International Journal of Social Determinants of Health and Health Services

This paper examines the extent to which health objectives of large-scale family planning programs coincide, reinforce or run counter to national policies aimed at reducing population growth. Several variables have been found to be associated with higher rates of maternal and infant mortality: maternal age over 35, parities of over 4, close spacing of births, and unwanted pregnancy. The health objectives of family planning are directed toward avoiding such births. This paper suggests that, at least in countries with high levels of mortality, avoidance of such pregnancies would result in considerably increased infant survival, and in reduction of maternal deaths. In population terms, however, the resultant growth would be more than offset by the simultaneous lowering of the birth rate. The indirect effects of providing family planning care in the health services are discussed in relation to policies aimed at limiting population growth.

The question of the relationship between human rights and population growth is examined from the perspective of the rights and status of women. A brief review of the literature indicates that no necessary connection between an improvement in the status of women and a reduction of fertility has yet been discovered. The most promising investigations are found in culturally and regionally specific studies. The involvement of women in birth control and population growth is classified, and the concerns of feminists identified. The partial contradiction between the goals of feminism and the control of population, and the relatively unresearched aspects of reproduction are made explicit. The paper concludes that the voice of women should be heard in the worldwide population debate and in the national action plans for contraception, not just as representatives of government, the academy, or the professions, but as women-the people most intimately affected by the present population policies.

Population growth has unfavorable consequences for economic transformation in much of the developing world. In this article characteristics of developing countries and their prospects for economic change are described. The impact of population growth on social and age structure, resource use, physical environment, spatial distribution, and occupational opportunity are discussed.

This article reviews the current status of birth control methods, emphasizing the reversible fertility control agents that will be needed during the next decade or two, notably in developing countries. Special mention is made of chemical approaches to abortion, hormonal agents, the intrauterine device, sterilization techniques, and male contraceptives. The prospects for reaching the goals of better research and more effective implementation are fairly dim unless major changes in public and governmental attitudes toward contraceptive research are instituted. Attention is drawn particularly to some of the operational problems associated with the development of new fertility control approaches in the female and in the male.

This paper is concerned with the political and ethical aspects of the development of family planning for the underprivileged and with the use of the underprivileged as subjects in clinical trials of new contraceptive technology. In the past decade family planning has evolved from a component of corporate philanthropy to a major U.S. government policy. The diffusion of family planning has been aided by its apparent “depoliticization” and “internationalization.” Differences of sex, race, nationality and class between researchers and subjects suggest ethical shortcomings in the clinical investigation of new contraceptive technology. The further diffusion of family planning depends partly on developing more acceptable methods and partly on developing new methods of dissemination. Various public opinion campaigns and incentive schemes designed to increase the acceptance of family planning by the underprivileged represent a move from voluntarism toward coercion. It is unfortunate that the development of the potentially liberating practice of family planning has been accompanied by these exploitative phenomena.

The three papers in this section explore the current status of methodologies in population planning as they are being developed and applied at three operational levels: policy formation, program planning, and program implementation. A common theme which emerges from these papers concerns the substantial limitation in the methodologies for providing a rational basis for guiding policy formation, program planning, and implementation. The deficiencies in current methodologies are best reflected in the debates and wide variations of opinions expressed throughout this volume on fundamental issues of population policy and programming, issues that could be examined critically and analytically if the methodologies were adequately developed.

Demographic methods provide an invaluable foundation for population program planning by giving quantitative expression to present and future characteristics of a population. It must be recognized that, while the formulas may be precise, the validity of the outputs are constrained by the quality of input data available and the assumptions required. Fertility projections present special problems because of the multiplicity of factors that can independently influence reproductive performance. The estimation of births averted by family planning programs is particularly tenuous. Population planners must be cognizant of all the dimensions of population change if effective programs are to be developed.

A systematic framework is provided for the analysis of the major administrative issues of interest in the organization of family planning programs. This framework includes clarification of the problem of concern, a review of alternative means for solution, and enunciation of concrete objectives regarding program structure, process (services provided), and product (end results). Eight administrative principles that arise from the analysis are formulated. These can either be accepted as general guides for application to each unique set of circumstances or used as a basis for pinpointing sources of disagreement and subjects for further research.

