Begegnungen
Schriftenreihe des Europa Institutes Budapest, Band 26:133–147.

EGON DICZFALUSY

Contraception and society

Lorsqu’une idée correspond ŕ la nécessité de l’époque,
elle cesse d’appartenir ŕ ceux qui l’ont inventée
et elle est plus forte que ceux qui en ont la charge.
Jean Monnet, Mémoires (1978)

History: What is it?

As John R. Seeley remarked in a lecture more than a century ago (Growth of British Policy), ‘history is past politics and politics present history’. Such a consideration makes it easier to understand why Elias Canetti divides humankind into two groups: ‘those who accept history and those who are ashamed of it’. He may be right and he may be wrong, depending on our definition of history.

‘There is history in all men’s lives…’ says Shakespeare (King Henry IV, Part II, III i. 80) and some 15 years before the publication of Canetti’s magnum opus, Karl Popper emphasizes that ‘there is no history of mankind, there are only many histories of all kinds of aspects of human life. And one of these is the history of political power. This is elevated into the history of the world’. Let us consider just for a moment the history of ideas. Are ideas not more important in shaping human destiny than kaleidoscopically changing political power? Jean Monnet is right in his statement selected as a motto for this paper: when an idea meets the exigencies of an epoch, it becomes stronger than political power; it becomes the common property of humankind and it may resist the historical forces of destruction for a long time. I am convinced that such an idea was that of contraception.

In a paper published in 1898, Sigmund Freud remarked that ‘Theoretically, it would be one of the greatest triumphs of humanity… if the act responsible for procreation could be raised to the level of a voluntary and intentional behaviour in order to separate it from the imperative to satisfy a natural urge’. A naive dreamer? In 1898, certainly yes, but in 1959, no longer! This is the year when the US Food and Drug Administration (FDA) approved the first oral contraceptive pill, Enovid^®. Two years later, in 1961, the Bundesgesundheitsamt in Berlin approved another oral contraceptive, Anovlar^®, and in 1962 the FDA approved a third one, Ortho-Novum^®. The contraceptive revolution had arrived to stay…

Every revolution has its adversaries and the contraceptive revolution was no exception in this respect. In my Gregory Pincus Memorial Lecture at the 5^th International Congress on Hormonal Steroids in New Delhi (1978), I tried to characterize the early history of the ‘pill’ by saying that ‘The first oral contraceptive was marketed in 1959 in a hostile atmosphere controlled by restrictive and conservative societal forces influenced by traditionalism, strong taboos and the persistent belief the technological progress can be stopped by ideological forces and political determination’. Like many strong beliefs, even that belief proved to be wrong and, by 1993, the United Nations estimated that some 550 million couples around the world were using specific contraceptive methods; a third of them resorted to female sterilization, 22% had intrauterine devices, 17% were using oral, injectable and implantable steroidal contraceptives, 8% were condom users, 7% adopted male sterilization, 6% practiced withdrawal, 5% used the rhythm method and 2% used vaginal barrier methods and other technologies.

In my opinion, the invention of contraceptives was just as fundamental for the evolution of humankind as the invention of the wheel; it triggered the most powerful social revolutions in reproductive health and gender equity and significantly contributed to an unparalleled demographic change (the demographic revolution of the 20^th century) in the history of humankind.

The demographic revolution and the tyranny of numbers

Some historical estimates together with recent estimates and projections of the world population by the United Nations Population Division (2001) may provide an idea of the magnitude of the demographic changes witnessed by humankind in the course of two millennia in general, and during the 20^th century in particular. To start with, the year AD14 was a memorable one, particularly in the history of the Roman Empire: Emperor Augustus died and was followed by Tiberius. Population historians estimate that the global population at this time was around 256 million and that there was little, if any, increase in the number of people living on this planet during the subsequent 1000 years.

It was the second millennium that brought about dramatic changes in the world population; it is estimated that global population exceeded 400 million by the year 1500 and 1600 million by the year 1900. Then population growth further accelerated and by the end of the 20^th century it had exceeded 6000 million people (Table 1).

