Q e n t i a l people. What was needed was massive education, to warn the p u b l i c t h a t over-population r e q u i r e d a c o l o s s a l investment i n education, p u b l i c h e a l t h s e r v i c e s , housing, water supply, t r a n s p o r t a t i o n , and the p r o v i s i o n of jobs. I t r e q u i r e d the co-operation of a l l agencies, p u b l i c and 40 p r i v a t e , to pass the word. As i n Western c o u n t r i e s , the medical p r o f e s s i o n stood on i t s r e c o r d , e x p l a i n i n g t h a t accusations of o p p o s i t i o n or i n d i f f e r e n c e were u n f a i r . I t s t r a i n i n g had been based on c u r a t i v e medicine not preventive p u b l i c h e a l t h programs. In a d d i t i o n , u n t i l about a decade b e f o r e , the high incidence of disease and shortage of doctors had been the reason f o r -41 medical i n a c t i o n i n the f a m i l y planning f i e l d . The geo-graphic d i v i s i o n of the country, r a c i a l a t t i t u d e s and popu-l a t i o n d e n s i t y were other o b s t a c l e s . Attendance at f a m i l y planning c l i n i c s i n the 1950s was d i s a p p o i n t i n g . As has been noted, the s e r v i c e s were i n i t i a l l y o f f e r e d i n a few c i t y c l i n i c s ; o p p o s i t i o n was vigorous, and the l i m i t e d f i n a n c i a l resources of the volu n -t e e r s made the obstacles almost insurmountable. Education, favorable fatwas by the "enlightened" ulema, support by other o p i n i o n l e a d e r s , and government backing had to be mo b i l i z e d . Besides b u i l d i n g a c c e p t a b i l i t y , t r a i n e d medical and paramedical personnel, e s p e c i a l l y women do c t o r s , were sadly l a c k i n g , and a simple, yet r e l i a b l e method was not yet invented. The e f f e c t on the b i r t h r a t e , i f any, was m i n i s c u l e . Age range, p a r i t y , income group and other r e l e v a n t data, were not inc l u d e d i n the Annual Reports f o r 1964 and I 9 6 7 , the only ones r e c e i v e d f o r study, but t o t a l s were a v a i l a b l e : TABLE VII Attendance at FPA of P a k i s t a n C l i n i c s , Year Ended June 30 1964 Lahore Dacca Karachi 7,112 Lahore 5,379 Dacca i ) Segun Bagicha 8,246 i i ) Gandaria 2,041 Karachi 7,709 Mobile van i ) West P a k i s t a n 750 i i ) East P a k i s t a n 2,048 Source: Annual Report, FPAP, Lahore, 1964, pp. 8-9; al s o 1967, PP. 24 - 2 9 . During the Second Five-Year P l a n , when the government took primary r e s p o n s i b i l i t y f o r the b i r t h c o n t r o l program, i t s work was very l i t t l e more e f f e c t i v e than t h a t of the PPAP. But from 1965, when the o f f i c i a l program was r e -organized, the emphasis was s h i f t e d from c l i n i c s to dais and, f i n a l l y , to educated f i e l d workers, progress began to be impressive. Through 1969 the t o t a l number of acceptors of ITJDs and s t e r i l i z a t i o n alone was 3>80$,000, re p r e s e n t i n g 15*9 percent of e v e r - e l i g i b l e women. TABLE.VIII Number of Acceptors, Government Program, I965-I969 ( i n thousands) Year East P a k i s t a n West P a k i s t a n T o t a l 1965 & before 237 313 50 1966 512 1967 449 377 827 1968 763 516 1,281 1969 736 399 1,135 Source: Dorothy Nortman, Population and Family Planning Programs: A Factbook, Reports on Population/Family P l a n n i n g , Population C o u n c i l , New York, J u l y , 1970, P. 5 8 . Though e f f i c i e n c y had s u f f e r e d from geographical, f i n a n c i a l , and l o g i s t i c a l problems, i n both the volunteer and the government programs, the former was a l s o reorganized i n the mid-1960s, and --' . .." was able to be u s e f u l i n s p e c i f i c p r o j e c t s which were w i t h i n i t s c a p a b i l i t y . Propa-ganda, research., t r a i n i n g and modest c l i n i c s e r v i c e s , were areas where a c t i o n was p o s s i b l e . Recognizing the u n i v e r s a l