The problem of “optimum population” involves maximizing a certain function of population level, distribution, and rate of growth. This paper describes a methodology developed to tackle this problem, as well as a demographic-economic model suitable for simulation purposes, developed specifically for the United States and for a time frame of several decades. This model calculates a “per capita welfare index” as a function of various demographic and economic parameters, making allowances for quantities not normally counted in the gross national product, such as household production and the value of leisure time; but disallowing the costs which arise from resource scarcities, urban disamenities, and the need for increased pollution control. In its simplest application, the model can be used to answer the question “Have we become better off or worse off as our economy and population have grown?” Aside from this historical investigation, it is of course possible to do simulation analyses and to evaluate the probable effects of specific policies on the future welfare of the population.

The creation of the Population Council more than 20 years ago symbolizes the traversal of a watershed in the initiation of major American bilateral assistance in the population field. A number of forces, some of which had been increasing modestly during the previous generation, converged in the creation of the Council. The most significant incentive was a growing recognition, during the years following World War II, that rapid population growth in developing countries was likely to become a major deterrent to their progress and development, which were held to be critical conditions for the harmonious world order that Americans sought to achieve.

This article reexamines the rationale for international assistance to population programs in the developing world. Defining the idea of development as a rationally guided effort toward better human conditions, population work is justified if it improves the welfare of the individual family. The renewed interest in providing family planning as part of comprehensive health and nutrition programs reinforces this approach. Allocation of funds for control of fertility is also justified on societal grounds. Excessive population growth hinders poor nations in their quest for adequate food supplies, job opportunities, education, and the other goals of development. It is argued, however, that fertility reduction is a necessary, but not a sufficient condition to achieve improved levels of living in poor countries; birth control should not be considered a substitute for traditional modes of development assistance, nor as a divergence from needed social and economic reform. A new approach to development assistance emphasizing equity in income distribution, even at the expense of overall increases in gross national product, suggests new hope for social justice as well as for the long-run reduction of fertility.

The United States Government has moved in a decade and a half from a policy of sharp repudiation of birth control to broad federal support for family planning at home and overseas. Private organizations and members of Congress were influential in urging government agencies to act. Presidents Kennedy, Johnson, and Nixon gave high level support. Throughout the country, the concept that nations and families could help to improve their economic position and the quality of life by avoiding unwanted children was widely accepted. For a number of reasons, Congressional support of family planning is strong even though other economic pressures may reduce foreign aid and domestic health and welfare expenditures. Since family planning is an important element in development programs, successes in this field could encourage continuing U.S. support for overseas assistance in general.

Since its inception in 1965, and especially since passage of the Title X Amendment to the Foreign Assistance Act in 1968, the population program of the United States Agency for International Development (AID) has grown rapidly to become the principal source of assistance to population and family planning programs in developing countries. At the current annual level of $125 million, AID provides more than 60 per cent of the resources available for international population program assistance. AID obligations for this program now total more than $0.5 billion. This paper describes the allocation of these resources by six functional categories: (a) demographic and social data, (b) population policy, (c) fertility control research, (d) family planning services, (e) information, education, and communication systems, and (f) manpower and supportive institutions. Noteworthy projects in each category are discussed. With continued strong support from the United States and increasing contributions from other countries, it should be possible for the world community to make great strides toward making family planning information, and the most effective and acceptable means of fertility control fully available to all persons of reproductive age in the developing world during the current decade.

A review of the history of the participation of the private sector in population programs indicates that the private foundations were supporting this work well before its importance was recognized either in the academic community or by the federal government. The contribution of the private sector in absolute amounts is slowly increasing with time, but, due to the entry into this field of governmental agencies such as the United States Agency for International Development, the United Nations Fund for Population Activities, and the World Health Organization, the percentage of support for population work which is contributed by the private foundations has declined annually. Nevertheless, there is a role for the foundations and the unique contribution which they are able to make.

The rich countries can best help the poor ones to lower their rates of population growth by providing assistance, including assistance for family planning, that will help to improve the conditions of life for the majority of the population in such a way that they will want and have fewer children. Although there is considerable empirical evidence for this position, it cannot be either proven or disproven on statistical grounds and must be based on political and moral reasons, as well as statistical ones. For the people most directly concerned, a reduction in the rate of population growth is not an end in itself, but only one of the factors needed to improve their conditions of life. These factors include, besides a lower ratio of children to adults, the following: rational urbanization, rising incomes, introduction of modern agricultural practices, more education, improved health services, higher levels of employment and education for women, better communications, greater opportunities for socioeconomic mobility, and reductions in infant and child mortality. Undue concentration on population control will be counterproductive in the long run, even in purely pragmatic terms, and it can have little moral justification.

