POPLINE Article Titles:

Shared HLA antigens and reproductive performance among Hutterites.

Shared histocompatibility antigens between spouses may affect reproductive outcome adversely as a result of prenatal selection against compatible fetuses. Evidence from both animal and human studies suggest that histocompatible fetuses may not initiate a maternal immunologic response that prevents rejection of the embryo. Therefore, parents sharing HLA antigens may produce compatible fetuses and consequently experience a greater frequency of early fetal losses and show poorer reproductive outcome than couples not sharing antigens. In the Hutterites, an inbred human isolate that proscribes contraception, we tested the hypothesis that couples sharing HLA antigens have poorer reproductive outcomes than couples who do not. The Hutterites are characterized by high fertility and large family sizes. Couples that share zero (n=21), 1 (n=15), and more than 1 (n=10) HLA-A or HLA-B antigens were compared for reproductive performance. Median intervals between births were larger among couples that share more than 1 antigen in 8 of 11 intervals examined. In addition, the median intervals from marriage to 1st, 5th, and 10th birth were consistently larger among couples that share more than 1 antigen. Differences among the groups appear to become larger with increasing parity, suggesting that the effect of histocompatibility on reproductive performance becomes more evident in later pregnancies. These differences in reproductive performance between couples that share zero, 1, or more than 1 HLA-A or HLA-B antigens may have significant evolutionary consequences. However, our results demonstrate that sharing HLA antigens does not preclude normal pregnancy and caution should be exercised before concluding that shared HLA anitgens are solely responsible for repeated fetal losses. (author's)

A two-generation study of human sex-ratio variation.

The authors report on the 1st vertical population study of human sex ratio variation. Sex ratio data for 2 generations from Akita, Japan have been analyzed. Parental age, birth order, sequences of the sexes at birth, and generations have no statistically significant effect on sex ratio. There is a slight excess of males at birth, as is typical for human sex ratio studies. There is evidence of sex ratio-dependent family planning. An analysis of vertical transmission of sex ratio modifying factors that excludes effects of birth order in both the parental and offspring generations has detected a marginally significant paternal effect. Genetic variability of the sex ratio, if present at all, is of very minor magnitude. (author's modified)

Life stress and chronic yeast infections.

This study investigated the relationships of positive and negative life change to yeast infections in women having a gynecological examination at a university health center. Subjects completed the Life Experiences Survey and a questionnaire about experiences with yeast infections and received, as a routine part of their visitation of the gynecology service, a standard gynecological examination, including a laboratory test for yeast infections. Positive life change was unrelated to any of the variables regarding yeast infections and was only minimally correlated with negative life change. Negative life change, while not related to the presence of current yeast infections, was positively correlated with the reported number of yeast infections during the past year, concern about these infections, and a number of physician visits for yeast infections. Negative life change was also negatively correlated with grade point average. Neither antibiotics nor contraceptive pill use interacted with negative life change to influence experiences with yeast infections. (author's)

Prescribing of oral contraceptives in Oxfordshire.

With the primary objective of examining the practice of prescribing oral contraceptives (OCs), a questionnaire was sent to 180 general practitioners and 45 community health doctors involved in family planning. 6 case histories were listed and doctors were asked to report their prescribing practice in 36 different hypothetical situations. They could choose 1 of 3 options--to prescribe the combined pill, the progestogen-only pill, or not prescribe OCs. They were also asked about changes in their prescribing practice, the 3 OCs prescribed most often, when a progestogen-only would pill be prescribed in preference to the combined pill, and views on the role of others in prescribing OCs. Completed questionnaries were returned by 124 (69%) general practitioners and 45 (80%) of family planning doctors. All were least likely to prescribe OCs in cases of hypertension or family history of ischemic heart disease. Diabetes and headache were each seen as less of a contraindication, and few doctors saw either age or fibrocystic disease of the breast as increasing the risk. Within each case history, smoking emerged as the most important contraindication. Almost all doctors reported changes in their prescribing practice; these related to enhanced understanding of the risks of OCs and to the availability of newer preparations. The 3 most commonly used OCs were the 30 mcg estrogen preparations (low and high progestogen) and the progestogen-only pill. Nearly all the doctors replied that they would prescribe the progestogen-only pill but not the combined pill in certain circumstances, the most commonly cited being when the woman was over age 35, was breastfeeding, had risk factors for cardiovascular disease, or smoked. The 2 groups of doctors showed different attitudes towards the role of other staff in prescribing OCs. Although 2/3 of the general practitioner group felt that prescribing should be limited to doctors, this view was shared by only 1/4 of the family planning group. (author's modified)

[Cytological and bacteriological changes in women using the IUD]

Vaginal cytological and bacteriological reports on 505 women with copper potentiated IUDs were examined and compared to those of a control group of 1050 women. No significant degree of difference in the incidence of dysplasia was observed though a modest increase in vaginal swelling, particularly that caused by monilia, was noted. (author's modified) (summary in ENG)

[Abscessing salpingo-oophoritis caused by Actinomyces in a woman using an IUD]

Recent studies have demonstrated that there is a connection between actinomycetic genital swelling and longterm use of the Lippes Loop. After a literature review, a case of actinomycetic abscessing salpingo-ovaritis in a woman who had worn the same Lippes Loop for 12 years is reported. It is concluded that Actinomyces must be always considered a potential etiological agent in all cases where genital swelling is found in patients fitted with such loops. (author's modified) (summary in ENG)

[The "other" advantages of the pill]

Oral contraceptives (OCs) not only prevent pregnancy but also have a number of advantages which, as a rule, receive less attention than the drawbacks. Use of OCs by women with menorrhagia can prevent iron deficiency anemia. Irregular menstrual cycles can be regulated and dysmenorrhea disappears in many instances with OC use. A number of studies have brought to light the fact that endometrial carcinoma and mammary cysts occur less often in women using the pill. Since Ocs suppress ovulation, the incidence of functional ovarian cysts is reduced considerably. Moreover, the use of OCs proves to decrease the risk of ovarian carcinoma development and the occurrence of salpingitis. A study of the literature justifies the conclusion that the advantages of OC use by young women outweigh the disadvantages. (author's modified) (summary in ENG)

Medical student education for primary health care: who teaches what, when?

Since primary health care (PHC) is central to good doctoring and pervades all levels of medical services, a suitable system for teaching must be developed. Whereas the traditional approach in teaching has been toward a set objective, PHC requires an approach that aims to meet urgent and changing needs. The PHC doctor must adapt to the prevailing requirements of his practice. Other teaching implications are those of organization and team training and continuing medical education. The conflict between different approaches is considered in an attempt to resolve the problem of who teaches what, when. (author's)

A planning cycle in the development of a community health program. An intervention program in mother and child care.

The Or Yehuda Intervention Program was developed in accordance with a planning cycle that includes a situation analysis, formulation of objectives, selection of strategies, development of an operational plan, implementation and evaluation, which lead, in turn, to a new situation analysis. The primary aims of the program are to reduce the infant mortality in Or Yehuda to the level prevailing in the rest of the area and to promote continuity of care and proper medical management during pregnancy, delivery, and the 1st year of life. Problems in implementation, especially those related to coordination and integration of the several medical facilities involved, information tools developed, and preliminary results are presented. (author's)

Saliva level of ethynylestradiol in presence of ethynodiol diacetate after oral administration.

In the presence of ethynodiol diacetate, the ethinyl estradiol concentration in serum and saliva after oral administration was measured by a rapid radioimmunoassay method developed by the authors. By means of the saliva/serum quotient, and from the concentration of ethinyl estradiol in the saliva samples, it was possible to infer the ethinyl estradiol content of the serum. Attention is called to the relation between the quotient and time, which should be taken into account when values are calculated. The saliva/serum quotients for an ethinyl estradiol dose of 0.05 mg were 0.27 at 2 hours, 0.76 at 4 hours, and 0.40 at 12 hours after oral administration. (author's modified)

Alternative causes of pelvic inflammatory disease.

Seminal fluid from asymptomatic men reveals a wide variety of aerobic and anaerobic bacteria. The number of bacteria tends to correlate with the sexual experience of the individual. Experimental evidence has shown that these bacteria can attach themselves to moving spermatozoa and travel through ovulatory-phase cervical mucus. Exogenously added bacteria also exhibit the same potential. These experimental results suggest a rational explanation for the development of pelvic inflammatory disease (PID) in promiscuous women with multiple sexual partners. In addition, the findings help to explain the marked difference observed in the rate of PID among patients using barrier type birth control and oral contraceptives as compared with the rate among women using IUDs, with which ovulatory-phase cervical mucus is unprotected. (author's modified)

Child need survey, Pakistan, 1979.

This study assesses the socioeconomic situation of children in deprived areas of Pakistan to identify how their basic needs are being neglected. Considered are: 1) health needs from conception to delivery, and follow-up through infancy and pre-school years; 2) food and nutrition; 3) education, formal and informal; 4) housing, water supply, and sewerage facilities; 5) recreational facilities; and 6) economic conditions of the family. Statistics are given for: age and parity of mother; sex and number of children in family; educational status; income; and availability of health facilities. Other tables provide data by province and area on such matters as 1) the interviewer's appraisal of children's appearance, cleanliness, and housing; 2) pre-natal care; 3) delivery situation; 4) birth order; 5) health problems and treatment; 6) breastfeeding; 7) age at weaning; 8) immunization; 9) infant and child mortality; and 10) % of children in school. In addition, brief descriptions of the socioeconomic characteristics of each sample area are presented. Differences between the status of the various ethnic groups are noted.

New discoveries in the field of population mathematics, applicable to planning and evaluation of population and family planning program in Indonesia.

The general aim of this paper is to develop a systematic method for determining family planning targets, and for assessing the impact of the family planning and population program in Indonesia on fertility rates and population growth. The approach emphasizes the program as an entity and the variables that exert influence on the system and their interrelationships. Chapter I contains an identification of problems, aims, purposes and utilites of this presentation. Chapter II contains the model construction and qualitative and quantitative system analyses. Qualitatively, a flowchart is constructed. Quantitatively, formulas, matrices, and mathematical equations for the variables are developed as tools for quantification. In Chapter III the constructed model is tested on its applicability for solving problems. Results in a number of cases are compared to those that have been achieved through the application of models currently being used. Chapter IV presents applications of the model on target quantifications and the results thereof on national and local scales. The results do not show any large differences; however, the newly discovered formulas are simpler and easier to apply and facilitiate the tasks of population and family planning workers.

Purdah and changing patterns of social control among rural women in Bangladesh.

Using data gathered in 1966 and between 1975 and 1982, this paper shows how changes in women's productive activities and in the demand for female wage labor have affected the accoutrements and expression of purdah among Bangladeshi villagers. Purdah is defined as the specific pattern of exchange between the sexes. Purdah, incorporating as it does patterns of social control in combination with religous justification, changes in saliency as social conditions change. 1 reason is that the ability of a society to institutionalize and perpetuate particular forms of social behavior depends on the continuation and stability of particular patterns of social organization. Traditional patterns of social control encompassed by the purdah system enhanced the status of the families of women who observed purdah, as well as providing the basis for the personal status of individual women. The traditional observance of purdah was generated and maintained by a distinctive sexual division of labor, and the status and condition of rural families contributed to the form of purdah observed in earlier periods of Bangladesh. An illustration of the changing nature of the purdah system was the advent and popularization of the burkha in perindependent Bangladesh. This garment, which conceals a woman from head to toe, actually increases the mobility of Muslim women, thereby enhancing their social participation and visibility, this paper argues, with mixed results. In the more recent period, as the ability of 1 person to support a family has decreased, and the household itself is threatened, women and children are increasingly forced to provide for their own subsistence. Having few skills except those related to agriculture, they seek employment close to their homes in areas related to agriculture. While it is apparent that old forms of repression and control have passed away, what has replaced them has had mixed effects on women. Greater mobility and freedom of movement have been gained because of deteriorating socioeconomic conditions; along with this great mobility, however, has come even greater personal responsibility for one's subsistence.

Recruitment, selection and retention of CBD workers: an issue paper.

The Community Based Distribution (CBD) model for the provision of family planning services is 1 method well suited to reach the urban poor and rural populations. Although much effort has been expended in the recruitment, selection, and training personnel in the system, little attention has been given to the retention of personnel, which is essential for long-term program effects. This issue paper reviews the literature and existing programs as related to the aforementioned personnel matters and examines the general aspects of selcetion criteria and reported experience with the program's operational point of view. In addition, the paper raises questions requiring further elucidation and study with the object of developing general rules to guide programs in personnel selection.

Community based contraceptive distribution in Haiti: some operations research issues.

This paper reviews the progress in making modern methods of contraception available in Haiti between 1973--when distribution 1st got underway--and the present. Some of the changes that have occurred in the types of family planning methods used and the focus of family planning efforts are considered. The changing role of operations research at the Division of Family Hygiene (DFH) is also examined. Tables provide data on acceptors, practice, contraceptive methods chosen, sources of distribution, and pregnancy rate.

The nature of institutional and community effects on demographic behavior: an overview.

This discussion paper was prepared for a World Fertility Survey (WFS) seminar session on the nature and empirical investigation of community effects on demographic behavior. It seeks to define and distinguish between community-level and institutional influences. The former are accessible through survey instruments such as the WFS Community Module; the latter call for more elaborate research strategies. Elements of a program designed to determine institutional effects through research on the objective and cognitive environments are sketched out. The research task is to explore a cognitively-structured setting and try to locate its sources of stability and change. Global variables of the sort that have been collected in the WFS Community-Level Questionnaire can be incorporated in other situations where contextual influences are likely, such as nuptiality and breastfeeding. Nearest to a community-module approach appears to be the kind of rapid-fire assessment of community settings that were carried out in the course of research on short-run migration in Indonesia. Focus group approaches are another option. The 5 session papers are drawn on for illustrations of alternative approaches to empirical research in such a program.

How to look after a health centre store.

Proper management of health center stores is a vital component in the effective organization and operation of supply chains for primary health care programs. This book provides basic guidelines for simplified approaches to such problems as storing essential drugs and other basic supplies properly, arranging for the reordering of supplies, and making the most efficient use of the available supplies. Among the topics covered are: 1) where to locate the store; 2) how to organize it; 3) necessary equipment; 4) how to obtain supplies; and 5) how to issue supplies and drugs; 6) how to store and protect supplies from damage and loss, including recognizing spoilt drugs; and 7) how to organize supplies and monitor availability. Annexes contain information on the properties and storage of some dangerous chemicals and drugs; how to use a cold chain monitor; how to recognize frozen DPT, DT, and TT vaccines; detailed working drawing for a tablet counter; and a temperature record form.

Population and development in Indonesia: a status report.

This publication attempts to review the dynamics of population and development relationships in Indonesia with the aim of getting a better insight of the characteristics of such relationships as guides to development planning, and of providing more solid bases for the formulation of a national population policy. Major topics discussed are: 1) an overview of the demographic profile from 1961 to 1980; 2) fertility patterns; 3) mortality rates; 4) migration; 5) labor force, employment and income (with an emphasis on the role of women); and 6) population dynamics.

Teenage parenting and child development: a literature review.

Research on teenage parenting together with medical and behavioral research related to child development is reviewed in an effort to determine causal factors related to reported developmental deficits among children of teenage parents. 4 general conclusions are suggested: 1) several researchers agree that children of teenage parents show poor social and intellectual competence when compared with children on non-teen parents. However, the amount of sound empirical data to support this view is minimal. For example, there are few published studies of the longterm effects of teenage parenting or of actual behavioral interactions of teenage mothers and their children. 2) It is unlikely that research along the lines of the "continuum of reproductive casualty" will lead to identification of causal factors sufficient to account for developmental deficits in children of teenage mothers. 3) Research along the lines of "the continuum of caretaking casualty" suggest numerous behavioral and environmental variables that may be related to the development of children of teenage mothers. 4) Research designs applied to the study of teenage parenting must shift from linear models to complex multivariate models that permit simultaneous analysis of organismic, environmental, and behavioral determinants of development. Finally, mental health specialists, government agencies, and researchers alike, must be willing to entertain the hypothesis that much of our knowledge of the childrearing skills of teenage mothers is based on myth rather than empirical fact. 1 such myth may be that below 19 years of age, maternal age in and of itself is an important determinant of infant development and parent-infant interaction. Poor social-economic status, family support systems, marital stability, nutrition and prenatal care may be far more important determinants of development for these children than the age of their mothers.

We need a more human perspective.

This article has been adapted from extracts from the recorded transcript of the author's address to the Medical Society of the World Health Organization. The author expresses his opinion in regard to inflationary tendencies in modern medical services with multiple British examples. An emphasis on progressive achievement of the prevention of illness is discussed in regard to the reduction of environmental exposures to physical and chemical substances, as well as through improved hygiene. There seems to be a need to look anew at the whole subject of promoting health. The programs that we try to implement should be beneficial to all concerned, the poor and the rich. We should seek to reach a kind of half-way house between the developed and the developing to the mutual benefit of the rich and poor.

Providing pills free: does it make a difference? Thailand's experience with a free pill policy.

Starting in the fourth quarter of 1976, the National Family Planning Program in Thailand abolished charges for oral contraceptives distributed through government outlets. The policy was largely carried out as intended in as much as most acceptors have been obtaining pills free. Evidence accumulated so far indicates that the free pill policy probably resulted in a substantial and sustained increase in new acceptors of the pill. The apparent increase had no evident adverse effect on the numbers of new acceptors of other methods nor did it involve much switching from other methods or substitution of free government pills for ones brought commercially. Moreover, continuation rates immediately following elimination of charges increased slightly although they have subsequently decreased. Recent evidence indicates that women who receive the pill free from the Program have higher continuation rates that those who pay. (author's modified)

Farm size, land ownership, and fertility in rural Egypt.

The purpose of this paper is to present the findings of a household level analysis of land availability and fertility variation among farm families in rural Egypt. Data were drawn from a survey conducted in 2 predominantly rural governorates in Lower Egypt in 1978, Beheira and Kafr El Sheikh. They were purposely selected in an attempt to obtain areas representing a range of socioeconomic and demographic conditions. The analytical model that underlies the study postulates that fertility variation in rural areas is influenced by family access to land for cultivation purposes and the conditions governing that access, as well as socioeconomic and demographic control variables. Among the 561 households sampled, the mean value for land ownership was .47. The mean value for household income measured in Egyptian pounds was 112.83 with a standard deviation of 84.76 pounds. The females had been employed 9.7% of the years since marriage. On the average, women had completed less than 3 months of formal education--.32 years. Access to land cultivation was significantly related to the other variables. Land ownership increased with farm size. Family income was closely linked to cultivated area. Landless laboring families had the lowest fertility. Wives of landless laborers were on the average younger, slightly better educated, and less likely to have worked for wages since marriage. The results support the hypothesis that the amount of land available to the family for cultivation is positively related to fertility. Land ownership was negatively related to children ever born. Per capita family income also exerted a negative influence on the number of children ever born. This indicates that income levels were such that the positive nutrition-induced income effect on fertility does not seem to prevail. Age at marriage was negatively associated with fertility and was statistically significant. The strongest variable was the woman's age.

The intra-uterine device and hospital admission.

A prospective study of gynecological admissions in Plymouth General Hospital, Devon, England was made in 1979. IUD-related problems accounted for 7%. Of these, pregnancy-related complications (87) consisted of: 1) legal abortions--having conceived with an IUD "in situ"--50%; 2) spontaneous abortions--caused by the IUD--39%; 3) ectopic pregnancy--8%; 4) threatened abortions with an IUD in place--2%; and 5) 1 overnight observation of an IUD termination at 11 weeks of gestation. There were 69 complaints of pain, bleeding, and discharge. 60 women elected sterilization, as their IUDs were adversely affecting them. There were 34 admissions for missing IUD threads--16 were found in the uterus; 2 were not found and are presumed to be expelled. 21 women were admitted for removal of an IUD after their general practitioners were unable to remove them. 10 women underwent hysterectomy with an IUD "in situ," 8 with menorrhagia and dysmenorrhea. 3 women were admitted specifically for IUD insertions. 54% of the women with IUD-related problems under age 25 were nulliparous. The age range of the 277 patients was from 18 to 55 years. There were 136 Copper 7's (55%); 95 Lippes Loops (38%); 12 Saf-T-Coils (5%); 1 Dalkon Shield and 1 Birnberg Bow. 26 of the 293 admissions (9%) can be considered incidental. Of the 267 remaining--234 (88%) involved a 5 day or more stay and/or administration of a general anesthetic. 1129 women days were spent in hospital. 3 gynecologic beds were occupied by IUD-related cases every day of the year. The incidence of IUD-related admissions was at least 1 in 15 or 6.7%. A study of 2250 consecutive deliveries revealed 36 (1.6%) cases of failed IUDs. A Copper 7 was involved in 19 cases, a Lippes Loop in 5, a Saf-T-Coil in 1, and unknown in 10.

A personal contraception record card.

A personal contraception record card is shown. It has been in use for 2 years, and is in regular use at Weaver Vale practice in Runcorn, Cheshire, England. Over 100 were issued the 1st year following the form's design. None have been lost. The size is 18 cm. by 34 cm. Medical, surgical, and family history are listed along with cervical smear results, rubella antibody tests, mammography, breast self examination, and blood group data. Provision is made for major and interval checks. It also provides a record of prescriptions and clinic attendances.

Laparoscopic sterilisation with Hulka-Clemens spring-loaded clip.

This paper reviews laparoscopic tubal occlusion with Hulka-Clemens clips in 250 patients performed at a district hospital over a period of 3 years. 244 patients were followed up between 6 months and 3 years after the procedure. The complications associated with the procedure were assessed. 1 case of failure resulted in an intrauterine pregnancy in spite of perfect application of the clip. Changes in menstrual loss were assessed by a postal questionnaire in women who had used neither the intrauterine contraceptive device nor the combined oral contraceptive pill prior to sterilization. 71% of patients stated that their periods were unchanged, 16% claimed that they had lighter periods and 13% claimed that they had a heavier menstrual flow. (author's modified)

Primary pneumococcal peritonitis following insertion of an intra-uterine device: case report.

A case of pneumococcal peritonitis occurring 2 weeks after insertion of a Copper device is reported. The patient, a 25-year-old nulliparous woman, had several episodes of watery diarrhea. The IUD was removed. Streptococcus pneumonia was isolated. The patient was given Cephalexin 250 mg. qid. Watery diarrhea is characteristic of pneumococcal peritonitis but is unusual in secondary peritonitis. Removal of the IUD is mandatory. An alternative form of contraception should be recommended for at least a year.

Use of a tenaculum [letter]

Is a tenaculum ever necessary in a conscious patient? This letter writer was taught to fit IUDs using a tenaculum. He soon found that he could insert them with less patient discomfort without the tenaculum. When he was unable to fit an IUD, he continued to be unsuccessful when he tried with a tenaculum or vulsellum. At a course for trainers run by the Family Planning Association, it was found that a substantial number of those attending had likewise abandoned using tenaculums. It is sometimes argued that though a tenaculum is not always necessary, there are many who cannot be fitted without one. Since 1974 the writer has fitted many different types of IUDs without using a tenaculum. His fitting failure rates (defined as: at the end of the day of attempted insertion, the woman is not fitted) for women who had been pregnant with no previous failure of fitting is 6 in 450 = 1 in 75 attempts; for women who had never been pregnant--7 in 47 = 1 in 7 attempts. The rate for a 2nd attempt within a few weeks was 4 in 9, nearly 1 in 2.

Use of a tenaculum [letter]

A tenaculum should always be used on the cervix when fitting an IUD. However, the purpose of holding the cervix with a tenaculum is to exert counter-traction on the cervix so that: 1) the cervical canal may be aligned with the uterine cavity; and 2) the operator is aware of the force he/she is exerting in inserting the IUD introducer and can detect when this touches the fundus. The tenaculum should be held in the operator's left hand throughout the insertion. Also, there is no need to use a vulsellum or sharp single-toothed tenaculum on the cervix. They are unnecessarily traumatic and never designed for conscious use. A Judd-Allis 8 inch tissue forceps has been used successfully for this purpose. This forceps should be applied well away from the externalos so that they do not impede the introduction of the sound or IUD introducer.

Use of a tenaculum [letter]

A tenaculum or similar instrument should be used when fitting an IUD to stabilize the cervix and to reduce angulation of the cervical canal and uterine cavity. A tenaculum with sharp ends tends to injure the cervix, sometimes producing bleeding. Allis forceps should be used instead of Luer's, Jardin's, or Teale's. They are easily applied and the majority of patients are not aware of them.

Questionnaires for the Contraceptive Prevalence Surveys in Paraguay (1977); Guatemala, El Salvador, and Sao Paulo State, Brazil (1978); and Jamaica, Panama, and Piaui State, Brazil (1979).

Questionnaires used in contraceptive prevalence surveys in Paraguay in 1977; Guatemala, El Salvador, and Sao Paulo state, Brazil, in 1978; and Jamaica, Panama, and Piaui State, Brazil, in 1979, are presented. Each questionnaire contains items on general household information and procedures for selecting a reproductive-aged female respondent. The type of general background information and demographic data collected varied slightly in each, with questions on age, education, income, occupation, labor force status, place of birth, ethnic group, mother tongue, literacy, and marital status among the items sought on some or all questionnaires. More detailed data was solicited on fertility history and current pregnancy status, with most or all asking the number of live- and stillbirths, abortions, number of children still living, date of 1st or most recent birth, medical care received at the most recent birth, whether the last pregnancy was wanted, and breastfeeding status. Questions on knowledge, attitude, and practice of various contraceptive methods were then asked, followed by items on reasons for using or not using some method, on availability and distance of contraceptive supplies and services, on attitudes toward community based distribution, attitudes and knowledge of sterilization, and family planning communications and use of mass media, especially radio. Most of the forms included some coding information and spaces for indicating results of the interview attempt.

Female and small-scale employment under modernization in Ghana.

The hypothesis that female employment opportunities in agriculture and traditional small-scale production are diminished in the early stages of industrialization is refuted in the case of Ghana, where female labor force participation has risen despite rapid industrialization. This paper analyzes the impact of industrialization on small-scale production and the predominance of women in such production. Female labor force participation increased from 57% to 64% in the 1960s, while male participation declined from 89% to 84%. However, sectoral analysis of employment patterns reveals that women's employment gains were restricted to the traditional sectors. The modern sector provided only 6% of new female employment compared with 61% of new employment for males. On the other hand, agriculture absorbed 46% of the increased female employment but only 10% of increased male employment. Small-scale manufacturing accounted for 26% of the total employment increase in the 1960s. Female participation in these industries rose from 60-70% in 1962-70, whereas it fell from 23-18% in non-small-scale industries. These results suggest that modernization is needed biased against female employment; however, there is no support in the case of Ghana for the hypothesis that modernization occurs at the expense of cottage industry. To utilize the resource of female labor power and to incorporate women into the development process, policies need to be oriented toward generating demand for small-scale production and avoiding subsidization of competing large-scale firms.

Religious differentials in reproduction: the effects of sectarian education.

Earlier studies have suggested that extensive education in sectarian schools may account for the higher net fertility observed among Catholic than Protestant women. To clarify this relationship, 3 hypotheses were investigated: 1) college-educated Catholic women have significantly higher fertility than college-educated Protestant women; 2) the more extensive the sectarian education, the higher the fertility of college-educated Catholic women; and 3) college-educated Catholic women do not have significantly higher fertility than college-educated Protestant women when the extent of sectarian education is controlled. Data were taken from the 1976 National Survey of Family Growth, which included 97 college-educated Catholic women and 246 college-educated Protestant women. Although duration of marriage was found to be the strongest predictor of number of children born at time of interview, college-educated Catholic women had an average of 0.29 more children than their Protestant counterparts. When fertility was controlled for age at marriage, duration of marriage, size of family or orientation, and residence, Catholic respondents still had an average of 0.28 more children than Protestant respondents (p<0.05), confirming the 1st hypothesis. Catholic respondents reported spending 3.82 more years in sectarian primary schools, 1.73 more years in such high schools, and 0.34 more years in sectarian colleges than Protestant respondents. Extent of attendance at a Catholic college or university (but not primary or secondary school) was significantly (p<0.01) associated with net fertility, confirming the 2nd hypothesis. Finally, religion had no net effect on actual fertility (p>0.05) when 6 measures of sectarian education were added to the multiple regression equation. Thus, a significant part of the Catholic-Protestant differential in births to college-educated womewas attributable to the Catholic women's greater attendance at sectarian colleges, supporting the 3rd hypothesis. Since enrollment at Catholic schools is increasing, the religious differential in cumulative fertility is expected to continue. Although this study concerned college-educated women, the trends observed are considered to apply to less educated Catholics as well.

[How far along is the demographic transition?]

The examples of England and France demonstrate the variability of patterns of demographic transition. Their establishment in modern form in the 17th and 18th centuries led to declining incidences of famine and epidemic, with formidable consequences. As soon as death began to be controlled it left the theological domain and became a scientific and administrative matter. In France, pressures of social striving led to a widespread desire to control family size; during the 19th century a slow fertility decline more or less adapted to the mortality decline took place. The demographic revolution preceded the industrial revolution by a good half century in France, the reverse of the situation in England. The experience of the past imposes a positive outlook on contemporary demographic problems. The demographic explosion is a perfectly comprehensible phenomenon which had a precedent in 19th century Europe. The process of adjustment will require time, and knowledge is needed concerning the determinants and effects of the transition which might best be provided through population censuses and civil registers. The historical experience of Europe suggests that a requirement of the transition may be an adaptation of ancient religious dogmas, achieved through protestantism, separation of church and state, or other means. The rate of growth of world population is 1.7%/year, but 32 developed countries have rates under 1% while 118 developing countries have rates over 2%. The highest mortality and fertility are currently found in Africa. On the whole the fertility declines of south and east Asia are not well established either, except in some island nations. Religious impediments to practice of birth control are strongest at present in the Moslem countries. Like rates of natural increase, fertility rates for individual countries take the form of U-shaped curves at this stage of world demographic transition.

Working life tables for females in Canada, 1971.

This paper attempts to construct some working life tables (WLTs) for females in Canada, 1971. Attention is directed to methodological problems in female WLT construction, a suggested methodology, and loss due to mortality. The working life expectancy (WLE), which refers to the average number of years that a person is likely to spend in the labor force during his/her lifetime, reveals the extent of his/her contribution to the national economy. Although working life tables have been prepared for Canadian males, no attempt has been made previously to develop a WLT for the Canadian females. In some countries, such as Canada, the long census questionnaire collects additional pieces of information on labor force participation (LFP), even though the coverage is only on a part (but sizable) of the population. It is suggested that the information on "weeks worked" (Canadian Census wording) can be used to smooth out the bimodality problem in the female LFP. If a working woman works for an entire year, i.e., 52 weeks inclusive of paid holidays and vacation, she is said to contribute 1 woman year of working (or economically active) life to the economy. On the basis of this concept of a woman year of working life, all females who are working full time, part time, and not working can be considered in regard to their respective contributions of working lives to the national economy. An age limit is not indicated in the definition. The number of hours worked per day cumulated for the year and scaled down to the base of 1 woman year of working life would make the analysis more realistic. If the census data on weeks worked are tabulated by single years of age, or age groups for the female population, the average number of weeks worked specific for the various age categories can be computed. Those who are unemployed are taken as contributing zero weeks worked in the computation of the mean. Then the age specific participation rate is obtained as the percent of the average number of weeks worked by females in a given age group to the total number of weeks in a year. From these age specific rates, the probabilities of LFP at an age interval is worked out by averaging 2 consecutive age specific rates. Employing the notion of woman years of working life and utilizing the average number of weeks worked from the 1971 Census of Canada PUST data, a set of age specific participation rates for the Canadian females was developed. With these participation rates, the WLT for the Canadian females is constructed. The WLE for a female in Canada in 1971 attains a maximum of 38.7 years at age 15 and declines with increases in age. A comparison with the males showed that the female WLE was higher in the latter and lower in the early years of life. (Summary in FRE)

Prolactin-lowering drugs.

This review of prolactin-lowering drugs focuses mainly on dopaminergic drugs, especially the dopaminergic ergot derivatives that are the main drugs used for treatment of hyperprolactinemia in humans. Drugs that can interfere with other types of central transmitter systems, mainly in the hypothalamus, thereby participating in the regulation of prolactin secretion, are also discussed. The article begins with a description of the numerous neurotransmitter systems involved in regulation of prolactin secretion: the tuberoinfundibular dopamine neurons, the tuberoinfundibular gaba neurons, the tuberoinfundibular cholinergic neurons, the reticular noradrenaline and adrenaline afferents to the hypothalamus, adrenergic beta-receptor stimulation or inhibition and prolactin secretion, reticular 5-hydroxy-tryptamine afferents to the hypothalamus, the paraventricular-infundibular TRH neuron system, the beta-endorphin and ACTH neuron system of the medial basal hypothalamus, the paraventricular-infundibular enkephalin system, the paraventricular-infundibular angiotensin-II-like immunoreactive neuron system, the paraventricular-infundibular cholecystokinin-8-like-immunoreactive neuron system, the substance P-immunoreactive hypothalamic nerve cells, the vasoactive intestinal polypeptide-containing nerve cells within the hypothalamus, and the neurotensin-immunoreactive nerve cells within the hypothalamus. The effects of other types of neuropeptides are assessed. The structure and effects of dopamine receptor agonists and gabaergic drugs are then described, followed by discussions of the prolactin-lowering action of nicotine, prostaglandins and prolactin, and clinical trials with prolactin-lowering drugs in humans.

Chronic dopaminergic sensitivity after Sydenham's chorea.

32 patients with Sydenham's chorea were studied at the La Rabida Institute for psychometric performance on the Minnesota Multiphasic Personality Inventory (MMPI). Questionnaires used included a definition of chorea and a description of choreic movements which the patients and members of their households were asked to read. Results were: 1) the only medical condition frequently reported was arthritis; 20/32 patients reported medical consultation for this complaint; 2) 19 patients including 2 with chorea gravidium, reported motor or psychiatric side effects from 1 or more agents; 3) in patients with multiple drug exposures a history of adverse motor reactions to decongestants was always associated with adverse reactions to anorectics or amphetamine in patients with exposure to all agents, and a similar pattern was noted with thyroid hormone and oral contraceptives (OCs); 4) 1 patient with chorea gravidium reported dyskinesias after administration of decongestants or amphetamine but tolerated OCs; and 5) MMPI scores from patients reporting adverse responses to amphetamines were statistically elevated in the psychotic tetrad. This study provides support for the belief that Sydenham's chorea is not a benign self-limited disease of childhood. In addition to mild residual neurologic abnormalities, the disorder appears to confer long-standing sensitivity to a variety of dopaminergically active agents.

Time and pace of fertility decline in China.

An effort is made to compile data available from China's existing population records, deriving them through indirect estimates of fertility levels at different points in time and particularly during the last 30 years. An attempt is also made to determine at what level fertility started to decline and the pace at which the decline progressed in subsequent years. 3 types of data were used: data on age sex distribution of the population from 1953 and 1964 censuses; data on age sex distribution of population from sample surveys of 1975 and 1979; and vital statistics records from 1964-79. Crude birthrates were estimated from the age distribution by using Reverse Survival Rate Method, the Census Survival Method, and Rele's Method. Although the fertility estimates obtained by the different methods varied, they indicated that fertility declined from a level of about 37% in 1949 to about 34% during the period of 1958-63, and then slightly increased during the 1963-68 period. After 1968, the marked decline in fertility was observed. During the 1943-48 period, fertility declined due to the effects of the 2nd World War and the War for Liberation. Generally, the population growth in China in the past 30 years can be divided into 4 stages. The characteristics of the medium growth period, 1950-57, was high fertility associated with fast declining mortality. The average growth rate of population kept at a level of about 22%. Fertility declined unnaturally during the low growth period, 1958-61, mainly due to the economic problems. The baby boom period of 1962-69 was associated with economic recovery, an increase in marriages, and the desire on the part of more couples to have children. Fertility was very high during this period with the crude birthrate reaching 43% in 1963. During the period of fertility decline, 1969 until the present and mainly after 1972, fertility greatly declined primarily because of the family planning program. Along with the decline in the crude birthrate, fertility patterns also changed. A sample of registration data from 1 Shanghai district is given in a table. This district is very advanced in fertility control, but its pattern may suggest the pattern of fertility decline in the whole country in coming years. In all 3 selected years--1952, 1964, and 1979, the fertility peak occurred in the age group 25-30 years. It was a city pattern. In rural areas, the mean age at marriage and the fertility peak usually are 3 or 4 years earlier. The factors responsible for the fast decline of mortality in China were the improvement in economic status, sanitation, nutrition, and medical care. The target of the Chinese government is to reduce the fertility level gradually and control the population size to 1200 million by the end of 2000 and, in the long run, to acheive the population size of 700-800 million.