The global population reached the 3000 million level in 1960, a fact that resulted in major anxiety at the international level; the prophets of ‘gloom and doom’ predicted that soon there would be only standing room on this planet, which would be unable to support a world population of more than, say, 5000 million people. Several so-called experts also predicted that (with unchanged growth rate) the ultimate population of the world might reach 20 000, or 25 000 million people. Hence, it is understandable that, from the 1970s on, less developed countries came under enormous pressure from the more developed countries to establish nationwide family planning programs. India took the lead in 1951 and by 1996 more than 90% of all developed countries supported such programs – albeit mainly for reasons of human rights, reproductive health and gender equity rather than demographic concerns.

Where do we go from here? The United Nations projects that rapid population growth will continue for at least another 50 years and that global population will exceed 9300 million people by the year 2050, corresponding to an increase of 55% in just 50 years time (Table 2).

However, as indicated by the data of Table 2, practically all the increase will take place in the less developed regions and the total population of the more developed regions will remain unchanged. Between 2000 and 2050, the population of North America is projected to increase from 314 to 438 million and that of Australia/New Zealand from 23 to 31 million people, but these increases will be counterbalanced by marked decreases in European (from 727 to 603 million) and Japanese (from 127 to 109 million) populations.

Those who like to view demographic history in terms of migratory pressures may be particularly interested in the numbers shown in Table 3, representing the estimated and projected evolution of European and African populations during the 100-year period between 1950 and 2050.

The United Nations projects that, between 1950 and 2050, the population of Europe (with its ups and downs) will increase by some 10%, whereas that of Africa will show a nine-fold increase from 221 to 2000 million people.

Growing older and (hopefully) wiser?

A common denominator of the demographic evolution, both in the less developed and in the more developed regions of the world, will be population aging. Estimates and projections of the percentage of elderly persons (people aged 60 years and over) in the world and in selected regions between 1975 and 2050 are indicated in Table 4. The United Nations projects that, between 1975 and 2050, the percentage of elderly persons will increase worldwide from 8.6% to 21.1%. By the year 2050, almost 30% of the Chinese population, more than 36% of the population of Europe and more than 42% of the population of Japan will be elderly.

Persons aged 80 years or more are called the ‘oldest old’; this part of the elderly population is receiving more and more attention, since it exhibits the fastest growth rate. Today the oldest-old number some 22 million in Europe, around 12 million in China and almost 5 million in Japan. The United Nations project that, by the year 2050, some 99 million oldest-old will live in China, 60 million in Europe and 17 million in Japan. The oldest-old as a percentage of the total population in these countries is indicated in Table 5.

Between 1975 and 2050, the oldest-old population of the world and also that of Europe is projected to show a five-fold increase, whereas the oldest-old population of China will increase 11 times and that of Japan 15 times.

The dramatically increasing elderly population will have a major impact on the population structure of most countries in the 21^st century; however, that impact will be compounded and further accentuated by a simultaneous worldwide decline in the population of children, as shown in Table 6.

As late as 1975, more than 36% of the global population and more than 39% of the population of China were children, i.e. younger than 14 years. According to the projections of the United Nations, there will be a rapid decline in the proportion of children in all regions and, by the year 2050, children will constitute only 21% of the world population and 16% of the Chinese population. In the European and Japanese populations, the proportion of children will be even lower: 14% and 12.5%, respectively.

The data shown in Tables 1–6 contain both estimates and projections. The reliability of projections, particularly long-term projections, can always be questioned. Obviously, projections – which are complex, multivariate extrapolations of past and present trends to the future – are uncertain. However, some of them are less uncertain than others and it may be worthwhile to remind ourselves that projections are not predictions; in fact, the elderly and oldest-old populations of the year 2050 (shown in Tables 4 and 5) are not figments of imagination; those people are already around us today as teenagers or middle-aged persons.