I suspect that social historians of the 21st century will describe the change in public attitudes toward population growth which have taken place during the past decade as the most rapid adjustment to new facts to occur in our century. To those who have been accustomed to seeing, on every hand, confirmation of the inevitability of social lag behind technical progress, it is still hard to realize how different the atmosphere of today is from that of the early 1960s. The most concrete expression of this new approach is in public support for family planning, and for “family planning” one must read “family limitation,” for despite occasional efforts to avoid this implication, the money and effort are available only to cut back present, unprecedented population growth rates.

As of the end of January 1973, the United Nations Fund for Population Activities was supporting almost 600 population projects in 76 developing countries and areas, with cumulative resources of more than $80 million contributed by 60 governments. The rapid expansion of resources and activities experienced by the Fund since its inception five years ago is evidence of the remarkable rate at which international concern for world population problems, once aroused, has been translated into action. The Fund, as the recognized focal point of population efforts of the United Nations system, has moved further toward its objective of encouraging universal participation in population activities. The Fund provides assistance to governments in the areas of collecting basic population data, population dynamics, population policy, education and communication, multisector activities, and, most extensively, family planning. The Fund's continuing role as a major multilateral source of assistance in the population field was confirmed in December 1972, when the United Nations General Assembly changed the Fund from a trust fund of the Secretary-General to a fund under the authority of the Assembly itself.

The United Nations World Population Conference 1974 will be held in August of next year. It will be a political gathering at which delegates speak for their governments and not as individuals, members of the academic community, or representatives of private organizations. As such, it will be the first of its kind concerned with population The 1974 conference will consider population trends and future prospects. It will take up the questions of the relationships among population and social and economic development, human rights, resources and the environment, and the family. A draft World Population Plan of Action will be considered. It is anticipated that certain parallel activities will be carried out simultaneously with the conference. The conference should succeed in focusing attention on population matters in national and universal perspectives. It should also advance the definition of national population policies and, from the totality of those, an international policy may emerge and find expression in the World Population Plan of Action.

In a recent visit to the People's Republic of China, the author learned first-hand that its family planning program is making remarkable progress—not only in the large cities, but also, more slowly, in the rural areas where 80 per cent of China's population still lives. Since China is the world's most populous country, with some 800 million people, the author asks whether the goals and objectives set there may not provide useful guidance in formulating a world population policy. When the United Nations World Population Conference, 1974 is held in Bucharest, Romania, next August, hopefully the governments assembled will reach agreement on a World Plan of Action to deal with the problems of the population explosion, which are already threatening many developing countries. The author suggests that the nations of the world at this important Conference should acknowledge in their Plan, as China has, that the human race must stabilize world population as soon as possible, with a goal of reducing the present growth rate from 2 per cent to 1 per cent by the year 2000. Tables are included with projections of the world population to 2050 assuming a 50 per cent reduction in growth rate compared with the continuation of present rates.

As part of its mandate and in answer to requests from governments, the World Health Organization works in three main areas relating to human reproduction, family planning, and population dynamics: the introduction of family planning into health services, provision of appropriate education and training for health personnel at all levels, and research in human reproduction, both biomedical and operational. The underlying strategy of the organization is to assist the strengthening of national health services, family planning being included as an integral part of health care. To help administrations to meet the demands posed by the increased scope and multidisciplinary nature of family planning, WHO pays particular attention to the planning, administration, and evaluation of projects, emphasizing the use of modern managerial techniques and the importance of operational research. WHO sponsors scientific and technical meetings in human reproduction, family planning, and population dynamics, to provide an international forum for collaborative efforts and to emphasize the importance of national and international coordination of efforts and resources.

The World Bank shares the widespread conviction that high population growth rates present a long-term threat to world viability and interfere with present efforts to improve standards of living. In trying to do something about the problem the Bank is moving on three fronts: increasing world awareness of the problems created by surging population growth; focusing the attention of national leaders on the demographic situation of their countries; assisting countries which want Bank assistance in building institutions and programs that will enable them to influence the growth of their populations.

Fully recognizing the dangers of overgeneralization, this paper is designed to highlight the similarities as well as the differences that prevail when one takes an overview of population activities in the different geographic areas of the world. The papers that follow are grouped by geographic regions but this overview will take certain liberties with this organization for purposes of better understanding. We will refer to only 6 areas: Latin America, Subsaharan Africa, the Middle East and North Africa, the Asian area including China and India, and briefly, the developed world, and the socialist world.