expectation of c h i l d r e n i n the P a k i s t a n i a g r i c u l t u r a l m i l i e u , the FPAP had urged, from the beginning, the spacing of pregnancies i n the i n t e r e s t s of c h i l d and maternal h e a l t h ; and, i n a d d i t i o n to c o n t r a -ceptive s e r v i c e s , i t had provided marriage c o u n s e l l i n g and treatment of s t e r i l i t y . This was the usual b a s i c p o l i c y of f a m i l y planning o r g a n i z a t i o n s , and, when overpopulation became more and more obvious, the i d e a of the s m a l l f a m i l y norm was added. When t h i r t y member countries of the United Nations, i n c l u d i n g P a k i s t a n , signed a r e s o l u t i o n advocating f a m i l y p l a n n i n g , the PPAP followed t h i s a c t i o n by adopting UN phraseology - that " f a m i l y planning was a duty, and a b a s i c human r i g h t " . Although c r i t i c s of the p r i n c i p l e of v o l u n t a r y b i r t h c o n t r o l have attacked t h i s phrase as en-couraging f e r t i l i t y i n a time of population e x p l o s i o n , the Family Planning A s s o c i a t i o n of P a k i s t a n , i n step w i t h s i m i l a r groups i n other c o u n t r i e s , chose to i n t e r p r e t the statement as meaning that duty to one's f a m i l y and one's country could only mean adopting b i r t h c o n t r o l methods, and governments should provide them to a l l c i t i z e n s , on a v o l u n t a r y b a s i s , as a human r i g h t . S p e c i f i c i n f o r m a t i o n on the e a r l y propaganda a c t i -v i t i e s of the PPAP i s not a v a i l a b l e , but the Annual Report f o r the year ending June 3 0 t h , 1964, noted t h a t , when the A s s o c i a t i o n was f i r s t formed, i t was ... a time when P a k i s t a n i s i n government or otherwise l i v e d w i t h the s h u t t e r s of t h e i r minds drawn t i g h t y ( s i c ) against the very name of f a m i l y p l a n n i n g . With t h i s background what could be more commend-able to the A s s o c i a t i o n and g r a t i f y i n g to i t s pioneers than that P a k i s t a n i s today one of the few count r i e s of the world where the Government i s implementing s u 0 dynamic population planning programme. 4 2 In the e a r l y y e a r s , the FPAP l e d a hand-to-mouth existence f o r c r i t i c i s m was heavy, and, although government gave g r a n t s - i n - a i d , these d i d not a r r i v e on a r e g u l a r b a s i s and were inadequate. However, a q u a r t e r l y j o u r n a l of i n -formation, B i r t h r i g h t was s t a r t e d , and a t u r n i n g p o i n t came i n 1964, when the A s s o c i a t i o n was able to set up a n a t i o n a l o f f i c e i n Lahore, w i t h an executive d i r e c t o r , an o f f i c e a s s i s t a n t , a t y p i s t , and a peon ( o f f i c e boy). A "Motivation O f f i c e r " and l i a i s o n o f f i c e r were soon added, and the o f f i c e was p r o p e r l y equipped to serve as a demonstration u n i t f o r - 4 3 o r g a n i z a t i o n and methods. In 1964 a l s o , the A s s o c i a t i o n organized a n a t i o n a l seminar, Pakistan's P o p u l a t i o n Quake, to i d e n t i f y problems, evaluate i t s past work, and plan f o r the f u t u r e . In a d d i t i o n , the session was intended to s t i m u l a t e p u b l i c support. The r o l e of r e l i g i o n and the economic consequences of population growth were examined, and study groups on m o t i v a t i o n , the r o l e of government, c u l t u r a l matters and c l i n i c a l t e s t i n g of contraceptive methods were h e l d . I t was agreed t h a t r e l i g i o u s o p p o s i t i o n was no longer of any great s i g n i f i c a n c e , and that i t had been p o s s i b l e to motivate the women i n the urban areas the PPAP had served. Put i t was now e s s e n t i a l to take the s e r v i c e to the v i l l a g e s and, as Stycos had suggested, make a greater e f f o r t to persuade men to adopt the