It also stands to reason that, in a population, if the proportion of elderly persons increases and simultaneously the proportion of children decreases, there will be a marked increase in the median age of that population, as a consequence (Table 7). In 1975, the median age of the global population was 22 years and that of China only 20.6 years. Now the United Nations projects that, by the year 2050, the worldwide median age will exceed 36 years and that of China 43 years. In Europe it will be close to 50 years and in Japan it will be 53 years. Hence, of the projected total European population of 600 million people, approximately half will be aged 50 years and over.

The long-term perspective of humankind’s aging is perhaps best shown by the changing population structure. A hundred years of change in the population structure of the planet Earth is illustrated in Table 8. In 1950, some 34% of the global population consisted of children; this percentage is projected to decrease to 21% by the year 2050. In 1950, the number of the world’s octogenarians was less then 13 million; today it exceeds 60 million and in 2050 their number will exceed 380 million.

The aging process is most advanced in the more developed world; its estimated and projected past, present and future population structures are shown in Table 9. The data indicate that in 1950 some 8 million octogenarians were living in the more developed regions of the world; their number is projected to exceed 113 million by the year 2050.

‘O brave new world that has such people in ‘t’ exclaims Shakespeare’s Miranda (The Tempest, V.i. 183); we could perhaps paraphrase it by saying: O brave new world that has such a brave old human kind in ‘t…

Our fertility: What has happened?

Data presented in Table 10 indicate that a marked and rapid decline in our fertility occurred during an unexpectedly short period of time, between 1965 and 1995. The global fertility rate was almost five children per woman as late as 1965. By 1995, it had declined to 2.8. By 1975, the total fertility rate in Europe and Japan had diminished below the replacement level and remained so during the subsequent 25 years, or even longer. It would thus appear that never before in history have birth rates fallen so far, so fast, so low and for so long all around the world. Although the implications – for good or for ill – are as yet unclear, some of them are more clear than others. If fertility remained below replacement level for a longer period of time, that would result in a decline of the population in question. For instance, the United Nations projects that, unless fertility rates dramatically increase in the not too distant future, the population of Europe will diminish from the present 727 million to 603 million people and that of Japan from 127 to 109 million.

What is behind the rapid fertility decline? It appears that a somewhat simplistic and emotion-loaded public debate is going on as far as the demographic impact of contraception is concerned. The ‘friends of contraception’ sometimes question, or tend to minimize, this impact, whereas its opponents (and they are not so few) are convinced that the worldwide use of contraception is the primary reason for the rapid decline in worldwide fertility. In fact, some of them are so concerned that they would be prepared to advocate a general ban on every form of contraception.

There have always been wishful thinking and naive people who refuse to accept that revolutions – like the contraceptive revolution – never go backwards. At any rate, it stands to reason that, in a world where more than 550 million couples are using various contraceptive technologies, contraception should have some impact on fertility rates. In fact, a highly significant correlation between fertility rate per woman and contraceptive prevalence has been found in more than 120 developing countries. However, contraception is only a means of achieving low fertility, not its cause. The causes underlying the demographic revolution are much more complex and manifold; in fact they reflect major societal changes of historical dimensions.

Among the key determinants of low fertility, one may mention inter alia increasing female autonomy, major gains in female education, increasing labour force participation by women, the rapidly changing pattern of union formation and the increasing instability of such unions and some strong, but rather diffuse, ideational changes in the public perception as to the new roles of women in society and in the family. In fact, there is considerable concern – particularly in Europe – about the decay of the family and the decline in its institutional quality.

There are some classical ingredients of this demographic change, e.g. the spectacular rise in life expectancy, the extensive use of contraceptive technologies, the urbanization and densification process, the elimination of illiteracy and a fundamental structural change in society worldwide, in the course of which uncertainty and instability more and more replace tradition. Among the new ingredients, Jean-Claude Chesnais mentions ‘social atomization’ and related feminism, collectivized pension benefits, ‘globalized nomadism’, the youth loss of majority and the ‘end of work’ syndrome.