There are numerous reasons why Latin Americans do not place a high priority on the control of their hitherto unprecedented rate of population growth. Some of these are known and discussed at length in the United States. Others seem more difficult for us to understand. They are usually little discussed and if they are, find little sympathy. This article focuses on these little discussed reasons. In order to improve communications between our nation and Latin America, it is important that we see population growth and its meaning as it appears to Latin Americans for whom the implications of large-scale demographically-effective family planning programs are very different from our own.

Latin America has been sparsely populated since colonial times. The importation of slaves during the first half of the 19th century and European immigration during the second half have provided the manpower needed for the expansion of the Latin American colonial economies. At the end of the last century, industrialization in the form of import substitution began where sufficiently large domestic markets, brought about through increasing exports, permitted it. Consumer goods industries were created near population centers of sufficient size to provide a sizeable domestic market.

After 1930, development became the driving force of economic growth in several Latin American countries. The extent to which import substitution could be accomplished depended on the size of the domestic market in each country. This is the reason that industrialization has made more headway in the three largest countries of the area. The small population size of many Latin American countries is now a constraint to their development. The enlargement of their domestic markets through the formation of free trade areas may spur development, but this cannot be achieved in the near future. For them, population growth is still important. Fertility is, however, already decreasing in Latin America and population growth is likely to diminish in the near future. In order to develop, most Latin American countries will have to integrate a larger proportion of their population into the markets, since they will not be able to continue to rely on population growth for the expansion of effective demand.

Development used to be a synonym for economic growth, but today, given the limitations that population growth places upon the increase of per capita income in the developing nations, there is a risk that foreign aid and international technical assistance could equate development with birth control. It is argued that development is something more than simple growth, that population policies must also be considered as an important element of a national strategy taking into account all aspects of the process of development, and that the adoption of such a policy must be a matter reserved to the autonomous decision of each state. This enterprise has been facilitated in the experience of Colombia because of the recent institutional reforms which strengthened the power of the government and institutionalized the process of national planning. This experience is interesting because Colombia used to be considered one of the most traditional countries in Latin America, particularly in the area of population where its political and religious leaders manifested a strong pronatalist tendency.

The comparative emptiness of Africa in relation to so many other parts of the developing world makes it difficult both for the administrator and the public to see the demographic advantages of a slower rate of population increase. This difficulty is accentuated by tensions among the tribes within a country, and by the racial tensions in the continent as a whole. Political difficulties are compounded by personal ones and there are deep psychologic impediments to family limitation. Although traditional methods of family planning are common in many tribes, there is much resistance to the modern methods that attempt to replace them. Yet even if the economic arguments for family limitation are not widely understood, progress has been made and family planning is slowly coming to be more widely accepted. Still, ominous portents for the future can already be seen. The recent bloodshed in Rwanda, on a scale which has had too little international publicity, seems to have been at least partly due to the pressure of people on land. This is a warning of what the continent can expect if her countries do not make good use of the time that most of them still have to implement rational population policies.

In much of Africa, family health and especially maternal and child health in its most comprehensive implications will meet with the greatest support and cooperation. While fertility control is necessary, it must be a part of family health if it is to be beneficial and economical. We should heed the expressed opinions of African leaders in evaluating the nature of their needs and should organize family health services that take into account all local characteristics and traditions.

At the international level the genocide theory is used to imply a covert or overt effort by the white races to eliminate or keep down the numbers of the colored races. Within Africa, however, more important problems are related to the balkanization of the continent into small states without reference to real physical or ethnic group boundaries. This has led to national insecurity which many feel would be allayed by increasing their national numbers. Within countries too, the new approach to democracy tends to make it possible for one tribe to be dominant over the other, and this in turn creates insecurity both for the tribe in ascendancy, making it want to maintain its numerical superiority, and for the minor tribe which would like to increase its numbers rapidly. The problem is worsened by very enthusiastic advocacy of population control as the main ingredient of economic advance and unguarded recommendations for methods of fertility limitation which may be completely unacceptable in cultural terms. The lack of real population and family planning experts on the African scene is particularly to blame as is also the disproportionate allocation of funds for family planning and population activities as opposed to overall developmental goals.

