Deep Politics Forum

National Security Study Memorandum 200

National Security Study Memorandum 200: Implications of Worldwide Population Growth for U.S. Security and Overseas Interests (NSSM200) was completed on December 10, 1974 by the United States National Security Council under the direction of Henry Kissinger.
It was adopted as official U.S. policy by President Gerald Ford in November 1975. It was originally classified, but was later declassified and obtained by researchers in the early 1990s.
The basic thesis of the memorandum was that population growth in the least developed countries (LDCs) is a concern to U.S. national security, because it would tend to risk civil unrest and political instability in countries that had a high potential for economic development.
Thirteen countries are named in the report as particularly problematic with respect to U.S. security interests: India, Bangladesh, Pakistan, Indonesia, Thailand, the Philippines, Turkey, Nigeria, Egypt, Ethiopia, Mexico, Colombia, and Brazil. These countries are projected to create 47 percent of all world population growth.
The report advocates the promotion of contraception and other population reduction measures. It also raises the question of whether the U.S. should consider preferential allocation of surplus food supplies to states that are deemed constructive in use of population control measures. The report advises, "In these sensitive relations, however, it is important in style as well as substance to avoid the appearance of coercion."

________________________________________________________________________

NATIONAL SECURITY COUNCIL
WASHINGTON, D.C. 20506

April 24, 1974

National Security Study Memorandum 200
--------------------------------------

TO: The Secretary of Defense
The Secretary of Agriculture
The Director of Central Intelligence
The Deputy Secretary of State
Administrator, Agency for International Development

SUBJECT: Implications of Worldwide Population Growth for U.S.
Security and Overseas Interests

The President has directed a study of the impact of world popula-
tion growth on U.S. security and overseas interests. The study
should look forward at least until the year 2000, and use several
alternative reasonable projections of population growth.

In terms of each projection, the study should assess:

- the corresponding pace of development, especially in poorer
countries;

- the demand for US exports, especially of food, and the trade
problems the US may face arising from competition for re-
sources; and

- the likelihood that population growth or imbalances will
produce disruptive foreign policies and international insta-
bility.

The study should focus on the international political and economic
implications of population growth rather than its ecological, socio-
logical or other aspects.

The study would then offer possible courses of action for the United
States in dealing with population matters abroad, particularly in
developing countries, with special attention to these questions:

- What, if any, new initiatives by the United States are needed
to focus international attention on the population problem?

- Can technological innovations or development reduce
growth or ameliorate its effects?

- Could the United States improve its assistance in the popu-
lation field and if so, in what form and through which agen-
cies -- bilateral, multilateral, private?

The study should take into account the President's concern that
population policy is a human concern intimately related to the
dignity of the individual and the objective of the United States is to
work closely with others, rather than seek to impose our views on
others.

The President has directed that the study be accomplished by the
NSC Under Secretaries Committee. The Chairman, Under Secre-
taries Committee, is requested to forward the study together with
the Committee's action recommendations no later than May 29,
1974 for consideration by the President.

HENRY A. KISSINGER

cc: Chairman, Joint Chiefs of Staff
NSSM 200:

IMPLICATIONS OF WORLDWIDE POPULATION GROWTH
FOR U.S. SECURITY AND OVERSEAS INTERESTS

December 10, 1974

CLASSIFIED BY Harry C. Blaney, III
SUBJECT TO GENERAL DECLASSIFICATION SCHEDULE OF
EXECUTIVE ORDER 11652 AUTOMATICALLY DOWN-
GRADED AT TWO YEAR INTERVALS AND DECLASSIFIED
ON DECEMBER 31, 1980.

This document can only be declassified by the White House.
----------------------------------------------------------

Declassified/Released on 7/3/89
-----------
under provisions of E.O. 12356
by F. Graboske, National Security Council
TABLE OF CONTENTS

Executive Summary 65 - 82
(Reader: For Parts One and Two, see Appendix 2)
Part One -- Analytical Section
-------- ------------------
Chapter I World Demographic Trends
Chapter II Population and World Food Supplies
Chapter III Minerals and Fuel
Chapter IV Economic Development and
Population Growth
Chapter V Implications of Population Pressures
for National Security
Chapter VI World Population Conference

Part Two -- Policy Recommendations
-------- ----------------------
Section I A U.S. Global Population Strategy
Section II Action to Create Conditions for Fertility De-
cline: Population and a Development Assis-
tance Strategy
A. General Strategy and Resource for A.I.D. Assistance
B. Functional Assistance Programs to Create Condi-
tions for Fertility Decline
C. Food for Peace Program and Population
Section III International Organizations and other Mul-
tilateral Population Programs
A. UN Organization and Specialized Agencies
B. Encouraging Private Organizations
Section IV Provision and Development of Family
Planning Services, Information and Tech-
nology
A. Research to Improve Fertility Control Technology
B. Development of Low-Cost Delivery Systems
C. Utilization of Mass Media and Satellite Communi-
cations System for Family Planning
Section V Action to Develop Worldwide Political and
Popular Commitment to Population Stability
EXECUTIVE SUMMARY - Index