What is ‘global nomadism’? A (perhaps not entirely theoretical) example: if the herring population around Ireland would be decimated again because of the overambitious activity of a Chinese, or Japanese fishing fleet, that would be a classical case of global nomadism.

What is ‘social atomization’? An example is shown in Table 11. The data indicate that, between 1975 and 1995, the proportion of Japanese women who never married markedly increased. Another example of ‘social atomization’ is presented in Table 12. It appears from the data of Table 12 that, in Italy, the share of women and men who did not live in any kind of partnership significantly increased in the cohort born in 1966–70, compared to that born in 1946–50.

Modern social atomization also affects ‘non-contraceptive’ age groups. In a recent study of ‘repartnering’ at the age of 50 and over in the Netherlands it was found that, whereas before 1974 some 77% of the study population remarried and only 3% lived ‘apart and together’, in 1985–92 only 24% did remarry and 52% lived apart and together.

What about our common demographic future? That future is not written, nor can it be written, since it will be created in the brains of the next generations. The general principle of uncertainty also applies to our demographic future, since some of the factors impacting on it – particularly fertility rates – are not irreversible. There is still a strong demand in many societies for a family policy of two children. Some decapitalization mechanisms make their appearance on the global economic scene, reforms of the welfare system are now in progress in many countries and a slow shift to post-materialistic values can be sensed in several cultures.

The name of the game: Institutional reform

There is an increasing realization of the fact that some of our institutions do not serve us well any longer; many of them were designed more than a century ago to cater for the needs of a population structure (with many children and few elderly persons) that no longer exists. Examples are social security, health care, housing, education and our sacrosanct nation states which, today, are too small to do the ‘big things’ and too big to concern themselves with the important ‘small things’. There is a need for institutional reform in several areas. What will be the biggest obstacle to those much-needed reforms? The usual one is political inertia.

What about some of our venerable basic institutions? Are our governments at a pleasant distance from reality, when they assume that, in the population at large, erosion of confidence in our basic institutions is rather rare? A number of surveys conducted during the past few decades indicate that this is not so. One of these, based on a sample of some 1000 interviewed individuals in each of some 20 countries, was conducted in 1990.

The proportion of people who expressed a negative opinion on courts and justice in a few selected – mostly European – countries (shown in Table 13) varied between 68% (Italy) and 35% (Germany).

The percentage of people interviewed who had little, if any confidence in the Church is indicated in Table 14. In this context, it should be borne in mind that the surveys measured attitudes about the Church as an institution and not religion as a belief. Although it is likely that the people interviewed attached different meanings to the word ‘church’, the data suggest that, in most countries, the majority of adults say they have ‘little’ or ‘no’ confidence in ecclesiastical institutions. As pointed out by Dogan, this finding is one of the most astonishing in these international surveys on values, since it raises an embarrassing question: what is the Church’s real audience in Western Europe today?

Finally, the proportion of people who said they have little, if any confidence in Parliament, is presented in Table 15. The data shown in Table 15 are perhaps perplexing, since many surveys indicate that a massive majority of Europeans are deeply attached to democracy as the only acceptable political system for their country. The lack of confidence in this crucially important founding institution of democracy seems to reflect its real decline in the functioning of representative democracies. Perhaps nothing is wrong with our institutions, only with the people representing them?

Sailing from doubt to mistrust

It is not necessarily detrimental that people are critical and express doubt in the functioning of some of our basic institutions; rather, it may be a healthy sign. As Louis Mencken pointed out: ‘For Men become civilized, not in proportion to their willingness to believe, but in proportion to their readiness to doubt’. In fact, few scientists need to be convinced about the fundamental importance of doubt for stimulating investigation and achieving progress. However, the sailing may become more perilous when it proceeds from doubt to mistrust, since mistrust may cost more to society in terms of lost opportunities than misplaced trust would cost from losses suffered through deception.