In spite of the genocide theory family planning and population programs are advancing in Africa. Progress will be accelerated, however, if such activities are seen as part of overall developmental activities aimed at improving the quality of life of all of the peoples. Success is much more likely if governments and technical assistant personnel make it obvious that family planning is to be undertaken within the context of human rights: respect for the dignity of the individual, and encouragement to individuals, families, and communities in the achievement of their own aspirations.

This paper takes a hard look at foreign initiatives in the field of population in Africa. Some important characteristics of the contemporary African scene are outlined, including the great diversity of attitudes regarding population control, and high infant mortality rates. A culturally insensitive approach to family planning characterizes most foreign initiatives in this area and has led to serious backlashes. The growing number of organizations active in this field and the increasing availability of funds for family planning contrasted with the lack of money for other concerns, which many Africans perceive as more urgent, has led recipients to question Western motives. The author underscores African irritation with so-called “experts” who know little or nothing about Africa, yet attempt to organize family planning programs. A new restiveness prevails among the younger generation of African administrators and intellectuals who demand that family planning be approached in the global context of development issues.

In tropical Africa the primordial presence of enormous young child death rates precludes a successful frontal attack on birth rates through specialized programs. Experience in Nigeria indicates that gradual, quiet pressure can influence the power structure to tolerate and eventually espouse child spacing as an integral part of a program of services for child saving. The approach involves four phases: a low visibility start; obtaining high level acceptance; establishment of a federal training center to train cadres for state training programs; and deployment of trained primary care auxiliaries as a local maternal and child health-family planning service. In tropical Africa governmental attitudes toward family planning range from positive policy, to neutrality, to strong opposition. At present most Anglophone countries are favorable. Most Francophone countries are opposed. The general trend is toward a more favorable attitude toward family planning when it is a part of maternal and child health services.

The countries of the Indian subcontinent provide some of the world's most evident case studies of the deleterious effects of population pressure. They also have undertaken some of the world's most massive family planning programs. India was the first country to declare a national population policy and to mount a nationwide family planning program. Pakistan and present day Bangladesh had a prolonged period during which the national family planning program had a separate organization with extremely high priority and official support. Continuing famines and two major wars in 25 years have contributed to high mortality. Nonetheless, population growth in these countries continues its inexorable upward curve. On the other hand, these programs must also be credited with some real successes and the birth rates in several Indian states are falling.

India depends heavily on foreign experts to formulate its population policy because those domestic political leaders involved in policy making are alienated from the masses—they hold to Western values, lack competence in technical skills, are reluctant to come to grips with urgent social problems, and have given way to pressure from powerful vested interests. National and foreign priorities are closely identified. Policy formulators have sidetracked the fight against the basic social and economic problems of the country and have identified population planning with a birth control that masquerades under the name of family planning. This has been a fundamental and almost fatal mistake. Because of this approach, all attempts at family planning have failed to bring their intended results, and it has not been possible to make a significant dent in India's population problem. A threshold level of social and economic development must be attained before any family planning program can begin to bring about a sustained drop in the birth rate. Family planning should be part of a broadly based integrated plan of social and economic development. This will require changes at the political, administrative, social and economic levels to allow development of suitable plans to effectively and expeditiously implement the social and economic development programs.

The 22 countries stretching from Morocco, at the northwestern tip of Africa, to Afghanistan, on the rim of Asia, present a spectrum of positions on population ranging from governmental policy to increase population growth rates, to no explicit policy, to explicit policy to reduce them. High population growth rates throughout the area have evoked various interpretations and responses from these largely Islamic nations, which have been grouped for presentation into five arbitrary categories. There are some family planning services available in practically all the states, although laws vary from frank interdiction of contraception to governmental national family planning programs. There has been remarkable movement toward articulated national population policies in the past decade. This is likely to increase in the future despite problems due to intranational heterogeneity, the Arab-Israeli hostility, certain values of Islamic culture and theology, and the present paucity of demographic and developmental data.