[Program of Investigation of Rural Employment Policies. Temporary migrations and the rural labor market in Latin America: a review of the problem and of the available information]

This work assesses the extent of temporary labor migration in rural Latin America and reviews available information on the topic for Latin America in general and for Argentina, Brazil, and Mexico in particular. The work has 3 substantive chapters, a chapter synthesizing the main findings, and a specialized bibliography. The 1st chapter is conceptual and theoretical, and proposes an analytical framework for temporary migration in developing countries based on recent views of the problem. The main objectives of the framework are to facilitate analysis of the variations in the organization of agrarian production and their implications for temporary migration. It delimits the functioning of capitalist agrarian enterprises at the microsocial level and specifies the conditions under which they adopt a system of temporary migration, as well as the elements of the peasant agrarian economy which are relevant to understanding the participation of members of peasant families in the temporary labor market. The 2nd chapter discusses available evidence from census data of the 3 countries which would shed light on the expected process of proletarianization of the agricultural labor force. The search for supporting data is based on the hypothesis that the transformations in capitalist production occurring in the 3 countries should lead to changes in the utilization of the labor force, with the wage-earning sectors growing in relative terms. A review of the census data suggests that not enough is known for firm conclusions to be drawn that proletarianization signifies a proportional growth in the relative or absolute numbers of wage-earning agricultural workers freed from all domestic production. The combination of temporary agricultural work with other jobs, in or outside the capitalist sector, in urban or rural areas, does not necessarily imply the expansion of a rural proletariat. The 3rd chapter considers case studies of temporary migration and its relationship to rural labor markets. 2 main types of temporary agricultural labor migration are distinguished, and the results are organized according to the perspectives of demand for and supply of rural labor. The final chapter presents some conclusions based on the 2 previous chapters and evaluates the utility and limitations of the analytical framework presented in the 1st chapter. Data shortcomings and theoretical problems are identified and specific recommendations for future work are offered.

[The health situation and population dynamics in Peru]

This study examines some of the most important aspects of the health situation in Peru: the principal causes of morbidity and mortality, the health status of infants and other population groups, the number and distribution of health personnel of different levels, the geographic distribution of health resources and future needs, and the interrelationship of the country's health needs and population characteristics. Peru in 1979 had over 17 million inhabitants, an increase of over 3 1/2 million since 1972. The total population is expected to reach almost 30 million by the year 2000. The population under 15 years accounts for 43% of the total. Over 1/4 of the population resides in metropolitan Lima. 44.2% of deaths in 1972 were caused by infectious and parasitic diseases; 3.8% by congenital causes; 5.6% by tumors; 8.7% by cardiovascular conditions; 4.9% by accidents, poisoning, and violence; 2.0% by mental illness and disorders of the sense organs; and 1.0% by complications of pregnancy. The rest were caused by undefined or other causes. The principal causes of morbidity in Peru are communicable diseases. The crude birthrate for 1975-80 was estimated at 39.37 and for 1980-85 at 37.60; the rates were highest in the poorer and less developed Andean departments. An estimated 62% of infants are the children of illiterate or semiliterate mothers, 43% are illegitimate, and 69.1% are born without modern medical attention. The infant mortality rate in 1979 was estimated at 101/1000 live births. Infant deaths accounted for 33.0% of all deaths. Surveys have shown that abortion, spontaneous and induced, plays a large role in maternal mortality. Only 6.6% of mothers have a postpartum medical consultation. The health system is composed of a multitude of public and private entities which are poorly coordinated, resulting in duplication of services, poor resource utilization, and exclusion of over 50% of the population. There are 10,246 physicians, 3318 dentists, 1276 obstetricians, 3334 pharmacists, 285 sanitary engineers, and 9688 nurses. The rates per 10,000 inhabitants at the national level vary from 5.9 for physicians to .16 for sanitary engineers. All types of medical personnel are concentrated in the cities and more developed areas. The entire country contains 330 hospitals and clinics, 548 health centers and medical posts, and 1230 sanitary posts. 44.4% of hospital beds are located in Lima and another 26.5% are in the 9 next most populous cities. The health centers and sanitary posts designed to provide simple health care to more dispersed populations lack resources, and many have been abondoned. A national health system with adequate resources is desperately needed.

Thromboembolic diseases. 3. Pulmonary embolism and infarction.

Pulmonary embolism is the impaction in the pulmonary vascular bed of a previously detached thrombus of foreign matter. Its major complication, pulmonary infarction, is the necrosis of lung parenchyma resluting from interference with blood supply. Almost all pulmonary emboli originate as thrombi; on occasion nonthrombotic materials such as amniotic fluid, fat, air, bone marrow, or tumor may embolize to the lung. Venous thrombi in the deep veins of the lower extremities are the most common source for pulmonary emboli, accounting for 80-90%. 30% of pulmonary emboli occur in cardiac patients, another 30% occur among medical noncardiac patients and most of the remainder occur postoperatively. Pathology is described. The effects of this condition are: 1) less blood proceeds through the pulmonary circuit to the left heart and systemic circulation, 2) there is a damming back of blood behind the mechanical obstruction, 3) hemorrhagic necrosis of the ischemic area may occur, and 4) pulmonary function is imparied. The manifestations may include sudden dyspnea, tachypnea, cyanosis, precordial or substernal oppressive pain, evidence of right-sided cardiac dilatation, and failure, anxiety, and hypotension. Diagnosis procedures are described. Treatment can include oxygen therapy, anticoagulants, thrombolytic agents, and surgery. Of those who succumb, about 90% die immediately or within the 1st 2 hours, and once vital signs are established, subsequent mortality approximates 7%.

The influence of malarial infection of the placenta on the incidence of prematurity.

Records of 512 deliveries were studied. In 15% the placental smear showed evidence of malaria parasites, a finding consistent with the parasite rate for adults in Ilaro during the period of the investigation. Of 68 apparently full-term deliveries from mothers with infected placentae, 29.4% weighed 5.5 lb or less at birth and were classed as premature, contrasting with the incidence of prematurity in 395 single, full-term births from uninfected placentae at 16.5% premature. This evidence lends weight to the suggestion that malarial infection of the placenta is a cause of premature birth in Africans of southwestern Nigeria. The advisability of using chemoprophylaxis is worthy of consideration but the possible effects on women's immunity needs to be studied.

Botswana's way with self-help housing.

Evidence from throughout Africa confirms that rural-urban movement is a selective process, the highest rates of mobility being recorded among the young who are better educated. For the latter movement is a decision to seek a better income and more secure employment and adaptation may be quick. This group is small compared to the large volume of poorly educated unemployed rural migrants who move to squatter settlements in the periphery of African towns. Policies designed to raise standards of water supply and sanitation in low income areas achieve greatest success when they form part of an overall strategy for the improvement of the social infrastructure and in which the residents participate. In the 1970s national strategies changed and squatter upgrading has become an acceptable urban development objective. 3 principles guide this policy: 1) the provision of social infrastructure is appropriate only if it can be afforded, 2) the costs are recoverable, and 3) the scheme can be repeated elsewhere. Fulfillment of these principles demands not only a low cost solution to social and environmental problems but also one which requires community participation. By allowing individuals a degree of freedom in the design and construction of their homes, city authorities ensure that cultural traditions are not destroyed and that maximum cooperation is enlisted. Proper use and maintenance is an important motive for continued tenancy. The project began in 1978 and by 1982 the resettlement was complete. In the future an increasing proportion of the social infrastructure must be provided by self-help methods as opposed to investment by public and private sectors.

[Failure to return to industry, the primary feature of the sequence of Turkish migration]

This article seeks to destroy the myth that the industrial experience of emigrated workers can be helpful in development efforts for the sending countries by supplying a highly qualified labor force. The extent and nature of unemployment in an underdeveloped country such as Turkey form the essential background. Insufficient demand for labor, oppressive living conditions for the unemployed, and the absence of hope for future improvement in employment conditions produce a high desire to work devoid of a specific job or career goals, tendencies which account for the willingness of workers to accept any kind of work as long as pay is adequate. Most Turkish migrant workers have been found to be oriented toward accumulating as much money as possible, not for use as a means of changing their structural situation or improving their employment qualifications, but as an end in itself. The hypothesis that polyannual migrants acquire new knowledge and ability to adapt to the mode of life of an industrial society, internalizing its structures, roles, and values, recieves little confirmation in the literature. A large proportion of Turkish migrants remain attached to preindustrial habits and preferences for work in a milieu that assures personal relationships. Few report in surveys that they learn significantly in their migrant jobs. Migrant workers who are only superficially familiar with industrial culture and who reject the mode of life of industrial society cannot be viewed as a force for change and innovation when they return. Migrant remittances are steadily increasing, but until the present, no structural changes have been made in Turkey to encourage their investment in productive enterprises. Personal or familial reasons, not desire to undertake new enterprises, are most often the cause of migrants' return; once they have done so, they aspire to new occupations in the tertiary sector rather than return to their earlier lines of employment. (author's modified)

Etiology and treatment of nongonococcal urethritis.

The significant progress of the last decade in determining the etiology of nongonococcal urethritis is reviewed, and current treatments are assessed. Convincing evidence that Chlamydia trachomatis is the cause of 30-50% of cases of nongonococcal urethritis has been developed by many groups from isolation data, serologic studies, urethral inoculation of monkeys, and studies of postgonococcal urethritis. Other evidence that C. trachomatis is a urethral pathogen is that its selective eradication results in alleviation of urethritis in C. trachomatis-infected men. The cause of nongonococcal urethritis when C. trachomatis infection cannot be proven by isolation or serologic testing is unclear. The most likely cause of a significant proportion of the C. trachomatis-negative cases is Ureaplasma urealyticum. Although studies of the role of U. urealyticum as a urethral pathogen have been complicated by the fact that in health the rate of urethral colonization is strongly correlated with an individual's total number of sex partners, and serologic studies have not supported a role for U. urealyticum, other evidence is consistent with such a role, including treatment studies and experimental inoculation. Assuming both C. trachomatis and U. urealyticum are etiologic agents, in another 20% of men with the disease neither organism is initially isolated. False-negatives probably account for some of the cases, but poor response to treatment for the 2 pathogens suggests they constitute another group. Although the incidence of gonorrhea has tended to stabilize recently, that of nongonococcal urethritis continues to rise sharply. Management requires diagnosis of urethritis, exclusion of urethral infection with Neisseria gonorrheae, choosing an appropriate antimicrobial for the patient, treatment of sexual contacts, and follow-up of the patient. When the patient is symptomatic, has a readily expressible discharge, and the exudate contains many polymorphonuclear leukocytes but not gram-negative diplococci, diagnosis is easy. However, when symptoms or signs are minimal, arbitrary criteria must be utilized in diagnosis. In individual cases it is impossible to distinguish between gonorrheal and nongonococcal urethritis on clinical grounds, and the final diagnosis requires laboratory examination for N. gonorrheae. Tetracyclines, erythromycins, and a combination of sulfonamides and an aminocyclitol, which almost always eradicate C. trachomatis, were recognized as the most effective therapies by the 1950s. Although many studies have been done, the optimal drug dose and duration of therapy have not been determined.

1980 census of population. Vol. 1: characteristics of the population. Chapter A: number of inhabitants. Part 54: Guam.

"This report presents statistics from the 1980 Census of Population on the number of inhabitants of the Area [Guam], its subdivisions, places, and certain other geographic areas." (EXCERPT)

1980 census of population. Vol. 1: characteristics of the population. Chapter A: number of inhabitants. Part 56: American Samoa.

"This report presents statistics from the 1980 Census of Population on the number of inhabitants of the Area [American Samoa], its subdivisions, places, and certain other geographic areas." (EXCERPT)

[The Revolutionary armies according to the call-up registers]

An analysis of the mortality of soldiers serving in the armies of France in the early years after the French Revolution of 1789 is presented. Differences in losses are examined by region. (ANNOTATION)

Microbiology and pathogenesis of acute salpingitis as determined by laparoscopy: what is the appropriate site to sample?

Acute salpingitis is a polymicrobial disease. Neisseria gonorrhoeae and anaerobic gram-positive cocci were the predominant microorganisms isolated from the fallopian tubes of salpingitis patients. Gonococci were isolated from the fallopian tubes in 8 of 35 (23%) patients; anaerobic bacteria were recovered from 10 of 35 (28.5%). Although Chlamydia trachomatis was not recovered from the fallopian tube exudate, there was abundant serologic evidence of chlamydial infection in the salpingitis patients. 23% of patients with paired sera had a 4-fold rise in IgM and IgG titer, which was consistent with systemic chlamydial infection. Comparison of cultures obtained via laparoscopy and culdocentesis suggested that culdocentesis is not an accurate reflection of the microbial milieu in the fallopian tube. (author's)

Stability and change in family size preferences among rural youth in Kenya.

An analysis of family size preferences among rural youth in Kenya is presented. The data concern 918 individuals between the ages of 13 and 21 who were interviewed in a two-round survey conducted in 1979-1980. The results indicate that "youth in rural Kenya have higher ideal fertility than desired fertility, that younger youth have higher family size preferences than older youth and that males generally have slightly higher family size desires than females." It is noted that "a unique feature of the data is that the same questions were asked of respondents nine months apart. While the period between interviews is not ideal for a test-retest reliability check, analysis indicates that the level of stability in response to family size preference questions was remarkably high for a population of this type." (EXCERPT)

1980 census of population. Vol. 1: characteristics of the population. Chapter A: number of inhabitants. Part 55: Virgin Islands of the United States.

"This report presents statistics from the 1980 Census of Population on the number of inhabitants of the Area [United States Virgin Islands], its subdivisions, places, and certain other geographic areas." (EXCERPT)

[1980 census of population. Vol. 1: characteristics of the population. Chapter A: number of inhabitants. Part 53: Puerto Rico]

"This report presents statistics from the 1980 Census of Population on the number of inhabitants of Puerto Rico, classified by urban and rural residence and by size of place; its municipios, municipio subdivisions..., places..., standard metropolitan statistical areas, standard consolidated statistical area, and urbanized areas." (EXCERPT)

Inventory of marriage and family literature, 1983.

The present volume contains citations to 3,302 articles on marriage and the family that were published in English in 780 journals in 1982. The bibliography, which is unannotated, is presented in three sections: a subject index, an author index, and a keyword in title (KWIT) index. A list of periodicals cited is also included. (ANNOTATION)

Migration and technological change in agriculture: results of a case study in the Green Revolution Belt of India.

The relationship between migration and technological change was studied at the micro level, using data gathered in a household survey conducted in 26 villages of the Ludhiana district in the Green Revolution belt of the Indian Punjab. Several important policy related questions were examined. The methodology adopted involved comparing the production pattern of and technology used by farming households which have experienced out-migration, in-migration or return migration with those households which have not (the control group). The field survey identified 1114 farming households of which 25 gave information for some questions and were therefore exluded from the analysis. Of the remaining 1089 households, 239 had at least 1 out-migrant each, 149 at least 1 in-migrant each, and 82 at least 1 returned migrant each. The number of farming households that had no migrant was 619. Analysis of the data points to several broad conclusions: out-migration of youthful members from the farming households did not appear to have adversely affected the adoption of high yielding varieties (HYV) technology; among the migrant households, returned migrant households appeared, on an average, to be relatively innovative and in-migrant households relatively less so; as among different farm size groups, large farmers tended to be initially more responsive to HYV technology than small and medium farmers; at the time of the survey there was more or less universal adoption of HYV in regard to wheat and rice, but the progress in the case of maize appeared to be considerably slower. Analysis of the data on the adoption of capital intensive technology showed that it was positively biased in favor of large farmers. As between migrant and nonmigrant groups, the percentage of households using a tractor was higher among the migrant groups, but there was no significant difference in the use of a thresher and a tubewell between the 2 households. The data analysis also showed that out-migrant households had adopted capital intensive technology relatively earlier than other households and in most cases prior to the out-migration of household members. The data on the improved agricultural practices showed that a relatively larger percentage of returned and out-migrant households used them as compared with non-migrant households. In general, study results suggest that out-migration of relatively more dynamic members from the farming households did not adversely affect the process of adoption of new technology. There was no evidence that loss of family labor reduced output or overall labor intensity. There was some evidence that out-migration from the farming households led to an improvment in land productivity, particularly in the long run.

Fertility impacts of irrigation and electrification in Northeast Thailand.

Preliminary results are reported from 2 household level studies conducted under the program in Northeast Thailand which were disigned to improve the knowledge base and to generate empirical information about the fertility effects of development. The 1st study conducted focuses upon the fertility impacts of agricultural irrigation systems and the second upon the fertility impacts of rural electrification. The general working hypothesis is that fertility is affected indirectly by development, i.e., availability and utilization of electrification and irrigation systems in combination with each other and other development projects alters the social and economic structure of households which affects norms of family size, infant and child mortality, the intermediate variables, and ultimately fertility. For the irrigation study, all villages in the Northeastern region of Thailand were stratified into 4 groups on the basis of the size and existence of agricultural irrigation systems (AIS). The groups were: large AIS; medium AIS; small AIS; and no AIS. A systematic random sample of 20 households from each village in each stratum was selected resulting in a total of 4500 households. Couples in villages with large and medium size irrigation systems had slightly lower fertility than couples in villages with either a small system or no system. Household participation in irrigation systems showed a curvilinear relationship with fertility where the highest fertility was found among households with "low participation" and the lowest fertility among households with "medium participation." The most important predictor among the development indicators was the "use of electricity." There was a direct relationship between use of electricity and couples income, and of the 4 development indicators the use of electricity was the more important predictor of income. Fertility showed a curvilinear relationship with use of electricity where the highest and lowest levels of fertility were found among households "using no electricity" and those using for "24 or more months," respectively. The use of electricity has a positive effect on income which in turn exerted a negative effect upon contraceptive practice. Contraceptive practice then affects recent fertility (births in the last 5 years) negatively. The effect of use of electricity on female labor force participation was negative, but female labor force participation affected desired family size positively, which in turn exerted a negative effect upon contraceptive practice.

Making rural development projects more effective: a systems approach.

This paper focuses on how to make existing rural development projects (RDPs) more effective. It describes a management systems approach to project planning and implementation. Through project experience, specific subsystems which contribute to the success of RDPs are identified. This approach stresses the interaction between subsystems as contrasted with the common approach of developing individual subsystems. Project design should be based on information about the behavior of the intended beneficiaries. Fieldworkers are vital for providing technical services, supply inputs, and education to the beneficiaries. A program research/evaluation/monitoring subsystem is important for providing information from the field level to the planners/administrators. Technology and supply inputs subsystems are vital for success; project managers, therefore, must understand the process of technology generation and adaptation to ensure that it is relevant and in useable form for the beneficiaries. Production, transportation, storage, and utilization of supply inputs must be carefully planned and monitored. RDPs often overlook the crucial issues concerning the dissemination and utilization of technology which involves fieldworker training and communication media/materials support subsystems. Training needs to be job oriented, and media should give priority to strengthening the project infrastructure by supporting the training and fieldworker subsystems. The role of the planning and administration/supervision subsystems is to draw upon and blend together all the other subsystems; without proper interaction, the overall project can fail. A systematic approach to involving specialists from all the subsystems must be developed. A successful project requires that managers understand the constraints to implementing the systems approach which are brought about by the organizational structure and other factors.

[Possible effects of alternatives in family size variations on the genetic and social composition and structure of Western populations]

The effects of alternative reproductive patterns on the genetic and social composition and structure of modern populations are explored. Topics considered include genetic inheritance, social mobility, and economic needs and opportunities. The authors point out that because of segregation and recombination, the global genetic effect of differential fertility is small per generation but possibly significant if the differential pattern is maintained for several generations. (summary in ENG) (ANNOTATION)

Maternal nutritional status and adolescent pregnancy outcome.

To investigate the determinants of low birth weight of infants born to adolescent mothers, the obstetric population attending at the Maternity Hospital of Lima, Peru was studied. From this population a sample of 1256 adolescent mothers ranging in age from 12 to 25 years was selected for study. The study included anthropometric and biochemical measurements used to evaluate nutritional status and physiological maturity of the mother and newborn. Findings indicate that the low birth weight of infants born to adolescent mothers is not due to premature delivery (short gestation) or low gynecological maturity. Furthermore, young adolescent mothers had smaller and thinner newborns than those born to older women who were adjusted for nutritional status during pregnancy and at delivery. That is, despite the similar nutritional status among the young adolescent mothers, the availability of nutrients for the accumulation of calories in the fetus (measured by skinfold thickness) was less than that of older women. Furthermore, the pregnancy weight gain associated with an optimal or average newborn weight is greater for young teenagers than for older women. These findings support the hypothesis that among rapidly growing teenagers the nutritional requirements of pregnancy may be greater than those of older women, and that this increased requirement competes with the growth needs of the fetus. (author's)

Baby bust and baby boom: a study of family size in a group of University of Chicago faculty wives born 1900-1934.

After over a century of declining birth rates, the fertility of American women rose during the baby boom of the 1940s and 1950s. A group of 60 University of Chicago faculty wives, 30 born in the years 1900-1914 (cohort 1), 30 in 1920-34 (cohort 2), are studied to see if their pattern of fertility is similar to that of the US in general. 2 models are proposed to account for the rise in fertility: model 1 is based on the Easterlin hypothesis that postwar affluence, contrasted with remembered poverty during the Depression, made young couples feel able to afford large families, and model 2 is based on Ryder's finding of a high level of unintended fertility during the baby boom. For model 1, in cohort 1, socioeconomic status (SES) family of origin was related negatively to number of children, but the relation was short of significance; in cohort 2, the relationship between number of children and SES family of origin was significant but positive, opposite from the prediction. Thus the data do not support the hypothesis for this sample. For model 2, cohort 1 women had a mean of .3 accidental pregnancies and women in cohort 2 had a mean of 1.3 accidental pregnancies; the difference was significant. Women in cohort 2 desired larger families than those in cohort 1, but the difference was not significant. Positive correlation between number of children and number of accidental pregnancies confirms the importance of unintended fertility in explaining large families in the study sample, thus confirming model 2. Dislike and/or difficulty in consistent use of birth control proved significance at the .05 level in explaining number of accidental pregnancies; this was more likely in cohort 2 than in cohort 1 and explains some of the variance in unintended fertility both within and between cohorts. Thus only model 2 is supported by this study.

Introduction.

This introductory section to "Modern Migrations in Western Africa" discusses the following: the migratory phenomenon in contemporary West Africa; the magnitude of the migratory phenomenon in West Africa; the mechanism of migration; the migratory phenomenon, element of the process of proletarization; the effects of migration, criticism of cost benefits analysis; other types of migration; migration and the national problem; and national seminar results. It would be difficult to underestimate the magnitude of the migratory phenomenon in West Africa. The general character of migratory movements in West Africa are well known and the following may be distinguished among them: the migratory movements of labor outside Nigeria, i.e., the flow from the regions of the interior towards the coast, in the direction of the plantation zones as well as cities, and the migratory flow from certain regions of Mali and interior Guinea towards the Senegalo-Gambian groundnut zone and the towns of Senegal; the migratory movements of colonization outside Nigeria; the migratory movements in Nigeria; the migration of skilled labor and that of merchants; the exodus from Africa (towards Europe) of nonskilled labor; and migrations to the west of Nigeria. The annual flow of movement is estimated at 300,000, concurrently composed of 2/3 seasonal migrants and 1/3 migrants who do not participate in the agricultural work in the country of their origin because of the duration of their absence. Settled migrants and their descendants, who have become proletarianized in towns or established as farmers on a permanent basis, reduce the need for seasonal migrants. The causes of migration cannot be separated from their consequences, for migration is not simply the consequence of unequal development due to "natural causes" (the natural potentialities of different regions). Migration is also an element in unequal development, reproducing the same conditions and contributing in this manner to their aggravation. Thus, evaluation of the effects of migration in terms of cost benefit analysis is equally deceptive. Migrants are clearly an impoverished proletariat. On the urban market, as well as on the plantations, they occupy the lowest postions and are the worst paid. Migrations in West Africa are mainly international in the contemporary legal sense, and they are also still very largely interethnic migrations.

The cytology of intrauterine contraceptive devices.

To study the cytology of the IUD, 52 young women using Lippes loops for periods ranging from 5 hours to 39 months were examined by means of clinical, cytologic, histologic, and cytohistochemical means. The loops were removed, placed on slides, gently smeared, fixed in ether and alcohol mixture, and stained by a variety of methods. The findings from urethral, vaginal, ectocervical, and endocervical smears were normal and corresponded to the cyclic hormonal status of the women. All smears were bacteriologically negative except for Doderlein's bacilli, and fewer than usual inflammatory changes were seen. Trichomonas or monilia albicans infestations were not seen. 3 kinds of cells were found in each of the loopal smear slides, macrophages, fibroblasts and their derivatives, and blood cells. Up to 50,000 macrophages showing stages of phagocytosis in their cytoplasma were present in each slide. The number of macrophages increased continuously in proportion to the duration of insertion, and neutrophilic polymorphonuclear leukocytes dropped to a minimum. In smears taken from loops removed during a menstrual period, decreased macrophages and increased polymorphonuclear leukocytes were observed. Young fibroblasts were second in number to macrophages in the smears from loops in use for longer than 1 month. Numerous mitotic figures also were observed among the fibroblastic cells, but phagocytic inclusion bodies were rare in these cells. Fine fibrous threads originating from the cytoplasm were frequently observed. Erythrocytes were numerous in the loopal smears, while polymorphonuclear leukocytes, lymphocytes, and monocytes were seen in equal proportion to that of a normal blood spread. Neutrophilic polymorphonuclear leukocytes were abudant when the loop had been used for a few days, and subsequently disappeared. Neutrophils increased during menstruation. Spermatozoa were occasionally seen in loopal smears but were generally degenerated. An insignificant number of bacteria were seen in smears from patients with no IUD complications. Endometrial aspirates from 50 symptom-free women who had never used an IUD showed few macrophages. In 2 women on whom the aspirations were performed during menstruation, small groups of macrophages were scattered among the erythrocytes. From the observations of the phagocytosis of spermatozoa and ovum-like globules in the loopal smears, it was concluded that the IUD acts as a contraceptive through the phagocytic and enzymatic action of macrophages.

Anti-sperm antibodies, HLA antigens, and semen analysis [letter]

2 groups of men seeking advice for infertility problems, those with an unusually high proportion of mononucleated cells in their semen and those who had had their vasectomies surgically reversed, were assessed for antibodies to sperm and for an association between antisperm antibody production and particular HLA antigens. The former group was investigated to determine whether the presence of mononucleated cells in the semen was an indication of antisperm antibody production. The vasovasostomy cases were investigated because of a suggestion that antisperm antibodies might decrease fertility by lowering sperm viability in men who had their vasectomies reversed. HLA antigen frequencies among men with and without antisperm antibodies were compared in men tested for antisperm antibodies as part of a clinical investigation of infertility. Most of the men were normospermic and none had been vasectomised. Antisperm antibodies were assayed in sera and/or seminal plasma by macroscopic gelatin agglutination assay. No association was found between the presence of a high proportion of mononucleated cells in semen and antisperm antibody production. Antisperm antibodies were detected in 29% of vasovasostomized men, a much higher frequency than that reported for vasectomized men. It appears that in some vasovasostomized men not only sperm but also antisperm antibodies pass into the ejaculate. HLA A28 was more common than expected among men who had produced antisperm antibodies without undergoing vasectomy. Limited study data did not support the hypothesis that antisperm antibodies might decrease fertility by lowering sperm viability in vasovasostomized men. Poor post-vasovasostomy sperm motility was however noted in both men whose wives became pregnant and men whose wives did not.

Endocrine aspects of acne.

Androgens stimulate growth of sebaceous glands and enhance the production of sebum. Acne often appears when androgen levels rise, and the ascertainment of elevated circulatory plasma androgens is much more successful than it was 10 years ago. There are only 2 sources of androgen production in the body, the adrenal and the gonad, but end organs such as liver, fat, and skin have the potential to further metabolize precursors into more potent androgens, thus essentially functioning as endocrine organs. Both the adrenal gland and the ovary may overproduce androgens if malignant tumors occur. The most useful screening blood tests to ascertain elevated levels of androgens in patients with acne are plasma-free testosterone and dehydroepiandrosterone sulfate. Rational hormonal therapy for acne is in its infancy and should be undertaken only in selected patients who have had appropriate endocrine evaluation and supervision. Empirically, both oral contraceptives (OCs) and low doses of glucocorticoids have been used with partial success for many years to treat acne. OCs with low (30 mg) to moderate (50 mg) doses of estrogen and a relatively nonandrogenic progestin such as norethynodrel, ethynodrel diacetate, and norethisterone or its acetate should be prescribed. Use of OCs eliminates the ovarian contribution to androgen excess and raises the testosterone-estrogen-binding globulin, thus lowering free androgens nonspecifically. Therapy with very low doses of glucocorticoids such as prednisone 2.5 mg, methylprednisolone .4 mg, or dexamethasone 0.25 mg may be useful as well. In the near future it is hoped that a group of drugs called antiandrogens, which prevent the action of the hormone at the target organ will be available.

Recovery of fertility following vasovasostomy.

A case is presented of a 29-year old man who had a vasectomy performed in 1974 and a vasovasostomy in 1977, and for whom no obvious reason for infertility had been found. Antiserum antibodies have been detected in up to 60% of men who have had vasectomies. Following vasovasostomy the antibodies tend to persist but it is not certain whether this affects fertility. This patient had a normal semen analysis and his partner was normal; it was assumed that the immunologic factor was playing an important role in his infertility. He was started on dexamethasone and subsequently a pregnancy was achieved. It is, however, not certain whether his ability to achieve pregnancy was due to diminution in antibody titer or to some other undefined effect of steroid administration. Other antibody mediated forms of male infertility have been treated with much higher doses of steroids, up to 96 mg methylprednisolone daily. (summary in GER)

Oral contraceptives, methionine and endothelial lesion.

Estrogen (mestranol), 1 mcg/kg administered for 1 week decreased the tolerance of rats for methionine, and women aged 20-30 years were prescribed oral contraceptives (OCs) after passing the methionine tolerance tests. The OCs prescribed for women were 0.25 and 1 mg cholersuperlutin combined with 0.08 mg mestranol. In 1 group this OC was combined with pyridoxine 120 mg daily in capsules. The study in rats showed oral administration of methionine 50 mg/kg to have no effect on endothelaemia counts. Tolerance for the same dose of methionine markedly decreased in animals treated for 1 week with with an estrogen preparation of mestranol 1 mcg/kg orally. The effect of estrogen treatment on methionine tolerance was completely prevented by simultaneous daily administration of pyridoxine 10 mg/kg. In women the results were expressed in terms of endothelaemia counts before and after the period of contraceptive treatment. In another group of women the OC was administered together with pyridoxine 120 mg daily for the same time period and no significant change in methionine tolerance was observed. The decreased tolerance in women was prevented by administration of OCs in combination with pyridoxine.

[Sexuality, contraception and pregnancy in adolescence]

Medical care for young girls should include attention to their developing sexuality. Girls of 13 or 14 desire information on sexuality and are receptive if the physician or nurse broaches the topic. The age at initiation of sexual relations is increasingly young, but is influenced by such factors as success in schoolwork and early maturation. The 1st sexual relations are usually unexpected and are seldom protected by contraception. Consistent failure to use contraception during adolescence is due to ignorance of the reproductive process, inability to structure their lives, romantic aspirations, and secret desires for a child. Pregnancies among minors are increasing in most countries and can compromise the career and marital future of the mother and the child's development. It is therefore important to motivate young women to use contraception. Withdrawal and rhythm are difficult to use and less certain than other methods. Barrier methods including vaginal spermicides have no side effects and appear suitable for use by adolescents who have only occasional relations. Spermicides with a diaphragm or condom permit greater contraceptive security and a sharing of the responsibility by the couple. Hormonal contraception is the surest, most frequently prescribed, and most acceptable method for young women. Low-dose combined pills and triphasic pills are recommended for young patients. Estrogen-only pills are indicated only rarely for young patients. Minipills have few side effects but are associated with menstrual irregularities in 50% of patients. Because of its strong central inhibitory effect, Depo Provera is seldom recommended for adolescents. Postcoital treatment with elevated doses of estrogen may be used but is associated with unpleasant side effects. Most of the objections to use of hormonal contraceptives in adolescents have been shown to be based on rare or not serious effects, and use is believed preferable to unintended pregnancy. The possibility of interactions with other medications, relative and absolute contraindications, and the need for careful follow-up should be kept in mind. In exceptional cases, IUDs may be prescribed but their rates of expulsion and infection appear high among adolescents.

Women, work, and family in the Soviet Union

This volume contains papers by a number of Soviet authors on questions related to female employment and its impact on family structure and demographic trends in the USSR. The papers, which are translated from Russian, are presented under three general headings: levels and patterns of female employment, the impact of female employment on the family, and policy for the 1980s. The papers included were previously published in Vol. 24, Nos. 5-7 of Problems of Economics, and selected papers were cited in Population Index. (ANNOTATION)

Subfertility and disruption in the Congo Basin

The harsh exploitation experienced in much of the Congo basin during the early colonial period set it apart from most other regions; this oppression was worst in the rubber-producing regions and the brutalities promoted the spread of venereal disease. That is, to avoid labor recruiters an alternative to escaping into the bush was to contract gonorrhea. This is considered a major reason for subfertility in the region, since there was not a history of conscious attempts to control childbearing in this area of Africa, a country with an overall birth rate higher than that of any other continent. It is thought that at some time in the past the circulation of women in the groups under consideration underwent some change which led to very high rates of infection. The cause of subfertility will probably have an effect for many years.

Introduction: population theory and the political economy of population processes.

This discussion of population theory and the political economy of population processes reviews the population problem, provides a brief history of population theory (Malthus, the Eugenicists, and the rising tide of the poor and environmental catastrophe theorists); political economy and population processes; international capitalism and population dynamics (the population establishment and 3rd world responses to population programs); issues in population processes (the value of children; women, reproduction, and power; and migration and the flow of labor); population processes in socialist countries; and population and the new politics of the family. Capitalism itself encourages population growth. Contrary to much of classical economics, surplus population, i.e., the number of people who are unemployed or underemployed, arises not because of natural increase outstripping resources but because the accumulation of capital which makes the people superfluous. Concern over the growing population of the 3rd world and, to a lesser extent, of the domestic poor, led in the late 1960s and early 1970s to a burgeoning literature on the "population bomb" and the limits to growth. These neoMalthusian analyses used mathematical models and computer simulations to show that the human race was outgrowing the capacity of the planet to support it. Analyses that weigh gross economic and demographic variables in an attempt to understand the relationship of the population to other socioeconomic factors ignore the international context in which population processes are played out, the relationships between and across societies, between the people of the poor countries and those of industrialized nations, between those in power and those whose lives they control, and even between women and men. The perspective taken is that population is not an independent variable, which "causes" poverty or underdevelopment, but a dependent variable--dependent upon the political economy of particular societies. In the simplest terms, the pressure of the superfluous population against wages lowers wages so that profits increase. If population growth is smaller than the demand for labor, wages will rise, but labor itself has limits to its productivity. If wages rise too high, the accumulation of capital is hindered. The demand for higher quality labor in the industrialized world resulted in a reduced fertility rate, but the penetration of industrial capitalism in to the 3rd world had the opposite fact. The penetration of capitalism in the 3rd world was totally different from its development in the West. NeoMalthusian concerns have provided the basis for US population policy in domestic and international assistance programs. Such policy holds the poor as responsible for using up the scant resources of developing countries, thus preventing investment that would lead to economic growth. There is no real evidence that a reduction in the birthrate leads to economic development, but some evidence exists that when development is broadly based, birthrates decline.

Cross-national labor migrants: actors in the international division of labor.

During periods of rapid capital accumulation, the process of accumulation that presupposes the expansion of production cannot proceed without the availability of surplus labor. In the context of this argument, 3 sources of labor reserves are traditionally considered: the floating reserve, which is repelled and attracted through cyclical and technological unemployment and employment patterns; the latent reserve, generated by the release of agricultural workers who are displaced by the introduction of large scale machinery into commercial production and thereby reduced to wages that are inadequate for household survival; and the latent reserve composed of the ever present irregularly employed working poor. By importing labor to the location of capital and the capital plant, capitalists in the core not only cut circulation costs but reduce the political and social costs of production as well. Attention here is directed to the role of foreign labor in the capital accumulation process, the rate of exploitation, the social costs of production (labor force reproduction; activity rates and dependency ratios; and health education and welfare); unemployment costs; the politics of class struggle; and unions, parties, and foreign workers. Within the core states, the use of an imported labor force offers many advantages, which can be identified in several aspects of the accumulation process. To the extent that cross national reserves of labor have been concentrated in those sectors of production offering the lowest paying, least skilled, most irregular, and most undesirable jobs, which are nevertheless essential to the ongoning functioning of the economic system, capital has been able to extract a higher rate of surplus values from these workers. Newly arrived waves of immigrants and migrant workers often form the most exploited and least privileged stratum of the working class. Social costs can be greatly reduced through the use of immigrant labor. Magnifying the social costs borne by the labor exporting regions is the selective nature of migration, which constitutes a skill drain as well as a capital drain. In addition to the savings in the social costs of producing an immigrant worker, the labor importing country also benefits from savings in the social maintenance of a foreign workforce. The reduced social welfare benefits which foreign workers receive is an additional source of social cost cutting. Many foreign laborers and their families do not qualify, or are unaware that they qualify, for the social welfare coverage commonly available to the domestic workers of most industrialized countries. Subtle advantages to capital acquire from the fact that immigrants, concentrated in unskilled jobs that are more heavily hit by unemployment, suffer disproportionately from cyclical unemployment. A proportionately greater part of the cost of supporting unemployment is transferred to the periphery. Union policies toward immigrant workers reflect a series of contradictions. Factors involved in the lack of active union organizing among foreign workers are identified.

Neo-Malthusian ideology and colonial capitalism: population dynamics in Southwestern Puerto Rico.