The mistrust of institutions indicated in Tables 13–15 should be interpreted in the context of a high level of distrust in large sectors of the society: a general distrust toward others and a reflection of a decaying moral space. In fact, when discussing progress in the three Kantian spheres (science, art and moral), contemporary intellectuals are in broad agreement that, during the past couple of centuries, progress has been spectacular in both science and art; the negative views are centered on our moral development since the times of Immanual Kant. We live in a period frequently labelled ‘late modernity’, which has brought to the extreme both the achievements and the costs of modernization. The great pioneer in theoretical sociology, Piotr Sztompka, points out that a crucial item on the negative side of the balance sheet is the decay of the moral space. He singles out three areas of empirical facts where such a decay seems evident, namely crime, collapse of trust and depleted social capital.

In addition to common crime, there is also a major increase in ideological crime, terrorism and ‘pure’ violence, committed for no obvious reason. The collapse of trust can be observed as growing litigiousness, increasing formalism in business deals, rapidly expanding vigilantism and a general ‘culture’ of distrust. Under the heading depleted social capital, the factors frequently mentioned are the erosion of the family, disappearance of networks of association, partnership in connivance, globalization of corruption and the collapse of cohesive communities (‘people in the US are now bowling alone’ says Robert Putnam). The final result of all this is growing egoism, rampant individualism, solitude and distrust.

Is the situation hopeless? Not really. Even a technologically more and more developed humanity needs an authentic, universal and inclusive morality and there are some traits of late modernity that generate hope for the reconstitution of the moral space. In a rapidly increasing segment of the world population, there is an accelerated perception of a global destiny, and the concept of ‘humankind’ is no longer only a textbook reality. Among the young people of today, there is an increasing revolt against the moral void and a reawakening of the moral impulse, resulting in a stronger and stronger demand for an increased transparency in public affairs.

In addition, and most importantly, new social ties are being established and various global communities are assuming a growing importance. At least five types of such communities have been identified: professional communities, value communities new ecumenical movements, integrative political movements and so-called virtual communities linked by contacts through the new technical media.

Indeed, in this new world, a brighter future can be predicted for international professional communities such as the European Society for Contraception. Such communities will embrace many specialties and will be increasingly multigenerational, trans-sectoral and transpolitical. They will play an increasingly crucial role in influencing health policies, because of their profound commitment to the improvement of the human condition all over the world by the judicious use of new scientific information.

New realities but old value systems

We are living in a world of new realities and it is not too difficult to see that, in a world in which the amount of new scientific information doubles in every 6–7^th year, the value systems of our various societies (based on historical tradition, parochial identities and religious dogma) are more and more in conflict with the new realities. No wonder that our contemporary history gives the impression of a stormy sea, where the fragile vessel of rationalism is constantly threatened by the high waves of passion, fanatic faith and emotion. A major challenge confronting us is how to convince our fellow men and women that fundamentalism and obscurantism cannot improve the human condition and that only science has the proven ability to do so. Would it help to remind our fellow men and women that for millions of years nature was shaping humankind, but today Homo sapiens is shaping nature and sets the boundaries between what is considered biologically possible and biologically impossible? In fact, contraception, assisted reproduction and genetic manipulation are just a few examples of those new realities. Not even scientists can always grasp the full potential of genomics for improving health care how can we then expect that lay people will be able to do so?

At the other end of the spectrum, there is a naive belief that science knows no limits, that it is omnipotent. Obviously, science is not omnipotent. Human knowledge is imperfect and it will remain imperfect forever. However, it is indefinitely perfectible. Research is indefinitely perfecting human knowledge and constantly improves health and the human condition in general. In times when, of the world’s 6000 million people, 1200 million live on less than $1 a day and 2800 million live on less than $2 a day, there is an enormous need to improve the situation of billions of human beings stricken by poverty.