The sharp decline in the death rate in Turkey after World War II caused a rapid population expansion. In 1965, Turkey had to change its traditional pronatalist policy. The objective of this new policy, specified in the First Five-Year Development Plan, was to counteract the adverse effects of rapid population growth on economic development. The plan envisaged a forceful implementation of its new policy. The subsequent Second and Third Plans, however, placed a lower priority on the control of population growth even though the actual rate of growth was not changed appreciably. The implementation of family planning programs by the government has always been slow and results have lagged far behind both targets set in the plans and public demand. It is encouraging that the public attitude continues to be favorable, in spite of slow government action, and that the level of contraceptive use is increasing. In fact, the small family norm is accepted by the majority of families in Turkey. Knowledge of modern contraception is rapidly being disseminated, though no modern means has yet displaced coitus interruptus as the most frequently used method. The probable reasons for the low priority given to family planning programs by the government are discussed. International agencies and governments which have bilateral agreements with the Turkish government always give a high priority to requests related to family planning. The resources they have provided, however, have not been utilized properly and have had little effect on the projects. Grant and loan giving agencies have recently requested the Turkish government to provide them with a long-range comprehensive program in population control so that they can coordinate their assistance within its broad framework.

Population in developing countries is generally considered a problem because of the adverse effect population growth has on the welfare of the masses. If a developing country is to improve its standard of living, the sudden decrease in death rate resulting from socioeconomic development has to be offset by a proportional decrease in fertility rate. This can be realized only if the population plan is inscribed in and implemented through a total economic plan. Therefore, family planning crash programs, which are started in some countries as a health oriented activity and are supported by advertising campaigns, meet ultimately with limited success. Presently the Egyptian population can be divided into three categories: (a) a rural community inclined to high fertility; (b) an urban community conditioned to low fertility norms; and (c) a transitional society which is ready to but has not yet adopted a small family norm. The economic plan should gear itself toward increasing the size of the last two categories by creating new social and economic situations which conflict with traditional behavior favoring high fertility. The role of population planning in this case will be limited to speeding up this transition.

Several of the countries in the Pacific region are pioneers in the national family planning movement of the developing world. Programs there focus on clearly specified demographic goals and operational targets and are usually given a high status. Several are among the most successfully implemented programs in the world. Good evaluation systems and innovative approaches are among their special characteristics. The programs have some weaknesses in common, however. Among these are inadequate input, failure to reach the hard-to-reach, inability to lower the norm of family size, and failure to encourage the use of some effective means of fertility control such as induced abortion. Some programs are also approaching an important stage of transition: a plateau of acceptance, a changing age structure of the population, and a possibly improved fecundability will, henceforth, make attainment of program goals increasingly difficult. More innovative approaches and dynamic leadership to save programs from the natural process of “aging” will be required in the future. Notwithstanding these weaknesses, the countries in the Pacific have a unique opportunity to demonstrate to the world that human fertility may be reduced through planned and organized effort.

This paper describes the setting in which the present population planning policy of the Philippines has emerged. To elucidate the development of the policy, significant activities and events which have contributed to the program are considered. Special emphasis is given to the implications of the present martial law in the country. Following this historical account, the significant dimensions of the current population policy are outlined. Finally, future policy requirements are considered as they relate to the implementation of the spirit and intent of the initial policy and its modifications in the light of new needs. Present trends indicate that population planning will continue to receive a high priority and that implementation will be carried out in a variety of new forms, many of which will include the use of incentives.

The decline in total fertility in Korea from 6.3 children per woman in 1960–1961 to 4.5 in 1970–1971 is attributable, among other factors, to the family planning program. Strikingly, fertility has declined most rapidly in the rural areas where the family planning program was particularly strong. Total fertility, however, has not declined since 1967–1968, generally because budgetary problems for the family planning program have been severe. The present annual population growth rate is 2.2 per cent and the prospects are bleak that a 1.5 per cent growth rate will be achieved in 1976, a goal made explicit in the government's Third Five-Year Plan. Government planning has not sufficiently recognized that even if age-specific fertility continues to decline, a changing age structure will increase the national growth rate to 1.8 or 1.9 per cent by 1981. The authors reconsider the stated national goal of a 1.5 per cent growth in 1976, concluding that it can only be achieved with increased government commitment to family planning, higher targets, incorporation of abortion into the program, and a great increase in the number of sterilizations.

China appears destined to become the first developing country to achieve effective population control before industrialization. Population control in China is one aspect of a total national policy of advancing human welfare which includes programs in general health care, maternal and child health, nutrition, and social security. A major national birth control program launched in the early 1950s reached its maximum effectiveness in 1965. This effort was largely aborted with the Great Leap Forward in 1958. The goal of a birth rate of 2 per cent of total population was finally achieved in 1965, but a setback occurred in 1966 when millions of young people were turned loose to launch the Cultural Revolution. In 1970 an immediate target of a 2 per cent rate increase was announced and a rate of less than 1 per cent was projected by A.D. 2000. The totalitarian government of China sees population control as a high priority goal. The major problems remain in the rural areas where women continue to view male offspring as essential evidence of their fecundity.