i d e a as w e l l . Greater c o - o r d i n a t i o n among s o c i a l workers, v o l u n t a r y o r g a n i z a t i o n s and government was needed, and more should be done to i n v o l v e the "Basic Democrats". To be e f -f e c t i v e , the government program should be reorganized, and given autonomous s t a t u s , f o r i t d i d not have the r e q u i r e d p r e s t i g e under i t s present a d m i n i s t r a t i o n . In i t s own promotional a c t i v i t i e s , the PPAP had made a documentary f i l m i n E n g l i s h , Urdu, and B e n g a l i , financed by the A s i a Foundation and the government of West P a k i s t a n . Along w i t h cinema s l i d e s , i t was c i r c u l a t e d by the govern-ment screening u n i t . A f i l m s t r i p i n Bengali and Urdu had a l s o been made w i t h the help of the Sweden-Pakistan P r o j e c t . A school c h i l d r e n ' s poster competition had been d i s a p p o i n t i n g , but another, more p r o f e s s i o n a l poster had been made, and 3,000 copies d i s t r i b u t e d . A press campaign had been i n a u -gurated, r a d i o t a l k s were being g i v e n , and a ten-minute monthly t e l e v i s i o n program was planned. A ten-day f a m i l y planning e x h i b i t had drawn two thousand people a day i n Lahore. S t a l l s and e x h i b i t s had been set up at f a i r s and e x h i b i t i o n s . Brochures on f a m i l y planning and vasectomy had been w e l l r e c e i v e d . Flashcards on the IUD had also been produced f o r use by h o s p i t a l s and other agencies, and f o r t r a i n i n g and education. Three thousand calendars w i t h f a m i l y planning slogans had been d i s t r i b u t e d . Signs had been put on k i o s k s as w e l l . A r t i c l e s i n newspapers and magazines had been w r i t t e n , and the FPA q u a r t e r l y j o u r n a l , B i r t h r i g h t , had become bi-monthly i n E n g l i s h and i n Urdu. The M o t i v a t i o n O f f i c e r had l e c t u r e d i n government o f f i c e s , f a c t o r i e s , and business concerns, had given c o u n s e l l i n g to males, and had made contacts w i t h other vol u n t a r y o r g a n i z a t i o n s to persuade them to i n c o r p o r a t e f a m i l y planning i n t h e i r s e r v i c e s . The o f f i c e r i n Lahore alone conducted 37 meetings, attended by 2,929 people, and counselled l , 3 k l c l i e n t s i n the year ending June 30 , 1966. Answering l e t t e r s of i n q u i r y had also become a r e g u l a r s e r v i c e • By 1967 the Family Planning A s s o c i a t i o n of P a k i s t a n was b e t t e r organized on a n a t i o n a l b a s i s , and i t s r e l a t i o n -ships w i t h the branches i n the two wings b e t t e r d e f i n e d . Each had more autonomy. Demonstration u n i t s were f u n c t i o n i n g i n East and West P a k i s t a n , and model programs f o r motivation and h e a l t h education were being developed. Both wings had i n -formation c e n t r e s , motivation o f f i c e r s were a c t i v e , and an u n s p e c i f i e d number of branch a s s o c i a t i o n s (10 i n West Pakistan) were f u n c t i o n i n g . Support and co-operation was being given by i n d u s t r i a l i s t s , s e r v i c e clubs and other o r g a n i z a t i o n s . In I968 t e l e v i s i o n spots were used, t a l k s and j i n g l e s were broadcast on r a d i o , and both s t a t i c and mobile e x h i b i -t i o n s continued to be popular. A s p e c i a l motivation scheme on the t r a i n running between Lahore and Saniwal had been 45 undertaken on a t r i a l b a s i s . The Family Planning A s s o c i a t i o n was urged by government to b u i l d communication w i t h e l i t e s i n p o l i t i c s , j o u r n a l i s m , s o c i a l work, labour, education and medicine, and to e n r o l them as members. This would be a good foundation f o r the day when a u t h o r i t a r i a n government was replaced by democracy. I t was also urged to experiment