What should be the message to all members of the European Society of Contraception? It comes from a speech delivered by the Director-General of the World Health Organization (WHO), Dr. Gro Harlem Brundtland to WHO staff members in 1998: ‘We can combat ill-health. We can do our part to combat poverty and suffering. Nothing in life as I see it has more meaning’. And nothing in life as I see it has more meaning than the professional activities of the members of this Society that are directed towards the continuous improvement of the human condition.

What is past is prologue

In an address delivered to the Royal College of Physicians in London in 1944, Winston Churchill remarked that ‘The longer you can look back, the further you can look forward’. It would appear that – some 20 years later – two American atomic physicists, Lesher and Howick, have followed this advice and looked back into our history some 50 000 years: ‘Eight hundred life spans can bridge more than 50 000 years. But of these 800 people, 650 spent their lives in caves or worse; only the last 70 had any truly effective means of communicating with one another, and only the last 6 ever saw a printed word or had any real means of measuring heat or cold. Only the last 4 could measure time with any precision; only the last 2 used an electric motor; and the vast majority of the items that make up our material world were developed within the lifespan of the eight hundredth person’.

May I add to this – as a rather personal note – that, in my own lifetime, I have witnessed more progress in science and technology than all scientists of all preceding periods together, since the dawn of history. It is not difficult to see this, given the fact that the acquisition of new scientific information occurs by and large on a geometric scale. In fact, when I graduated from medical school in 1944, the ‘crude size’ of the medical sciences was probably 5% or less of that today. The assessment of Shakespeare was (again) correct: ‘what is past is prologue’ (The Tempest, II. i. 261).

Travelling without arriving

In his poem, The Rock (1934), T. S. Eliot asks three rather disturbing questions:

Where is the Life

we have lost in living?

Where is the wisdom

we have lost in knowledge?

Where is the knowledge

we have lost in information?

In fact, we are living in a world overwhelmed by information. However, information does not constitute knowledge, unless it is critically assessed and integrated into the body of knowledge. I profoundly believe that knowledge does not constitute wisdom, unless it can be used to improve the human condition. The discovery of the atomic bomb was anything but wisdom, whereas the discovery of the ‘pill’ really was. It has fundamentally improved the situation of millions and millions of women all around the world. The enormous social significance of the ‘pill’ is rather self-evident; this was recognized shortly after its approval. In the 1960s in a letter to the New York Times, D. Cameron wrote: ‘Few contributions to medical knowledge have done so much to bring to women everywhere a sense of worth and dignity’.

Some representatives of the drug industry sometimes tell me that today they have a limited interest in the development of new contraceptives, because it is a mature market. Is it really? The WHO underlines that, in 1990, at least 100 million couples had an unmet family planning need and about 300 million couples were using contraceptive methods with which they were dissatisfied, or which they considered unreliable. A mature market? The WHO also emphasizes that up to 40% of all pregnancies – estimated at 210 million per year – are unplanned and about 45 million abortions are carried out each year.

Some 25 years ago, I wrote that ‘steroidal contraception is not a finished chapter in history, but rather an ongoing act in the big drama of technological, cultural and social change called evolution’. Sometimes, it is rather difficult to distinguish between evolution and revolution. To me, the development of a variety of specific methods of contraception was a revolution, but – at the same time – a powerful catalyst of the social evolution of the 20^th century.

In retrospect, it is easy to see that the discovery of the ‘pill’ and the contribution of Gregory Pincus was a monumental achievement. However, as Albert Camus remarked more than half a century ago, ‘An achievement is a bondage. It obliges one to a higher achievement’. Now a new generation of scientists is challenged by our unfinished research agenda; there is a major need for the development of contraceptives for the male, improved emergency contraceptives, new vaginal microbicides and improved female and male condoms.

During a long life, I have learned that travelling is more important than arriving and, if one reflects a moment or two, it is easy to see that in your professional life, be it patient care, laboratory research or clinical research, there is never any final destination, only travelling and more travelling. That travelling should provide much professional satisfaction, because it will result in diminished suffering, better health and an improved quality of life for hundreds of millions of women and men.