This article describes present attitudes and future prospects of population planning in the People's Republic of China. New knowledge available since China has broadened its contacts with the rest of the world permits the drawing of a fairly detailed picture of the family planning program developed there over the past 18 years. Family planning is an integral part of a national health services system. Integrated with all administrative and production units and including virtually the entire population, this system makes extensive use of “barefoot doctors” selected from local communities as well as a large and growing corps of professional health personnel organized to serve effectively both the cities and the countryside. Family planning is achieved by social and medical methods of fertility control including late marriage, use of contraceptives, abortion, and sterilization. The analysis of reasonably reliable data on family planning in six city, suburban, and rural communes with a total aggregate population of 170,500 located in three parts of the country, shows some startling results. Late marriage has lowered the proportion of married women of child bearing age to 14 per cent. A surprising 68 per cent of these women are practicing birth control, and almost two-thirds (65 per cent) of these are protected definitively by sterilization. The third who are using reversible methods are further protected by the availability of abortion on demand. It may well be that about 35 per cent of all potentially fertile women in China are now practicing family planning. It seems probable that this effective mix of methods can be fairly rapidly extended to cover the whole nation and that it will make enough of a contribution to slowing population growth to have a significant effect on the ability of China to meet its economic and security objectives and to raise its standard of living.

The recent drop in birth rates in the United States to a point below replacement may well take much of the wind out of the momentum which developed during the late 1960s for a comprehensive national population policy. Such at least would appear to be a “natural result” given the characteristic patterns of American politics, whereby broad and coherent policy making is rarely produced except in moments of obvious crisis. Such a result, moreover, would dovetail with the general drift of the Nixon Administration away from the domestic and foreign activism of the Johnson years. Despite its “naturalness,” however, that result would be unfortunate. The arguments for a comprehensive national population policy are best grounded in the circumstance that population effects are long-term. This article explores the reasons for instituting such a policy from the standpoint of a central concern of political science—the quality of governance. It is argued that population stabilization would, on balance, enhance the capacity of the United States governmental structure to cope with policy problems, both domestic and foreign.

Between 1960 and 1964, the projected population of the United Kingdom at the end of the century was revised from 64 to 75 million. Ecologists and others clamored for a policy aimed at controlling population growth before it placed intolerable burdens on resources and amenities. Skeptics retorted, however, that population policy was not a substitute for environmental policy, that average family size (about 2.5 children) was already relatively low, and that the problems were being exaggerated. Successive British governments showed little enthusiasm for the adoption of a positive policy on population growth. In the late 1960s public birth control services were extended, but these were regarded as a part of health care and not as an instrument of population policy. The only measures to limit numbers were those adopted in the 1960s to restrict immigration from the British West Indies and other parts of the Commonwealth. In 1971 the government set up a panel of experts to assess the available evidence on the significance of population trends.

A much more purposeful attitude had been adopted toward the problems associated with uneven distribution of population. After the Second World War, plans for building construction and most other forms of development had to conform to physical planning policy. New towns were established to draw population from congested urban areas, and businessmen were given incentives to expand in those areas where unemployment tended to encourage migration to more prosperous parts of Great Britain.

The present population policy in France is examined from the perspective of its historical evolution. Certain factors unique to France's development, including a diminution in family size that occurred earlier than in other European countries, served to make urgent a dramatic reorientation of policy toward increased natality, especially in light of the pressures brought to bear by the First and Second World Wars. The consequences of the increased rate of postwar population growth for such areas as unemployment, immigration, and material, environmental, and human resources, has redirected the climate of opinion away from further population growth. Some current trends and prospects of population policy in France are discussed.

A look toward future implications of population growth and the possibilities of practical programs to ameliorate unfavorable interactions with quality of life seem to be an appropriate way to close this review of the state of the world's population. More than virtually any other discipline demography has become the modern gloomy science with doomsday predictions, rising steadily in a crescendo of concern based on the conflicting predictions of population experts. The optimistic note that emerges from the present worldwide concern is that enough international awareness has been stimulated so that concerted and realistic action is now possible. The fact that the organizers of the 1974 World Population Year are trying to get international concurrence on a “World Population Plan of Action” carries the hope that planning may make programs more realistic and effective.