w i t h new ideas and develop 46 models which could be emulated by the government program. In response to i t s recovered p r e s t i g e , the FPAP agreed t h a t , i n a d d i t i o n to i t s ordinary propaganda a c t i v i t i e s by means of f i l m s , p o s t e r s , l e a f l e t s , puppet shows, f o l k - s i n g i n g , push c a r t s and give-aways (bed covers, p i l l o w s l i p s , and towels w i t h f a m i l y planning slogans) mobile e x h i b i t i o n s , i t s R i v e r Boat P r o j e c t , mobile c l i n i c s and l o c a l motivation teams - i t would sponsor population and f a m i l y l i f e education i n three types of courses - one f o r 14-20 year o l d s , another f o r p r o s pective married couples and newlyweds, and the other f o r parents and teachers. Information on research before the 1960s i s l a c k i n g , but those present at the Fourth A l l - I n d i a Conference on Family Planning i n December, 1961, heard Begum Saida Waheed report that the A s s o c i a t i o n had conducted an a t t i t u d e survey among 10,000 f a m i l i e s i n West P a k i s t a n which revealed that 62.5 percent favored f a m i l y p l a n n i n g . Plans f o r f i e l d s t u d i e s i n the Lahore and Dacca areas, a research centre to co-ordinate s t a t i s t i c a l i n f o r m a t i o n and data on s o c i a l c o n d i t i o n s , and plans to do contraceptive t e s t i n g , e s p e c i a l l y of o r a l s , were 47 a l s o i n hand. By 1964-65 some four to f i v e thousand record cards were p r o v i d i n g data f o r the I n s t i t u t e of Development Economics, research on IUDs f o r government had been undertaken, a foam t a b l e t a c c e p t a b i l i t y t r i a l had been undertaken f o r the IPPP, 600 women were on an PPAP supervised o r a l contraceptives t e s t , a study of the r o l e and a t t i t u d e of dais to f a m i l y planning was undertaken i n two cen t r e s , and attendance at the model 48 c l i n i c i n Karachi was analysed. In 1966-67 the s t a t e funded c l i n i c a l and a c c e p t a b i l i t y t r i a l s f o r foam t a b l e t s , IUDs and O r a l s . In 1970 an IUD r e t e n t i o n study was done. C l i n i c a l t r i a l s of magestrolacetate -a micro-dose o r a l contraceptive - were also undertaken. A new study of the a t t i t u d e of the dai to f a m i l y p l a n n i n g , e s p e c i a l l y to the id e a of an i n c e n t i v e payment f o r IUDs, was al s o done. An a n a l y s i s of r e a c t i o n s to a press campaign i n 49 Lahore was undertaken as w e l l . A survey of post partum f a m i l y planning propaganda i n three West P a k i s t a n h o s p i t a l s was planned and the PPA was also to examine ways and means of i n t r o d u c i n g f a m i l y planning through the Red Cross, the TB s a n i t o r i a , Day Nurse r i e s and the A l l - P a k i s t a n Women's A s s o c i a t i o n . By 1970 the PPA was als o h e l p i n g w i t h more government p r o j e c t s , i n c l u d i n g the t e s t i n g of i n j e c t i b l e s . Research methods and e v a l u a t i o n were improving, but programs i n the u n i v e r s i t i e s needed strengthening and the gathering of s t a t i s t i c s , e s p e c i a l l y v i t a l s t a t i s t i c s , was s t i l l i n -e f f i c i e n t . New p i l o t p r o j e c t s which the government could 50 take over i f s u c c e s s f u l were also needed. T r a i n i n g was undertaken by the volunteers as e a r l y as 1958, when an eight-day course was held f o r t h i r t y doctors of the D i r e c t o r a t e of Health S e r v i c e s . Women were among those a t t e n d i n g . This course was followed hy short courses con-ducted hy the D i r e c t o r a t e of Health Services i t s e l f . The f o l l o w i n g year, under the FPAP auspices, experts from the United Kingdom and the United States i n c l u d i n g Dr. Helena Wright and Dr. Abraham Stone, r e s p e c t i v e l y , were able to give two-week courses f