Neo-Malthusianism is based on the concept that because of the finite nature of economic resources (particularly land), the economic well being of a country or population cannot be improved if there are too many people competing for those resources. The theory is based on the assumption that population will automatically increase unless measures are taken to limit it. This notion is ahistorical, meaning that it cannot be disproved. Thus, it amy appear that the easing of demographic conditions in many areas has been a result of the implementation of population planning policies. This appearance is false, and radical scholars must make this point. This essay, which analyzes demographic processes in southwestern Puerto Rico, is 1 step in that direction. In Puerto Rico, population growth frequently has been cited during the 20th century as the key to the country's economic problems. Discussion of population dynamics and employment in southwestern Puerto Rico suggests that population growth in the plantation periphery can best be understood in terms of the reproduction of labor power. This is a process frequently fraught with contradictions. In the case of Puerto Rico, the process of proletarianization most adequately explains the process of social structural transformation leading to relative surplus population. Although this formulation cannot be shown conclusively, it is both plausible and testable. In contrast to the neo-Malthusian interpretations, it does not depend on untestable concepts of cultural values as causes of changes. Additionally, the emphasis upon social structural transformation and proletarianization is consistent with the other recent efforts to rewrite Puerto Rico's social history. It is appropriate in this analysis to respond to the question of why would the population not have grown as it did. The cost of producing a new human being was minimal in terms of such socially necessary resources as education. Clearly, population growth was a contradictory response to difficult circumstances, and the growth of the proletariat was 1 of a complex set of factors that effectively coopted its chances of revolutionary or even rapid evolutionary change. These conditions werew altered and the past century has seen important demographic changes. The population is growing at a rate in excess of the continental US, and it probably will continue to do so well into the future. The contradiction between production and consumption in a colonial capitalist economy was not resolved. It was simply ameliorated by the industrialization program, which created new problems of its own. In Puerto Rico the current crisis will result either in further population growth or a new strategy for dealing with incompatibilities of its status.

Properties of anti-sperm antibodies.

The properties of antisperm antibodies are examined to see whether they could have a role as a possible male contraceptive agent. In a 1959 study of 2015 male partners of infertile marriages evidence of antisperm antibodies was found in 3% but none were found in 416 men with pregnant wives. A serum titer of 32 is generally accepted as the minimum for significance in men. Following vasectomy antibodies are found in 60-80% of men and women tend to have relatively low titers of antisperm antibodies which produce head-to-head agglutination. A 1964 study found evidence of spermagglutination in 78% of women with unexplained infertility. In 1968 a study comparing 15 fertile and 21 sterile men showed a negative correlation between the concentration of antibodies and the ability of sperm to penetrate ovulatory cervical mucus. The spermatozoa antiglobulin reaction test screens spermatozoa in fresh human semen for antisperm antibodies and when used with 775 semen samples from the male partners of infertile marriages a satisfactory reaction was obtained with 86%. Of these, for 95% of patients without sperm antisperm antibodies the test was negative (less than 10% of motile spermatozoa attached to red cells) and positive in 93% of men with significant titers of agglutinating antibodies. It was concluded that impaired sperm penetration is dependent on the presence of immunoglobulin A antibodies in the semen, and at least 2 different auto- and isoantigens are involved. In a study 45 males who had been infertile for 2-10 years with positive antisperm antibody tests and impaired sperm penetration of cervical mucus were treated with repeated 7-day courses of methylprednisolone 32 mg 3 times daily from day 21-28 of their wives' menstrual cycles. 31% of the wives became pregnant in a cycle following treatment of the husband. The production of pregnancy was always associated with a marked drop in sperm immobilizing titer and usually with the disappearance of antibodies from seminal plasma. Antisperm antibodies were measured in serum and seminal plasma in 130 males before and after vasectomy reversal. Spermagglutinating antibodies were found in the serum of 79% of patients, seminal plasma antibodies were present in only 9.5% before reversal and this rose to 26% afterwards. The type of antibody produced in naturally infertile men is more potent in blocking fertility but pregnancies can be produced after vasectomy reversal even with high titers of seminal plasma antibodies. Much of the antibody produced after vasectomy is immunoglobulin G which does not impair penetration of cervical mucus. At present production of these antibodies is too unpredictable and their effects on fertility are too unstable to permit them to be used as a contraceptive.

The mode of action of 6-chloro-6-deoxysugars as antifertility agents in the male.

Alpha-chlorohydrin appears to exert its contraceptive effect by inhibiting glucose metabolism in spermatozoa. The 6-chloro-6-deoxysugars have a reversible antifertility effect in the male rat and marmoset monkey which provides a model of an ideal male contraceptive. They are too toxic to be used by humans, but it may be possible to develop related compounds with a more favorable therapeutic index from specific metabolites once these have been identified. The induction of spermatoceles in rats may not be such a serious obstacle since this effect was not observed in other species given high doses of alpha-chlorohydrin, nor in marmoset monkeys given 6-chloro-6-deoxygulcose. The relative efficacy of the various compounds as male contraceptives in the rat was different from the order to their neurotoxicity in the mouse. A wide range of substrates is available to spermatozoa in the female reproductive tract and spermatozoa from rats treated with 6-chloro-6-deoxyglucose can oxidize non-glycolytic substrates as well as controls can; it is probable that the inhibition of sperm glycolysis produced by 6-chloro-6-deoxysugars and by alpha-chlorohydrin is responsible for their contraceptive effect. It is also possible that the in vitro effect of alpha-chlorohydrin is not related to the effect of the drug in vivo and that the contraceptive effect on spermatozoa results from a change in the epididymal environment produced by perturbations in the physiology of the epithelium. Low doses of the 6-chloro-6-deoysugars or of alpha-chlorohydrin render spermatozoa infertile, but have no detectable effects elsewhere in the body. Selectivity could be produced by 2 mechanisms: 1) spermatozoa are exposed to a higher concentration of the active metabolite than other tissues, and 2) spermatozoa have some unique features which render them especially sensitive to the effect of the metabolite.

The effects of propranolol and some other beta-adrenoceptor blocking drugs on human sperm motility.

Because human semen volume is small and motility varies greatly between and within individuals, an acceptable method for studying drug effects on sperm motility should require sufficiently small volumes to make possible multiple compressions on a single ejaculate. The transmembrane migration ratio is now used to compare the effects of d- and dl-propranolol on human sperm motility; the difference between the 2 compounds was not statistically significant. Isoprenaline neither stimulated sperm motility nor reversed the inhibitory effects of propranolol. The inhibitory effect of propranolol on sperm motility is almost certainly dependent on its local anesthetic activity rather than beta-blocking activity. Drugs with membrane-stabilizing activity such as oxprenolol inhibit sperm motility while those with little or no such property such as setalol cannot decrease sperm motility to 50% of control. It is possible that the local application of the drugs discussed in appropriate dosage forms in to the vagina before coitus would act an an effective contraceptive.

Toxicological and serendipitous leads to male contraception.

The search for a male contraceptive agent involves looking for an agent which selectively affects some stage or stages of the formation and maturation of spermatozoa, the spermatozoa themselves, or the ejaculatory process. It has been reported that male rats fed a diet deficient in vitamin A alcohol but containing vitamin A acid develop testicular damage, affecting mainly spermatocytes. Win 13900 mainly acts on spermatids resulting in a fall in sperm count and a decrease in sperm motility; the drug does not affect Leydig cell factor. Nitrofuran derivatives affect the primary spermatocytes. It was noted in 1976 that an extract of hamster adrenal gland could induce whiplash motility and the acrosome reaction in hamster spermatozoa in vitro. A number of metals can also cause testicular damage such as cadmium; in addition spermatozoa partially depleted of zinc by being washed in the presence of albumin show certain biochemical differences from normal spermatozoa. Selenium and boron also affect the male. Pesticides can cause testicular damage; dichlorodiphenyltrichloroethane interferes with spermatogenesis and also diminishes the number of Leydig cells. Cytotoxic agents have been shown to induce infertility as well but their use as contraceptives for men is doubtful because of the danger of genetic damage such as sterility and testicular atropy. Benzanthrone, a dye, causes testicular damage as well. A 1976 study reported that the diamine-oxidase activity of human semen negatively correlatives with sperm motility. The author concludes: 1) there is a need for advancement in methodology inlcuding a quicker screening procedure, 2) a pharmacological analysis of the testicular vascular supply is needed, and 3) functionally inhibited spermatozoa should be produced.

Some social and demographic consequences of widening sex differentials in mortality.

The demographic consequences of the widening gap between male and female mortality are first examined, with particular reference to developed countries. The author then discusses some of the economic and social consequences of such differentials. It is concluded that the demographic consequences of excess male mortality are very slight, although deaths of men under 60 years of age are more common than deaths of women under 60 and attract considerable concern. (ANNOTATION)

The effect of birth interval on perinatal survival and birth weight.

The association between birth interval and 2 pregnancy outcomes was investigated: infant death and low birth weight. In addition to birth interval, maternal age and parity were treated as explanatory variables and the effect of previous pregnancy outcome was controlled by restricting the analysis to infants of women whose pregnancies ended in live offspring who remained alive at the time of the birth of the index child. The data used for this analysis consist of 12,995 singleton births of 2nd or higher order parity delivered in what was formerly called the Queen Farah Maternity Hospital in Tehran, Iran in August 1977-78. This hospital serves a population of primarily lower socioeconomic status. The 2 outcome variables were examined: infant death occurring before the mother's discharge from the hospital (perinatal mortality); and the incidence of births that weighed no more than 2500 gm. At the interval between births lengthened, the perinatal mortality rates (before hospital discharge) declined markedly for the 1st 3 years and then began to increase. The mortality of infants born after a 2-4 year interval was less than half that of infants born after a very short interval (9-12 months). Although the decrease in mortality reversed after 3 years, it remained less at 6 years than it was in the 9-12 months interval. The incidence of babies of low birth weight decreased steeply between 9-24 months since last birth. After 2 years, the incidence of low birth weight babies showed a slow downward trend until 6 years before it began to increase again. Perinatal mortality rates declined for the first 2-3 years postpartum and then began to increase. In general, mortality increased with parity; it was more than twice as high among women of parity 6 or higher (35/1000) as it was among women of parity 2 or 3 (14/1000). There was no significant parity interval interaction effect, but both parity and interval contributed significant main effects. In each parity stratum, the incidence of low birth weight declined over the 1st 2-3 years. The greatest interval effect was present in the low parity and high parity women where the incidence of low birth weight was more than 2.5 times higher for deliveries with a 9-12 months interval. For each stratum of maternal age, perinatal mortality decreased over the 1st 3 years of birth interval. When all maternal age birth interval combinations were considered, babies of women younger than 20 years had the highest mortality (58/1000) in the 9-12 months interval and the lowest mortality (8/1000) for a birth interval greater than 3 years. The incidence of low birth weight declined in each age stratum through the 25-36 months birth interval. By the logistic regression model, both interval and age contributed significant main effects.

The influence of rural-urban migration on the fertility of migrants in developing countries: analysis of Korean data. Final report.

This study investigates the impact of Korean migration from rural to urban areas on the fertility of women migrants, using data from the Korea World Fertility Survey of 1974. It was found that a woman's level of education and probability of labor force participation prior to marriage increase with increasing extent of urban background. But the percentage of women working at least once after marriage declined with the extent of urban background, contrary to expectation. Both family size preference and actual children ever born decreased with extent of urban background. Also about 1/3 of the migrants married within 1 year before or after their last migration, suggesting a close relationship between these events but without showing the direction of causality. The model used assumes that an individual wishes to maximize utility by choosing some combination of children and competing material goods under the constraint of a given household income and particular relative prices of children and goods. It is assumed that rural-urban migration has the effect of raising the price of children relative to other goods, so one expects to observe lower fertility among such migrants than among an appropriate control group. An autoregressive, or lagged variable, model in which fertility behavior at 1 time is a function of fertility of previous times and several other variables such as age and duration of marriage, is used. Major conclusions are: 1) adaptation to urban life is a significant phenomenon in explaining lower fertility of rural-urban migrants compared with that of rural strayers; 2) a major reduction in national fertility is assumed with the high volume of rural-urban migration that occurred during 1965-75; 945,000 women migrating from rural to urban areas during 1965-70 would reduce their fertility during the rest of their childbearing years by 1.31 million births; 3) rate of adaptation increased with duration of current urban residence for several 5-year periods, then fell; and 4) cumulative adaptation increased with the urban destination size. Some policy implications are: 1) the younger the age of migration, the more births will be reduced because of the longer exposure to urban lifestyle during the childbearing period; 2) policymakers must recognize that rural-urban migration is not a random action; and 3) selectivity has only a weak effect on fertility adaptation rates.

Male fertility potential in terms of semen quality: a review of the past, a study of the present.

Comparison of data from 1951 and from 1966-77 indicates that there has been no substantial change in the numerical aspect of semen quality over this period. Other researchers have suggested that a depression of spermatogenesis has occurred in US males. The 1951 baseline data are taken from MacLeod and Gold's study of 1000 "infertile marriage" patients. Modern trends are extrapolated from the authors' survey of the ejaculate volume and sperm counts in 14,476 men evaluated in 1966-77 because of infertile marriages. 9000 of these men were receiving their 1st semen examination, whereas 5476 had been examined elsewhere prior to referral. Semen specimens were obtained by masturbation after 3 days of continence in both studies. Over time, no consistent trend in sperm count was detected. The median count among the 1000 men examined in 1951 was 74 million/ml, whereas the median among the 9000 men examined sequentially in 1966-77 was 76.5 million/ml. In terms of the overall count frequency distribution, 16% of those in the 1951 study fell in the 100 million/ml group were 38% and 36.5%, respectively. None of these differences are significant. The average ejaculate volume of the 14,476 recent patients remained stable at 3.2 ml throughout the study period. Most notable was the orderly nature of the sperm count frequency distributions around the medians over the 1966-77 decade. Critical analysis of other studies from the 1951-77 period points to the need for clear definition of the types of populations studied since population nuances can produce some divergent results. For example, subjects from infertile marriages appearing for their 1st semen examination have the best semen qualtiy of any infertility population. Although no change was noted in semen quality standards, the authors concur with earlier suggestions that the minimal standards recommended by the American Fertility Society be modified. It is particularly urged that the present minimum sperm count of 40 million/ml be reduced and accompanied by a rider that any count level is meaningless unless the sperm motility parameter is included. Future articles will focus on changes in the qualitative aspects of ejaculate, sperm motility, and sperm morphology. The authors expect to demonstrate that significant changes have occurred in these parameters since 1951.

Reproductive impairment and the malformed uterus.

The reproductive potential of the malformed uterus is assessed, with emphasis on problems of vertical and lateral fusion. An obstructive transverse vaginal septum, which appears to result from a rare autosomal recessive gene, can be encountered in infancy or may not manifest symptoms until the onset of menstruation when menstrual blood accumulates. Hysterectomy is the recommended treatment, except in rare cases where there is only partial failure of the cervix to develop or there is a very short distance between the vagina and the endometrial cavity. Only 1 case of successful reproduction has been documented among women with this condition. Pregnancies have been reported in instances of partial transverse vaginal septum; however, postpartum pyometra and pyocolpos can develop, requiring emergency surgical drainage. Symptoms in women with obstructed lateral fusion are related to the site of obstruction. Reproduction may occur after removal of the vaginal septum in women with a uterus didelphys with a double vagina and low vaginal obstruction. Ectopic pregnancies have been reported inw women with an obstructed rudimentary horn. Unilateral obstruction is almost always accompanied by absence of the ipsilateral kidney, suggesting that bilateral obstruction is associated with bilateral kidney agenesis with consequent nonviability of the developing embryo. Reproduction appears to be somewhat compromised by infertility, pregnancy wastage, and premature labor in patients with either a didelphic or a unicornuate uterus. The bicornuate uterus causes only minimal reproductive problems, while the septate uterus is almost always associated with reproductive failure. Examination under anesthesia or laparoscopy may be required to distinguish between these 2 types of double uterus. Excision of the septum by wedge is the recommended operative treatment of a septate uterus. After this procedure, 77% of patients in 1 series had a term delivery. 73% of all pregnancies following the surgery were carried to term.

STD education: challenge for the 80s.

Discussion focuses on 3 aspects of sexually transmitted diseases (STD) education: the need for and appropriateness of school-based STD education; some elements of timely, high quality STD education; and strategies for dealing constructively with controversy. More than half of the estimated 20 million STD victims in the US this year will be persons under age 25. Almost 1/4 will be victims of STD before they receive their high school diplomas. STD are the most pervasive, destructive, and expensive communicable disease problems facing American youth. If the twin criteria of true experimental design and of measuring appropriate outcomes are applied to published studies, then the effectiveness of classroom STD education has not as yet been properly evaluated. The evaluation criteria which should be applied to health education programs are uniquely based on nonacademic goals, that is, ultimate outcomes are generally not observable in the academic environment. The federal government has been virtually precluded from supporting or conducting appropriate behavioral studies because of laws protecting individual privacy, and most school systems are similarly restricted when it comes to asking students about their personal or family lives, of which sexual matters are among the most intimate. Programs designed according to accepted concepts of learning and decision making need to be implemented, even if their benefits must be regarded as potential, until such time as research obstacles can be resolved. STD education objectives should be drawn from the behaviors relevant to the prevention, acquisition, transmission, and disposition of an STD. The behaviors are organized into 5 behavioral sets and described here as decision steps: decisions about when, how, and with whom to engage in sexual behavior; decisions specific to health protection if sexual behavior includes genital contact; decisions in response to suspected illness; decisions in response to diagnosed disease; and decisions related to other people. Within each decision step are various alternative choices, some that enhance health and others that jeopardize it. Once behavioral objectives have been formulated, decisions about content should be directed toward predisposing, enabling, or reinforcing those behaviors. Emphasis should be on the following: risk reduction; recognition; response; referral; and responsible resource. No particular instructional methods possess inherent superiority. It is questionable whether young people derive a maximum benefit from STD instruction if they have not initially learned rudimentary physiological and sociological facts of sexual life and how to discuss such matters. School systems should not delay efforts to meet the 1990 goal of high quality, timely STD education for every child in the US. Guidelines for community leaders who plan education programs are listed.

Contraceptive development for the future.

New methods of fertility regulation that are currently under investigation and development are described in accordance with their intended methods of interference with specific reproductive processes. A large number of chemical compounds and pharmacologic agents, steroidal or nonsteroidal, that interfere with spematogenesis appear inappropriate for human use because of severe untoward side effects. Among the more promising methods under study are luteinizing hormone releasing hormone agonists and antagonists which suppress spermatogenesis; new approaches to vas occlusion that would be more acceptable to men, including nonsurgical percutaneous techniques and electrocautery; a double plug reversible vas occlusion device made of polymer with an external suture loop for later removal; and chemical compounds for vaginal use that interfere with the fertilizing capabilities of sperm rather than relying on spermicidal effects. Improved vaginal sponges, diaphragms in which the spermicidal material is incorporated, a spermicidal-releasing vaginal ring, water-soluble spermicidal condoms made of polymer, custom-fitted latex cervical caps, and intracervical devices to release continuous low doses of progestins that interfere with cervical mucus are other possibilities under scrutiny. Transcervical approaches to female sterilization using quinacrine or methylcyanoacrylate, reversible methods of obstructing the uterotubal junction, IUD modifications to control side effects, long-acting preparations and delivery systems including injectable steroids and nonbiodegradable or biodegradable contraceptive systems which provide continuous medication at minimal daily doses, and immunological approaches including antipregnancy immunization and sperm antigens are at various stages of development.

Rural-urban migration and rural development.

Focusing on the various consequences of rural urban migration for rural development, attention is directed to the short-term impact of such migration on agricultural output, skill composition, resource composition, longterm shift in the labor supply, flow of remittances and return migration, and the overall effect of rural migration on rural socioeconomic structure. Whatever evidence there is tends to support the hypothesis that the allocation of work and resources, subject to the constraints under which a farming economy operates, is usually efficient, and withdrawal of labor would reduce production unless such withdrawal is synchronized with the agricultural cycle, off season migration, or when other compensatory measures are adopted. The 4 main compensatory measures would be the following: a shift in the crop combinations in favor of less labor intensive crops, or crops which would be cultivated by women; a technological shift towards labor saving capital equipment; a greater participation of the intermittent labor forces, particularly of women in work; and a greater reliance on hired labor from other villages. In regard to the impact of migration on the longterm supply of labor in the rural areas, it is expected that the absence of adult male migrants from the family would adversely affect the reproduction rate, both by delaying marriages and by reducing the period that couples stay together. This decline in the birthrate, coupled with the transfer of population, might in some situations lead to an absolute decline in the population living in rural areas. Another effect is the changes that migration brings about in the sex ratio. Broadly speaking, returned migrants can be classified as those who have been successful in the towns, those who are returning because they have failed, and those who originally left at the time of a disaster and returned when normal conditions were restored in the village. The impact of return migration essentially depends upon the type of return. The extent to which a returning migrant can become useful to the village community largely depends on the nature of skill and experience gained in the town, as well as the ability to acquire new values and ideas. Although migration has helped to ease pressure on the rural job market, it has not led in a vast majority of countries to an absolute decline in the size of the rural population because of a continually high rate of population growth. An appropriate migration policy should not simply aim at preventing migration through administrative fiat and restrictive measures. The 4 broad aims of a government's migration policy should be to ensure that migratory movement is not induced by rural frustration, intrarural inequality and rural urban inequality; is directed towards smaller urban settlements and avoids very large urban agglomerations; is slowed down to a pace which avoids a serious disruption of life or economic activity either in that place of origin or in that of destination; and does not simply have the effect of transferring a problem from 1 area to another.

Fertility levels and trends as assessed from twenty World Fertility Surveys.

Basic findings on fertility levels and trends from 20 developing countries for which World Fertility Survey (WFS) data are available are presented and compared. 13 are among the 35 most populous developing countries. The 3 largest, Bangladesh, Indonesia, and Pakistan, appeared to have poor quality data for both fertility trends and levels but detailed data assessment provides little evidence of a sustained fertility decline in any by the mid 1970s. Nepal and Kenya, among the 13 most populous, also had trend data of questionable quality with no indication of decline; there was good evidence in Kenya of a total fertility rate as high as 8.3 in the mid 1970s. Colombia, Malaysia, Mexico, Peru, Philippines, Republic of Korea, Sri Lanka, and Thailand, the other 8 large-population countries, all showed substantial rates of decline, ranging from 36% in Colombia to 17% in Mexico and 18% in Peru. All 8 had total fertility rates in the early to mid 1960s equal to or below the average of 5.3 for all 20 countries combined. In 1965-75, Mexico had a weak family planning effort and Peru had none. 6 other countries had strong or moderate family planning programs. Of the 7 small countries, Jordan and the Dominican Republic had above average fertility levels but poor data quality do not permit trend assessments. WFS data for the Dominican Republic shows a fertility decline, possibly exaggerated, for the late 1960s to the early 1970s. Costa Rica, Fiji, Guyana, Jamaica, and Panama, all showed relatively low fertility levels and those with adequate trend data showed declines ranging from 46% in Costa Rica to 25% in Jamaica. Guyana had a 30% fertility decline from about 1963-73 in the absence of an official family planning program. In sum, fertility declines were solid and accelerating by the early 1970s in the 12 countries for which data permitted trend assessment, but in those with the greatest data needs, WFS surveys failed to provide reliable estimates of fertility levels and trends.

The effects of population on nutrition and economic well-being.

The effects of population on food supply and economic well-being are theorized. Food production is affected by the demand for food; an increased demand for food eventually leads to a greater supply. Topics examined include innovations in subsistence agriculture, market agriculture, the advancement of technology, transportation networks, and the relationship between population, food and land. It is argued that population growth may actually speed up the adoption of agricultural innovations. In the past, farmers produced only what they could eat and market. Therefore, the amount of food produced cannot be used as a clear indication of the production capacity. Malthusian logic is concerned with increased population pressure on agricultural land. Contrary to Malthusian theory, this article suggests that food can be provided with increasing, rather than decreasing, ease as population and income grows. Population growth often causes people to expand the amount of arable land, plant more intensively, and invent and adopt new food-producing techniques. Roads, communications, and other infrastructures result from sufficiently high income and dense population settlements. These, in turn, results in long-term increases in productivity and cheaper food, with higher consumption per person. In developed countries, increased food is produced by fewer farmers. The number of farmers can also be expected to be reduced in developing countries as they get richer. A key aspect of a modern economy is its ability to deal quickly with newly arising problems. Although there will continue to be temporary food shortages in the future, modern technology will assure that mankind will prevail against the scarcities.

Economics and population growth: a comment.

This comment is addressed to 3 articles which modify the Malthusian schema and complicate Malthus' insights. Malthus' weak point, to Etienne van de Walle and Susan Watkins, is in the assumed relationships among nutrition, morbidity, and mortality--the means by which the positive check coming from a diminished food supply in relation to population was thought by Malthus to achieve an equilibrium, at the subsistence wage, between agricultural supply and population demand. To Thomas McKeown, the required modification to Malthus lies in the need to alter the implicit assumption of a fixed technology of agricultural supply, around which population pressure fluctuates in response to the positive check of mortality and to the preventive check of fertility control. Whereas McKeown implicitly accepts the concept of diminishing returns to increased inputs of labor in agriculture, Julain Simon overturns even that. An increasing population and even an increasing agricultural labor force can be sustained by the existence of endogenous and continuous technological change which leads overall to increasing rather than diminishing returns to population growth. All 3 articles reject the notion of a long-run equilibrium in the relationship between resources and population. The articles of McKeown and Simon discuss the sources of technological change. McKeown states that technological change is the means by which mankind escaped, during the industrialization period, from the Malthusian trap. Simon attributes the advances in agriculture and transportation directly to the impact of increasing population.

Population, policy, and political atavism.

The Presidential Address at the Annual Meeting of the Population Association of America (PAA) outlines the effects of the current political climate on the field of demography. First, government cutbacks have forced many experienced demographers to leave government service; moreover, austerity measures have produced a decline in the quality of data collected, a loss of geographic coverage, diminished access to data, and curtailed dissemination of results. Of major concern to demographers is the recent decision to reduce the size of the Current Population Survey and the National Health Interview Survey. Second, support for basic data collection and analysis from international agencies, including the US Agency for International Development (USAID) and the World Bank, has been reduced. The United Nations Fund for Population Activities (UNFPA) has been reluctant to follow through with technical assistance for data processing of the 1980-81 censuses it helped to launch. The future status of population policy centers located in planning ministries in numerous countries is also in doubt. Countries in sub-Saharan Africa, where there is an acute need for more accurate information, have been hardest hit by cutbacks in research. A 3rd area of concern involves the intellectual foundations of population policy. Revisionist writings, asserting that the effect of population growth on development is at best indeterminate, are on the upswing. Research in the field of population is further threatened by the dramatic growth of antiscience religious groups. As these groups grow in political influence, funds for population research will be increasingly vulnerable. PAA is considering affiliation with the Consortium of Social Science Associations, a coalition which has been involved in efforts to forestall cuts in federal research funding. It is concluded that continuous efforts are required to maintain conditions under which the field of demography can flourish.

An immunological approach to male fertility control using antibodies to FSH.

Despite the lower circulating luteinizing hormone (LH) levels, testosterone production does not appear to be affected in follicle-stimulating hormone (FSH) immunized animals. Active immunization was performed in 4 sexually mature rhesus monkeys in 1977. The antigen used was a highly purified ovine FSH preparation. Testicular biopsies were performed 12 months after immunization and histological examination revealed a depletion of the germinal epithelium and a narrowing of the seminiferous tubules. During the 1st 6 months, extensive testing of antiserum specificity failed to detect any antibodies to LH. The results of the in vitro binding studies at a constant serum dilution of 1/5000 show that the binding of iodine-125-labelled hLH were low and generally not distinguishable from the non-specific binding. One explanation could be that LH antibodies interfere in the in vitro LH bioassay system where mouse Leydig cells are used but do not neutralize rhesus LH action in vivo. One way of avoiding the production of LH antibodies during active immunization with FSH is through the use of the beta-subunit of FSH as the antigen. These studies show that spermatogenesis does not remain suppressed after the 2nd year and that the monkeys are no longer infertile despite the continuing presence of high antibody titres. Alternative ways of maintaining high levels of antibodies without the need for continual boosting and the associated possibility of changing antibody characteristics is required.

Gossypol.

Gossypol is a yellow compound, insoluble in water, which occurs in pigment glands in various parts of the cotton plant. It is asymmetrical polyphenolic dinaphthyl dialdehyde, a reducing agent and very susceptible to oxidation. A publication from China in 1978 announced that 4000 healthy men had been on gossypol for over 6 months with an antifertility efficacy evaluated by semen examination of 99.89%, an investigation that arose from the finding that cooking with crude cottonseed oil, which contains gossypol, could lead to infertility. The author conducted a study in which gossypol given to 25 fertile men in a dose of 60-70 mg day for 35-42 days caused a progressive increase in the percentage of immobile spermatozoa, followed by oligospermia, necrospermia, and azoospermia in all subjects; recovery could occur around 3 months later. The antifertility effect was retained with a dose of 25-35 mg daily and side effects were reduced at the lower dose level. Another recent study states that 8806 men have taken part in a study with gossypol in China; the antifertility dose is 20 mg/day for 75 days (over 99% effective) and the maintenance dose for the study was 50 mg once weekly with main side effects of fatigue (12.61%), gastrointestinal upset (7.36%), an hypokalaemic paralysis (0.75%). Most of the latter responded to potassium supplementation. Recovery of spermatogenic function was followed in 2067 cases over 1-4.5 years posttreatment with 1523 roughly recovered, 339 showing evidence of recovery, but 205 remaining azoospermic. Toxicological studies emphasize the small margin of safety, with chronic ingestion in nonruminant animals leading to signs of malnutrition and ill health. The author maintains that inhibition of the proliferative stages of spermatogenesis by steroidal or nonsteroidal compounds such as gossypol is generally impracticable because of the delay before azoospermia is established and thus infertility guaranteed. From the clinical trial point of view, aspermatogenesis does provide a measurable end-point, but there is still a need for an oral contraceptive chemical which exerts an effective action both rapid in onset and in reversibility. The toxic effects of gossypol involve uncoupling respiratory chain-linked phosphorylation. It is hoped that the contraceptive action of gossypol will not depend on such a universal cell function but on some more special mechanism.

Potential contraception by interference with capacitation.

Capacitation is the period in which sperm are not immediately able to fertilize eggs as the sperm is in a transition from a non-fertilizing to a fertilizing gamete. This period appears to provide an ideal target for contraceptive attack but ultimate proof of capacitation requires fertilization of eggs. Capacitation is generally defined as a process which prepares the sperm to undergo the acrosome reaction but there is no general consensus as to when the capacitated fertilizing sperm loses its acrosome. The capacitation process has also been shown to be reversible in at least some species, yet the acrosome reaction is clearly irreversible. The acrosome reaction involves the fusion of plasma and outer acrosomal membranes, and involves considerable alteration in membrane associations, but changes during capacitation are not as clearly defined. The potential exploitation of a decapacitation factor (DF) compound as a contraceptive has been made impracticable by the reversible nature of DF-sperm association and by the failure thus far to identify the specific target of a DF. In addition, the removal of specific sperm plasma membrane components such as sterol sulphates, leading to effective membrane destabilization during capacitation, has been suggested. Metabolic activity appears to play a crucial role in the capacitation process and acrosome reaction of sperm from many mammalian species, suggesting that a contraceptive method directed toward irreversible inhibition of the glycolytic pathway would render sperm infertile. Another method of rendering the sperm infertile during capacitation might be by interference with complete dispersal of the acrosome-free sperm with hyaluronidase inhibitors. The possibility that alterations detected in vitro may not be identical to those in vivo has been studied as well. 1 potential drawback may be the questionable relevance to the human of responses obtained in nonhuman species. An attraction of the in vitro systems utilizing various species of laboratory animals is the rigorous assessment of capacitation that is now possible.

Food.

This article reviews possible trends in food production and population growth in the developing and developed worlds through the year 2030 and concludes that the world as a whole should be well able to feed itself both in 2000 and in 2030. World population is projected to increase from about 4.4 billion in 1980 to 6.2 billion in 2000 and 8.2 billion in 2030, while in 90 developing countries excluding China the increase is expected to be from 2.3 billion in 1980 to 3.6 billion in 2000 and 4.3 billion in 2030. In the mid 1970s average per capita calorie supplies for the world as a whole exceeded average requirements, but the developing countries were 5% short of requirements while the developed countries had 129% of requirements. By 2030 developing countries should have 25% more than minimum requirements on average, although disparities will persist and shortages will take longer to eliminate in the poorest countries. The percentage of the world population that is undernourished is expected to decline from 23% in 1980 to 11% in 2000 and 4% in 2030. Large differences in per capita calorie consumption will persist. Food demand in the developing world is expected to rise faster than domestic production. Large increases in captial investments and current inputs will be needed to realize the assumed growth rate, with the total investment in the primary crop and livestock sector amounting to about $70 billion in 2000. The ratio of current inputs to agricultural gross domestic product should increase from 20% in 1980 to 28% in 2000. 1/3 of developing countries will reach the limits of their resources in cropping intensity, arable land, potential yield, or some combination by 2000. Research in new agricultural technologies will be crucial in expanding production. In international trade the developing countries' net import deficit in cereals will continue to grow. The developed countries will be able to produce the amount of cereals needed by developing countries. The impact of growth on poverty and income distribution are difficult to predict, but over time agricultural growth is likely to reduce absolute poverty. Growth alone is unlikely to eliminate or greatly reduce poverty in the foreseeable future. Supportive measures will be needed to give access to inputs, benefits, and credit to small farmers, to encourage group and cooperative action and to redistribute livestock, forestry, fisheries, irrigation facilities and other inputs and resources toward small farmers and landless laborers.

Economic motivation versus city lights: testing hypotheses about inter-Changwat migration in Thailand.

Major theoretical models of migration and the hypotheses derived from them as well as previous research on migration in Thailand are reviewed as background for a discussion of the methodology and results of this study of migration flows between provinces (changwats) in Thailand. The analysis differs from previous studies in that it includes all nonzero inter-changwat migration streams in the analysis, examines all changwats together and includes separate analyses for Bangkok and non-Bangkok migration; analyzes female and male migration streams separately and also pools the data; includes interaction effects in the equations; tests relative and expanded gravity models which assume respectively that only the characteristics of the destination relative to the origin are important or that characteristics of origin and destination can be examined separately; and measures some key variables in a different way. The data were obtained primarily from the 1970 population census. The economic variables included in the analysis were chosen for relevance to the Thai context and therefore include rural to rural migration; the availability of farmland was added to the standard economic variables of income and unemployment, and the proportions of population living in urban areas was added to test the city lights hypothesis. The multivariate analysis indicated among other findings that economic factors predominate over the noneconomic attributes of urban areas; the economic conditions in destinations relative to origins have significant relationships in the hypothesized direction; male and female migration streams respond to per capita income and unemployment in the same way but males are more responsive to the availability of farmland; migration to and from Bangkok responds similarly to relative income and the availability of farmland as migration to and from other areas; in the unconstrained model, conditions in the area of destination all have significant relationships of the hypothesized signs; conditions in the area of origin play a more complex role, since they determine the push to migrate and also the ability to migrate; and the sign and significance of other economic variables at the origin vary depending on the specifications. The main conclusion of policy relevance is that the level of migration will increase with economic development, but the direction of movement will depend on the relative economic opportunities in various changwats, which may in turn be most susceptible to policy manipulation.

[Course of normotropic pregnancy in IUD users, with or without IUD extraction, under echographic observation]

125 patients who became pregnant while using IUDs were prospectively followed up according to a uniform protocol which required sonographic evaluation of the location of the device in relation to the embryo, and removal under sonographic control in all cases in which the strings were in place. 64 of the women used Lippes loops and 61 had copper Ts. 93 had had the devices inserted between 45-60 days postpartum, and 32 had had insertions during menstruation. 25 women were under 20 years old, 41 were 21-24, 35 were 25-29, 16 were 30-34, and 8 were 35 or over. 59 had 1 child, 35 had 2, 17 had 3, 7 had 4, and 7 had 5 or more. Of the women with Lippes loops and Cu Ts, 27 and 21 respectively had had the devices for 1-12 months, 14 and 21 for 13-24 months, 9 and 6 for 25-36 months, 3 and 7 for 37-48 months, and 11 and 6 for 49 months or more. Among users of Lippes loops, 29 confirmed the pregnancy at 6-10 weeks gestation, 27 at 11-15 weeks, and 8 at 16-20 weeks. 32 of the 64 had their IUDs removed. The 32 extractions were followed by 5 abortions, 2 premature births, and 25 term births. Among the 32 cases in which the devices were not removed, there were 15 abortions, 2 premature births, and 15 term births. Post-extraction abortions occurred at a gestational age of 14.5 weeks on average, compared to 16.7 weeks for cases without extraction. Among the 61 Cu T users, 31 entered the study at 6-10 weeks gestation, 23 at 11-15 weeks, and 7 at 16-20 weeks. The device was extracted in 30 patients, followed by abortion in 7 cases at an average gestational age of 12.9 weeks, premature birth in 4 cases, and a term birth in 19 cases. Among 31 women in whom the device was not extracted, there were 8 abortions at an average gestational age of 12.4 weeks, 6 premature births, and 17 term births. The main conclusion of the study was that prompt removal of the device should be the norm in IUD users who become pregnant. Sonographic follow-up is suggested as a routine procedure for purposes of prognosis and management. (summary in ENG)

Sojourners versus new urbanites: causes and consequences of temporary versus permanent cityward migration in developing countries.

The causes and consequences of the contrasting patterns of migration are important and remain essentially unexplored. Those who regard themselves as sojourners in the city will seek different kinds of housing, demand fewer amenities and services, behave differently with respect to making friends and joining organizations, use accumulated savings for different purposes, and respond to different political issues and candidates than will people committed to the city as their permanent home. Where a large proportion of inmigrants regard their stay as temporary, patterns of informal and formal urban social organization, the nature and degree of demands on urban government, and even the physical development of the city will be affected. This will hold regardless of whether the migrants who expect to return to their home places in fact do so. As long as they plan to return, their intentions will shape their behavior in the city. Attention in this comparison of sojourners and new urbanites is directed to the following: variation in the permanence of cityward migration (intercountry differences, the long run trend toward permanence); causes of variation in the permanence of cityward migration (economic and social consequences, levels and patterns of political participation, migration patterns and national political dynamics). Clearly, the stability of demand for urban labor partly determines the mix of temporary and permanent migrants. Differences in levels of industrialization and the pace of economic growth must account for much of the contrast in migration patterns between South Asia and Africa, on the 1 hand, and Latin America, Taiwan, and Korea on the other. Tensions among ethnic groups are a less noted urban factor which may affect the permanence of migration. Urban conditions in general, or as they bear on specific groups, are only part of the explanation for varying migration patterns. For example, except where strong economic discrimination is involved, urban economic conditions fail to explain the behavior of atypical streams--temporary or cyclic migrants in places where permanent migration is the norm or permanent migrants in heavily temporary settings. Rural migrants' desire and ability to return home after a shorter or longer stay in the city are strongly affected by their access to the land or to alternative sources of rural livelihood, by rural kinship structure, the importance of age graded social roles, the cultural and religious significance of the land, and by customs or events which make outcasts of certain groups of people. Rural conditions probably are the most important explanation for the particular forms of temporary migration in different areas but for the behavior of atypical streams. Commitment to the city strongly influences the flow of private savings into urban housing and associated amenities.

The effect of cancer and its therapy upon fertility.

When gynecologic cancer is treated by either surgery or radiation therapy, definitive infertility usually results. However, less is known about the aftereffects of these therapies when they are applied to the growing number of nongynecologic cancers that are now curable. Late effects of cancer treatment after total body exposure and low dose ranges include impaired fertility because of radiosensitivity of the precursor cells of the gametes. In males, impaired fertility produces no associated loss of libido, but in females, hormonal production may stop or lessen, causing loss of libido. Of the cells involved in the various stages of spermatogenesis, the spermatogonial cells are the most radiosensitive. Directly after irradiation no change in fertility is expected because mature sperm are not affected, and the supply of mature sperm will only be interrupted when a deficit occurs as a result of damage done to the spermatogonia. In females, the situation is similar in regard to exposure of the ovaries; sterility would not be expected until a mature form and its radio-resistant precursors became depleted and no new eggs matured. The question of the genetic effects of irradiation is controversial. The chance that the offspring will show evidence of being compromised in the 1st or 2nd generation is small, but the problem may reveal itself in future generations. It has been estimated that 30-80 roentgens constitutes the radiation dose that would double the mutation rate. In men, decreased sperm production begins about 60-80 days after exposure and the duration of the decrease depends on the dose given. With single dose exposure, complete recovery of sperm production occurs up to 18 months after 100 rads or less, within 30 months after 300 rads, and 5 or more years after 600 rads. Testes receiving standard fractionated doses greater than a 1000 rads total dose will be sterile. Testosterone production remains normal unless the doses are very high. In an effort to prevent sterility in female patients undergoing radiotherapy, the ovaries may be surgically removed out of the treatment field at laparotomy. Subsequent pregnancies apparently result in normal children, but latent genetic change has not been evaluated. There is evidence that alkylating agents, probably the most commonly used drugs in cancer chemotherapy, may result in permanent sterility in some cases.

The effects of schistosomiasis on the fallopian tubes in the African female.

104 patients among 151 subjected to removal of genital tissue for gynecological purposes in the practice of 1 physician at the Harari Central Hospital in Salisbury, Rhodesia, were adequately assessed for evidence of bilharziasis in the Fallopian tubes, as well as for the presence of bilharzial ova in the urine, stool, or rectal biopsy. Of the 104, 10 had definite evidence of bilharziasis in the tubes, and 3 also had Schistosoma hematobium in the urine, stool, or rectal biopsy. Another 3 had evidence of S. mansoni associated with Schistosoma hematobium in the rectal biopsy. 4 had no evidence of bilharziasis in the urine, stool, or rectal biopsy. 31 patients had no evidence of bilharziasis in the tubes, but S. haematobium was present in the urine, stool, or rectal biopsy. 63 patients had no evidence of bilharziasis in the tubes, urine, stool, or rectal biopsy. During the same period 38 ectopic pregnancies were treated by salpingectomy and the tubes examined. 6 of the patients (16%) had concomitant bilharzial involvement, compared with 4 of 66 patients (6%) without ectopic pregnancy, not a significant difference. In only 2 of the 6 ectopic pregnancies associated with bilharziasis was enough inflammatory reaction present to have been a possible factor in the production of the ectopic pregnancy. In the other 4 cases the ova probably caused no structural damage to the tubes and cannot therefore be implicated in the causation of the ectopic pregnancy. It was not possible to demonstrate any significant difference between the fertility of patients with bilharziasis of the tubes compared with those without it. The findings suggest that ectopic pregnancy associated with bilharziasis may occur at a somewhat earlier age than ectopic pregnancy associated with pyogenic salpingitis.

[Relation of infant mortality to maternal age and birth order. Chile, 1969 - 1974 - 1979]

This article analyzes infant mortality according to maternal age and parity in Chile in 1969, 1974, and 1979, 3 years in a period of marked decline in infant mortality rates. Since 1952 the Naitonal Health Service has been responsible for preventive health care for the entire population and for curative services for 70%. Between 1954-79, the National Health Service continued established programs of maternal and child health care and added provision of reversible contraceptives to women requesting them. Birthrates, infant mortality rates, neonatal mortality rates, and rates of late infant mortality in 1954 and 1979 respectively were 34.9 and 22.1; 120.7 and 36.6; 41.0 and 18.3; and 79.7 and 18.3. The close relationship between the fertility decline and infant mortality decline since 1964 was not due to chance. In the 10 years preceding the family planning program, neonatal mortality declined by only 41.8%, while in the ensuing 16 years it declined by 49.1%. Late infant mortality fell 19.2% in the 10 years before the program and 68.5% afterwards, achieving nearly the level of neonatal mortality. Data from birth certificates and infant death certificates were used to assess the characteristics of the infant mortality decline more closely. A decline in infant mortality rates was observed for all maternal age groups between 1969-79, but was more marked in the 20-24, 25-29, and 30-34 cohorts than in others. The number of births to mothers under 20 and 20-24 years old increased slightly between 1969-79. In 1974, mortality rates of infants 0-28 days old and 29 days-11 months old were 28.3 and 41.2 for all mothers, 33.5 and 54.0 for mothers under 20, 25.5 and 38.3 for mothers 20-34, and 38.3 and 40.9 for mothers 35 and over, respectively. Corresponding rates for 1979 were 20.0 and 20.1 for all mothers, 24.2 and 30.3 for mothers under 20, 18.2 and 17.5 for mothers 20-34, and 26.5 and 22.7 for mothers over 35. In both 1974 and 1979, rates of neonatal mortality and later infant mortality and of 4th and subsequent births, were significantly higher among mothers under 20 in rural areas than in urban areas, and in lower than in higher socioeconomic groups. Birth order is clearly related to infant mortality rates; the rise in the time periods with parity was relatively slight for birth orders 1-3 and began to increase more rapidly after birth order 4. In the 3 years considered and in all maternal age cohorts, infant mortality rates increase with birth order, and the tendency is especially marked in mothers under 20 and over 40. Grand multiparity appears to be more significantly related than maternal age to infant mortality in mothers over 20 years old.

Oncological endocrinology.

This comprehensive and detailed review of oncological endocrinology is divided into 3 major sections which discuss normal ovarian function, peripheral steroid metabolism, and abnormal ovarian function. Emphasis is placed throughout on the incidence, diagnosis, etiology, prevention, and treatment of oncological endocrine disorders. The section on normal ovarian function describes the processes of ovarian and adrenal steroidogenesis; hypothalamic and pituitary control of ovarian function, ovarian endocrine function of the follicle, corpus luteum, and interstitial stroma; oocyte depletion and the menopause, including surgical, radiation, premature, and normal menopause; and postmenopausal ovarian function. The section on peripheral steroid metabolism discusses extraglandular estrogen production, hepatic steroid metabolism, and estrogen and progesterone action. The section on abnormal ovarian function assesses the oncogenic and other pathogenic effects of exogenous steroid therapy in relation to the indications for steroid replacement; anovulation and polycystic ovarian disease, including polycystic ovary syndrome and stromal hyperthecosis; ovarian function in pregnancy and trophoblastic disease, including theca lutein cysts and pregnancy luteoma; sex steroid-producing ovarian and adrenal tumors, including stromal hyperplasia and hilus cell hyperplasia, pure stromal tumors of the ovary, ovarian sex cord tumors, steroid production with nonfunctioning ovarian tumors, and virilizing adrenal tumors; other hormone-producing ovarian tumors; and steroid production in dysgenetic gonads.

Fertility and family: new currents and emerging emphases in research and policy.

An attempt is made to highlight some major issues and currents that ran through the meeting of the Expert Group on Fertility and Family, held to identify those areas in scientific knowledge and concerns regarding fertility and family that are of greatest salience for policy formulation and implementation. Particular attention was to be paid to shifts that have occurred since the 1974 Bucharest Conference. This overview focuses on 3 main themes: advances in knowledge of fertility levels and trends; advances in understanding of the relationships between development, fertility, and the family; and theoretical advances and practical experience with respect to policy formulation and implementation. Initially, it is necessary to review the most salient changes in the situational context that have occurred since Bucharest. Among developing countries, the beginnings of fertility decline, though far from being universal, are no longer confined to a few "exceptional" countries. Fertility decline is now becoming discernible in an increasing number of countries. Both recognition that existing fertility patterns may act as a break on development and acceptance that fertility is a legitimate area for governmental policies and programs are much more widespread. Knowledge of existing patterns and their composition has increased markedly over the last decade, largely as a result of the exploitation of more data and better estimation techniques for measuring overall fertility levels and trends; and new approaches to studying the reproductive process and family formation. The combination of new methods and data has made systematic examination possible for the first time for several of the proximate determinants and has considerably improved the state of knowledge for those for which some information did already exist. The failure to provide anything close to a full understanding of the interrelationships between development, fertility, and family to serve as a basis for policy formulation, is evident. Most of the analyses to date, especially the empirical analyses, have been carried out at the micro level, focusing on the individual decision maker. 4 important trends can be discerned in policy formulation and implementation: trends in the definition of desirable goals; new directions in terms of the institutional means for realizing those goals; shifts in perception of the individual's freedom of choice; and assessment of the potential utility and effectiveness of policy and program efforts.

Growth and management of Seoul metropolitan region.

Discussion focuses on 2 interrelated aspects of urbanization in Korea: 1 aspect relates to the process and consequences of urbanization, and an attempt is made to evaluate government policies specifically designed to control urban concentration of population and industries; and the other aspect is the Seoul Metropolitan government's efforts to accomodate the growing population and to provide them with basic urban services. The last 2 decades have seen an accelerated growth of urban population in Korea, and much of the growth is strongly correlated with economic development. Since the 1st 5 Year Economic Development Plan (1962-66), the Korean economy experienced a rapid growth. The gross national product grew at an average rate of 7.7% a year during the planning period. The 2nd and 3rd planning periods have seen higher rates of growth, i.e., 10.2% and 11.5%, respectively, and the urbanization accelerated during this era to the extent that it reached the 50% mark. The population share of Seoul relative to total population of urban areas increased from 29.6% in 1955 to 42.7% in 1970. In 1970 the cities with population over 1 million accommodated 65.6% of the total urban population in Korea. The factors of interregional migration, administrative changes such as annexation and official designation of cities, and natural increase of population are basically responsible for urban concentration of population. Both natural increase of population and administration annexation were as contributory as immigration to Seoul's growth. With urbanization, primacy phenomenon appeared in the early 1960s. The population and industrial concentration in the primate city of Seoul Metropolitan area discomforted government policy makers. Various policy planning measures were instituted to dissipate the "undesirable" phenomenon. Industrial location policies were also geared in this direction. Several large scale industrial estates were created in strategically selected regions throughout the country, and reasonably priced industrial sites with all the necessary infrastructures were provided for the incoming firms coupled with financial and tax incentives. Locally developed industrial estates were also promoted with similar assistance and incentives. Physical planning measures such as greenbelt and new town development were devised in the same vein. A new town has been under construction in Banwal, 80 kilometers south of Seoul, in order to relieve the increasing pressure of Seoul. Additionally, Saemaul Undong, a bottom up community development movement, has been set in motion with the basic objective of reducing the visibly widening economic disparities between rural and urban areas. The Undon attracted small scale plants into rural areas. As a combined result of these policies and planning measures, a polarization reversal trend has set in since the early 1970s. The population growth rate of Seoul has slowed down substantially. Seoul has managed quite well to accomodate its rapidly growing population and deliver basic urban services. The general level of services has improved, except for a few areas such as housing and pollution.

The urbanization process in the Third World: explorations in search of a theory.

The theme of the essays in the first section of this volume devoted to the urbanization process in the 3rd world is a growing disillusionment with the application of the theories that have emerged from the study of the urbanization process in the West. Discussion in the 3 chapters cover the urbanization process--Western theory and 3rd world reality; the rural urban continuum debate--the preindustrial city and rural urban migration; and revolutionary change and the 3rd world city--a theory of urban involution. The 2nd section of essays indicates how field experience in Southeast Asia, and particularly Malaysia, reinforced the belief that similar path models are inadequate for explaining social, economic, and political changes in both the Western world and the 3rd world. The form of the urbanization process in the 3rd world may appear to be the same as that which characterized the West, but the different mix of the components of the urbanization process in the 3rd world suggests that this factor is of such importance that at least 1 element of Western theory should be discarded when investigating the 3rd world city. This is the view that the city induces change. In the context of the majority of 3rd world countries, it seems that a theoretical framework which regards the city as the prime catalyst of change must be discarded. The city must be seen as a symptom of processes operating at a societal level. To diagnose accurately the characteristics and roles of these cities, it is necessary to investigate the condition of underdevelopment which characterizes these countries, of which cities are only part. The typology of rural and urban models presents a more realistic framework to assist in the investigation of both rural and urban differences and rural urban migration. Its advantages over the simple rural urban continuum are numerous. The countries of the 3rd world are at different stages of development, or underdevelopment, as a result of their varying historical experiences of capitalism, their indigenous socioeconomic structures, and the interaction of the one on the other. It appears that the revolutionary changes will be delayed longer in countries where the traditional structures are more resilient, and where there are social and economic outlets for the indigenous population, than in countries where these structures have been subverted by capitalist penetration, or where no effective traditional structures ever existed.

Some demographic and economic correlates of primate cities: a case for reevaluation.

Recent literature, in a rather general way, is concerned with the characteristic dominance and economic role of primate cities in underdeveloped countries and how they differ in their economic impact from the cities of the industrialized West. Yet, this literature is for the most part speculative, with little or no concrete data being presented or specifically taken into consideration. Presented here are some results of an exploratory study of the correlates of the degree of "primate city" urban structure in relation to various socioeconomic and demographic variables. 87 countries, for which at least 2 sets of data--degree of primacy and per capita gross national product (GNP)--were available, have been studied. The objectives were to examine the relationship between the degree of primacy and certain demographic and ecological characteristics of these countries and to be able to indicate tentatively whether or not "primate cities" have a deleterious effect on the national economies. There was little or no indication that primacy is associated with the level of urbanization. If per capita international mail flow is taken as an index of the extent to which countries are ecologically and culturally bound with other countries, there is no indication that countries with the more developed bonds of this nature are either more or less likely to have a "primate city" urban structure. There was some slight indication that countries, particularly the least developed nations that have an export dependency on raw materials are more likely to have a "primate city" than countries whose export trade is composed of a larger proportion of processed and manufactured goods. The most salient characteristics related to the primacy of urban structures were size of population and area of the countries. It would appear that countries that are large in terms of population and area have hinterlands that are regional rather than national in character. Conversely, smaller countries tended to have a "primate city" urban structure since the largest city can have the whole country for its economic hinterland with a virtual monopoly over numerous functions. Population density of countries was not at all related to the degree to which primacy of urban structure is developed. Overall, there was no relationship between the level of economic development and the degree of primacy.

[Migration of the Sarakolese from Guidimaka to France]

The Sarakole are a cohesive ethnic group, strongly traditional, based on extended families of up to 30 or 40 members who reside and work together. A major subgroup live on both banks of the Senegal River. Just before and after WW1, there was some migration of this subgroup to France. Between 1954-69, the flow expanded quickly, mostly for employment in the automobile industries; due to governmental restrictions, it levelled off in 1970-1. On the Mauritanian bank of the river, both this migratory movement and the ethnic group are strongly concentrated in 1 department (administrative subdivision). Circumstances described in the study, including specific social mechanisms of migration, made it possible to identify and isolate factors relevant to the migratory flow, the amount of savings, their use, and the effects in this area. Total annual savings of the migrants for 1970-1 were estimated to be 335 million CFA in money alone, and conservatively estimated at around 480 million CFA including goods and commodities (around 1,900,000 US). They accrue to a population of slightly over 25,000 inhabitants. This means that total savings/head in the area are as much as GDP and that the great majority of men in the younger age groups are involved. Identified uses appeared to be largely standardized: taxes, food, housing and household commodities; clothing and jewelry, and cattle as safe capital. An unknown amount of hoarding must be added. Further analysis showed that preferences change over time with cumulative savings at family and village levels and moves from the beginning to the end of the above list. Recently, there has appeared some interest in buying plots and shops in town as well as agricultural equipment. Consequences are manifold and sometimes striking. More basic food is available; houses, household equipment, and clothing have improved substantially. Considerable import of foreign goods is apparent. Other marked features are the monetization of most trade, a switch from basic food crops to cattle breeding, and some development of modern crafts and trade. Intially women and children replaced the missing agricultural manpower; later wage-earning seasonal migrants from neighboring Mali worked the millet fields and Peul herders tended the cattle. Less basic food is exported from the area (to other Mauritanian regions where it is badly needed) and total cultivated areas may be decreasing. In social relations, nothing has changed thus far; village chiefs and family elders still hold full authority. Agricultural techniques and work distribution continue as in the past. But there is much cohesion between former migrants; what they do with their savings is their own choice. This is still traditional, with some selected items of modern consumption added to their own way of which life remains otherwise unchanged. Until a high level of cumulative savings has been reached, these will be devoted to security--quite realistic behavior in light of past history and present conditions in the area. What happens in the future will largely depend on the new national development policies and how far they benefit the area. (author's modified) (summary in ENG)

Dispersing population: what America can learn from Europe.

This work examines the growing trend toward population concentration in the US, the recently attained consensus that further concentration should be discouraged, and the relevant experiences of 5 European countries that had faced similar problems of population concentration, had concluded that the growth of their largest cities should be controlled, and had then enacted ambitious and comprehensive programs to that end. The country studies for Great Britain, France, Italy, the Netherlands, and Sweden report on the goals of each program, the accomplishments, the current status, and future direction of such efforts as viewed by politicians, administrators, and independent observers. A concluding chapter attempts to apply the experiences of the other countries to the case of the US. The limited 1st steps of the European countries subsequently led to complex structures of mutually reinforcing measures, including comprehensive regional development planning, generous cash grants to investors, disincentives to the growth of major cities, and decentralization of governmental agencies, universities, and state-controlled industries. The birthrate decline of the early 1970s and the spontaneous reversal of the trend to concentration in the US somewhat reduced the urgency of the problem, but did not completely eradicate it. This work argues that if public preference for a policy of population dispersion in the US becomes overwhelming, the experience of the European countries can serve as a guide to planning a program of measures which are likely to be popular, affordable, and effective.

Frequency and distribution of salpingitis and pelvic inflammatory disease in short-stay hospitals in the United States.

Estimates of the frequency and distribution of pelvic inflammatory disease (PID) in short-stay hospitals in the US as measured by the Hospital Discharge Survey (HDS) of the National Center for Health Statistics are presented. Annual estimates of International Classification of Diseases codes for acute salpingitis, chronic salpingitis, unspecified salpingitis and PID for 1970-75 were pooled and the results presented as mean annual numbers for the period. The probable errors of the estimates ranged from a low of +or- 2.3% to a high of +or- 30.0%, and depended on the magnitude of the estimate. Overall, there were 212,611 diagnoses of salpingitis and PID yearly, of which 146,115 were PID and 66,496 were salpingitis. Chronic salpingitis (23,555 cases) was diagnosed about twice as frequently as acute salpingitis (12,961 cases), but almost 1/2 of cases were not specified. When the diagnosis was acute salpingitis, it was the principal cause for admission in 81% of all cases, compared to a corresponding rate of 38% for chronic salpingitis. Diagnosed salpingitis was the principal cause for admission in 53% of cases, compared to 70% for PID. Overall the 2 conditions were the principal reasons for hospital admission in 65% of cases. The mean and median days of hospital stay for patients with salpingits or PID as the principal diagnosis were 6.6 and 6.2 days, respectively. The median age of women with a principal diagnosis of acute salpingitis was 23 years while for chronic salpingitis it was 29 years. The overall rate of hospitalization for salpingitis and PID was 199/100,000 population . For white women the rate of 154 and for all other races it was 509/100,000. In 204,596 cases in which marital status was known, the highest risk groups were separated and divorced women, with rates of 867.4 and 617.9 respectively. Among women, 10.3 of every 1000 hospital admissions, excluding those for pregnancy, were necessitated by salpingitis or PID. The group at highest risk was 20-24 years of age, while the risk in women over 40 was quite low. Salpingitis and PID were the cause of 1 in every 11 hospital admissions in women aged 20-24 in races other than white. The overall frequency of hospital deaths among women with diagnoses of salpingitis or PID was 4.3/1000 hospitalized women. Surgery was performed on 42.3% of patients with principal diagnoses of salpingitis or PID and 76.1% of women with secondary diagnoses. 54.3% of the hospitalized women underwent operations, of whom 45.6%, or 52,634 women, underwent hysterectomies.

On the transfer of conceptuses from oocytes fertilized in vitro.

Details of the transfer of conceptuses into the uterus after fertilization of oocytes in vitro are supplied. Transfer has usually been carried out at the 3- to 6-cell stage about 44 hours after insemination. When the transfer of more than 1 conceptus is done, the 2nd and 3rd conceptuses may be in a much earlier stage of development. The transfer catheter, of American Wire Gauge number 20 Teflon tubing, has an internal diameter of .8636 mm and an outside diameter of 1.4732 mm. A side notch is cut in the tubing so that a stream of liquid forced from the catheter will eject at a 45 degree angle. Each catheter measures about 30 cm in length. Culture medium and conceptus are drawn into the catheter by a 1 ml tuberculin syringe with a number 18 needle. The catheter is inserted through a carrying tube with a slightly curved tip made from number 12 steel needle tubing with a 2.157 mm internal diameter. The catheter is flushed for about 25 cm once or twice prior to loading the conceptus. The conceptus is transferred to a 60 mm tissue culture dish for convenience in loading and to have a flat surface for photography. The conceptus is drawn into the catheter under the microscope in such a way that it lies about 11 cm from the side opening near the catheter tip, with the entire column of medium including 2 air gaps occupying 22 cm of catheter length. Transfer is carried out in the knee-to-chest position so that patients' uteri are in the normal anterior position. Patients receive 250 mg of tetracycline 4 times daily on the day before and the day of transfer. The tip of the metal catheter is inserted barely into the mucus at the external os, and the transfer catheter is passed through the cervix for a predetermined distance. The entire column of medium is quickly ejected, followed by air to clear the catheter. A moment or 2 later the catheter is withdrawn and examined for presence of conceptus. The patient remains prone in the recovery room for a minimum of 4 hours. The procedure was used 94 times from January 1, 1981-June 30, 1982, resulting in 21 pregnancies. Difficulty was encountered only once in passing the catheter into the uterine cavity, and a conceptus was found remaining in the catheter only once after a transfer.

An evaluation of immunologic factors of infertility.

This paper reviews earlier studies identifying 3 possible immunologic causes of infertility: autoimmunity, ABO blood group incompatibility, and isoagglutination, and presents results of recent studies, including an analysis of the incidence of isoagglutinations, autoagglutinations, and ABO incompatibility in a group of couples with unexplained primary or secondary infertility and couples with an organic cause of infertility; incidence of antibodies in postpartum women, women in early pregnancy, unmarried women, and prostitutes; the relationship between ABO incompatibility and/or sperm-agglutinating antibodies to postcoital testing of cervical mucus; results of condom therapy in couples with positive isoagglutinins; a comparison of hemagglutination test with the microagglutination test; and preliminary studies of the immunoglobulin responsible for a positive microagglutination reaction. Results obtained from 292 women and 176 men indicated that in the 64 couples with primary unexplained infertility, 24 wives had isoagglutinins and 5 of the husbands had autoagglutinins. Among 32 couples with secondary unexplained infertility, 16 wives had isoagglutinins and only 1 husband had autogglutinins. 50 couples with organic causes of infertility and 25 unmarried women had a 20% incidence of isoagglutinins. Positive serologic reactions were found in 35 of 48 prostitutes. 15 of 44 women in the 1st trimester of pregnancy had isoagglutinins to at least 1 of 3-5 donor semen specimens, but serums of 7 of the women gave negative reactions when tested against the husband's ejaculate. The 2 women in the group who aborted had negative antibody titers. Only 1 of 29 serums from postpartum women gave positive agglutination reaction. Among 68 couples, 19 subjects had positive microagglutination test reactions but only 7 had positive hemagglutination reactions. No specific relationship was found between ABO incompatibility and the results of postcoital testing of cervical mucus in 58 women tested or positive circulating issoagglutinins in 62 women tested. 27 of 68 couples with primary unexplained infertility, 18 of 33 with secondary unexplained infertility, and 13 of 46 with organic causes of infertility had ABO incompatiblity. Autoagglutination, unless massive, was not incompatible with pregnancy. Circulating antisperm antibodies fell to undetectable levels after 2-12 months of condom therapy. Careful timing of ovulation is essential because of the increase in antibodies after reexposure. Results of condom therapy in terms of pregnancies were disappointing.

The National Gonorrhea Therapy Monitoring Study: II. Trends and seasonality of antibiotic resistance of Neisseria gonorrhoeae.

The Gonorrhea Therapy Monitoring Study was designed to monitor the efficacy of gonorrhea treatment and the antibiotic susceptibility of isolates of Neisseria gonorrhoeae in vitro and to correlate characteristics of patients and gonococcal isolates with rates of therapeutic failure. Since November 1972, isolates of N. gonorrhoeae were collected from study patients before treatment and tested in vitro for susceptibilities to penicillin, ampicillin, tetracycline, and spectinomycin. Since 1974, some isolates have also been tested in vitro for susceptibility to amoxicillin, since 1975, to erythromycin and trimethoprimsulfamethoxazole (TMP-SMZ); since 1976, to cefoxitin. This report describes recent trends of resistance and examines the seasonality of resistance of N. gonorrhoeae to antibiotics. Cultures of N. gonorrhoeae were obtained for all patients before and after treatment. Trends and seasonality were analyzed by use of a harmonic regression technique. 3 components of the data in Jaffe's earlier analysis (1975) were considered: the differences in resistance among years; the differences in resistance among months within the year; and the changes in year to year seasonality. The proportion of isolates relatively resistant to all 4 antibiotics--penicillin, ampicillin, tetracycline, and spectinomycin--decreased over the November 1972 to October 1977 period, and the proportion of isolates relatively sensitive to all 4 antibiotics increased. More than 50% of the isolates collected between May 1977 and October 1977 had MICs of penicillin of less than 0.03 mcg/ml. Between November 1972 and April 1974, 31-35% had MICs of penicillin of less than 0.03 mcg/ml. For ampicillin, there was a similar increase in the proportion of isolates that were relatively susceptible strains. The increase in the percentage of strains susceptible to tetracycline was even more dramatic; the smallest increase was that for spectinomycin. Although the percentages of strains very resistant and very susceptible to penicillin, ampicillin, tetracycline, spectinomycin, and amoxicillin vary somewhat from 1 6-month period to the next, the general overall trend for each geographic area was toward increasing susceptibility. The data are in accord with those of Jaffe et al. who showed that in the US the resistances of gonococcal strains to antibiotics started to decrease after 1972. The proportions of therapeutic failures for disease due to N. gonorrhoeae with different levels of MICs of penicillin, ampicillin, tetracycline, spectinomycin, and amoxicillin have remained stable during the period studied. The findings indicate no need to increase dosages of antibiotics in the treatment schedules because of increasing resistance.

The program for in vitro fertilization at Norfolk.

The general procedures utilized in the 2 major phases of the Norfolk in vitro fertilization program in 1981 are described. When the program began, it was believed desirable to exploit the natural menstrual cycle instead of a stimulated controlled cycle, to aspirate the single dominant follicle at the last possible moment prior to expected ovulation, since it was believed impossible to further mature an oocyte in vitro; to utilize a reliable method to predict the hour of ovulation; to utilize a proven aspiration technique; to take extreme measures to maintain a special environment for the oocyte; and to provide means of inseminating the egg with the least possible delay. The results for 1980 were disappointing; from 41 laparoscopies only 19 fertilizable ova were obtained, and no pregnancies resulted from in vitro and in vivo attempts. For phase I beginning in 1981, a protocol was adopted calling for stimulated controlled ovulation using human menopausal gonadotropin (hMG). Exogenous human chorionic gonadotropin (hCG) was used to substitute for the midcycle luteinizing hormone (LH) surge. Laparoscopy for follicular aspiration was scheduled 36-38 hours after hCG administration. The use of a realtime sector ultrasonograph to monitor follicular growth became routine, quality control in the laboratory was tightened, and supplementary maturation in vitro of oocytes prior to insemination was initiated. In Phase I, 48 fertilizable eggs were obtained in 26 of 31 cycles; cleavage was obtained in eggs from 12 cycles, and 2 pregnancies occurred. In 1981-Phase II, several changes in procedures were made. Serum E2 values became available on a daily basis, so that hMG injections could be controlled. There were further improvements in laboratory quality control, such as measures to insure a toxin-free water supply. It became possible to incubate morphologically immature oocytes which subsequently accepted fertilization. In 1981 Phase II, fertilizable eggs were obtained in 22 of 24 laparoscopic cycles, eggs were fertilized from 21 of the 22 cycles, transfers were made in 19 cycles, and there were 5 pregnancies. The importance of transferring more than 1 conceptus became evident from the 31 cycles with transfers: the pregnancy rate was 13% with transfer of a single conceptus, 31% with 2, and 50% with 3.

Migrant adjustment to city life: the Egyptian case.

This paper examines the adjustment of Egyptian villagers to life in Cairo, arguing that the abrupt transition to a completely altered way of life predicted by sociologists for rural immigrants ignores the many mechanisms by which villagers are able to cushion the shock of urban life and surround themselves with familiar institutions and persons of similar cultural background. The fact that over 1/3 of the present residents of Cairo were from outside the city, mostly from rural villages, suggests that migrants are probably shaping the culture of the city as much as they are adjusting to it. The numerically dominant migrants whose adaptation is described were nonselective in the sense that land shortages and lack of opportunities in the villages were what propelled them to Cairo; their lower capacity for assimilation led them to attempt to replicate their rural culture within the city. Cairo is more rural than would be expected, not only because of the influx of rural population, but because of the continual incorporation of preexisting villages within the metropolitan region. A directory of village benevolent associations in Cairo provides indirect evidence that rural migrants have tended to concentrate in distinct areas according to their region of origin, marital status, and occupation within the city. Migrants to Cairo minimize cultural change by gravitating to areas near the rural-urban fringe or which have a cultural resemblance to semirural areas, but they must still adjust to considerable crowding and loss of privacy due to new housing forms, the loss of valued space such as courtyards and oven rooms, and occasionally to changes in dress. Agriculture, the nearly universal rural employment, is replaced for men in the city by manual labor which is probably more taxing, certainly more evenly distributed over time, and usually less solitary than rural work. Women on the other hand often have a slightly lighter work load but must perform far more of their tasks in solitude at home. In the social realm, the culture of Cairo differs from that of a western city in that it cannot be characterized chiefly by anonymity, secondary contacts, and other attributes of urban life. Migrants to Cairo are active creators of a variety of institutions whose major function is to protect them from the shock of anomie. It is also debatable to what extent Egyptian villagers are typified by peculiarly rural outlooks, and to that extent their adaptation to urban life is probably eased.

Government programs to control sizes of large cities.

City planners and government officials in both developed and developing countries share a concern that the largest cities are overly large. Most government programs to limit the growth and size of cities are aimed at employment location, particularly with regard to manufacturing plants. This paper analyzes the determinants of large city size, the reasons for considering such cities overly large, and the most appropriate government programs to control city size. There are 4 sufficient conditions for the emergence of large cities: 1) the presence of some industries where capital and labor inputs can be substituted for land inputs; 2) some activities with scale economies; 3) expensive transportation; and 4) a complex input-output structure in the city's industries, with many linkages between producers and users of commodities and services. Undesirable characteristics of large cities include pollution, congestion, and infrastructure. The main effect of city size controls on pollution and congestion has been to move the problem elsewhere, not abate it. Such market failures can be resolved only by improving resource allocation in the appropriate sector. Infrastructure investments and subsidies for local government services are often overconcentrated in a country's capital city. A more efficient arrangement would be to allocate infrastructure investment according to a market model, giving a single government jurisdiction over an entire metropolitan area where taxes are raised locally for infrastructure investment and local government services. This would allow local governments to compete with each other to attract firms and residents. More research is needed on the relationship of governmental organization to city size distribution. It is suggested that government attempts to control city size through location regulation may exacerbate the problem and stifle industrial growth. In particular, equity-motivated government locational programs in developing countries aimed at transferring resources from large to small cities and redistributing income to the poorest groups may hinder development by forcing industry to locate where it is not viable and cannot grow to its full potential.

The political economy of urban squatting in metropolitan Kuala Lumpur.

This article discusses the growth of urban squatting in Kuala Lumpur as a response to government development policies and rural land shortage, and examines the ethnic and economic correlates of Kuala Lumpur's squatter population. The major source of data was intensive and extensive ethnographic participation. Mass squatter invasion has not been the usual pattern in Malaysia. Widespread squatting on state land has occurred in Kuala Lumpur, with a main characteristic being the heterogeneous economic activities of the squatters, who despite their poverty are represented at lower levels of all the major developmental and economic sectors. In 1978, 243,000 squatters represented 25% of the Federal Territory's population. Squatting primarily occurs because the noncompetitive economic groups to which squatters belong are denied access to land resources. Squatter interests may, however, be accomodated in other ways by a patron-client system. Ethnic plurality is demonstrated by the physical spacing of the Malay, Chinese, and Indian communities, which are monoethnically segregated in 172 of the 201 squatter settlements. Although the physical environment of the squatter settlements often improves somewhat with the age of the settlement, most have substandard amenities. 44% of the squatter population, 64% of the Malays, 59% of the Indians, and 23% of the Chinese, are believed to be in the definite poverty group. Ownership and control of the means of production are of less importance in determining the socioeconomic relations of the squatters than are the patron-client network and ethnicity. No sense of class consciousness or class solidarity has emerged between the urban squatters of the 3 ethnic groups, because of the heterogeneous character of their occupational structures, the weak socioeconomic association of individual coworkers, and the feeling of deprivation that stops short of a sense of marginalization out of the urban economy. The most powerful absorbent of radicalization and cross-ethnic class antagonism is, however, the patron-client system, which is most strongly developed among the Malay squatters and weakest among the Indian. Whereas patrons view the squatters as useful political units, urban politicians and administrators tend to view them as a problem.

Some thoughts on emigration from the Mediterranean basin.

In addition to emphasizing that the kind of migration characteristic of the 1960s between Mediterranean and western European countries has serious implications for the former, this discussion explores the more questionable consequence of "lassez-faire" emigration for employment and development; proposes a method of analysis--the human resources approach--which facilitates insight into undesirable development, incipient or future bottlenecks, and how far they may be caused by outmigration or could be removed by the purposeful organization of return migration; and raises for examination various principles and instruments of emigration policy connecting international movements of human resources with development in general and employment policy and manpower planning in particular. Wherever migrant workers go abroad temporarily, which has been claimed to be the feature of Mediterranean western European migrations, they are not totally lost to their country of origin. They may be considered to remain part of the national labor force. Consequently, the human resources available for the country's development (hereafter termed the "national" labor force) comprise both the domestic population and the temporarily absent population. Migration streams may consist of seasonal (S), temporary (T), and permanent (P) workers according to the intentions of the migrants or their legal status. To obtain the effective numbers of S, T, and P migrants, it is necessary to weigh the figures of intending S, T, and P migrants with the actual emigration experience of each category. Applying hypothetical proportions to the known S (15%), T (80%), and P (5%) figures for Yugoslavia would give the following effective rates (as percentages of total outmigration: S = 13.5%; T = 49.25%; and P = 37.25%. In the case of Yugoslavia, which may be considered fairly representative, the temporarily absent workforce would be less than 2/3 of the annual outflow postulated. Thus, 1 in 3 migrants leaving Yugoslavia is irrelevant for manpower planning purposes. Net outmigration at seasonal peaks or throughout the year reduces the available labor supply directly. It also does so disproportionately, for it involves the most able bodied persons. To obtain positive effects, the contribution of migrants to the home country's economy would have to be larger than before migration. The question is what effect does foreign emigration have on the spatial, economic, and social modernization of the rural sector. Most Mediterranean countries are characterized by widely scattered settlements, many of which are unviable and costly to service. The economic organization of the rural sector may be affected through labor shortages inducing wage pressure and mechanization. The traditional social organization of the rural sector may receive jobs from outmigration that could speed up its replacement by modern structures.