o r f o r t y doctors i n Lahore and f o r t y h e a l t h v i s i t o r s and s o c i a l workers i n Dacca. Two t r a i n i n g teams were able to b e n e f i t from the v i s i t o r s ' i n s t r u c t i o n as w e l l . In 1959 the t o t a l t r a i n e d was 1,000 - h e a l t h department em-51 ployees, volunteers a.nd v i l l a g e a i d personnel. The Family Planning A s s o c i a t i o n of Karachi reported a s s i s t a n c e to gov-ernment i n preparing t r a i n i n g s y l l a b i and o r g a n i z a t i o n and urged that standards be uniform, and that not only medical students but other undergraduates be i n s t r u c t e d i n f a m i l y p l a n n i n g . The FPAP model c l i n i c s i n Lahore, K a r a c h i , Dacca and G-andaria (Dacca) became u s e f u l t r a i n i n g centres for these purposes. By October, 1965, the government had set up seven tralning-cum-research i n s t i t u t e s f o r medical and paramedical personnel, and there were four mobile t r a i n i n g teams i n each province to concentrate on teaching Family Planning o f f i c e r s and Lady Organizers ( d a i s ) . The l a t t e r group was large -30,000 - and l a c k of education and motivation made them d i f f i c u l t to train?; so the Family Planning A s s o c i a t i o n secured funds f o r t r a i n i n g dais and motivation o f f i c e r s as w e l l . At the request of the government of East P a k i s t a n , the Pamily Planning A s s o c i a t i o n i n t h a t province t r a i n e d 15 doctors i n vasectomy techniques, gave l e c t u r s to f i n a l - y e a r p h y s i c a l education students, 5 dais and 1 doctor. Two student s o c i a l w e l f a r e workers and four d e t e c t i v e s were given f a m i l y planning t r a i n i n g i n 1968. Motivators' t r a i n i n g was also 53 undertaken. C l i n i c a l s e r v i c e s were more l i m i t e d hut a review i s of some i n t e r e s t . In 1958 the model c l i n i c i n Lahore was h o l d i n g two sessions d a i l y . Mornings were f o r a l l comers, and afternoons by appointment. A s l i d i n g scale of charges based on a b i l i t y to pay was used. In 1959 the government approved the use of Maternal and C h i l d H e a l t h Centres, and i t was hoped then t h a t a l l such f a c i l i t i e s would be used f o r f a m i l y planning by the end of the Second Plan period i n 1965. M u n i c i p a l and govern-ment di s p e n s a r i e s were scheduled to d i s t r i b u t e diaphragms and j e l l i e s , and home v i s i t i n g was planned i n order to give out foam t a b l e t s and condoms. By 1964 the PPAP model c l i n i c at Lahore had added w e l l -baby s e r v i c e s , marriage c o u n s e l l i n g , and i n f e r t i l i t y s e r v i c e s . A lady doctor was i n charge, w i t h a s t a f f nurse, d a i , and part-time c o u n s e l l o r on s a l a r y . A volunteer surgeon was performing vasectomies, and two volunteer p h y s i c i a n s were p r o v i d i n g b i r t h c o n t r o l information and methods f o r men. S i m i l a r a c t i v i t i e s had developed i n Karachi and Dacca, and, by I967 a second model c l i n i c on the same l i n e s was opened i n Gandaria.-^^ The FPA had agreed w i t h the government to continue to run i t s model c l i n i c s , mobile vans, propaganda 56 and research p r o j e c t s . In East P a k i s t a n , a long d e s i r e d r i v e r boat educational and c l i n i c u n i t , financed by a Western benefactor and the IPPF, commenced to operate i n the many waterways of the d e l t a country. By J u l y , 19^9» government s e r v i c e s had been extended throughout both p r o v i n c e s , i n c l u d i n g t r i b a l areas, and were organized on a. d i s t r i c t b a s i s w i t h D i s t r i c t Family Planning Boards. I n c e n t i v e s f o r both medical and paramedical personnel and f o r acceptors to promote IUDs and s t e r i l i z a t i o n s had been introduc e d , and small charges had been i n s t i t u t e d f