Sexually transmitted diseases on a tropical island.

The epidemiology, control, and treatment of sexually transmitted diseases (STD) in Singapore are outlined. The incidence of gonorrhea and syphilis increased from 136 and 14 cases/1000, respectively, in 1970 to 149 and 21.4 cases/1000 in 1975. The number of cases of syphilis fell from 428 in 1975 to 201 in 1976, and a further 40% decline was recorded for the 1st half of 1977. Gonorrhea rates increased overall in 1976, but the number of cases among men declined and the identification rate among women (who outnumber men by 3:1 among gonorrhea cases) markedly improved. Singapore has exceptionally high rates of chancroid any lymphogranuloma venereum. 30% of STD cases are ages 20-24 and 21% are ages 25-29. 18.5% of male cases are ages 15-19 in contrast to only 5.6% of female cases. Health education programs are aimed at the general public, secondary school children, and boys in military service. A national health campaign against 6 infectious diseases, including STD, was launched in 1976 and followed in 1977 by a booster campaign on STD alone. A significant increase in knowledge was measured among students and military personnel. Since prostitutes comprise an important source of infection, a medical scheme to periodically check and treat prostitutes was initiated in 1976. The decline in syphilis and in gonorrhea among men observed in 1977 is attributed to this scheme. Contact tracing has a 30% success rate. All contacts are investigated but not routinely treated. If epidemiologic investigation suggests infection, the contact is treated after tests are performed. STD patients may seek treatment from a general practitioner or from a free public clinic operated by the Hospital Division of the Ministry of Health. Syphilis is treated with the long-acting benzathine penicillin and gonorrhea with either 3 megaunits of injection procaine penicillin or 2 gm of ampicillin with probenecid. Although there is no full-time department of dermato-venereology in the university, medical students are taught the entire spectrum of STD. It has been government policy to share Singapore's advanced laboratory facilities and expertise with neighboring countries.

Place of laparoscopy in pelvic inflammatory disease.

577 laparoscopic examinations were performed in women presenting with sterility, chronic abdominal pain, primary or secondary amenorrhea, and irregular menstrual periods. 125 cases of chronic pelvic inflammatory disease (PID) of both the tuberculous and nonspecific varieties were detected through this procedure. 59 of the 125 cases were diagnosed as tuberculous. Investigations prior to laparoscopy had yielded significant results in only 12 cases. 87 of the 125 cases had no abnormal clinical findings, and only 18 of the 37 tubo-ovarian masses were diagnosed by bimanual examination. These results indicate that laparoscopy is an invaluable tool for the diagnosis of PID. It can reveal peritubal adhesions, tubercles on the tubes, small tubo-ovarian masses, and hydrosalpinx cases that cannot be detected clinically. It is considered a more suitable tool than culdoscopy, which less frequently notes adhesions to the fallopian tubes and pathological conditions in the upper pelvis. Laparoscopy can play an especially valuable role in India as a prelude to tuboplasty, given the high incidence of pelvic tuberculosis. Of the 316 cases of primary sterility examined in this study, 51 had genital tuberculosis and 39 had nonspecific PID. Laparoscopy can also be useful in disproving cases wrongly labelled as chronic pelvic disease. 15 women in this study who reported chronic lower abdominal pain had normal findings, and only 13 cases of PID were confirmed among the 33 cases preoperatively diagnosed as PID. A significant number of PID cases are attributed to operative procedures such as hysterosalpingography and ventrisuspension that are repeated unnecessarily and without proper sepsis. Thus, the possibility of a flare-up of infection during laparoscopy, especially due to hydroperturbation, should be considered. Women in this study who were found to have PID were given postoperative antibiotics. No significant postoperative complications were observed.

Epidemiologic detection of low dose effects on the developing fetus.

This paper examines the ways in which evaluation of risks of exposure to noxious substances differ in the field of reproduction from the risks of carcinogenesis, and presents models of the effects of varying doses of exposures to smoking and alcohol drinking on spontaneous abortion and birthweight. Models to assess risks associated with varying doses of exposure are almost all based on data about cancer, but the models for risk assessment in reproduction and in oncogenesis differ in at least 3 fundamental ways: 1) the range of relevant adverse reproductive outcomes is more varied and may involve different underlying mechanisms; 2) the relation of timing and duration of exposure to outcome may be different in reproductive endocrinology and in oncogenesis, with many morphological effects depending on exposure at a precise and relatively short period of development; and 3) in reproduction, the exposure can effect 2-3 individuals, although the outcome is usually described in terms of the fetus or infant only. 1 advantageous aspect of the biology of reproduction that has no parallel in carcinogenesis for the study of modest effects is that, for anomalies that are lethal in utero, the search for etiologic factors among aborted fetuses is considerably more parsimonious in terms of the numbers of pregnancies which need to be studied than a similar search among births would be. For example, the sample sizes for exposed and unexposed populations which would be needed to detect, with 80% statistical power, a doubling of the rate of trisomy 21 at conception would be 15,217 births or 1117 abortions. A study of dose-response relations of exposure to smoking and alcohol drinking on spontaneous abortion and birthweight was based on data drawn from an ongoing epidemiological study in 3 New York City hospitals which compares women admitted with spontaneous abortion to a comparison group matched for maternal age and payment status whose pregnancies continued longer than 28 weeks. The data indicate a dose-response relationship between the number of cigarettes smoked each day and both spontaneous abortion and lowered birthweight. In both instances, a logarithmic curve best described the data. A dose-response relationship was also found between alcohol drinking and spontaneous abortion; the odds of abortion increase linearly with increases in the number of days each month on which alcohol is consumed. No relation was found between smoking and alcohol drinking in their effects on spontaneous abortion. The relationship between the exposures of alcohol drinking and smoking and the outcomes of spontaneous abortion and birthweight are used to illustrate some of the problems in attempting to determine a safe level of exposure.

Pregnancies in humans by fertilization in vitro and embryo transfer in the controlled ovulatory cycle.

50 infertility patients with occluded or damaged fallopian tubes were randomly allocated to 3 treatment groups to compare use of the natural ovulatory cycle and hormonal control of ovulation in fertilization in vitro and embryo transfer. Group 1 patients were not given drugs or hormones to control ovulation. They were admitted to the hospital when cervical mucus changes and follicle size >1.7 cm indicated imminent ovulation. When 3 consecutive urine samples showed a sustained increase in luteinizing hormone (LH) excretion rate, laparoscopy for oocyte collection was scheduled for 25.5-27.5 hours after the midpoint of the 1st urine sample. Group 2 patients were given 150 mg of clomiphene citrate on days 5-9 after onset of menstruation. They were hospitalized when the largesf follicle was estimated to be >1.7 cm, and timing of laparoscopy was determined as in group 1. Group 3 patients were also given clomiphene citrate. On day 12-14, depending on the follicular growth rate, 4000 IU of human chorionic gonadotropin (hCG) was injected and laparoscopy scheduled for 35-36 hours later. Embryos developing to the 4-cell or 8-cell stage after 45-76 hours in vitro were transferred to the uterine cavity with a Teflon catheter. Embryos were transferred to 11 of the 20 patients (55%) in group 1 (natural cycle), but only 1 patient showed evidence of increased beta hCG and no pregnancies resulted. Embryos were transferred to 7 of the 10 patients (70%) in group 2 (clomiphene and natural ovulation), 1 of whom showed increased beta hCG; 1 pregnancy was noted in this group. Embryos were transferred to 16 of the 20 patients (80%) in group 3 (clomiphene and hCG); 6 showed increased elevated hCG and 3 became pregnant. These results demonstrate that hormones can be used to control the ovulatory cycle for in vitro fertilization. Use of clomiphene and hCG overcomes the difficulties encountered with the natural ovulatory cycle, including the need for frequent blood or urine sampling to detect onset of LH release, the uncertainty of establishing the state of the LH surge in some patients, and the increased chance of ovulation prior to laparoscopy. However, the pregnancy rate observed in this study (4 in 34 patients receiving embryos) is considered unsatisfactory and indicates that the embryos have reduced viability or the transfer process and subsequent patient management could be improved.

Prevention of congenital syphilis and other adverse pregnancy outcomes due to syphilis: a demonstration project proposal.

A demonstration project, scheduled to commence February 1, 1982, seeks to improve antenatal screening efforts for congenital syphilis in Zambia. Although such screening is mandatory in Zambia, it is characterized by late or sporadic attendance, a lack of useful screening methods, delays in treating reactive women and their husbands, and failure to recognize infection acquired after the initial screening. The demonstration project will target 3 antenatal clinics in Lusaka, each serving a population of 20,000-40,000. Serologic screening tests will be performed on all clinic attendees at their 1st visit and again at the beginning of the 3rd trimester of pregnancy. Seroreactors will be treated with benzathine penicillin or, if allergic to penicillin, with erythromycin. The accuracy of laboratory results will be evaluated. In addition, patient education will be conducted with groups and individuals, and community leaders will be asked to suggest ways to improve the antenatal screening program. Finally, the effects of the intervention system on pregnancy outcome will be evaluated.

Genital chlamydial infections in the female.

Current concepts of genital Chlamydia trachomatis infections in women are reviewed. The primary sites of infection are the columnar epithelium of the cervix, the urethra, and the paraurethral glands. Chlamydial infections of the cervical epithelium are a source of infection of the male urogenital tract, the neonate during passage through the birth canal, and of ascending infection in the women. Spread of infection to the tubes generally takes place through the genital canal and is enhanced by IUD use. About 20% of women showing symptoms of sexually transmitted diseases or genital infections have been found to harbor C. trachomatis in the cervix. Infection is often asymptomatic. Double infection with both C. trachomatis and N. gonorrhoeae is common. 1 study found a 4 times greater incidence of chlamydial genital infection among women ages 15-34 than gonococcal infection. The need for partner treatment is highlighted by a study showing that 65% of female contacts of men with chlamydial urethritis and 52.5% of male contacts of women with chlamydial cervicitis are culture positive for C. trachomatis. Chlamydial infection is complicated by endometritis, which is believed to account for a proportion of the intermenstrual bleeding in contracepting women. C. trachomatis also accounts for a high proportion of salpingitis cases. Gonococcal salpingitis has a significantly higher fertility prognosis than chlamydial salpingits. Although there have been no longterm studies in this area, laparoscopy has revealed close fallopian tubes in women with chlamydial salpingitis. Women whose infertility is attributed to tubal occlusion have further demonstrated a higher prevalence of chlamydial antibody than pregnant controls. Further work is needed in the following 6 areas: 1) development of guidelines for the surveillance, control, treatment, and follow-up of genital chlamydial infection; 2) simplification of diagnostic standards; 3) clarification of the immunologic host response to genital chlamydia; 4) the role of genital chlamydial infection in developing countries, especially its relationship to infertility; 5) the possible role of cervical chlamydial infection as a promoter of neoplastic changes in the cervical epithelium; and 6) mechanisms underlying the canalicular spread of cervical chlamydial infection, perhaps leading to therapeutic methods for preventing acute salpingitis and subsequent infertility.

"Epidemiological" treatment in venereal diseases other than syphilis.

The use of prophylactic and epidemiologic treatment in trichomoniasis, nongonococcal urethritis, and gonorrhea is reviewed in relation to the epidemiologic profile of these diseases. Epidemiologic treatment is widely used with male partners of females with vaginal trichomoniasis, although the risk of infection may be less than 50%. It is also used with female partners of males with nongonococcal urethritis, but there is no evidence that such treatment prevents recurrences in infected males. Treatment of gonorrhea is administered in the presence of positive smears but in advance of culture results. This approach, justified on the basis of the seriousness of the disease and the time-consuming and complex nature of accurate diagnosis, is practiced in 92% of female and 98% of male venereal disease clinics in Great Britain. The use of postexposure prophylactic treatment when the venereal status of the source of exposure is unknown is not approved in the UK, but is used in selective cases in 15% of clinics. Epidemiologic treatment is used routinely in 5.8% of male clinics and 22% of female clinics. When clinical evidence of gonorrhea exists, these percentages increase to 12.2 and 28.4 respectively. 22.2% of male clinics and 76.1% of female clinics use epidemiologic treatment at least in selected cases when there is epidemiologic and clinical evidence of infection. Selection is most likely to be used for wives, regular partners, pregnant women, those about to travel, treatment defaulters, promiscuous persons, and passive male homosexuals. Clinicians who advocate epidemiologic treatment stress the importance of examination and follow-up. Patients should be examined by smear and culture at the 1st visit, and treated patients should be followed as if the disease had been identified. A discussion which follows this article illustrates the controversy surrounding epidemiologic treatment. Concern is expressed that it will be used indiscriminately, that a deterioration of clinical standards will result, and that lowered rates of disease prevalence will not be noted. (summary in FRE)

Possible transplacental transmission of Herpes simplex infection.

A case of neonatal herpes simplex infection suggestive of intrauterine transmission is reported, and all 42 cases of such infection previously reported are reviewed. The case, a slightly premature male, was in good condition until the 6th postnatal day when fever, mild cyanosis, increasing respiratory distress, and central nervous system irritability developed. Bacterial cultures were negative. He died at 10 days of age. Herpes simplex was cultured from the brain, liver, adrenals, esophagus, kidney, lung, spleen, heart, spinal cord, and cerebrospinal fluid, but not from the stool. Microscopic examination of the placenta revealed numerous foci of villous necrosis, but no inflammatory reaction. The mother had developed fever, chills, and malaise 3 days before the onset of labor. Poor progress of labor and fetal distress led to delivery by cesarean section. The father suffered from recurrent herpes progenitalis; however, the last outbreak was 6 months prior to delivery. There was no contract between infant and parents after delivery. Although virus was not cultured from the placenta, the unusual placental lesions, characteristic of hematogenous dissemination of infection and histologically similar to the visceral lesions in the infected infant, suggest that the disseminated fulminant form of herpes simplex infection began before birth. Virus was recovered in 23 of the 42 previously reported cases of neonatal herpes simplex. The diagnosis was rarely made before death, which occurred in 6-12 days in the 38 fatal cases. Hepatic and adrenal necrosis was striking. Maternal disease, in the form of fever or skin, vulvar, or oral lesions, is frequently present immediately before or after delivery in these cases. Such illness in mothers of infants with severe acute disease without demonstrable bacteriologic etiology should alert physicians to the possibility of disseminated neonatal herpes simplex infection. Without demonstration of virus or of diagnostic lesions in the placenta, 2 other types of evidence could document the occurrence of intrauterine transmission of the virus: 1) destructive lesions clearly associated with the organism before or at birth, and 2) clinical disease and/or neonatal death at an interval after delivery less than the minimum incubation period of 1-12 days.

On the etiology of epididymitis.

An exceptionally high frequency of acute epididymitis has been observed among military recruits in basic training. 28 soldiers presenting with an episode of acute tender swelling of the epididymis were evaluated. Average age was 21 years. 8 patients reported gonorrheal infection within the preceding 2 months. None had a recent history of trauma or prior operation, and no systemic symptoms or upper respiratory infections were noted. Acute tubular destruction with some micro abscesses in the tubules and some degree of interstitial inflammation was observed in 13 of the 24 cases for which laboratory specimens were adequate. Polymorphonuclear leukocytes were the predominant cells and some cases showed vasculitis. In 8 of the specimens with no tubular involvement, a chronic type of interstitial inflammation was noted. Lymphocytes were the main cells found in these cases. Testicular tissue was normal in 8 patients. Depressed spermatogenesis was noted in 20 patients, 9 of whom manifested inflammation. All viral and culture studies were negative. It was concluded that acute epididymitis is not caused by any culturable bacteria or virus; however, a chemical etiology is possible. Epididymitis appears to be mainly a disease of people who have extended periods of unaccumstomed strenuous physical exertion. Reflux up the vas deferens, induced by the physical strain of basic training, may be a major cause of the high rate of acute epididymitis observed among military recruits. Gonorrhea may also be a contributing factor. Antibiotic use is recommended in such cases to prevent secondary testicular atrophy.

Acute pelvic infection (P.I.D.).

Acute pelvic infection accounted for 7.3% of all admissions and 19% of emergency gynecological admissions to the Enugu Specialist Hospital in Nigeria in 1971. Records of 100 consecutive cases treated from January 1971-mid 1972 were reviewed to assess methods of management. 28 of the patients were aged 10-19, 60 were 20-29, 11 were 30-39, and 1 was 43 years old. 55 were nulliparas, 10 had 1 child, 5 had 2, 8 had 3, 5 had 4, 6 had 6, and 3 had 7-10 children. 58 of the women were married but only 6 of 44 cases of induced abortion occurred in married women. 100 patients complained of abdominal pain, 50 of feverishness, 28 of nausea or vomiting, 22 of vaginal bleeding, 14 of abdominal swelling, 14 of constipation, 10 of diarrhea, and 6 of abnormal vaginal discharge. Abdominal tenderness was elicited in 92 patients and pelvic tenderness in 72. 78 patients had elevated temperatures of 100 degrees fahrenheit or over. Excitation tenderness was present in 63, including all who eventually underwent surgery. Abdominal mass was found in 13 and pelvic mass in 14. 12 had an offensive discharge. Criminal abortion was responsible for 44% of cases, unknown causes for 30%, puerperal sepsis for 14, spontaneous abortion for 7, and IUD use probably for 5.48 cases required some form of surgery, of which 28 required laparotomy including 5 originally treated by colpotomy and drainage alone. 13 cases had laparotomy because of the finding of an abdominopelvic mass. A unilocular abscess was found in 1 case, multilocular abscesses in 19, and salpingitis only in 8. Dense adhesions were found in 21 and no adhesions in 3. Pus was found in all cases. 12 of the 28 had uneventful recoveries, 12 had wound sepsis, 2 had injury to the bowel, and 1 had pulmonary embolism and infarction. There was 1 death. The average hospital stay was 6.9 days for cases that had evacuation of uterus, 8.7 days for those treated medically, and 35.8 for those having abdominal surgery. Medical treatment is usually begun with penicillin and streptomycin alone unless the patient's condition is very serious, in which case broad-spectrum antibiotics are used. Surgery is indicated when the physical signs and symptoms suggest a serious peritoneal infection, inflammation, and pus formation, but the decision to operate is often difficult because of the poor condition of the patients on admission. The surgical procedure is usually determined at laparotomy, but attempts to mobilize and excise the diseased organ are usually avoided because of the need to operate quickly, the poor condition of the patients, and the dangers of damage to other organs. No residual pelvic mass was found in any patient at follow-up, no case has undergone a 2nd operation, and the mortality rate has been 1%.

The male factor.

The use of a specific radiolabeled antiglobulin test to detect antisperm antibodies has given positive results in 7% of infertile men and 13% of infertile women, and may be a reliable means of identifying and possibly treating patients whose infertility is caused by immune mechanisms. The importance of studying the infertile couple rather than the women only has been emphasized; the sparse data available suggest that deficiencies may occur in the man in as many as 1/2 of the estimated 10-15% of couples who are infertile. Most infertile men are still classified as having idiopathic oligospermia, implying sperm counts below those associated with ready fertility, without apparent cause. It is now clear that the fertility potential of both partners must be evaluated in assessing the importance of oligospermia, making assessment of the response to therapy more difficult. The diagnosis of oligospermia itself is beset by such difficulties as the variability of the sperm count at both normal and low levels and the overlap between presumed fertile and infertile levels of sperm. The maximum number of sperm necessary to define oligospermia has declined over recent years to 10 million sperm/ml. Oligospermia appears to represent a common response of the male reproductive system to a variety of insults. Most patients have abnormal pituitary responsiveness related to decreased feedback control of hypothalamus and pituitary by the testis. Altered testicular function is most likely when the sperm count is below 5 million/ml. Environmental factors, intrinsic testicular defects, and androgen insensitivity due to a decreased number of androgen receptors are other possible causes. The probable diversity of pathogenesis and the difficulty of obtaining properly controlled studies are reasons for the inconclusive results of most therapeutic efforts. However, significant progress in the understanding of testicular disorders in the past few years has led to an outburst of scientific and collegial activities related to andrology, and there is reasonable hope for a more definite understanding of male fertility in the near future.

Gonorrhea and acute epididymitis.

To determine whether the true incidence of gonorrheal urethritis in acute epididymitis is obscured by inadequate detection methods, all males admitted to the Urology Service of an American military hospital between February 1975-April 1977 with a diagnosis of epididymitis underwent 4 separate screening tests for concomitant gonorrheal urethritis. Assessment of the 4 screening methods showed that a culture of a calcium-alginate swab of the anterior urethra obtained prior to the 1st morning urination was positive in every case of gonorrhea detected, and was the most consistent means of detection. In the 2nd test, neither a gram stain smear nor the culture of the sperm sediment of a "urethral wash" proved reliable. Smears of the urethral wash yielded 36% false negatives while cultures yielded 54% false negatives. The Gram stain and culture of ejaculate were both reliable, but fewer than 1/2 of the patients with positive cultures were able or willing to provide a specimen. Among the positive cases, there was 1 false negative among the 5 ejaculates available for Gram stain, and all 5 ejaculates were positive on culture. The final method, Gram stain and culture of discharge, proved inadequate because a discharge was absent in 50% of the positive cases. Neither the patients' histories nor physical findings were diagnostic because of the overlap between positive and negative cases. 14 of the 88 consecutive patients admitted with acute epididymitis (16%) were found to have N. gonorrheae urethritis as well. The actual incidence may have been even higher since 31% of the patients were taking antibiotics prior to admission. The diagnosis of concomitant gonorrhea in acute epididymitis confirmed by culture offers the advantages of assuring adequate treatment of the patient and prompt treatment of the sex partners, preventing reinfection from untreated contacts, and assuring proper epidemiological reporting and appropriate serologic screening for concomitant syphilis.

Professional education and the control of the venereal diseases.

Although practicing physicians treat 80% of cases of venereal disease (VD) in the US, the teaching of VD control has almost disappeared from the medical schools. With the advent of penicillin treatment for syphilis, the medical profession became complacent about the dangers of syphilis, it was relegated to a minor position in medical school curricula, and federal budgets for VD control declined sharply. These factors, along with the decrease of infectious cases, brought about a general loss of interest, particularly in research and teaching. In many cases the physician undertaking VD treatment has not been prepared to do so. A 1965 survey receiving 450 replies from 76 countries indicated that an average of 17.1 hours were spent on VD when it was treated as a separate subject while 25.6 hours were spent when it was combined with another subject, usually dermatology, preventive medicine, or urology. Public health and epidemiological aspects apparently received little attention. Letters accompanying the survey replies, however, indicated a great interest in the problem and need for assistance. In an effort to promote the teaching of VD control, a demonstration project was established in the Department of Medicine at the New York Hospital and Cornell University Medical College with the assistance of the VD Control branch of the Centers for Disease Control. During 1971, 555 new cases of syphilis were studied, including 4 of neurosyphilis, 4 of cardiovascular syphilis, and 40 of syphilis in pregnancy. Close liaison is maintained with the Department of Infectious Diseases at the hospital, and the assistant residents and elective students rotate through the clinic. A contact investigator from the New York City Department of Health is assigned part time to the clinic, and students and residents participate in the investigations. Group discussions are held with residents of various other departments, especially medicine, obstetrics, and dermatology. The pilot project indicates that with a relatively small teaching grant, an active syphilis teaching program can be maintained in a university hospital. Educational materials describing proper diagnosis and treatment of VD should be made available to practicing physicians through state and county medical societies.

Antibodies to Chlamydia trachomatis in acute salpingitis.

A modified micro-immunofluorescence test was used to assess the level and prevalence of different immunoglobulin classes of type specific chlamydial antibodies in sera and in fluid aspirated from the pouch of Douglas in women with laparoscopically verified acute salpingitis, and the findings were related to the visual clinical grading of tubal inflammation. Laparoscopy was carried out on the day of admission for all patients admitted to the Department of Obstetrics and Gynecology of the University Hospital in Lund, Sweden, with the presumptive diagnosis of acute salpingitis. The study includes patients admitted between 1973-77. Serum samples were collected on the day of admission from 143 women with acute salpingitis, peritoneal fluid was collected during laparoscopy from the pouch of Douglas of 27 patients, and serum samples were collected from 19 women with no signs of genital infection who had also undergone laparoscopy. 88 of the 143 patients with acute salpingitis (62%) had chlamydial IgC antibody levels of 1/64 or greater in their sera. The geometric mean titre (GMT) of antibody in all 143 women was 1/51. The results indicated a correlation between the inflammatory grade of salpingitis, the percentage of women with high levels of IgG chlamydial antibody, and the GMT of their antibody. 73% of women with severe salpingitis had significant levels of antibody and also the highest GMT of chlamydia IgG antibody, 1/527, compared to 1/63 in women with mild and 1/189 in women with moderate salpingitis. Only 2 of the 19 women with no salpingitis had high levels of antibody. IgM chlamydial antibody was detected in only 33 of 142 women tested. Fluid aspirated from the pouch of Douglas in 27 women with acute salpingitis had high GMTs of both IgG and IgA chlamydial antibody, and again the GMTs and percentages of women with high levels of IgG antibody increased with increasing severity of tubal inflammation. In 83 of 88 women in whom IgG chlamydial antibody was demonstrated, the predominant type-specific antibody was of the paratrachoma (D-K) serotype, while in the remaining 5 patients it was of the C/J type. The study indicates that C. trachomatis is the probable etiological agent in as many as 66% of women with acute salpingitis.

Semen analysis in unilateral epididymitis.

Semen analyses were done on 16 men between 18 and 45 years of age who had unilateral nongonorrheal epididymitis, to evaluate its effect on the sperm. 8 men were black and 8 were white; average age was 28 years. 5 had had children before the onset of the disease but none had impregnated their wives since becoming ill. Patients whose past history or physical examination revealed factors that might contribute to abnormal semen analysis were eliminated from the study. Semen specimens were taken at intervals of from 5 days-1 1/2 years after onset of acute epididymitis. Chronic prostatitis with Bacteriaceae alcaligenes urinary tract infection was seen in 2 cases. Average ejaculate volume was below 2.4 cc in 9 of the 16 subjects, 4 had average volumes between 2.4-3.3 cc, and the remaining 3 had volumes above 3.3 cc. 1 case was azoospermic and 6 had average counts below 20 million/cubic cm. Abnormal motility (less than 40% active sperm/field) was seen in 3 of 16 cases. At no time were fewer than 60% oval forms seen. It has been estimated that in normal men, after 3 days of continence, sperm count should be at least 20 million/cubic cm. 40% of the sperm should be motile, and at least 60% should be normal in structure. In this series a man with a count of 5 million/cubic cm had 2 children by his 1st wife before the onset of epididymitis but was unable to impregnate his 2nd wife in 6 months of follow-up. Sterility work-up by the wife's gynecologist was negative.

Bilharzia of the Fallopian tube.

Results are reported of a study to determine the incidence of tubal bilharziasis and its role as an etiological factor in ectopic pregnancy and salpingitis, and to detect specific symptoms and signs of tubal infestation with the schistosome. Fallopian tubes removed from patients admitted to the gynecological ward of Harari Hospital, Salisbury, Rhodesia, with a diagnosis of either ectopic pregnancy or severe salpingitis were examined macroscopically, after which transverse sections were taken from the middle and ends of each tube. The remainder of each tube was opened longitudinally and examined for irregularities before being digested in sodium hydroxide for 12 hours. The centrifuged deposits were then examined microscopically for the presence of ova. 50 subjects of similar age who had not complained of symptoms of tubal pathology and on whom autopsies were performed for other reasons served as controls. The incidence of tubal bilharziasis among 50 patients in each group was 20% in the autopsied women, 28% in the group experiencing ectopic pregnancy, and 32% among those with salpingitis. Only 30% of patients in whom ova were found to be present on digestion were diagnosed histologically. The different incidence of bilharziasis in the 3 groups was not statistically significant, suggesting that bilharziasis is not an important etiological factor in ectopic pregnancy or in salpingitis. 55 patients with tubal bilharziasis diagnosed over a 9-month period, 17 with ectopic pregnancies and 38 with acute salpingitis, were compared with equal numbers of patients of the same age suffering from the same conditions, without bilharzia. Findings in the 2 groups for parity, menstrual cycles, incidence of dysmenorrhea, intermenstrual vaginal discharge, and acute and chronic abdominal pain were very similar, while abnormal uterine bleeding was less common in the bilharzia group. A history of bilharzia was not helpful in the diagnosis of tubal bilharzia. It was concluded that tubal bilharzia does not produce symptomatology or operative findings which are diagnostic of the presence of the condition.

Chlamydial infections in selected populations in Kenya.

A pilot study on the prevalence of Chlamydia trachomatis in selected populations in Kenya is reported. Specimens were collected from 112 men with gonococcal urethritis, 96 women with genital ulcer disease, and 58 women with abnormal vaginal discharge seen at the Nairobi Sexually Transmitted Disease Clinic; from 54 women attending the antenatal clinic at Kenyatta National Hospital; from 57 women attending a family planning clinic in Nairobi; and from 67 prostitutes. By patient group, the percentages of N. gonorrhoeae and C. trachomatis infections isolated, respectively, were as follows: gonorrhea patients, 100% and 9%; genital ulcer patients, no data and 4%; vaginal discharge patients, 23% and 7%; antenatal clinic patients, no data and 6%; family planning clinic attendees, 17% and 4%; and prostitutes, 8% and 5%. There was no significant difference in the percentages of serologically positive sera between the different groups of women. The median age of women with documented chlamydial infection was 24 years, with a range of 19-42 years. 90% of women had experienced a chlamydial infection by the age of 20 years. The median immunofluorescent (IF) titer was 1:16 in men and 1:32-1:64 in women. 72% of all women but only 22% of men had a titer of 1:32 or above, and significantly more pregnant women than family planning clinic patients had a titer of 1:64 or greater. Overall, only 9% of the women and 20% of the men had no IF antibodies. The high prevalence of antichlamydial IgG antibodies contrasts sharply with the relatively low isolation rates observed in this study. However, frequent genital reinfection with C. trachomatis may incur some form of immunity, resulting in failure to isolate the organism. An inverse antibody titer-isolation rate correlation has been noted in patients with chlamydial salpingitis. Research on the impact of chlamydial infection in pregnant women and their offspring should be a priority in countries with high rates of perinatal mortality and morbidity.

Urban-rural income transfers in Kenya: an estimated-remittances function.

The quantitative magnitude and empirical determinants of urban rural remittances for Kenya were investigated, using data on the average, monthly amount of money urban workers send to rural areas along with the joint distribution of several of their socioeconomic characteristics. In the spring of 1971 the Institute for Development Studies of the University of Nairobi conducted a survey of African households in Nairobi. The sample was confined to low and middle income areas of the city. The survey schedule included questions on basic socioeconomic variables as well as questions on income remittances. Of the 1140 males in the sample who had some income in December 1970, 88.9% responded that they regularly sent some money out of Nairobi. The average amount remitted was 85.7 shillings per month; 20.7% of the sample urban wage bill was remitted. Most of the money was intended for consumption by the extended family. 2 sets of regression results are presented regarding the relation between the total income transferred out of Nairobi each month (T) as a function of monthly income in Kenya shillings. For incomes in excess of about 1600 shillings per month, the estimated marginal propensity to remit was negative but was not significantly different from zero. Each child residing in a rural area increased the fraction of income remitted by .0164; each child in Nairobi reduced the fraction by .0188. The absolute values of these estimated coefficients were not significantly different from one another. Urban rural income transfers represent about 1/5 of the urban wage bill in Kenya. The analysis showed that the amount which individuals transfer is systematically related to income and other socioeconomic variables. To the extent that rural and urban residence is a useful distinction, the magnitude of urban rural income transfers implies a very significant increase in rural welfare from what is implied by comparisons of relative incomes alone. The results imply that the welfare of the typical individual in Kenya depends rather significantly on the number and closeness of relatives working in the high wage sector. A general increase in the urban wage level has the effect of lowering the fraction of the wage bill remitted to rural areas and lowering the level of employment. The net effect of an increase in the urban wage on aggregate urban rural transfers is positive only if the elasticity of transfers with respect to income exceeds the absolute wage elasticity of labor demand.

Urban development and employment in Abidjan.

The city of Abidjan in the Ivory Coast has grown physically, economically, and demographically at rates exceeding all reasonable expectation. Yet, as in many other development nations, the employment generated by Abidjan's rapid economic expansion has failed to keep pace with the increase in working population it has attracted. Consequently, economic success has been accompanied by a variety of social strains. Some of these have been discussed in earlier issues of the "International Labour Review" by Louis Roussel. This discussion expands on Roussel's earlier treatment by focusing more specifically on several facets of the urban employment problem created by the rapid growth of Abidjan. Attention is directed to labor supply and employment, factors affecting migration, foreign Africans in the Ivory Coast labor force; the urban informal sector; urban infrastructure and development; social problems of population pressure; employment policy options (current government policies and other policy options); and general issues and policy alternatives (motivations for rural urban migration, smaller urban centers as alternative growth poles, and distributing the gains from development). Several essential features of the employment problem stem from the rural urban distribution of the workforce. The rural labor force, including temporary seasonal workers from the savannah countries to the north, remains more or less in balance with increasing rural employment opportunities, since the migration of Ivory Coast nationals to the cities is balanced by the inflow of foreign workers. In contrast, the influx of migrants into urban areas has led to a more rapid increase in the urban labor force than in urban employment, with a consequent rise in unemployment. In 1970 the Abidjan rate of open unemployment was probably around 20%. At this time, most people's idea of a desirable job is one in the formal sector of the urban economy. If there is to be any hope of an eventual balance between expectations and reality, it must be realized that an increasing share of the urban labor force will have to end up in the informal sector. Different attitudes towards work in the informal sector are needed on the part of both young people entering the labor force and of government policy makers. The latter should be seeking ways to increase productivity and incomes in the informal sector rather than for ways to destroy it. Current government policies include the training and educating of nationals to replace foreign technicians and managers, increasing the attractiveness of the rural milieu by the promotion of cooperatives, attempts to reform the land tenure system, the supply of electricity to villages, and the introduction of educational television; and adapting the educational system and technical training programs to the needs of the economy.

Genital tuberculosis.

Genital tuberculosis is almost always secondary to tuberculosis elsewhere in the body, generally in the lungs or peritoneum. The tubes are usually the intital site of infection. Primary sterility was the presenting symptom in 75% of genital tuberculosis cases observed by the author and secondary sterility in 14%. The high incidence of sterility is due to tubal closure. Amenorrhea was noted in 7% of cases and abdominal pain in 50%. Latent genital tuberculosis cases far exceed those showing clinical signs, making diagnosis difficult. Endometrial biopsy or curettage has become an important source of discovery of latent endometrial tuberculosis. Other diagnostic methods include radiology, bacteriologic examination, guinea pig inoculation, cultures of menstrual discharge and cervical mucus, uterosalpingography, and pelvic calcification studies. The current treatment approach involves application of chemotherapy for at least 1 year. The main drugs in use are streptomycin, isonicotinic acid hydrazide, and para-aminosalicyclic acid. Combined treatment with antituberculous drugs and estrogen is advocated if genital tuberculosis is accompanied by both sterility and amenorrhea. Transuterine instillation of cortisone and streptomycin is often used to treat occluded tubes in tuberculous salpingitis. Treatment is most effective in cases with mild endometrial involvement. Most pregnancies among women with genital tuberculosis result in tubal implantation or spontaneous abortion, although prolonged chemotherapy may improve the pregnancy outlook. Antituberculous treatment or surgical repair is of little benefit in cases where the inflammatory process has caused complete occlusion of the tubal ostia and destruction of the tubal lumen. Chemotherapy may restore fertility in the small number of cases where the tubes are free from infection, as in isolated endometrial tuberculosis. Pregnancy is most likely in women in whom antituberculous treatment for the primary pulmonary or peritoneal lesion was instituted when the process in the uterus and tubes was in its initial stage and before inflammation caused tubal occlusion.

Laparoscopy/laparotomy evaluation of artificial donor insemination failures.

The cases of 24 women who failed to conceive after 6 months of donor artificial insemination (AID) are reviewed. Preliminary examination before AID, including endometrial biopsy and hysterosalpingography, revealed no discernible cause for infertility. When conception had not occurred by the 6th treatment cycle, the patients were reevaluated for a tuboperitoneal cause of infertility. Laparoscopy was used in 4 cases, laparoscopy and laparotomy in 4 cases, and laparotomy alone in 16 cases. 15 of the 24 women (62.5%) were found to have pelvic factors potentially detrimental to fertility. Uterine fibroids were the most common disorder (6 cases), followed by pelvic endometriosis (5 cases) and pelvic inflammatory disease (5 cases). Surgical correction, including myomectomy, uterotubal implantation, and fertility laparotomy, was attempted in these women. Following surgery, AID was resumed. Although follow-up data are not complete, 4 pregnancies are known to have occurred. These results confirm the value of discontinuing AID after the 6th failed cycle and reevaluating fertility potential through laparoscopic examination.

Epidemiology of penicillinase-producing Neisseria gonorrhoeae in Singapore.

The incidence of penicillinase-producing Neisseria gonorrhoeae (PPNG) infections in Singapore increased alarmingly from 3 cases in 1976 to 1792 cases in 1979, in which year such strains comprised 19.2% of total gonorrhea infections. This increase was parallelled by a decrease in the number of non-PPNG cases from 8036 in 1978 to 7540 in 1979. Female prostitutes contributed 72.7% of PPNG infections in 1979. In that year, 32% of gonorrhea infections among women other than prostitutes were PPNG strains. This has implied an increased occurrence of ophthalmia neonatorum and pelvic infection. The group at highest risk of infection includes single men aged 15-29 years engaged in semiskilled or unskilled labor. 85% of patients cited Singapore as the place of contact. Professional prostitutes were the primary contact in 72% of cases in 1978 and 66.8% of cases in 1979. Boyfriends or husbands contributed 10% of infection in both years. Contact tracing has produced a 51% success rate. Non-PPNG strains have been isolated from 15% of primary contacts, suggesting concomitant infection with both PPNG and non-PPNG strains. Measures to control sexually transmitted diseases are vigorously pursued in Singapore. These include intensive bacteriologic surveillance, effective treatment, determined contact tracing, and control of infection in prostitutes. About 5000 prostitutes have been registered with a medical scheme to which they report for periodic examination. The success of this scheme is indicated by the reversal of the male-to-female ratio for gonorrhea from 3:1 in 1975 to 1:3 in 1979. All patients with suspected gonorrhea have smears and cultures performed, and N. gonorrhoeae isolates are screened for penicillinase production by the iodometric method. A 98% cure rate has been achieved through a single 2 gm dose of kanamycin. However, these measures have not been able to contain the spread of PPNG infection. As infection with these strains becomes more prevalent, it may be necessary to switch to more costly treatment methods, e.g., aminoglycosides. Such treatment would increase the risk of 8th nerve damage and renal toxicity, and might not abort incubating syphilis. Since Singapore is a busy port and a major tourist center, global dissemination of PPNG infection constitutes a serious danger.

Family, fertility, and sex ratios in the British Caribbean.

Evidence is cited in support of the view that the pattern of marital instability and relatively casual mating characteristics of the family system in the British West Indies depresses fertility levels considerably, and the attempt is made to show why such data may not be as conclusive as has been believed. It is argued that previous researchers have drawn conclusions concerning societal fertility levels based on evidence that may be valid only at the level of fertility differentials among individual women. The systems approach to the study of fertility is emphasized. The assertion that fertility would be higher if these societies had stable conjugal systems is based on several assumptions. The belief that evidence valid for individuals would also hold at the societal level was based on the assumption that a trend toward conjugal stability would not be accompanied by declines in the proportion of mated women. In reviewing the historical pattern of male deficits it is shown that this 2nd assumption is untenable for most British Caribbean societies from the date of the earliest censuses until 1960. Depending on both the time period and the society, anywhere from 20-50% of women would have been forced to remain without partners due to the scarcity of males. British Guyana and Trinidad and Tobago are the exceptions to this general British Caribbean pattern. For the other societies it is apparent that a trend toward conjugal stability would have resulted in an increase of unmated, and thus childless, women. A 3rd assumption is that there would be no rise in the average age of female entrance into 1st sexual union. At this time Caribbean women form their 1st union in their late teens. It is expected that any movement toward a more stable conjugal system would be accompanied by a rising age at 1st union formation. A demographic factor that is operating is that a scarcity of males in a monogamous society normally forces the average age at union entry for females to rise. And a rise in the average age at 1st conjugal union for females would most likely be significant. In addition to the effect brought about by the demographic factor of male shortages, it is necessary to consider the sociocultural context in which any trend toward stability of family institutions in the West Indies would occur. If the family systems in this area were to become stable by conforming to European normative guidelines the following pattern would emerge: a marked reduction in illegitimacy, a rising age at union formation, an increase in permanent female celibacy and childlessness, and, consequently, no rise at all in the birthrates. There would be no gain in fertility potential because a stable family system confronted with large and prolonged male deficits encounters the same problem facing an unstable system--a significant amount of time when women are free from the risk of pregnancy.

Contraceptive sponge makes debut.

A vaginal spermicidal sponge, made of polyurethane and containing nonoxynol-9, is expected to be on the market in Fall 1983. It will be sold under the name "Today" and will cost about $1 each. US Food and Drug Administration (FDA) approval of marketing of the sponge was obtained in March 1983. The device, which was developed by the VLI Corporation, is already marketed in the UK. Among the unique features of the sponge are the following: 1) an absence of potential adverse systemic side effects; 2) 1 universal size, eliminating the need for professional fitting or prescription; 3) ease of insertion and removal; 4) over-the-counter marketing; 5) the possibility of multiple acts of coitus during the recommended 24-hour wearing time, without additional preparation; 6) the combination of spermicidal activity with a barrier method of contraception; 7) no need to wait after insertion; 8) the opportunity for sponge insertion hours in advance of intercourse; 9) disposability; and 10) lack of leakage of excess medication during and after coitus. Research studies involving about 2000 women worldwide found the sponge's effectiveness to be in the range of other vaginal contraceptives. An overall failure rate of about 10-18% is claimed. Fewer than 2% of users in clinical trials experienced irritation; however, persons sensitive to spermicides may have an allergic response. Sponge use will be monitored to determine whether there is a risk of toxic shock syndrome. Other concerns center on the use of polyurethane and the possible presence of carcinogenic compounds. Studies of possible 48-hour use are in process. Noncontraceptive benefits are expected to emerge with more widespread use. 1 study suggested that nonoxynol-9 offers some protection against gonorrhea and other sexually transmitted diseases.

Migrant women speak.

This report, comprised mainly of personal accounts by women migrants of their living and working conditions, represents the initial findings of the Working Party on Women Migrants, Churches Committee on Migrant Workers. The 6 chapters focus on the following areas: North African women in Marseilles, France, describe their living conditions; migrant workers in Belgium relate their working conditions; Portuguese women in France discuss their family life and children's education; the French wages for housework campaign organized by migrant women is described; the Women Migrants' Manifesto drawn up in 1974 at a conference held in Switzerland is presented; and Italian migrant women discuss their anticipated return home. The personal statements elucidate the oppression and exploitation women migrants face as women, migrants, workers, wives of migrants, mothers, and foreign women. Women migrants face severe isolation since language barriers and ties to traditional customs cut them off from the receiving country. The lack of job training limits employment opportunity. Money and children are the 2 main concerns of migrant women. Action around migrant women must take 4 areas into account: 1) improvement of material living conditions; 2) consciousness raising among women migrants to break their isolation and recover their identity; 3) return migration, including the reintegration of women migrants; and 4) present migration practice, including the absence of a coherent migration policy in either the receiving countries or the countries of origin to promote the personal, social, and occupational advancement of migrant workers. A global and comprehensive approach to migration must be developed. In addition, actions aimed at improving the plight of migrant women must be part of a broader strategy to improve the status of all women.

Birth-canal injuries.

Indigenous gynecological procedures are responsible for severe stenosis of the genital tract in some tropical countries. Female circumcision may be followed by vulval stenosis whose severity depends on how much of the vulva is removed. The radical circumcision and infibulation of Egypt and the Sudan may result in dyspareunia, interference with urination, dystocia, and other serious aftereffects. Insertion of caustics into the vagina is a common method of treatment for a variety of gynecological disorders; a crude base for herbal remedies in Western Nigeria containing palm oil and potash can cause severe chemical vaginitis, while insertion of rock salt in the puerperium, practiced in Arabia to shrink the lower genital track to its nulliparous state for the husband's greater sexual gratification, may lead to necrosis and sloughing of the vaginal wall, severe stenosis and dyspareunia, and total occlusion of the canal. Subsequent plastic reconstruction of the vagina requires a 2-stage operation in which the scar tissue is totally removed and a graft from the thigh is inserted. The high incidence of contracted pelvis in many tropical areas where maternity services are inadequate makes vasicovaginal fistulae of obstetric origin a major public health problem. Among 335 consecutive cases of vesicovaginal fistulae treated in Ibadan between 1953-67, 325 resulted from difficult labor and only 6 from gynecological operations. Complicating factors included previous attempts at repair in 82 cases, concomitant rectal defects in 64, extreme vaginal stenosis due to scarring in 35, and multiple fistulae in 14. Among the 335 cases, 62% of 141 juxta-urethral, 67% of 61 massive, 82% of 55 mid-vaginal, 85% of 13 vault, and 91% of 65 juxta-cervical fistulae were successfully closed at the 1st attempt. Diversion of the urine into the bowel is sometimes necessary. 2 of 5 deaths followed transplantation of the ureters into the rectum, 2 resulted from involvement of the ureters in repair of high fistulae, and 1 followed an accident of anesthesia. Successful repair depends on experience and expert nursing to ensure continuous drainage of the postoperative catheters. Rectal injuries to the lower 1/2 of the vagina are not difficult to repair, but such injuries in the upper 1/2 result in total fecal incontinence. 45 of 53 cases involving repair of high rectovaginal defects were successfully treated at the 1st surgical attempt.

Repeated congenital infection with Toxoplasma gondii.

The thesis that congenital infection with Toxoplasma gondii can occur only during the time of parisitemia following primary infection and that intrauterine transmission cannot be repeated in subsequent pregnancies due to the presence of antibodies was disputed in a study of 70 women with a history of repeated miscarriages, premature births, and stillbirths. 137 specimens from these women and their fetuses were examined for Toxoplasma through inoculation into healthy white mice. Toxoplasma were isolated from 36 specimens in 23 women or fetuses. Positive materials included brain (11 specimens), abrasion material (4), placenta (4), fetal fluid (2), lochia (2), menstrual blood (12), and maternal milk (3). 19 of the 23 women showed serologic reactions consistent with a primary infection with Toxoplasma gondii which occurred a long time before the pregnancy in question. All had Sabin-Feldman dye test titers up to 1:1000 and negative complement fixation reaction titers. A negative reaction to both these tests was observed in 4 cases. In 6 cases Toxoplasma was isolated before the 20th week of pregnancy, and in 1 case from fetal fluid from a miscarriage in the 17th week of pregnancy. This contradicts prevailing opinion that Toxoplasma cannot penetrate the placental barrier before the 2nd half of pregnancy. It was possible over a duration of many months to isolate Toxoplasma from menstrual blood, but in most cases serologic examination revealed only a low level of antibody titers. This suggests that a locally limited proliferation of the organisms can exist in the uterus for several months without causing new production of antibodies. The theory that intrauterine transmission cannot be repeated was contradicted by 1 case in which Toxoplasma was isolated from the brains of 2 successive stillborn fetuses, and by a 2nd case in which Toxoplasma was isolated from menstrual blood each of the months between 2 pregnancies, both of which ended in miscarriage. It is concluded that the process of placentation during a new pregnancy provokes a new local proliferation of ruptured cysts, without an increase in antibodies. Since serologic examination cannot reveal latent foci in the uterus, prophylatic treatment with sulfonamides is recommended. Such treatment was followed by the birth of 40 healthy infants to 46 women with a history of repeated reproductive failure.

Seminal analysis in fertile and infertile Nigerian men.

Semen quality was evaluated in 53 Nigerian men of proven fertility and 370 men from infertile marriages. Average age in the 2 groups was 28.9 years and 33.2 years, respectively. No statistical difference was noted between the 2 groups in the mean ejaculate volume, which was 3 ml among the fertile men and 2.3 ml in the infertile men. However, more men in the latter group had a seminal volume <1.5 ml. The mean sperm count for fertile men was 71.2 million/ml, compared with 46.8 million/ml in men from infertile marriages (p<0.001). 7.6% of the fertile men but 40.3% of infertile men had counts <20 million/ml. The 4 cases of oligospermia identified in the fertile group were all classified as mild, while 34 of the 128 cases in the infertile group were severe and aspermia was found in 23 cases. Only 5.7% of the fertile men had an average percentage motility grade under 40% in contrast to 28.7% of the infertile men. Similarly, 3.8% of fertile men demonstrated a percentage of abnormal sperm morphology in their ejaculate. The results highlight the significance of the male contribution to infertility. Prospective epidemiologic studies are needed to determine the causative factors in the increasing male sterility in Nigeria. There may be a relationship between gonadal sclerosing factors, prevailing stress factors, and widespread sexually transmitted diseases. Artificial insemination is recommended in cases where therapeutic recovery leading to conception cannot be achieved by conventional methods.

Mycoplasma and human reproductive failure. I. The occurrence of different Mycoplasmas in couples with reproductive failure.

An epidemiological study of the occurrence of different Mycoplasmas in seminal fluid and in cervical secretions from patients with reproductive failure and in 2 control groups is described. All patients underwent a series of fertility tests before inclusion in the study and those with abnormal findings were excluded. Group A consisted of 36 couples in whom no cause of infertility could be found and group B of 19 couples in whom serum antibodies agglutinating donor sperm in different titers were detected in the women but not in the men. 2 control groups consisted of 40 women in group C attending a prenatal clinic and 23 men in group D married to women in the 3rd-9th month of pregnancy. Among the subjects, sperm specimens were obtained from the men and cervical swabs from the women on the 2nd or 3rd day of the menstrual period and cultured for Mycoplasmas. Cervical swabs taken after postcoital tests, and cervical and sperm specimens taken during the luteal phase were also cultured. Cervical and sperm specimens from the controls were also cultured. In group A, large colony-forming Mycoplamas were found in cervical secretions of 7 women and in seminal fluid of 2 men. T-Mycoplasmas were found in both spouses in 28 couples and in 3 women and 2 men with negative partners. In group B, large colony-forming Mycoplasmas were found in 2 women and 1 man whose partners were negative. T-Mycoplasmas were isolated from both spouses in 17 of the 19 couples and from the wife only in 2 couples. In group C, classical Mycoplasmas were found in 3 and T-Mycoplasmas in 9 of the 40 cases. In group D, no classical Mycoplasmas were discovered but T-Mycoplasmas were found in 6 of the 23 cases. The observed difference in frequency of T-Mycoplasmas between patient and control groups was highly significant statistically. T-Mycoplasmas were found growing from the spermatozoa but not from the supernate in 7 of 10 specimens obtained from men in group B. In 2 of the remaining 3 specimens, T-Mycoplasmas were found both in spermatozoa and in the supernate, while in the last specimen, no growth was found.

A proposed classification of pelvic endometriosis.

The correlation between extent of endometriosis and pregnancy rate was analyzed in a study of 107 infertile women who underwent conservative operative treatment for pelvic endometriosis. The diagnosis was established or suspected on the basis of history and physical examination in 84.1% of cases. Endometrial involvement was classified as mild, moderate, or severe. Major factors considered in developing this classification scheme included extension and size of the lesion, scarring and retraction of the tissue involved, pelvic and peritubular adhesions, and significant bowel or urinary tract involvement. Presacral neurectomy, removal of endometrial implants, plication of the uterosacral ligaments, and uterine suspension were performed in all cases. Overall, 49 of the 107 women (45.7%) became pregnant following surgery. The pregnancy rate declined with the length of infertility, with the highest rate (57.1%) found among women whose infertility had been 1-2 years in duration. Patients' age, which ranged from 20-39 years, was not significantly related to achievement of pregnancy. 40.7% and 61.5% pregnancy rates were observed among women with primary and secondary infertility, respectively. 35 of the 49 pregnancies were achieved during the 1st year after surgery. 48.5% of women with ovarian implants became pregnant. A 45% rate was achieved in the group of women who showed involvement of the cul-de-sac, bladder peritoneum, uterosacral ligaments, and 1 or both ovaries. 8 patients were classified as having mild endometriosis, and 6 (75%) became pregnant. 60 were classified as having moderate endometriosis, and 30 (50%) became pregnant. Of the 39 cases classified as severe, 13 (33.3%) became pregnant. These results suggest that the duration of infertility prior to surgery and the degree of endometrial involvement are central factors in the obstetric prognosis of patients undergoing conservative surgery for endometriosis. Further studies are being conduted to determine whether major health problems develop in women with endometriosis who do not have conservative surgery and/or never become pregnant.

Sexually transmitted diseases in the tropics. Epidemiological, diagnostic, therapeutic, and control aspects.

Sexually transmitted diseases, especially syphilis, gonorrhea, granuloma inguinale, and lymphogranuloma, are on the increase in the tropics. Several environmental factors contribute to disease transmission, including polygamy, high bride price, prostitution, civil war, urbanization, and economic development. Diagnosis is generally made on clinical grounds due to inadequate laboratoary facilities, and it is not possible to differentiate syphilis from yaws. This diagnostic inaccuracy has meant that there are no reliable data with which to assess epidemiologic trends, institute control measures, and evaluate their effects. Inadequate treatment, caused by a lack of drugs and poorly trained medical attendants, is also a major problem. Inappropriate treatment has caused over 80% of gonococcal strains in some areas to be penicillin-resistant. Late complications of gonorrhea, epididymitis, and salpingitis are frequently seen and lead to sterility in many cases. These complications are as prevalent in some areas today as they were in pre-sulfonamide days. A determined effort is needed to control the spread of these diseases. A central unit with modern facilities for diagnosis and treatment should be established. Diagnostic tests, such as culture and serology, should be introduced at the district and provincial levels. Rural health centers should employ a polyvalent microscopist who is trained to recognize gonococcus in stained smears. Given the high default rates, treatment should be simplified, using a single dose schedule where possible. The impracticality of follow-up requires epidemiologic treatment of contacts in many cases. If mass screening of pregnant women is not possible, Crede's silver nitrate eyedrops are recommended to prevent ophthalmia neonatorum. High risk populations, including bar girls, migrant workers, soldiers, and sailors, should be targeted for health education campaigns. Such education should focus on regulation of sexual behavior, condom use, and, when infection is present, the importance of avoiding self-medication, early treatment, and cooperation in contact tracing.

The manual of microvascular surgery. Contains a 23 page bibliography entitled, Microsurgery a bibliography.

This manual is a guide to microvascular anastomosis in the laboratory using the femoral artery and vein of the rat. Step-by-step directions are given for selected microsurgical techniques, including end-to-end microvascular anastomosis of an artery using the conventional suture method, end-to-end microvascular anastomosis of a vein using the conventional suture method, end-to-side anastomosis, and vasovasotomy. The concisely written directions are accompanied by line drawings, including cartoons. The manual was developed in conjunction with a microsurgery course at the Ralph K. Davies Medical Center. It is estimated that at least 1 month is required to master the complex skills of microvascular surgery. At least 95% of failures in such surgery are considered due to technical errors. Also presented is a 465-entry bibliography covering areas such as micro instruments, microneurovascular repairs, experimental microsurgery, tissue transfers, nerve repair, and replantation.

Epidemic disease control.

A dramatic decrease in the prevalence and mortality from communicable diseases has been noted since establishment of the People's Republic in China of 1949. Disease control has been based on health education to improve personal hygiene habits, mass inoculation programs, and destruction of animal and insect vectors. The population has been mobilized in this effort, and mass health campaigns have been linked with mass campaigns in other areas such as agriculture. Central to mass mobilization is the "mass line" concept. It is believed that a line of action can serve the people only if they are thoroughly committed to that line. Thus, an attempt is made to provide power, knowledge, and motivation to the public to secure their participation. Close interaction is maintained between the government and the people through mass meetings. The campaign against venereal diseases is illustrative of this approach. A 1st step involved eliminating prostitution, the institution most reponsible for the spread of sexually transmitted diseases. Brothels were closed, and prostitutes were given literacy training and employment in factories. Programs for detection and treatment were coordinated on a national level. The masses were actively involved in eradication efforts. Large numbers of paramedical personnel selected from local populations were trained to diagnose, report, and treat venereal diseases. Individual conformity was achieved through community pressure and commitment to building a socialist society. As a result of this effort, venereal diseases have been eliminated as a major health threat. Less progress has been made in the control of infectious diseases such as tuberculosis, trachoma, malaria, filariasis, and hookworm, although control efforts through mass campaigns are underway.

Mycoplasma and human reproductive failure. III. Pregnancies in "infertile" couples treated with doxycycline for T-mycoplasmas.

54 couples with primary infertility of more than 5 years' duration were treated with doxycycline for T. mycoplasmas. Sperm-agglutinating serum antibodies were detected in 16 couples (Group A), but could not be demonstrated in the remaining 38 couples (Group B). Concentrations of doxycycline in serum and sperm specimens during the 3 months of treatment were determined, and the effects of the treatment on the growth of the mycoplasmas were analyzed. The results of the doxycycline treatment were studied in detail in 11 couples. Genital mycoplasmas were eradicated from all 11 men during the 1st treatment and from 9 of the 11 women. An increase of dosage eliminated the mycoplasmas from a 10th woman; however, the final woman still harbored mycoplasmas in her cervical secretions. A total of 15 pregnancies occurred in Groups A and B during the treatment period. 7 of these pregnancies occurred after the 1st month of treatment and all were among women with negative mycoplasma cultures. The pregnancy rate was 25% in Group A and 29% in Group B. 13 of the pregnancies resulted in term deliveries of normal children; 2 miscarriages occurred during the 1st trimester. No side effects of the doxycycline treatment were noted in the infants. It is emphasized, however, that the high incidence of pregnancy observed in this series after eradication of T. mycoplasmas may be coincidental.

Investigation and treatment of the infertile male.

The investigation of 117 infertile couples in a clinical practice is reported. Results of testicular biopsies were categorized as follows: Type 1, normal testis; Type 2, germinal cell aplasia; Type 3, germinal cell arrest; and Type 4, sloughing effect. A diagnosis of block in the epididymis or vas was made by injecting saline up the vas toward the urethra and by finding inspissated spermatozoa in the distended tubules of the epididymis. (This method was later replaced by radiologic evidence of the patency of the vas by vasography and epididymography.) 2 men were found to have Klinefelter's syndrome. Local surgical conditions associated with infertility were noted in 7 cases. There were 36 infertile men with seemingly normal semen. A strongly positive Kibrick's macroagglutination test was found in the plasma of 9 of these men, and similar antibodies were noted in 5 of their wives. Of the 22 men with aspermia, an obvious explanation existed in 8 cases (e.g., Klinefelter's syndrome, retrograde ejaculation, mechanical obstruction). The sloughing effect was noted in 11 of the 14 men without an obvious cause for aspermia. Oligospermia was diagnosed in 60 men. Testicular biopsies in 21 of these cases revealed the sloughing effect in 10 specimens, germinal cell arrest in 3, and aplasia in 8. Of the 29 oligospermic men treated with fluoxymesterone, 14 showed improved sperm density and all showed improved motility. Sustained improvement in sperm density was observed in 11 of the 25 men treated with clomiphene. Only patients who showed sloughing off in the biopsy had improvement with either treatment method; however, sloughing did not always predict an improvement in sperm density. The persistently oligospermic man may be helped by artificial insemination of centrifuged semen or by pooling concentrated sperm. Plasma antisperm antibodies can be washed off spermatozoa and a concentrated specimen of semen injected directly into the cervix. Pregnancy has been achieved in 3 of the 12 cases where this method was tried. Finally, in cases with a positive Kibrick's reaction in the wife's plasma, prednisone can be administered to the woman over the period of artificial insemination with washed spermatozoa. This has achieved 1 pregnancy to date in this series.

Spermatogenesis in Klinefelter's syndrome.

The results of an analysis of seminal fluid, chromosomal formula, and testicular tissue performed on 32 men (including 2 prepubertal boys) with Klinefelter's syndrome are presented. 11 patients failed to yield any seminal fluid, and in 12 patients the seminal volume was less than 2 ml. Seminal density was normal in 50% of cases and diminished in the remainder. Azoospermia was noted in 20 cases, aspermia in 11 cases, and oligospermia in 1 case. Histologic study revealed tubular hyalinization and complete lack of cells involving most seminiferous tubules in 20 patients. A nuclear chromatin study revealed a positive pattern in 31 of the 32 patients. Karotype determination showed a 47,XXY formula in 15 of 16 patients studied. The low volume of ejaculate noted in the majority of these men suggests a severe hypoandrogenism and atrophy of the sex accessory glands. The presence of small amounts of fructose in the semen of these patients reaffirms the existence of a certain degree of androgenic function in Klinefelter's syndrome. Small areas of spermatogenesis were also observed in this series, suggesting the possible existence of an XY cellular line in the gonads whose action permits a certain amount of development of the germinal epithelium. Fertility is possible in some such cases. This syndrome is thought to be present in a latent form during early life, until the arrival of puberty brings about testicular alterations. Both prepubertal boys in this series showed immature tubules, populated almost exclusively by undifferentiated cells resembling presertolian cells. (summary in SPA)

In search of an ideal single-session penicillin schedule for the treatment of gonorrhoea in Uganda.

To determine the most effective, economical therapy for gonorrhea in Uganda, 5 single-session penicillin schedules were compared in a group of 460 university students with urethral discharge. A total of 590 episodes of gonococcal urethritis were treated. Patients were randomly allocated to 1 of 5 schedules. Treatment schedules and cure rates were as follows: 1) aqueous procaine penicillin 2.4 m.u. (125 cases), 90.3%; 2) procaine penicillin 2.4 m.u. plus ampicillin 1 gm (143 cases), 97.1%; 3) procaine penicillin 3 m.u. (90 cases), 89.8%; 4) procaine penicillin 3 m.u. plus probenecid 1 gm (103 cases), 97.1%; and 5) probenecid 1 gm orally followed by benzyl penicillin 5 m.u. (129 cases), 96.8%. 30 of the 31 treatment failures were successfully treated with an alternate schedule. The results obtained with procaine penicillin alone are considered unfavorable. Although highly effective, the probenecid and benzyl penicillin regimen is expensive and requires the preparation of penicillin with lignocaine solution and an extra 30-minute wait, making it inappropriate for Uganda's busy multipurpose clinics. The procaine-ampicillin combination was also highly effective, but its high cost limits it use to private practice. The 3rd highly effective schedule, the combination of procaine penicillin and probenecid, appears to most closely approximate the ideal single-session penicillin schedule for treatment of gonorrhea in Uganda. It is both inexpensive and easily administered. Moreover, the prolonged penicillinemia achieved by 3 m.u. procaine penicillin may be more effective in eliminating cases of incubating syphilis than benzyl penicillin. Long-acting procaine penicillin in oil with aluminum monostearate (PAM), which is the most widely used treatment regimen in the rural medical units of Uganda, is no longer indicated and may, in fact, be encouraging the spread of less sensitive strains of gonorrhea. Any change toward a more effective treatment schedule must, however, be accompanied by improvement in the diagnostic and treatment facilities in the country. (summary in FRE)

Sperm motility.

Current literature dealing with sperm motility is reviewed. Laboratory observation has led to the hypothesis that the sperm tail moves when the microtubules, powered by adenosine triphosphate (ATP), slide past one another, moving by means of their dynein arms, which are actual molecules of ATP activity. This sliding microtubule hypothesis is considered to explain the motility of the 9+2 sperm tails and all cilia and flagella. The clinical usefulness of determinations of various glycosidases in semen has been assessed in recent years. The neutral alpha-glycosiderase specific activity of sperm has been correlated with the percentage motility. It is postulated that an abnormal function of the epididymis may be related to decreased production of alpha-glucosidases. The subjective nature of visual assessment of motility is a persistent problem for researchers. Objective appraisal is hampered by variation in the appraisals of different researchers and striking, unexplained differences in motility in successive visits. Quantitative methods that can provide reproducible information on overall motility and percentage of motile sperm and can distinguish the speed of progression from ineffective vibrating and circling motions are not yet available to clinicians. Factual knowledge of the process of sperm maturation in the epididymis and the special quality of the environment in the epididymis that supports maturation or sperm storage is lacking. Various groups of compounds have been used to stimulate the in vitro motility of sperm, including methyl xanthines, nucleotides, carnitine and acetylcarnitine, arginine, and kallikrein. Sperm washing will occasionally enhance motility. There is agreement that sperm lose their motility within 15 days after vasectomy. The split-ejaculate method has demonstrated that the distribution of sperm cells is not uniform throughout the ejaculatory process. Insemination with the 1st portion of the split ejaculate has been effective in achieving pregnancy in infertile couples. Therapy for increasing sperm motility includes low dosage androgen and human chorionic gonadotropin. Research has been directed at improving the survival of motile sperm during the process of freezing, storing, and thawing human semen. However, storage of fertile semen does not guarantee future fertility.

The role of urban-to-rural remittances in rural development.

The return of money and resources by migrants to their respective home areas is 1 of the effects of rural to urban migration. An attempt is made here to answer a set of basically empirical questions: what is the extent of urban to rural remittances; what are the determinants of these observed financial and resource flows; and what use is made in the rural areas of the remittances received. A recent survey of literature for the International Labor Office on the rural impact of rural urban migration in developing countries included some 50 different studies which shed some light on this subject. The evidence provided in these studies on each of the 3 questions is summarized. When viewed from the perspective of the income earned by migrants, the extent of money and resources remitted appears to be substantial. The literature indicates that the volume of migrant remittances varies considerably from 1 rural community to another. The practice of remitting funds is predominantly an African phenomenon but is evident in a number of Asian and in some Latin American countries. International migration appears to generate the largest remittances. Particular rural families derive substantial benefit from remittances received. In those rural communities, where young people must leave to obtain formal education, all or most of the remittances received by the community may be offset by monetary outflows needed to pay for the education. Results of 3 studies reporting an explicit test of hypotheses of possible determinants of urban rural remittances are provided. On the key income variable, the results appear to be contradictory. The findings in 2 studies indicate that the proportion of income remitted does not vary significantly with the length of time the migrant has been resident in town. In the 3rd study the longer the period of urban residence, the smaller the amount of money remitted by the migrants. In most cases where rural areas receive substantial remittances, it seems certain that little is used directly as investment for rural development. In sum, most of the literature surveyed supports the conclusions reached by Connell et al. on the basis of Indian village study data that the migrants, during their absence, do not appear to exercise much, if any, control over how the remittances are utilized in the rural areas. Yet, particularly at the local village level, there is scattered evidence of investment of remittances in productive rural activity. The evidence is supportive of the earlier thesis of Mitchell (1969) that the migrant faces a life cycle of obligations to his home area.

Cervical choriocarcinoma associated with an intrauterine contraceptive device: a case report.

Choriocarcinoma most commonly occurs within the uterine corpus. Just as placental implantation rarely occurs in the cervix, choriocarcinoma of the cervix is unusual. A case is presented of a 35-year old white woman, para 1-0-0-1 who had an uneventful term pregnancy 1 year prior to admission. She used an IUD and reported regular menses until 3 months prior to admission when she noted irregular bleeding. At initial examination a serum pregnancy test was positive, indicating a mass thought to be a cervical leiomyoma and bilateral cystic ovaries. Pathologic interpretation of an endocervical curettage was choriocarcinoma. At that point a hysterectomy was performed; there were no further complications and the patient subsequently received 3 additional courses of methotrexate. Cervical choriocarcionoma may develop from cervical metastases from a primary tumor in the corpus which later spontaneously regresses, malignant transformation of a cervical pregnancy, or transport of chorionic cells from a preceding pregnancy that undergo malignant transformations after a dormant period. In the nulliparous patient the conservation of reproductive function should be considered if possible.

Population planning. Congressional presentation, fiscal year 1984 [excerpt]

The US Agency for International Development (USAID) has requested US$212,231,000 for population activities in Fiscal Year (FY) 1984. The FY 1983 appropriation was US$211,000,000. $94.6 million of the total request will be allocated directly to regional and national population programs. This includes US$10.6 million for Africa, US$63.5 million for Asia, US$13.3 million for Latin America and the Caribbean, and US$5.8 million for the Near East. A major emphasis of the Latin American population assistance programs will be encouraging a greater role for the private sector. US$119 million will be allocated to the Office of Population. Of this amount, US$85.1 million will support family planning service delivery, US$23.2 million will be allocated to development and the transfer of technology, and US$12.4 million will support training and the dissemination of information. The objective of USAID's population assistance program is to enhance the freedom of individuals in less developed countries to control their family size and to encourage population growth consistent with the growth of economic resources and productivity. The largest share of population assistance is directed to centers where there is strong governmental commitment, an infrastructure capable of delivering services throughout the country, and social and cultural acceptance of family planning. USAID seeks to make all areas of its development strategy for each country (e.g., population, health, education, nutrition, employment, agricultural productivity) mutually reinforcing. Decreased dependency on external resources is encouraged through local fund raising, voluntarism and community participation, fee-for-services, and improved management efficiency.

Contraceptive use by lactating women in the United States.

Statements have been made by various health organizations such as the World Health Organization that there are possible adverse effects of combined oral contraceptive (OC) use on milk quantity, and possible steroid transfer to the infant, and it has been recommended that other contraceptive methods be used during lactation. A study in 1981 found that 63% of physicians affiliated with the International Planned Parenthood Federation in developing countries prescribed OCs during lactation while only 40% in developed areas do; in North America only 26% did so, mostly because of patient preference. Data from the 1973 and 1976 National Surveys of Family Growth are analyzed in this paper for an analysis of OC use during lactation in the US. Some results are: 1) there is a lower percentage of lactating women using OCs but an increased percentage using IUDS and barrier methods; in 1976 there was a decline in the use of sterilization among these women; 2) contraceptive use was lower in the black population in the 1st 3 months postpartum in 1973 although this decreased by 1976; 3) prevalence of OC use was higher among blacks and remains high in 1976; 4) the use of barrier methods is high and increases with time and with months postpartum in the white population; 5) there is a higher level of OC use in the 15-29 age group during each month postpartum than in the 30-44 age group; 6) between 1973-76 there was a decrease in OC use in both age groups, probably due to a shift to interval procedures for sterilization during this time; 7) there was a decrease in IUD use between 1973-76 in older women; 8) there is still OC usage of up to 30% of women aged 15-29 in the 1st 6 months postpartum; and 9) a much higher percentage of short-term lactators use OCs although they do not manifest an excess of total overall contraceptive use. The higher percentage of OC use among black lactators may be associated with the higher percentage of these women who use organized medical services rather than private physicians as compared to whites. There is also a positive association between OC use and shorter lactation inspite of overall similar levels of contraceptive use in the short and longer term lactators.

A community development approach to raising health standards in Central Java, Indonesia.

The author describes programs which he helped to establish in Central Java, Indonesia to raise the health standards of the people. These programs attempted, more than just serving those who came for treatment, to promote the concept of how to live a healthy life. A maternity clinic was upgraded to become a maternity hospital where abnormal cases could be assisted and equipped with a children's ward and a family planning clinic; expensive equipment was not used and auxiliaries were used because of the shortage of qualified nurses and because of financial considerations. But this effort failed because the costs of using the facility were still too high for the underprivileged. In the village of Begajah an existing outpatient clinic was made into a health center; a village committee was set up to assist in getting support from the villagers. Agricultural methods were also improved and rice production was almost doubled. Infant mortality fell from 100 to 69/1000 live births. This experiment proved that a comprehensive approach in raising health standards through community development could be implemented and was also cheap and appropriate. Housing was also improved. In 1965 in the community of Sumberlawang the need for a health facility was expressed. Village committees were established and an infant nutrition program was successfully implemented. Other similar projects are described. The author also introduced the idea of a health fund in some of these villages aimed at providing inexpensive treatment. Each member of a village "block" would pay a certain amount (about $0.0125) per month, or .5% of the average monthly income and had the right to be examined by the doctor in the hospital and to obtain medicine. Eventually services were extended to include health and nutrition education, and family planning. Training courses for young doctors and nurses in the community development approach consisted of exposing them to the situation, allowing them to interact with the people and to help them mobilize available resources.

Meeting basic health needs in Tanzania.

The overall objective of current health care policy in Tanzania is better coverage of the population. The 1967 Arusha Declaration, which defined Tanzania's social and economic policy for the current period, directed that rural areas should receive priority in all development programs. Thus, the development of health services has been incorporated into overall rural development. Tanzania is among the 25 least developed of developing countries. The scarcity of economic resources has impeded progress in the health sector. However, the impact of meager resources has been somewhat offset through an emphasis on disease prevention, widespread health education, use of auxiliary personnel, and community involvement and self-help. Rural health care is provided by rural medical aides, maternal and child health aides, health auxiliaries, and medical assistants who work under the supervision of the next tier of the health service. The country's basic health units are the district hospitals, rural health centers, and dispensaries. There were 1555 dispensaries in 1974, with a district/population ratio of 1:9000. 100 new dispensaries will be built each year to raise this ratio to 1:6000-8000 by 1980. The 108 health centers existing in 1974 led to a 1:99,750 center/population ratio. 25 new centers will be constructed yearly to reach the target ratio of 1:50,000 by 1980. There are 123 hospitals, 60 of which are voluntary. Growth of the hospital sector is not a priority. The number of beds will be increased by 3% annually to keep up with population growth. Tanzania hopes to collaborate with other countries on health services to maximize the impact of meager economic resources and avoid costly duplication of services. The Tanzanian example shows that better population coverage can be attained under conditions of underdevelopment through good planning, good leadership, and self-reliance.