o r condoms "57 and foam t a b l e t s . A d d i t i o n of o r a l s to the government program was planned, l i b e r a l i z a t i o n of abo r t i o n was under c o n s i d e r a t i o n , and rewards f o r c h i l d l e s s f a m i l i e s were being contemplated. A l l these methods had been pioneered by the vo l u n t e e r s . As i n I n d i a , during the F i r s t Five-Year P l a n , 1955-1960, the Family Planning A s s o c i a t i o n of P a k i s t a n was given r e s p o n s i b i l i t y f o r importing a l l c o n t r a c e p t i v e s . These were conventional methods - u n s p e c i f i e d i n such r e p o r t s as are a v a i l a b l e , but b e l i e v e d to have been foam t a b l e t s , condoms, diaphragms, j e l l i e s and creams. In 1958 the FPAP was also u r g i n g the government to promote s t e r i l i z a t i o n and to r a i s e the marriage age f o r a l l P a k i s t a n i men and women. By the time of the Thi r d P l a n , i n 1965* ^ n e govern-ment had adopted the IUD and s t e r i l i z a t i o n as the main methods i n i t s campaign. As i n I n d i a , high hopes of the former were h e l d , though the l a t t e r was not expected to be very popular i n such a t r a d i t i o n - b o u n d s o c i e t y . As i t turned out, the ITJD acceptance d e c l i n e d from 1 9 6 8 , as i n I n d i a and Ceylon, and r e t e n t i o n r a t e s dropped from 7 5 percent at the end of the f i r s t year to 4 7 percent at the end of the second. East P a k i s t a n had a higher r e t e n t i o n r a t e than West P a k i s t a n . But the IUD was not the magic method so long d e s i r e d . Condoms, foam t a b l e t s and a e r o s o l foam were much favored. O r a l contraceptives were, and s t i l l are, experimental o n l y , though they are s o l d f r e e l y at a low p r i c e on the open market. Suf-f i c i e n t research has been done i n both Ceylon and P a k i s t a n , however, to show that c o n t i n u a t i o n r a t e s could be r a i s e d to more than 6 2 percent at the end of twelve months i f d i s t r i -b u t i o n was on a house-to-house b a s i s . By the time the Fourth Five-Year P l a n was being d r a f t e d , s t e r i l i z a t i o n had become very popular among men, and female s t e r i l i z a t i o n was also being promoted. Acceptance of vasectomy was higher i n East P a k i s t a n t o o . Men were u s u a l l y 40 years of age or more, and women 3 2 years and above. The average couple had 4 or 5 c h i l d r e n , i n c l u d i n g two or three l i v i n g sons. (See Table U,t Appendix f o r a d d i t i o n a l d a t a ) . No b i r t h c o n t r o l methods were manufactured i n P a k i s t a n u n t i l I 9 6 7 , when IUDs were made, and i n I 9 6 9 m a t e r i a l s f o r o r a l contraceptives were imported i n bulk f o r t a b l e t i n g . Foam t a b l e t s were also manufactured from t h i s time on. More than 2 5 0 , 0 0 0 cycles of o r a l s were s o l d i n the p r i v a t e s e c t o r i n 1968, and, "by the end of 1967, 21,000 gross condoms, 16,000 dozen foam t a b l e t s , 9,000 tubes of cream or - j e l l y , and 700 diaphragms had been purchased, i n d i c a t i n g increased .58 i n t e r e s t i n f a m i l y p l a n n i n g . Modest help was o r i g i n a l l y given by the P a t h f i n d e r Fund and the IPPP to the Family Planning A s s o c i a t i o n , but, by I969, f o r e i g n a s s i s t a n c e to P a k i s t a n f o r b i r t h c o n t r o l t o t a l l e d more than $U.S. 32.1 m i l l i o n . The P o p u l a t i o n C o u n c i l , Ford Foundation, R o c k e f e l l e r Foundation, S I M , US AID, UNESCO, UNICEF, the Netherlands, the United Kingdom governments had a l l c o n t r i b u t e d . The P o p u l a t i o n C o u n c i l had financed e s t i -mates of population growth and given demographic t r a i n i n g . Pord Foundation had given a d v i s e r s , t r a i n i n g , help i n r e s e a r c h , and had a s s i s t e d the N a t i o n a l I n s t