Promotion of breastfeeding in Chile.

Early weaning has reached high levels in Chile, with only 11% of urban mothers (19% rural) feeding only breast milk in the 1st 6 months of life and 77% feeding only bottled milk (63% rural); as a result undernutrition has shifted to the early months of life. A program in western Santiago to encourage breastfeeding aimed at motivating mothers towards prolonged breastfeeding, teaching successful techniques, and evaluating the health status reached by breastfed children is described. A total of 1536 newborns were included in this study. 4 lectures on advantages and techniques of breastfeeding were given and was begun for each mother when she came to the health center for the 1st time, when the baby's age was 8-12 days. Each mother was given a minimum of 3 programmed consultations for her infant during the 6 months of followup. A control group of 70 babies not included in the program was used. 24% of the group dropped out, mostly because they moved. Some results were: 1) breastfed girls had greater body weight than the control group with a statistically significant difference (p<0.05), and the same difference appears in boys from the 2nd month; 2) 86.6% of the mothers started exclusive breastfeeding in the 1st month postpartum and 50.7% were continuing in the 6th month, but in the control group 57.2% started and only 22.9% continued; and 3) morbidity is significantly lower at all ages in infants being breastfed. Mothers were shown healthy breastfed infants compared to undernourished bottlefed babies and thus interest was stirred in breastfeeding practices. Educational and psychological motivation of the mother towards breastfeeding helps to increase the percentage which will practice it and the following recommendations are made: 1) discourage promotion of artificial feeding, 2) allow mothers to choose their infant's method of feeding, 3) prevent unsuccessful breastfeeding techniques from being taught, 4) avoid giving the infant water or artificial milk at 1st to encourage breastfeeding, and 5) encourage mothers to avoid weaning.

Structural changes of the genital tract associated with in utero exposure to diethylstilbestrol.

Lower and upper genital tract abnormalities detected in a group of women exposed in utero to diethylstilbestrol (DES) are reported. Data are from the Baylor College of Medicine, which is 1 of 4 participating centers in a National Cancer Institute project studying the incidence of genital tract abnormalities and cancer in DES-exposed offspring. Patients were recruited through physician referral and record review or were walk-ins. Gross anatomic changes of the cervix were noted in 178 (33%) of the 537 women with documented DES exposure. The occurrence of these changes decreased significantly when DES exposure was after the 20th week of gestation. An earlier study by the author noted upper genital tract abnormalities in 185 (69%) of 267 DES-exposed women on whom hysterosalpingography (HSG) was performed. Abnormal x-ray findings included a T-shaped uterus with a small cavity in 57%, a T-shaped uterus alone in 19%, a small uterine cavity in 13%, a T-shaped uterus with a constriction ring in 13%, and constriction rings alone in 4%. Uterine changes were unrelated to age or the occurrence of prior pregnancy. An abnormal HSG was 4.5 times more likely in women with structural cervical changes, occurring most often in women with a small uterine cavity. 146 (82%) of 179 women with vaginal epithelial changes had abnormal x-ray findings. Women with vaginal changes were 5 times more likely to show abnormal x-ray results. A gradual decrease of abnormal x-ray findings was noted with increasing gestational week of beginning DES exposure. The poor pregnancy outcome noted in DES-exposed women is believed to be associated with structural, cervical, and uterine changes rather than with DES exposure per se. The author's analysis of 93 DES-exposed women revealed the following pregnancy outcome statistics for women with abnormal and normal x-rays respectively: term pregnancy, 29% and 50%; spontaneous abortion, 27% and 16%; ectopic pregnancy, 7% and 0; and never a term delivery, 54% and 34%. These figures underscore the need for careful observation of DES-exposed women during pregnancy.

Fertility after childbirth: changes in serum gonadotropin levels in bottle and breast feeding women.

Changes in basal serum gonadotropin levels were analyzed in relation to level of ovarian activity in a longitudinal study of 24 breastfeeding and 7 nonlactating women ages 21-40 years. Ovarian activity was categorized as showing complete suppression, follicular activity only, inadequate luteal phases, or normal menstrual cycle. Resumption of follicular activity, menstruation, and ovulation was significnatly delayed (p<0.001) among lactating compared with nonlactating women. The 1st postpartum menstrual period was preceded by ovulation in 13 (55%) of lactating women. Complete suppression of ovarian activity during lactation was associated with normal levels of follicle stimulating hormone (FSH) but low levels of luteinizing hormone (LH). Resumption of follicular development was not accompanied by increased levels of either gonadotropin. LH levels were significantly (p<0.01) lower at 4 weeks postpartum than at any other time, but showed significant increases by 8 weeks postpartum and remained unchanged thereafter until normal ovulatory cycles resumed. FSH secretion remained at a level comparable with the follicular phase of normal ovulatory cycles throughout the postpartum period. Nonlactating women did not demonstrate change in mean basal LH levels as ovarian activity resumed. Mean basal FSH levels were significantly (p<0.05) lower when ovarian activity was suppressed than during the follicular phase of normal cycles. In addition, mean FSH levels during absent or reduced ovarian activity were lower at 4 weeks postpartum than they were in lactating women. However, total estrogen levels were significantly (p<0.01) higher among nonlactating women at this time. These results confirm earlier reports that FSH levels increase after pregnancy and remain within the normal range of menstrual cycles in the postpartum period, while LH levels increase to and remain at the lower limit of normal. They suggest that decreased LH but not FSH secretion may be important in maintaining the infertility associated with lactation. The absence of changes in LH or FSH levels at the onset of follicular development suggests that an alteration in the sensitivity of the ovary to gonadotropins or in the pattern of gonadotropin secretion may be involved in postpartum ovarian activity patterns observed during lactation.

Role of bilharziasis in female sterility.

Genital bilharziasis is considered to be a decisive factor in the etiopathogenesis of female sterility in Africa and other bilharziasis endemic areas. More than 1/4 of the female population in some regions of Africa is sterile, and the incidence of bilharziasis infection may be as high as 50%. Schistosoma haematobium is the most frequently encountered species. S. mansoni is less common, but produces more serious genital lesions. Genital involvement is a central aspect of this parasitic septicemia rather than just a complication. Lesions in the female genitals and their expression as an inflammatory reaction are related to migration of the eggs through the venous network of the urogenital apparatus. From 1959-65 genital biopsies of women presenting at the A. le Dantec Hospital in Dakar with sterility or disorders of the genital tract were systematically studied. Isolated or combined bilharziasis lesions of various segments of the gential tract were observed in 39 cases (12%). The lesions were localized in the cervix in 5 cases, the adnexa in 5 cases, and the vagina in 2 cases. In nearly all cases, ovarian involvement was linked with tubal lesions. A bilateral bilharziasal hematosalpinx was noted in 1 case leading to the diagnosis of extrauterine pregnancy. The lesions produced by S. haematobium may affect the mucosa of the tubes. These observations suggest 3 mechanisms in the bilharziasis-sterility relationship: 1) sterility may result from mechanical and infectious causes preventing normal nidation or completely impeding migration of the spermatozoa or ova, 2) ovarian fibrosis may also impede expulsion of the ova, and 3) genital bilharziasis may disrupt the biological conditions for pregnancy by changing the pH of the female genital tract through alkaline necroses.

Development, primacy, and systems of cities.

The relationship between the evolutionary changes in the city size distribution of nationally defined urban systems and the process of socioeconomic development is examined. Attention is directed to the problems of defining and measuring changes in city size distributions, using the results to test empirically the relationship of such changes to the development process. Existing theoretical structures and empirical generalizations which have tried to explain or to describe, respectively, the hierarchical relationships of cities are represented by central place theory and rank size relationships. The problem is not that deviations exist but that an adequate definition is lacking of urban systems on the 1 hand, and a universal measure of city size distribution, which could be applied to any system irrespective of its level of development, on the other. The problem of measuring changes in city size distributions is further compounded by the lack of sufficient reliable information about different systems of cities for the purposes of empirical comparative analysis. Changes in city size distributions have thus far been viewed largely within the framework of classic equilibrium theory. A more differentiated continuum of the development process should replace the bioplar continuum of underdeveloped developed countries in relating changes in city size distribution with development. Implicit in this distinction is the view that processes which influence spatial organization during the early formative stages of development are inherently different from those operating during the more advanced stages. 2 approaches were used to examine the relationship between national levels of development and primacy: a comparative analysis of a large number of countries at a given point in time; and a historical analysis of a limited sample of 2 advanced countries, the US and Great Britain. The 75 countries included in this study cover a wide range of characteristics. The study found a significant association between the degree of primacy of distributions of cities and their socioeconomic level of development; and the form of the primacy curve (or its evolution with development) seemed to follow a consistent pattern in which the peak of primacy obtained during the stages of socioeconomic transition with countries being less primate in either direction from that peak. This pattern is the result of 2 reverse influences of the development process on the spatial structure of countries--centralization and concentration beginning with the rise of cities and a decentralization and spread effect accompanying the increasing influence and importance of the periphery and structural changes in the pattern of authority.

The pill's many noncontraceptive benefits.

Evidence concerning the noncontraceptive benefits of oral contraceptives (OCs), estimated to be currently used by approximately 50 million women worldwide, is summarized. The most widely recognized benefit is the decrease in menstrual flow, which is of particular importance in developing countries where there is widepsread chronic anemia among women of childbearing age. There is also a decrease in dysmenorrhea and menorrhagia. OC use for more than 1 year has been shown to have a protective effect in pelvic inflammatory disease (PID), which is significant due to the recent increase in sexually transmitted diseases. In addition, there is an almost complete protective effect against ectopic pregnancy. Rheumatoid arthritis occurs less often among OC users. Contradictory evidence exists regarding the relationship between OC use and development of benign and malignant breast disease. However, more recent studies have noted a definite decrease in benign breast disease and no rise in the risk of malignant disease. Benign ovarian retention cysts are less frequent among OC users, producing a decline in the number of laparoscopies and laparotomies required in clinical practice. OC use may also be associated with a decreased incidence of ovarian carcinoma. Although sequential OCs have been linked to an increased risk of endometrial carcinoma, combined formulations appear to have a protective effect, especially in nulliparous women. According to a recent estimate, OC use prevents about 60,000 hospitalizations per year and as many as 51,000 episodes of PID. Although concerns about possible complications of OC use remain, these problems can be minimized by screening out women at high risk of the major cardiovascular effects.

Colonization in Eastern Bolivia: problems and prospects.

In Bolivia the related problems of increasing demographic pressures and scarcity of arable land in the highlands have led to a series of efforts to redistribute the population of this Andean nation. To the east there lies the vast and unexploited lowland territory with its promise of abundant agricultural opportunity to anyone willing to challenge the wilderness. This area has repeatedly been looked to for solutions to the country's problems of overcrowding in the intermontane valleys and on the high plateaus. 2 methods of settlement, directed and spontaneous, have been recognized by the government planning agencies. Directed colonization implies the availability of outside assistance to the colonist in the form of monetary aid, food, tools, housing, and/or technical advisors. The primary index of the success or failure of a colonization project is the number of original settlers who remain. In accordance with this criteria, the Organization of American States (OAS) rated 10 settlements in existence prior to 1962. The significant components of each of these various colonization efforts are analyzed further, and several factors become apparent as probable determinants of the ultimate outcome of any settlement project in the Bolivian Oriente. Land productivity is a prime element influencing the stability of an agricultural colony. When areas with initial conditions of poor soil quality are chosen for colonization projects, there is little hope of establishing a permanent community. Both the Huaytu and Cuatro Ojitos colonies were settled by miners who were faced with both problems of adapting to an entirely different ecological zone and having no experience in crop cultivation. The availability of markets and trade centers also has had a great impact on the longevity of settlement programs. Recruitment of colonists for directed projects is usually achieved through government propaganda and advertising campaigns in the highlands. The people are enticed into the program with promises of title to free land, loans, food, tools, and other assistance. The generally higher incidence of success among the spontaneous effort is due, in large part, to the commonly used method of gradual acclimation over time and the lack of dependence on outside assistance. Each organized effort to the east in the form of a planned settlement program has been faced with adversities and doomed to almost certain failure. This low incidence of success may be attributed to several factors relating to initial planning, administration, and social and cultural patterns of the highland immigrants. The problems to be surmounted are enormous. The Yapacani project is presented as a case study to focus on the actual quality of life experienced and the innumerable obstacles encountered by the colonist in the effort to survive.

The costs and returns of human migration.

The purpose of this discussion is to develop the concepts and tools with which to determine the influence of migration as an equilibrating mechanism in a changing economy. Some of the important costs and returns to migration--both public and private--are identified, and to a limited extent methods for estimating them are devised. This treatment places migration in a resource allocation framework because it deals with migration as a means to promoting efficient resource allocation and because migration is an activity which requires resources. Within this framework, the goal is to determine the return to investment in migration rather than to relate rates of migration to income differentials. The studies of net migration conducted thus far partially reveal the functioning of the labor market, yet they provide little more than the fact that net migration is in the "right" direction. The estimated response magnitude of net migration to gaps in earnings is of little value in gauging the effectiveness of migration as an equilibrator. There are several alternative approaches. 1 simple approach is to compare rates of (gross) migration with changes in earnings over time. Numerous compositional corrections would be required, and this approach would still have to answer the difficult question of how much equalization of earnings should be brought about by a given amount of migration. A better alternative, at least analytically, is to cast the problem strictly as one of resource allocation. To do this, migration is treated as an investment increasing the productivity of human resources, an investment which has costs and which also renders returns. The private costs can be broken down into money and nonmoney costs. The money costs include out of pocket expenses of movement, and the nonmoney costs include foregone earnings and the psychic costs of changing one's environment. For any particular indivdual, the money returns to migration will consist of a positive or negative increment to his real earnings streams to be obtained by moving to another place. This increment will arise from a change in nominal earnings, a change in costs of employment, a change in prices, or a combination of these three. It was found that psychic costs of migration can be ignored since they involve no resource cost. Likewise, nonmoney returns arising from locational preferences should be ignored to the extent that they represent consumption which has a zero cost of production. In sum, migration cannot be viewed in isolation. Complementary investments in the human agent are probably as important or more important than the migration process itself.

A general typology of migration.

The best known model for the analysis of migration is the typology constructed some years ago by Fairchild who classifies migration into invasion, conquest, colonization, and immigration. Fairchild uses 2 main criteria as his axes: the difference in level of culture; and whether or not the movement was predominantly peaceful. His 4 types can be represented schematically. This criticism of Fairchild's classification illustrates 2 general points: that it is useful to make explicit the logical structure of a typology; and that the criteria by which types are to be distinguished must be selected carefully. Together with most other analysts of migration, Fairchild implies that man/woman is everywhere sedentary, remaining fixed until impelled to move by some force. This can be matched by an opposite, i.e., man/woman migrates because of wanderlust. Like all such universals, these cannot explain differential behavior. It might be better to say that a social group at rest, or a social group in motion, tends to remain so unless impelled to change, for with any viable pattern of life a value system is developed to support that pattern. Sometimes the basic problem is not why people migrate but why they do not. The fact that the familiar push pull polarity implies a universal sedentary quality is only 1 of its faults. The push factors alleged to "cause" emigration ordinarily comprise a heterogeneous array, ranging from an agricultural crisis to the spirit of adventure, from the development of shipping to overpopulation. Few efforts are made to distinguish among underlying causes, facilitative environment, precipitants, and motives. If no distinction is made between emigrants' motives and the social causes of emigration, analysis lacks logical clarity. When the push pull polarity has been refined in 2 senses, by distinguishing innovating from conservative migration and by including in the analysis the migrants' level of aspiration, it can form the basis of an improved typology of migration. 5 broad classes of migration, designated as primitive, forced, impelled, free, and mass, are discussed. Such a typology is a tool, and it is worth constructing only if it is useful. Possibly the most useful distinction in the typology is that between mass migration and all other types, for it emphasizes the fact that the movement of Europeans to the New World during the 19th century does not constitute the whole of the phenomenon.

Housing policy, urban poverty, and the state: the favelas of Rio de Janeiro, 1972-1976.

An important way to understand the contemporary authoritarian state is a detailed analysis of the evolution of its policies toward different sectors of civil society. The urban lower classes, especially those grouped in the spatially distinct units formed by "favelas," "barriadas," and the like, are particularly important in this regard, and this discussion reviews the evolution of public policy in Rio de Janeiro toward the favelas since 1972-73. Possibly, the most current and useful contribution to theory in this area is the concept of the bureaucratic authoritarian state, developed by Guillermo O'Donnell (1975). Based largely on the recent experiences of Brazil, Chile, and Argentina, the concept of the BA state summarizes a series of central features, generally accepted as characteristic of this form of government. Among them are: the effort to weaken or eliminate working class organizations or other instruments of popular demand making; the transformation of popular needs into administrative matters outside the policital realm; the containment of inflation at the expense of popular consumption; and the attempt to generate "confidence" among international captial investors by guaranteeing a stable environment economically and politically. Both types of populist authoritarian regimes--the civil and the military--have approached the problem of urban squatter settlements in a similar manner. The fundamental orientation has been toward in situ improvement of existing settlements. This "urbanization" policy takes the form of legalization of land titles, credit for construction materials, and extension of urban services. It is rare that the population of a settlement is eradicated by force. When removal occurs, it is usually at the request of the inhabitants themselves. In the civil single party state, assistance for squatter settlements is deliberately erratic and granted on a case by case basis. In contrast, the reformist military regimes try to give their urban policy a certain internal coherence. The "military oligarchic" state considers demand making from below as, in principle, subversive. Popular masses are not politically manipulated or integrated but reorganized on the basis of government blueprints. Directives determining their situation are issued from above and supported by the liberal use of coercion. The idea of "order" in the city is ultimately translated into the physical segregation of the different classes and the preservation of the most desirable areas for exclusive use of the middle and upper class. Housing and other welfare programs are originally established to alter the image of a regime based on force, but, in turn, widespread use of force makes possible the perversion of their original goals for the benefit of intervening bureaucracies and their new chosen clienteles.

Evolution of and prospects for U.S. funding of international population and family planning programs.

At this time US population assistance is experiencing one of the most challenging periods in its 20 year history. Increasing developing country acceptance of population programs and expanding needs for external assistance are coinciding with resource scarcities that result in serious shortfalls of US and other major donor assistance. 15 years of US Agency for International Development (USAID) program experience offer useful lessons that can improve the efficiency and the effectiveness of US assistance in coming years. The lessons which emerge reflect the various forces that have shaped US involvement in population assistance during this period. During 1965-74, the USAID program was preoccupied with getting activities underway. The principal critics of population assistance at this time viewed foreign assistance in the field of family planning as evidence of "demographic imperialism." The 1974-78 period was a time of program consolidation. Direct support for government programs increased as a proportion of total USAID population assistance as more countries adopted official family planning programs, especially after the World Population Conference of Bucharest. Meanwhile, the central program of the Office of Population became better established. The period 1979 to the present has been a time of increasingly urgent questions regarding resources and future funding. A new generation of critics expressed misgivings similar to those encountered 2 decades earlier, i.e., is population assistance really necessary to achieve development goals; is it a legitimate area of government concern; and is it effective. At least 6 useful findings deserve attention in the design of future US assistance programs--programs which are likely to be funded somewhat less abundantly than in years past: family planning programs address real needs in developing countries, and they can work effectively; successful population programs usually occur where there is a combination of favorable socioeconomic setting, strong program management, and sustained political support; private sector activity is critical for initiating programs and for stimulating innovation; resident field staffs can significantly increase the effectiveness of population assistance; program growth eventually plateaus; and plateaus on assistance can contribute to declining program performance. The following points of emphasis are considered essential for the successful implementation of USAID's strategy in future years: facing performance plateaus; allocation priorities; measures of success; management and training emphasis; and coordination with other donors. It is unclear at this time whether resources will be adequate to apply the lessons learned and to address the needs and opportunities in the years ahead.

[Introduction]

About 15 years ago, when family planning programs were introduced in Latin America, the use of male or female sterilization was hardly mentioned as a definitive method of birth control. Sterilization attracted great opposition, both from potential patients and commentators and the medical profession, which viewed sterilization as a procedure to be undertaken on strictly medical indications such as to preserve the life of the mother in cases of grand multiparity. Some years later a few gynecologists quietly began to practice contraceptive sterilization for socioeconomic indications, but the scarce information available suggests that the techniques utilized were not the most appropriate. A more liberal definition of health, backed up by pronouncements in the Constitution of the World Health Organization, helped improve the climate for voluntary contraceptive sterilization in Latin America. Little data is available as yet as to the prevalence of sterilization in Latin Ameirca, but it is expected that more information will be available in the near future. Although contraceptive sterilization is still not readily available in many sectors of Latin America, demand for the procedure will undoubtedly increase in the near future. Some physicians however refuse to recommend or perform contraceptive sterilizations because of legal ambiguities; a lack of government assistance or support could hamper its spread; public opposition could be fanned by a confusion of voluntary and involuntary sterilization; or religious opposition could impede its practice, probably more through the power of religious leaders than through the convictions of the people. The greatest obstacle to the use of contraceptive sterilization at present however is the lack of qualified personnel and equipment necessary to carry out the procedures for all who request them. The greatest future demand will probably be for surgical techniques, especially minilaparotomy, whether as a postpartum or interval procedure. Minilap does not require specialized training or equipment and can be done on an ambulatory basis, important considerations where hospital facilities are scarce. Future needs include training of more personnel in rural areas and medium sized cities, and provision of information about the procedure to potential clients.

[Social and demographic environment for the practice of sterilization. Cultural and economic determinants. Acceptability - Applicability - Prevalence - Effectiveness]

The world population has increased to 4 billion and the population of Colombia is expected to double every 22-24 years at current rates of growth. However, the Colombian birthrate has begun to decline, particularly in urban areas and among the more educated. High rates of fertility are still recorded, such as the average of 5.1 live born children by age 30-34 reported in a rural survey in 1969 or the average of 5.5 pregnancies by age 28.6 years reported by women interviewed in a hospital survey of abortion. Such women, who have already exceeded their expressed family size aspirations, face another 15-20 years of reproductive life. The number of women desiring to space their births or to terminate childbearing altogether is bound to increase. The ability to determine freely the number and spacing of births has been accepted as a fundamental human right. In the 20th century, sterilization was 1st practiced in some cases of mental illness, then almost exclusively on medical indications for women whose lives would be threatened by pregnancy, and finally, in the 1940s and 1950s, for high parity women who had difficulty controlling their fertility by other means. In general, female sterilization is not well known by the community. Various fears impede its acceptance, including fear of infant mortality and resulting loss of old age security, fear of surgery, fear of sexual side effects, and fear of damage to the moral fiber of the community if the possibility of pregnancy is absent. The technology of female sterilization has advanced rapidly and the procedure can now be done without sophisticated manpower or equipment, inexpensively, and on an ambulatory basis or as a postpartum procedure. Voluntary female sterilization for contraception has become widely diffused in several countries such as Puerto Rico and Thailand and has had a significant impact on birth rates. Surveys have indicated that the overwhelming majority of women are highly satisfied with the procedure.

[Medical and socio-demographic indications. Role in programs of family planning. Motivation and education]

Voluntary sterilization for socioeconomic indications, despite some legal and religious opposition, has become accepted by many physicians in several countries as a legitimate procedure, and the availability of safe, simple, and inexpensive services has led more and more women to request it. Female sterilization for medical indications is being eclipsed numerically by procedures carried out for other indications. The decision to sterilize for medical reasons should never be made without careful reflection, and should be individually made in each case, taking into account such factors as the patient's age, number and sex of children, marital stability, psychological state, and availability of medical resources. Both spouses should be in agreement with the final decision, especially the wife. Accepted obstetric indications for female sterilization include several previous cesarean sections, grand multiparity, hemolytic disorders, genetic disorders, history of toxemia, and other obstetric pathology, while general medical indications include cardiopathy, renal disorders, hypertension, diabetes, psychiatric disorders, leukemia, and breast cancer. In cases of sterilization for socioeconomic indications it is particularly important to take individual factors into account. In some circles the number of living children multiplied by the mother's age is taken into consideration; if it equals or exceeds 120, the operation is considered justified. However, any woman with 5 living children or more and any couple agreeing that they have achieved their desired family size, and who are unable or unwilling to use reversible contraception, should be considered candidates for tubal sterilization. In all cases, sterilization should be viewed as a last resort, particularly for relatively young women whose circumstances may change. Patients should understand that the procedure is permanent, but the physician should also make clear that only the reproductive function and not sexual performance will be affected. More than any other aspect of family planning, sterilization should be absolutely voluntary. It is essential that the woman understand the general nature of the procedure. Technical information may be imparted in a group setting, but the couple should also have a private interview with the physician to clarify any doubts.

[Definitions. Classification of the techniques. Evolution]

Techniques of female sterilization in current use or under development include surgical techniques, endoscopic techniques, transcervical techniques, radiation, and immunologic methods. Surgical techniques are designed to suppress some portion of the genital tract or to establish some interruption or obstacle in it. Abdominal or vaginal hysterectomy should not be considered primarily a method of sterilization, but should be reserved for cases of genital pathology. The ovaries should be preserved if possible because of the importance of their endocrine function, a goal that may be accomplished by ovariotexy. The fallopian tubes lend themselves most readily to sterilization by a variety of methods and routes. Methods of tubal sterilization have undergone great refinement in the past decade or 2, culminating in the development of minilaparotomy, a safe, convenient, and inexpensive procedure suitable for ambulatory sterilizations. Development of endoscopic techniques represent a great advance in female sterilization techniques. The laparoscope, hysteroscope, and culdoscope were originally developed for diagnostic purposes and their use was later extended to tubal sterilization. Each is suitable for a wide variety of sterilization techniques such as cauterization, ligation, and placement of clips. Perfecting of the techniques is a continuous process, with new developments also taking place in the endoscopes. The hysteroscope can be considered as still under study, and results reported for it by various authors differ widely, probably because of the very nature of the procedure. Transcervical routes for administration of substances such as quinacrine or copper or zinc acetate are under investigation as affording simple and practical procedures that would reduce the need for sophisticated equipment and training, but results obtained by different investigators have varied widely and the techniques have not come into wide use. Cryosurgery for ablation of the endometrium to achieve sterilization is in experimental stages. The use of X-rays or radium to achieve sterilization has been abandoned as too risky, but techniques utilizing ultrasound or laser are under investigation. Various methods of immunological sterilization are also under study.

[Surgical techniques]

This document describes the most commonly practiced tubal sterilization procedures as well as the diverse techniques of abdominal or vaginal access to the pelvic cavity utilized for interval or postpartum operations. The work contains a large number of diagrams of operative procedures for all techniques described as well as photographs showing the steps in minilaparotomy and the required surgical equipment. A description of bilateral salpingectomy, not recommened as a procedure purely intended for contraceptive purposes, is 1st provided, followed by descriptions and diagrams of various techniques of tubal ligation or interruption including those of Irving, Pomeroy, Madlener, Aldridge, and Uchida, and of ovariotexy. Differences between the techniques are described, their advantages, disadvantages, and special uses are identified, and required operating equipment is listed. Minilaparotomy, which utilizes the abdominal route, is discussed separately for interval and postpartum procedures. Each section specifies indications, absolute and relative contraindications, important information about the nature of the procedure and postoperative instructions to impart to the patient, preoperative procedures and premedication, anesthesia, patient position, postoperative care, problems and complications, morbidity and mortality, comparison with other methods, and results. The section on postpartum minilaparotomy also discusses the sterilization decision and the optimal timing of the procedure relative to delivery. 2 procedures by the vaginal route, tubal sterilization by colpotomy and sterilization by posterior colpotomy using the culdospeculum, are discussed in comparable detail. Laparoscopic techniques are briefly described and differentiated from minilaparotomy.

Unusual intrauterine objects: potential pitfalls in ultrasonographic identification.

Ultrasonography has been used effectively to evaluate the endometrial cavity in search of a missing IUD. Specific ultrasonographic features of IUDs include posterior acoustic shadowing, type-specific morphologic features, and entrance-exit reflection. This article presents 3 cases of echogenic objects in the uterine cavity. In the 1st case, the object was osseous tissue from an incomplete septic abortion. In the 2nd case, the object was a polyethylene stent which had been used in a left cornu reimplantation. The 3rd object was a cotton swab. Ultrasonographic features in all 3 cases were similar to those of IUDs. The medical history of each patient made correct interpretation of the ultrasonographic images possible. In the absence of such histories, these objects would have been wrongly identified as IUDs.

Practices in pregnancy and family planning of women in slum and the government housing project of the Din-Daeng community, Bangkok, 1981.

Family planning and pregnancy knowledge and practice were studied in 1097 low-income married women ages 15-49 in Bangkok's Din-Daeng community in 1980. 587 women were from the slum areas and 510 were from the government housing project (flats). There was an average of 3.3 pregnancies, 2.79 children ever born, and 2.68 living children/woman. 6.93% had never been pregnant, 7.38% were currently pregnant, 71.3% wanted no more children, 25.6% had experienced abortion, and 7.6% had experienced stillbirth. The women's average age at marriage was 20.6 years. Of the 502 respondents who had been pregnant during the previous 5 years, 87.5% of slum women and 96.8% of flat women had received antenatal care. However, 17.5% did not seek such care until the 3rd trimester. The main reason given for nonattendance was time constraints. Postpartum complications were greater among women from the slum (9.6%) than from the flats (6.3%). 8.3% of slum dwellers had home deliveries compared with none of the housing project women. 9.5% of slum women and 4.9% of women from the flats were pregnant at the time of interview. 57.1% of the former and 80% of the latter women were attending antenatal clinic for the current pregnancy. Although 71.4% of slum women and 70.6% of flat women want no more children, birth control was being used by only 61.7% and 56.9% of these women, respectively. Tubal resection was the most popular method in the flats (23.3%), while slum women reported tubal resection and oral contraceptives with equal frequency (both 21.3%). Misunderstanding of conception was found to be the main reason for not practicing birth contol (31.6%). The number of pregnancies and number of children born among women in this study are slightly higher than those reported in the Contraceptive Prevalence Survey 2 of 1981 for Bangkok women. It is hypothesized that this is due to the difference in mean age at marriage among the 2 study populations (20.6 years and 22.2 years, respectively). These results indicate the need for an education campaign on the benefits of antenatal care and for antenatal service during the weekend or evening hours. (summary in THA)

A model of labor migration and urban unemployment in less developed countries.

An economic behavioral model of rural urban migration is formulated which represents a realistic modification and extension of the simple wage differential approach commonly found in the literature, and this probablistic approach is incorporated into a rigorous model of the determinants of urban labor demand and supply, which when given values for the crucial parameters can be used among other things to estimate the equilibrium proportion of the urban labor force that is not absorbed by the modern industrial economy. Additionally, the model will provide a convenient framework for analyzing the implications of alternative policies designed to alleviate unemployment by varying 1 or more of the principal parameters. A more realistic picture of labor migration in less developed nations would be one that views migration as a 2 stage phenomenon: in the 1st stage the unskilled rural worker migrates to an urban area and spends a certain period of time in the "urban traditional" sector; and the 2nd stage is reached with the eventual attainment of a more permanent modern sector job. This 2 stage process allows one to ask some basic questions concerning the decision to migrate, the proportionate size of the urban traditional sector, and the implications of accelerated industrial growth and/or alternative rural urban real income differentials on labor participation in the modern economy. In the model the decision to migrate from rural to urban areas is functionally related to 2 principal variables: the urban rural real income differential and the probability of obtaining an urban job. To understand better the nature of the supply function to be used in the overall model of the determinants of urban unemployment, it is helpful to state the underlying behavioral assumptions of the model of rural urban migration: it is assumed that the percentage change in the urban labor force as a result of migration during any period is governed by the differential between the discounted streams of expected urban and rural real income expressed as percentage of the discounted stream of expected rural real income; the planning horizon for each worker is identical; the fixed costs of migration are identical for all workers; and the discount factor is constant over the planning horizon and identical for all potential migrants. The model demonstrates the overall net impact of allowing these parameters to vary over time and/or choosing alternative values. It underlines in a simple and plausible way the interdependent effects of industrial expansion, productivity growth, and the differential expected real earnings capacity of urban versus rural activities on the size and rate of increase in labor migration, and, therefore, ultimately on the occupational distribution of the urban labor force. Possibly the most significant policy implication that emerged from the model is the great difficulty of substantially reducing the size of the urban traditional sector without a concentrated effort at making rural life more attractive.

European migratory labor: a myth of development.

The migratory labor system in modern Europe has developed a sustaining myth, a myth which reinterprets the observed exploitation of temporary immigrants in euphemistic and bourgeois liberal terms, i.e., a myth of development. The myth maintains that certain less fortunate lands which, through accidents of history, overpopulation, and lack of resources, have entered the modern era impoverished are offered the chance, through the exportation of their workers, of relieving their overpopulation while simultaneously obtaining from the remittances of the emigrants the capital they need for economic development. And migratory labor is thus a most effective solution to the problems of underdeveloped areas, and the continued prosperity of Northern European capitalism, combined with unrestricted freedom of movement for labor, may be viewed as the principal condition for the solution of poverty in the Mediterranean countries. The great weight of evidence contradicts every supposed benefit. Each element of the myth is examined in some detail. There can be no question that for the individual worker migration is the only alternative to a life of near starvation. It is this basic fact, and none of the other presumed benefits of migration which motivates millions and tens of millions of workers to disrupt their home and family life, to spend years in foreign and unpleasant climates, among people whose language they do not speak, who treat them with coldness or hostility. The availability of these laborers, so crucial to the existence of North European capitalism, depends absolutely on the seemingly hopeless poverty of the workers' homelands, and on the large differentials in wages between the developed and the underdeveloped countries. The "overpopulation" which results from the typical high birthrates in underdeveloped countries is not simply a matter of an excess of workers relative to available jobs. It also involves a low activity rate, which results from the too high proportion of dependents to active working adults. It is precisely this imbalance which is aggravated, rather than alleviated, by the emigration of workers. Regarding the claim that migratory workers are the least economically productive members of their home societies, so that their loss is of no great economic significance, this is only the case within the framework of the total national economies. Regarding training, the more serious problem for the economy of the country of emigration seems to be that whatever bit of training the migratory workers may receive by simply doing their jobs fails to fit the pattern of needs of their home countries. The 4th and 5th presumed advantages of the migratory labor system are that the remittances of the workers should help to rectify their home countries' chronic balance of payments deficit in international trade and that this money may then serve as investment capital to develop the industries of their home countries.

Sadikin closes Jakarta.

Governor Ali Sadikin closed Jakarta, Indonesia against internal migrants. Relying on his reputation for making decisions unilaterally, Sadikin somehow hoped that the psychological force of the decree would prevent would be immigrants from swarming into the Indonesian capital city at a rate that was conservatively estimated in 1970 as being 11,000 persons/month. The handful of Indonesian and foreign urbanists who have examined the city's questionable statistics and taken random samples of various types of scientific studies say the decree has worked to some extent. Sadikin's officials claim the inflow has decreased by 50%. The DCI (Jakarta government) claims now that only about 1400 people come into the city each month looking for work, hoping for homes. According to the rules, anyone migrating to Jakarta must apply for a "short visit" card. 6 months later, if an individual can prove he/she has a home and a job, the financial deposit is refunded. Migrants pour into Jakarta at a rate 4-5 times higher than the DCI statistics of 1400 monthly. In general, the grimness of urban squalor is probably the fate only for about 50,000 immigrants. Most find a saudara--a relative or friend from their village who has made it. A survey found that up to 84% had no cards. Enforcement by local officials is weak and corrupt. The 1970 decree closing the city was followed by new and harsher measures against the riffraff of the capital. The World Bank is interested in some form of low cost housing programs, but the main problem seems to be that low cost housing is still too expensive an item for the DCI budget and would really mean housing for the middle class. Under the city's "kampong improvement" plan, some existing Kampongs of legal, but poor, housing brings about an immediate rent increase of 100-200%, which means the former tenants have to move out. Sadikin's policy is an ad hoc solution. The experts seem to be saying that the only alternative to Jakarta is to build another Jakarta.

Urbanisation, housing and the development process.

This volume examines the problems of housing provision for the urban poor in the 3rd world. As shelter cannot be isolated from other aspects of urban life and both its production and consumption are closely linked to other problems experienced by low income groups, the question of housing provision is examined within the development process as a whole and is related in the early chapters to current ideas on this subject. The discussion covers 4 main types of accommodation--government, private, squatter, and slum--in terms of their current and potential roles in meeting low cost housing needs. The crucial question raised is whether the present system in any particular country meets the real needs of the urban poor or is intended to satisfy other goals set by the established elites of the society, whether government or private. The question is dealt with in a series of detailed case studies drawn from a deliberately restricted number of Asian countries. Increased housing investment is shown to be a function of political or economic rather than social considerations, and it is the latter which is still used to justify changes in funding. Yet, the provision of a better dwelling is only part of the task of improving the life of the urban poor. Effective social development also necessitates expenditure on other essential elements of the alleviation of poverty and exploitation, such as the provision of education and health facilities and the expansion of employment opportunities. In sum, housing provision needs to be seen in perspective. Although improved social welfare, including better housing, is not incompatible with economic development, there are few 3rd world or 1st world countries which have successfully managed to blend the 2. This has recently led to a new wave of regional development theory which has as its principal objective the promotion of balanced growth aimed at bringing a fair share of benefits to those sectors, spatial and social, most neglected within the present systems. Any successful housing programs which currently exist in the 3rd world, successful in terms of the benefits brought to the urban poor, usually occur despite overall development goals and investment priorities. A need exists for flexibility in both housing programs and investment policy in order to cope successfully with changes in social, political, and economic circumstances. The limited nature of most housing investment means that implemented programs must be as comprehensive as possible and draw on all potential sources of low cost housing, whether conventional or nonconventional. Finally, housing policies should be appropriate to the task and circumstances at hand, i.e., scaled to meet the requirements of specific groups of people, within their technical and financial capabilities and employing as many local resources as possible.

Urban ethnicity and the cultural process of urbanization in Ethiopia.

A descriptive analysis is presented of ethnicity among the Gurage in Addis Ababa, Ethiopia. Discussion centers on the specialized occupational roles, status positions, and rural urban kin relations of the Gurage, but with more adequate data available it also could be demonstrated that similar forms of urban ethnicity are manifested in the social behavior of other ethnic groups in Addis Ababa: the Wallamo, Dorze, and Gimira, to mention only a few. Urbanization of the Gurage began in 1889. Many were brought at that time to Addis Ababa as defeated tribesmen, and though some migrated as free laborers in the early 1900s, as late as 1925 most Gurage were indentured slaves in the "sefer" (military camp) of Fitawrari Hapte Giorghis. Before focusing on the patterns of urban ethnicity which subsequently developed among Gurage town dwellers and migrants, as manifested in forms of neighborhood groupings, labor undertakings, voluntary associations, and rural urban relationships, the major features of Gurage tribal organization are described along with those rural factors which have stimulated the migration of Gurage to town. The Gurage social and political system is typical of segmentary lineage organizations of shallow genealogical depth found elsewhere in Africa. The homestead and village are at the lowest levels of lineage segmentation. At the upper limits stand named patrilineal exogamous clans where political authority is vested in clan chieftainship. For most Gurage men labor migration is a seasonal undertaking. The peak of migration is reached during the slack period of agricultural work when young single and married men are relieved from homestead environment. Urban Gurage are mainly concentrated in Tekle Haimanot municipal district (wereda). Urban ethnicity among the Gurage reflects the lack of an urban status system alternative to that based on the Amhara sociocultural model, one by which wealth accrued from business and enterpreneurship, economic undertakings of the majority of well to do Gurage, would be an acceptable channel to higher status. Urban ethnicity establishes a socioeconomic status system within the Gurage community, its members being ranked according to the prestige values that Gurage themselves assign to occupational roles they commonly perform. In other words, differential status structures obtained between the Gurage community and the larger urban society. The Gurage form of urban ethnicity is an extension of the rural social and economic network of kinship and tribal relations restructured in terms of the Amhara dominated urban social structure.

Peruvian migrant identity in the urban milieu.

Some of the aspects of regional highland culture are examined as expressed by migrants interacting in the urban context of Lima, Peru. Focus is on some of the more public features of this behavior, and an attempt is made to evaluate its place and importance. It appears that migrants' allegiance to their native culture and homelands has contributed substantially to maintaining the quality of migrant social life in Lima. At the same time both formal and informal aspects of regional culture as expressed in Lima have made a distinct and positive contribution towards the development and social integration of a pluralistic country. The highlanders who leave their villages for the city or the coast enter a new culture with pronounced differences in language, religious practice, spatial and temporal orientation, occupation, and sex and age roles. The highlanders have been traditionally regarded as inferior by coastal dwellers, who make them the butt of jokes and generally exploit their ignorance of city ways. The subsequent development of provincial cultural forms and associations in Lima provides means for blunting the cruder effects of such confrontations. Regional associations provide a frame of reference for socialization to the urban and national context. Experimentation occurs in a friendly ambience within the club where one can work out new social and political roles and develop organizational skills. Recreational needs are met for people who would otherwise be excluded from participation in established social clubs and who do not enjoy adequate public facilities or stable neighborhoods. On a personal level, clubs' activities provide time for rewarding social interaction and stimulate positive, goal oriented behavior which otherwise might not be open to the migrant. Association activity involving family and hometown friends helps to maintain the functional integrity of the extended family in the urban setting, where people live in widely dispersed areas. For example, dances give the opportunity for the migrants to find suitable peers for spouses. This is particularly important since few have the opportunity to live in stable residential communities and the highly mobile young people of the lower socioeconomic segment of the population work long hours. The growth of regional clubs has been accompanied and buttressed by the growth of regional pride and culture within the urban context. As the number of migrants increased in Lima, a greater ethnic consciousness has developed. The great barrier of the Andes which helped produce the regional subcultures of the highlands is being overcome by the effects of migration and of the radio.

The effects of labor migration on rural Liberia.

This discussion of the effects of labor migration on rural Liberia reviews the history of labor migration and focuses on motivation to migrate, demography of migration, social and economic effects, and assessment. The history of the development of labor migration differs widely for the various regions of Liberia. For the people of the Kru coast, marketing and wage work on ships began perhaps as early as the 17th century. After the arrival of settlers in the 19th century, these and other peoples within some 50-75 miles of a coastal settlement began traveling to sell produce and to work for wages for the settlers. What may be termed the concession period began with the coming of the Firestone Company and the establishment of the Harbel and Cavalla plantations in the 1920s. The heavy labor requirements for the initial clearing and planting of rubber plantations led to recruitment over wide areas of Liberia, including the hinterland areas farther inland from the coast. With the expansion of the Liberian road network, other concession sites were established and these served as alternate attractions. Another source of wage work for migrants is the Liberian National Guard. Economic factors, either push or pull or both, are central in the thinking of most Liberians but a wide variety of precipitating events can tip the individual to decide to migrate at a given time. The incidence of migration seems to be higher from rural areas served by the road system than from those more isolated from the centers of employment. Both the the number and age sex characteristics of migrants have an important bearing on the quality of rural life for those who remain. The migrant labor system is not destroying rural economic life. Riddell points out that for the Mano, subsistence food production has not decreased on a per capita basis despite the loss of labor of migrants and the increasing investment of land and labor in cash crops. Carter indicates that for the Loma study area there was no evidence that per capita rice production has been seriously impaired and that the town is clean and well kept. Similarly, there is nothing in McEvoy's account to suggest that the Sabo village economy has suffered. In other parts of Liberia, especially in those areas adjoining concessions of large areas of often absentee owned private farms, there are villages which have badly deteriorated physically as well as socioeconomically, together with the remains of those which have ceased to exist. Within a few miles of Totota there are several village sites abandoned in the last 20 years, the people having migrated to the main road and usually farther afield.

Growth and management of the Bangkok metropolis.

Attention in this discussion of growth and management of the Bangkok, Thailand metropolis is directed to the following: Bangkok and its growth momenun (unbalanced urbanization pattern and the overwhelming primacy of the Bangkok metropolis and impacts of unregulated growth, i.e., inadequacy of services and urban sprawls and poverty); effects of primacy on national development; the BMA under central government domination; absence of unified development framework; the Fifth Plan approach (eastern seaboard development, regional cities development policy, spatial control and urban programs, administrative improvement, and the role of the private sector); and trends and perspectives (degree of urbanization intensification, financial viability, and future management capacity). The rate of urbanization in Thailand has been moderate but extremely unbalanced relative to other developing countries. The primacy of Bangkok is shown in the share of its urban population which increased from 59% in 1975 to 61% in 1979 and to 63% in 1980. The unbalanced urbanization pattern with growing primacy of the Bangkok metropolis is due to locational advantages, weak policy guidelines, and the overconcentration of activities. This unregulated growth has effects on the low quality of urban services, uncontrolled urban sprawls, and urban poverty. The allocation of the national budget for the development of the Bangkok metropolis and for the solution of subsequent problems will continue to get larger. Efforts at regional development and a more balanced urban system are inevitably undermined. The BMA administration and its financial managment are under tight control by the central government, which has brought about a lack of coordination of work, institutional fragmentation, and an inadequate and ineffective planning process. The Fifth Plan emphasizes the decentralizing policy, but it is expected that the primacy of the Bangkok metropolis will continue at least for the next decade before the countermagnets of the eastern seaboard and the regional urban centers can be properly developed. The financial viability of the BMA is expected to be strengthened by the adoption of property tax. It is appropriate for the government to consider decentralization of economic activities and the administrative machinery. The functions of the public and private sectors must be analyzed to determine common interests, if any, regarding, urban development.

Study on packaging, logos, names, and colors of contraceptives in Haiti.

This study of commercialization of contraceptives in Port-au-Prince, Haiti was conducted to generate information about packaging design, logos, names, colors, and prices that could influence potential users to buy contraceptives and to determine factors related to uses of methods that could influence their choices. Specific study objectives were as follows: determining certain characteristics of the market such as incidence of contraceptive use and user's age and socioeconomic class; determining the list of benefits sought by users and potential users of contraceptives, the ideal contraceptive, usage information, and incidence of selling price; identifying certain factors, i.e., needs, desires, opinions of present services; and determining preference for brand name, packaging design, logos, and colors of contraceptives. A total of 300 interviews were conducted--100 women for the oral contraceptives (OCs), 100 women for the foaming tablets, and 100 men for the condoms. The following were among the study findings: in general, all respondents were aware of 1 contraceptive method; from 100 interviewed, 82% knew about OCs, and 85% of the 82 were past users; 71% of the present OC users (49) purchased their pills at a pharmacy, and 21% preferred the Ortho Novum brand; 24% of the 82 ever users would prefer 2 cycles in a package, and the same percentage preferred more than 3 cycles; among the 100 interviewed regarding the condom, 68% were past users of a contraceptive method from which 74% (50) were condom users, and 69% were presently using the condom; in general, reasons given for using condoms were mainly easy availability, no side effects, no medical visit, and disease prevention; the benefits sought from the ideal condom were thin, resistant, inexpensive, and available by unit; among the 69% current condom users, 29 buy them in a pharmacy or small shop and most of them asked for Tahiti brand; respondents said they are willing to pay anything less than US$1 for good quality condoms (they indicated that Tahiti was "not good quality"); 70% of those interviewed about foaming tablets knew about this method, but only 20 respondents were past users of the tablets and 35 were actual users; most foam tablet dropouts considered the method inefficient; reasons given by respondents for having chosen foaming tablets were recommended by relative or friends and do not require daily utilization; and 66% of foaming tablet users bought their products in a pharmacy.

Trip reports--Haiti, January 25-30, 1981.

Malcolm Donald, senior staff member of the Futures Group, and ICSMP consultant Santiago Plata visited Haiti during January 1981 to assess the activities and progress of the Commerical Section of the Division d'Hygiene Familiale (DHF) and propose recommendations to expand this limited program into a more complete CSM program. Initial activities of the Commercial Section consisted of the installation of condom vending machines in downtown locations of Port au Prince. To supplement the machines, a commercial distribution program was initiated in 1980. The program would supply different contraceptive products to the pharmacies of Port au Prince who in turn would sell to their customers at a low predetermined price. The contraceptive market in Port au Prince is well supplied. Several brands of condoms are available in the pharmacies at prices ranging from US$1.00 to US$1.50 for a box of 3. Several brands of orals are available from different distributors and can be bought at prices between US$2.00 and US$3.00 depending on the brand. Other barrier methods are available and their prices are also fairly high. The International Planned Parenthood Federation (IPPF) financed some promotional efforts which consist primarily of posters and booklets on the condom and Neo Sampoon tablets, but they have not been distributed very widely. The US Agency for International Development (USAID) mission is interested in continuing with the commercial distribution program and will supply funds and commodities. There is some question as to the level at which the program should be conducted. USAID is interested in including other product lines such as oral rehydration salts in the program. The results of the Commercial Section of the DHF to date have been unsatisfactory although personnel exist and some experience in sales has been gained. Since free condoms will continue to be distributed, it is recommended that a new brand be introduced through the Commercial Section of the DHF and used exclusively for sales to pharmacies and other retailers. The new brand name should be selected after a marketing survey had been conducted. The DHF is currently selling Neo Sampoon through the pharmacies and thus far it appears it will be a successful product. The existence of the commercial section and its activities over the past 2 years is significant in that it equals tacit government approval at all levels and approval by the medical and pharmaceutical community.

Trip report--Port au Prince, Haiti, March, April 1981.

The Futures Group sent Senior Staff Member Malcolm Donald to Haiti during March 1981 with Marketing Research Expert consultant Randi Thompson from Porter, Novelli, and Associates to introduce Thompson to Dr. Ary Borden and Patricia Gibson of US Agency for International Development (USAID)/Port au Prince and to help facilitate CRS project implementation in Haiti. The CRESHS (copy attached) proposal was discussed in terms of being expensive and not all pertinent to marketing. The apparent top heavy management was also discussed. After discussion, it was decided that "haggling" at this point might delay the project. Gibson felt that 100 interviews in Port au Prince and Cap Haitian pharmacies may be too many. The CRESHS proposal indicates interviews in 5 cities: Port au Prince, Cap Haitian, Cayes, Hinche, and Jeremie. Gibson is concerned about using Dr. Darlene Bisson more in Haiti because she speaks French. The budget request to International Planned Parenthood Federation is attached.

Vasectomy failure using an open-ended technique.

An open-ended vasectomy technique that involved purposeful creation of a sperm granuloma on the testicular side of the vas was used in 4 patients as a possible contribution to easier reversal, since animal and human studies suggest that such a granuloma prevents pressure-induced epididymal damage and favors maintenance of normal spermatogenesis. The 4 vasectomies were performed at an outpatient clinic using local anesthesia. Through transverse high scrotal incisions, .5 cm segments of vas were removed, and the abdominal side lumina were cauterized to a depth of .5 cm. The testicular side was neither cauterized nor ligated. No complications occurred in any patient, and all wounds healed normally. Examination of semen specimens 15 ejaculations after vasectomy revealed azoospermia in 2 men and active motile sperm in 2 others. Repeat semen analyses on the 2 men up to 5 months after vasectomy revealed persistence of motile spermatozoa. Repeat vasectomies were preformed, at which time sperm granulomas .5 cm in diameter were excised, and both vas lumina were cauterized, resulting in azoospermia on later semen analysis. The failure rate of 50% with the open-ended technique is clearly unacceptable. Cauterizing or removing a longer length of vas and transposition of the open testicular end to a separate fascial plane might reduce failure rates to acceptable levels, but until this is proven in large-scale studies, vasectomy should be presented as a permanent operation.

Nigeria. Hard times are changing attitudes.

Nigeria's growth rate is 3.3% per annum, and by 2000 the population will total 150 million, yet population planning is not a government priority. The objective of the 4th National Development Plan (1981-85) is increased national self reliance and an improvement in the standard of living of the population. Despite massive efforts on the part of the various governments, this task is proving to be difficult. If anything, living standards have declined and continue on a downward trend. Per capita food production has been falling. Basically an agricultural country, Nigeria is now having to import rice, wheat, meat, and fish. Soaring food prices affect the not so poor as well as the poor. The average family can no longer afford to eat well. Water and electricity supplies are failing to meet demands and are having to be cut off from time to time. Nigeria has established a National Population Commission, but official population policy emphasized accelerating the rate of growth of the economy rather than on a direct action to achieve a marked or immediate reduction in the overall birthrate. At present, the government is integrating the various voluntary family planning schemes into an overall basic health and social welfare program. Yet, the federal government appears to lack the will to adopt family planning as a matter of serious national policy. Consequently, it is left to the various state governments and the voluntary nongovernmental agencies to do what they can do. The seeming lack of a direct action by the government to make a frontal attack on the population problem has its roots in the attitude of Nigerians generally. Traditionally and culturally, men and women in Nigeria love children who are more highly valued than wealth. Religion is also a constraint on many who may secretly want to limit the number of children they have. The mere mention of family planning draws hostile reactions from many people. Yet, these are hard times in Nigeria, and the sheer desire for survival is causing many families to at least begin to seek information and advice on how to cease having children. The Planned Parenthood Federation of Nigeria, with fewer than 250 staff members, have done a great deal to make the idea of family planning more acceptable to Nigerians. Teaching hospitals and other hospitals and clinics dispensing primary health care also have had some success, but the total number of acceptors are a mere drop in the ocean. There is increasing awareness, especially among women, of the personal benefits to them of limiting the number of their children.

Mozambique. Transforming society.

In Mozambique women are considered an element for the transformation of society. Since before independence, the party argued that women must play an equal role with men in the task of building an equitable society and overcoming underdevelopment. That policy has made it possible for women to be more vocal and visible in community and national affairs, and women are now encouraged to go to school and train for jobs outside their homes. This has merely expanded women's tasks. The Central Committee of Frelimo considers the family unit as the most important in Mozambican society. It also sees women as the mainstay of that unit. Women of childbearing age and children under 5 years make up 60% of that number. Infant mortality is 114/1000, and many women suffer a high rate of pregnancy wastage. It is this segment that is the target group of the country's preventive and primary health care policies. Health posts and health centers have been set up all over Mozambique, and most "communal villages" have their own health worker to give basic hygiene and nutrition information to mothers. Training for health workers at all levels stresses mother and infant care. The Ministry of Health has been concentrating on family spacing, and this is the primary thrust of family planning education. In rural areas, this has been aided by a traditional belief that a husband and wife should not resume sexual relations until after the baby has been weaned. Polygamy supports this tradition, or possibly helped create it. As polygamy disappears, men are refusing to abide by this practice even though breastfeeding is still almost universal in rural areas of Mozambique. At one point the Ministry of Health was intending to launch a public campaign to educate people about various birth control methods, but it has stalled. Strong evidence exists that having too few babies is perceived by Mozambican women as having much more of a problem than having too many. The number of requests for medical treatment to solve the problem of sterility are much greater than the requests to resolve the problem of too many babies. The high incidence of fertility problems is largely due to infections. Mozambique's concentration on primary health care and training of health care workers will make a contribution to solving these problems.

Asserting our rights.

In Africa a controversial subject is population growth and whether or not to curb it. Only a few African nations have official population policies, possibly because most Africans see human reproduction as a highly personal matter and strongly resent governmental advice on how and when to procreate. A man who does not have children is pitied. Having a large number of children means that a man's social security is guaranteed in old age, as each child, on becoming an adult, is expected to look after his or her parents. In rural Africa, the number of children determines the level of economic productivity within the household, and since most rural Africans are peasants children provide the manpower needed to till the land, herd cattle and goats, and pick coffee or cotton or tea. There are also large numbers of men who work in towns and cities but whose "proper" homes, where their families live, are in the rural areas. These are usually workers who cannot have their families join them in towns or cities. For these men, the urge to have as many children as possible is determined by the same reasons identified: pride; security; manpower. Among African urban dwellers, there is still a deep rooted tendency to have as many children as possible, yet the realities of housing comfortably a large family in a city or town has emerged as a strong deterrent to having large families. In cities like Nairobi and Lagos, more and more men who want to live with their families are constantly faced with the decision of whether or not to limit their fertility. Possibly the single most important factor affecting fertility in Africa today is the emergence of women as independent human beings. This independence, which will continue to change the relationship between African men and women, is born of women's ability to earn a living independently of their husband. A married woman who has 2 or 3 children and also has a job is bound to resist strongly all efforts by her husband to increase her family. The current persisting high fertility rates in Africa will be lowered by women's changing attitudes toward themselves, their men, their combined and separate futures.

Pre-empting problems in Bhutan.

The Buddhist kingdom of Bhutan, landlocked in the Himalayas between India and China, has embarked on a tentative policy of demographic planning. There is hardly any data to go by in this society which has only recently emerged from medieval isolation. Although a census was conducted in 1981, the King admits that its findings may be inconclusive. Many Bhutanese, apparently, gave evasive or misleading answers, fearing new taxes or enforced labor. The survey indicated a population of 1.16 million, a growth rate of 2.2%, and a density of 25/sq km. There are several additional disturbing factors. 70% of Bhutan's 46,500 square kilometers is forested, 21% of the land is mountainous wilderness, and only 9% is under the plough. Nearly 2/3 of the population is under 30, suggesting that the 1.73 million projected for 2000 AD may be exceeded. The concentration seems to be disproportionately heavy in the 4 (out of 18) tropical districts bordering India to the south. They account for nearly half of the total and boast a growth rate of more than 8%. Attention is focused on the south where a US$700,000 Family Welfare Training Center financed by the UN Fund for Population Activities (UNFPA) has just been completed in the border town of Gaylegphug. Birth control still plays only a small part, though the Bhutanese claim that 500 people were sterilized last year. Modest incentives are offered, but the scheme may be abandoned. Assistance from the World Health Organization is expected to give impetus to the existing campaign to provide clean water, to provide instruction in hygiene, and to reduce the incidence of measles, pneumonia, polio, diptheria, tetanus, whooping cough, and diarrhea. The basic health units try to space births and distribute free oral contraceptives. Vasectomy and tubal ligations are performed in a few referral hospitals. A more explicit strategy may be formulated when the detailed enumeration now in progress makes more information available, but poor communications and the rough terrain may make a streamlined system difficult. The current (1981-87) US$455 million 5-year plan is committed to improving the quality of life of the population.

Indonesia sets new targets.

Indonesia has set the goal of 12.7 million current contraceptive users and 3.5 million new users in the year 1983-84. The target must be reached if the country is to realize a reduction in its fertility rate of a half by 1990. 11 provinces have been selected for intensive efforts. Targets in each region will vary according to the density of its population. The objective is to achieve a 65% acceptance rate on the crowded islands of Java and Bali and a 25% acceptance rate for fertile couples on the less populated islands. The campaign will encourage the use of the IUD. Currently, oral contraception (OC) is the most commonly accepted contraceptive method in Indonesia, but the drop out rate is high. In Bali, a predominantly Hindu community, family planning programs have been very successful. Responsibility for IUD insertion and follow-up was transferred from a few clinics run by doctors to a larger number of units operated by paramedical workers. Just over half of all eligible couples use some form of contraception in Bali. 70% of users have IUDs, 20% use OC, and the others use condoms or have been sterilized. Attitudes toward vasectomy are changing in Indonesia. In Bali, where the vasectomy program is relatively new, 2.7% of couples have opted for it. It is felt that more would choose vasectomy if the operation were more easily available. At present, the national figure for sterilization is only 3.2%. 1 team of 10 paramedics from the Bethesda Hospital in Yogjakarta provides a vasectomy service to towns and villages in the area around the hospital. Increasing the services of the mobile family planning clinics will be an important part of the program planned for other parts of Central Java. The UN International Children's Emergency Fund (UNICEF) in Indonesia plans to support the program by integrating their activities, aimed at reducing infant mortality, into the family planning services network. UNICEF is working with the government to "piggy back" nutrition programs on existing family planning services and will now help to integrate the Extended Program of immunization with this system.

A saving solution.

Dr. Mujibur Rahaman, senior scientist at the International Center for Diarrheal Disease Research in Bangladesh, was interviewed recently in regard to oral rehydration therapy (ORT), a simple and inexpensive way of treating the loss of essential fluids and minerals that accompanies diarrhea. According to Rahaman, ORT, developed quite a while ago, is recently gaining more publicity and wider acceptance as a menas of replacing the water and electrolytes lost during acute diarrhea attack. The standard ingredients of the ORT mixture, as it is used in Bangladesh, are 3.5 gm of sodium chloride, or common salt, 2.5 gm sodium bicarbonate, and 1 gm of potassium chloride. To this one should add either 20 gm of glucose or 40 gm of sugar. This mixture should be dissolved in 1 liter of plain drinking water. Plain sugar is good enough. How much is needed depends on the severity and the duration of diarrhea. Calculations have shown that, as a rule of thumb, a child of 10-12 kg may require little more than a liter in about 24 hours. If the child has diarrhea of sufficient severity, it may require more than a liter. If the diarrhea is prolonged, it may require 2 liters. For children who are in danger of dying from dehydration, parents are warned to be watchful because further treatment and follow-up may be required. In Bangladesh a national program is currently providing the ORT in remote rural areas. At present about 1/3 of Bangladesh is covered. The national health service is distributing the solution free of cost in the villages where they have health volunteers. Although ORT is simple to make and simple to administer, one has to exercise some degree of caution with it in order to prevent infants getting dangerous symptoms like hypernatremia. ORT makes it possible for health educators to enter into the family. It is not totally correct to say water is the main problem or causative factor in producing diarrhea. In infantile diarrhea, the cause is most often a virus. Viral transmission is not associated with water. Water can affect the incidence of diarrhea in several ways. The mother's hygiene can be affected by the availability of water, not just the quality but also the quantity. A most exciting study going on now is measuring the impact of water and sanitation on diarrheal diseases.

Romania.

Attention in this discussion of Romania is directed to the following: people; geography; history; government; political conditions; the economy; foreign relations; defense; and relations between the US and Romania. In 1981 Romania's population was estimated to be 22.4 million. The annual growth rate was 0.9%. The infant mortality rate is 31/1000. In 1974-77 life expectancy was 69.3 years for men and 71.8 years for women. About 88% of the population are ethnically Romanian, a group that is traced to Latin speaking Romans and Thracian, Slavonic, and Celtic ancestors. Most of the minority populations reside in Transylvania or areas to the north and west of Bucharest. The government's policy toward the national minorities is nondiscriminatory and allows them a degree of cultural autonomy. The Jewish community surviving World War 2 has been reduced by more than 90% over the past 3 decades by emigration to Israel. Romania occupies the greater part of the lower basin of the Danube River system and the hilly eastern regions of the middle Danube basin. It lies on either sie of the mountain systems. Romania has had 22 centuries of violent and dramatic history. Romania was an independent kingdom from 1881 until December 30, 1947, when the communist dominated government forced the abdication of King Michael. In March 1945 King Michael was forced to appoint a communist front government. The King abdicated under pressure in December 1947, when the Romanian People's Republic was declared. With their accession to power, the communists effectively subordinated national Romanian interests to those of the USSR. Since the early 1960s, there has been a resurgence of Romanian nationalism and several significant foreign policy differences between Romania and the Soviet Union. The 3 principal branches of government are the unicameral Grand National Assembly, with its Council of State; a centralized executive consisting of a Council of Ministers, operating ministries, and state committees; and a judiciary. After 1947, the new government followed the Soviet example of agricultural collectivization and forced industrialization accompanied by a remodeling of the state along totalitarian communist lines. Political leadership since the late 1950s has been very stable. Romania is one of the less developed countries of Europe. The government is determined to show continued impressive growth rates along with a large measure of economic independence. Growth rates declined in the late 1970s and fell close to zero in real terms in the early 1980s. Since the early 1960s, Romania has increasingly asserted its national sovereignty and has sought closer ties with noncommunist countries. After a 15-year period of coolness, the US and Romania began in 1960 to improve relations by signing an agreement providing for partial settlement of American property claims.

Use of combined oral contraceptive pills and cancer.

In a letter dated October 20 to doctors in the UK Sir Abraham Goldberg, chair of the Committee on Safety of Medicines, discusses 2 papers on the use of combined oral contraceptive (OC) pills and cancer which appeared in "The Lancet" of October 22, 1983. The letter includes the following points: the study by Professor Pike et al. does not establish a causal link between longterm use of combined OCs with a progestogen potency of 5 or more and breast cancer, nor are its findings yet confirmed by other published studies; there are extensive published data which fail to find any association between use of OCs by older women and breast cancer; Vessey et al. failed to establish a causal link between OC use and cancer of the cervix because, despite the efforts of the investigators, some unidentified confounding factor could have influenced the results; and the Committee, taking all considerations of OC safety into account, recommends that women should be prescribed a product with the lower suitable content of both estrogen and progestogen. The CSM letter to doctors was accompanied by a list of combination type OCs licensed in the UK, including the amounts of estrogen and progestogen which they contain. The list also included the "progestogen potency" of each product, derived by the method adopted by the Professor Pike and his colleages. From the paper by Vessey et al. the Committee noted that all cases of invasive cancer in the study that were detected by means of cervical cytology were treated effectively. The use of OCs with a low hormone content continues to be an acceptable method of contraception so long as screening precautions are observed.

A message for men [editorial]

In this issue "People" attempts a feature section composed very largely of words spoken by local people. The central question was why women in most parts of Africa continue to have and want large families when in much of Asia and Latin America fertility rates are falling and desired family size is commonly lower than the actual one. The results of the effort have proved valuable. They bring home the important issues in a direct, personal, and at times moving way. They also add to the understanding of women's lives in Africa today and the pressures which influence childbearing. On the basis of the voices reported here, there can be no question as to the continuing strength of traditional African male attitudes which equate many children with a man's pride, his social status, and security. Nor can there be doubt regarding the strength of family pressures which reinforce the view that a woman's worth should be measured in terms of the children she bears, and particularly sons. These deep rooted attitudes have hardly been touched by the decline in the infant mortality rates, which still remain high enough to make death during early childhood a commonplace occurrence. Nor do they seem to have been affected seriously by education. Even among the well informed minority, there is grave concern about the safety or suitability of modern contraceptive methods. The interviews, and the commentaries accompanying them, reveal that powerful forces for change are under way. They show an increasing awareness by governments of the urgency of slowing population growth rates and helping women to space their pregnancies. At a personal level, the rising cost of living is making itself felt and men are beginning to question the number of children they can support. Pressure is also coming from women who have found paid work and a degree of independence. From women's leaders the call is coming for better immunization and postnatal care of children, allied to better local information and family planning services. This along with campaigns to involve and inform men could speed up a process of change which is bound to be slow but is more urgently needed if Africa is to overcome its deepening development dilemma.

Kenya. Poignant problems.

Kenya's population growth rate is the highest in the world at around 4%. 48.34% of the population is under age 15. In 1962 the Kenyan woman had on average 6.8 children. She now has 8.1 children. These are not unwanted children. Improvements in the health services mean people live longer, and the infant mortality rate is falling. The government is aware of the problems a rapidly growing population will bring. As it is, Kenya has recently been forced to import food. More and more people are in need of jobs. The cities are unable to sustain the growing numbers who arrive looking for jobs. Kenya has 9 million people of working age, but only 1 million paying jobs. The situation may not seem much different from other developing countries, yet for Kenyans the problem is particularly poignant. The tremendous development of Kenya in the years since independence has been in marked contrast to many other African countries. Yet it faces the same problems as its poorer neighbors. The government still tries to provide free modern services to its people such as primary education and health care. Maternal and child health services and immunization programs are exemplary for African and the idea is to link family planning to this well developed infrastructure. Yet, recruitment of family planning acceptors between 1974-78 achieved less than half of the target of 600,000. Drop-out rates are high and few acceptors carry on using family planning methods. The results of the Kenya Fertility Survey of 1977-78 indicate that only 11% of women between the ages of 15 and 50 had ever used a modern contraceptive method. Thus far the burden of family planning has been on women, yet they do not have the power to make decisions in an intensely male dominated society. Rumor and irresponsible media reporting must take responsibility for much of the confusion about family planning. Future plans for the government seem to emphasize education. It is hoped that by explaining the need for family planning, by providing services, and by allaying fears and rumors about contraceptives through information and education, some results will be seen. Planners now see the need to incorporate family planning into other aspects of community development.

Children that prove a woman's value.

The social power of African women is founded on the role they play in childbirth, upbringing, education, training, and nurturing of the African personality. Most Africans acknowledge with alacrity the roles their mothers have played in their upbringing and general welfare. African men feel so tenderly towards their mothers that they can divorce their wives for failing to respect their mothers. They also admit that they only got to know their fathers when they misbehaved. Childbirth and care in most African societies is a woman's affair, childbirth particularly because it concerns a woman's body. Most women in Africa indicate that they want to have at least 4 children. Many will say that they want 10. Through children, the African man's need to ensure that the male remains in control of political power, even though the economic and social base of that power is really women, is guaranteed. In the power structures of Africa, successful family planning can only be realized if its political advantages are made known to men. Even the urban, employed woman is under intense pressure to maintain her value of womanhood, and representatives of her culture--mother, mother-in-law, aunts, grandmothers--question the value of her education and try to ensure that she retains the values of her traditional culture. Nowhere is the conflict more evident than in the field of childbirth where the traditional attitude toward having many children to prove a woman's value prevails over the newly learned values of the small family. The rigid sexual division of labor in childhood is accompanied by a deliberate traditional education which inculcates the political ideology of male supremacy. The birth of a son is an occasion for great rejoicing in most African families. The husband and his relatives are assured that there is now someone to carry on their ancestral line. A barren woman is a helpless woman in Africa. She has no security against growing old. She cannot inherit anything from her husband, in most societies, should he die. She can easily be divorced by her husband and will find it very difficult to find another husband in the rural areas. She is a frustrated woman who does not value herself, having been brought up to value herself in relation to her ability to fulfill the wishes of the patriarchal society. Until Africans experience a real change in their condition they are unlikely to regard family planning as a rescue from their impoverished state.

Botswana. Government aims to extend family planning services.

In Botswana family planning is primarily aimed at women who already have children, although increasing emphasis is given to family life education for young people and men. Family planning is included in the maternal and child health (MCH) program which covers most of the women of fertile age and children under age 15. Family planning services were initiated in 1967 when women in Francistown asked the government surgeon for contraceptives. He obtained supplies from the International Planned Parenthood Federation (IPPF) and in 1969 a project to establish MCH/family planning clinics was set up in Serowe with government approval. In 1973 the government took over responsibility for the program. Since 1975 the national program has had 4 aims: to reduce infant and neonatal morbidity and mortality; to improve the health of preschool children; to reduce maternal morbidity and mortality; and to enable parents to plan the size of their families. There seem to be no taboos against family planning, but 1 taboo is that parents do not talk with their children about sex or contraception. There is limited sex education in the schools and the lack of knowledge of human reproduction, together with parental attitudes, partly accounts for the many teenage pregnancies. About 14% of women of reproductive age use contraceptives. The oral contraceptive (OC) is the most popular method, used by 70% of the women who use contraceptives. IUDs can be inserted by nurses with training in midwifery. Injections of Depo-Provera are not promoted but are available for women who already have children. Condoms, diaphragms, and foam are available at all family planning clinics. Money should not be a constraint as far as contraceptives are concerned, the fee being only US$.40 per year, irrespective of method. Distance and temporary shortages in supply are more serious constraints. So is low motivation among women. Abortions are legal only when the life of the mother is endangered, and there seems to be no strong motive for legalizing abortions. Sterilization is legal but is mostly performed on women; husband's consent is required. Many men are negative about contraceptives, saying that they will cause adultery. The Occupational Health Unit is now establishing a project to introduce family planning education among men in 3 large work places in different parts of the country.

Zimbabwe. Getting at the man.

Zimbabwe citizens, 3 years after independence, continue to enjoy the routine of a settled existence with the result of more and more babies. A radio program broadcast on ZBC promoting responsible parenthood is part of a new phase in a government-backed initiative that is being developed by the Child Spacing and Fertility Association (CSFA) of Zimbabwe. Known more simply as "Family Planning," the program is in the process of becoming a para-statal body under the Ministry of Health. At the village level there are already 400 educator distributors, and by 1986 there should be 600. The CSFA is restructuring itself to work more systematically with savings clubs, women's clubs, schools, factories' clinics, trade unions, and agricultural extension workers, as well as through ministry departments. Zimbabwe is a strongly patriarchal society, and women have been very discriminated against by the State. The government is bringing in changes, but they take time. Women were given the right to independence at the age of 18 last December, and if this is well implemented it will bring them much. Yet, implementing legislation is difficult. There are some maternity benefits, allowing women to return to their same jobs, but it is not paid maternity leave. And, discrimination through the tax system has yet to be challenged. A man and a woman may earn the same salary, but a woman will be taxed much more heavily depending on what her husband is earning. The system encourages women to stay at home and have babies. The status of women means that more emphasis will be placed on men in future family planning programs. Women know the benefits of family planning, but it is the man who is the decision maker in this society. Women know that they can benefit from smaller families, but their men don't think the same way, and their attitudes are encouraged by their families. As women receive more education and are involved in careers things change, but the pressures on them are great. Men still feel that they are not marrying for themselves but for their families. Hopefully, the majority bill, granting independence to women, is helping to change attitudes.

Tanzania. A sensitive area.

The government of Tanzania's policy is aimed at birth spacing, not at fertility control, and contraceptive services are for married women with families, not for the unmarried or those who want to postpone starting a family. Abortion is illegal, as is sterilization. Resistance by men to family planning has been a problem in Tanzania. Christine Nsekela, Executive Secretary of the Tanzanian Family Planning Association, believes most Tanzanian men will accept the principle of family planning if they are educated. Family planning services are part of the government Maternal-Child Health clinics. Part of the problem is that rural women, while doing most of the work to support a family, derive their identify from being wives and mothers. Although the government espouses a policy of equal educational opportunities for men and women and encourages women to be village leaders, little has changed. According to Nsekela, education and infrastructure are the answer. The Association has a coordinator based in each region, giving talks, organizing support and training for medical and parmedical personnel. 1 of the Association's most important functions is to train maternal and child health aides and other Ministry of Health and voluntary agency personnel in family planning techniques. The Association remains a private organization although it has access to government health services. 1 organization, the Population/Family Life Project has produced publications and teaching materials on family management, child spacing, breastfeeding, and responsible parenthood. Basic literacy plays a leading role in increasing the effectiveness of health services and agricultural training, involvement in local decision making, and improvement in the status of women. All of these should contribute to lower fertility in the long run. In the short-term, the country's economic crisis is likely to have more dramatic effects.

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