WORLD DEMOGRAPHIC TRENDS - Index

1. World Population growth since World War II is quantitatively and qualitatively different from any previous epoch in human history. The rapid reduction in death rates, unmatched by corresponding birth rate reductions, has brought total growth rates close to 2 percent a year, compared with about 1 percent before World War II, under 0.5 percent in 1750-1900, and far lower rates before 1750. The effect is to double the world's population in 35 years instead of 100 years. Almost 80 million are now being added each year, compared with 10 million in 1900. 2. The second new feature of population trends is the sharp differentiation between rich and poor countries. Since 1950, population in the former group has been growing at 0 to 1.5 percent per year, and in the latter at 2.0 to 3.5 percent (doubling in 20 to 35 years). Some of the highest rates of increase are in areas already densely populated and with a weak resource base.
3. Because of the momentum of population dynamics, reductions in birth rates affect total numbers only slowly. High birth rates in the recent past have resulted in a high proportion in the youngest age groups, so that there will continue to be substantial population increases over many years even if a two-child family should become the norm in the future. Policies to reduce fertility will have their main effects on total numbers only after several decades. However, if future numbers are to be kept within reasonable bounds, it is urgent that measures to reduce fertility be started and made effective in the 1970's and 1980's. Moreover, programs started now to reduce birth rates will have short run advantages for developing countries in lowered demands on food, health and educational and other services and in enlarged capacity to contribute to productive investments, thus accelerating development.
4. U.N. estimates use the 3.6 billion population of 1970 as a base (there are nearly 4 billion now) and project from about 6 billion to 8 billion people for the year 2000 with the U.S. medium estimate at 6.4 billion. The U.S. medium projections show a world population of 12 billion by 2075 which implies a five-fold increase in south and southeast Asia and in Latin American and a seven-fold increase in Africa, compared with a doubling in east Asia and a 40% increase in the presently developed countries (see Table 1). Most demographers, including the U.N. and the U.S. Population Council, regard the range of 10 to 13 billion as the most likely level for world population stability, even with intensive efforts at fertility control. (These figures assume, that sufficient food could be produced and distributed to avoid limitation through famines.)
ADEQUACY OF WORLD FOOD SUPPLIES - Index

5. Growing populations will have a serious impact on the need for food especially in the poorest, fastest growing LDCs. While under normal weather conditions and assuming food production growth in line with recent trends, total world agricultural production could expand faster than population, there will nevertheless be serious problems in food distribution and financing, making shortages, even at today's poor nutrition levels, probable in many of the larger more populous LDC regions. Even today 10 to 20 million people die each year due, directly or indirectly, to malnutrition. Even more serious is the consequence of major crop failures which are likely to occur from time to time. 6. The most serious consequence for the short and middle term is the possibility of massive famines in certain parts of the world, especially the poorest regions. World needs for food rise by 2-1/2 percent or more per year (making a modest allowance for improved diets and nutrition) at a time when readily available fertilizer and well-watered land is already largely being utilized. Therefore, additions to food production must come mainly from higher yields. Countries with large population growth cannot afford constantly growing imports, but for them to raise food output steadily by 2 to 4 percent over the next generation or two is a formidable challenge. Capital and foreign exchange requirements for intensive agriculture are heavy, and are aggravated by energy cost increases and fertilizer scarcities and price rises. The institutional, technical, and economic problems of transforming traditional agriculture are also very difficult to overcome.
7. In addition, in some overpopulated regions, rapid population growth presses on a fragile environment in ways that threaten longer-term food production: through cultivation of marginal lands, overgrazing, desertification, deforestation, and soil erosion, with consequent destruction of land and pollution of water, rapid siltation of reservoirs, and impairment of inland and coastal fisheries.
MINERALS AND FUEL - Index

8. Rapid population growth is not in itself a major factor in pressure on depletable resources (fossil fuels and other minerals), since demand for them depends more on levels of industrial output than on numbers of people. On the other hand, the world is increasingly dependent on mineral supplies from developing countries, and if rapid population frustrates their prospects for economic development and social progress, the resulting instability may undermine the conditions for expanded output and sustained flows of such resources. 9. There will be serious problems for some of the poorest LDCs with rapid population growth. They will increasingly find it difficult to pay for needed raw materials and energy. Fertilizer, vital for their own agricultural production, will be difficult to obtain for the next few years. Imports for fuel and other materials will cause grave problems which could impinge on the U.S., both through the need to supply greater financial support and in LDC efforts to obtain better terms of trade through higher prices for exports.
ECONOMIC DEVELOPMENT AND POPULATION GROWTH - Index

10. Rapid population growth creates a severe drag on rates of economic development otherwise attainable, sometimes to the point of preventing any increase in per capita incomes. In addition to the overall impact on per capita incomes, rapid population growth seriously affects a vast range of other aspects of the quality of life important to social and economic progress in the LDCs. 11. Adverse economic factors which generally result from rapid population growth include:

reduced family savings and domestic investment;
increased need for large amounts of foreign exchange for food imports;
intensification of severe unemployment and underemployment;
the need for large expenditures for services such as dependency support, education, and health which would be used for more productive investment;
the concentration of developmental resources on increasing food production to ensure survival for a larger population, rather than on improving living conditions for smaller total numbers.

12. While GNP increased per annum at an average rate of 5 percent in LDCs over the last decade, the population increase of 2.5 percent reduced the average annual per capita growth rate to only 2.5 percent. In many heavily populated areas this rate was 2 percent or less. In the LDCs hardest hit by the oil crisis, with an aggregate population of 800 million, GNP increases may be reduced to less than 1 percent per capita per year for the remainder of the 1970's. For the poorest half of the populations of these countries, with average incomes of less than $100, the prospect is for no growth or retrogression for this period. 13. If significant progress can be made in slowing population growth, the positive impact on growth of GNP and per capita income will be significant. Moreover, economic and social progress will probably contribute further to the decline in fertility rates.
14. High birth rates appear to stem primarily from:
a. inadequate information about and availability of means of fertility control;
b. inadequate motivation for reduced numbers of children combined with motivation for many children resulting from still high infant and child mortality and need for support in old age; and
c. the slowness of change in family preferences in response to changes in environment.
15. The universal objective of increasing the world's standard of living dictates that economic growth outpace population growth. In many high population growth areas of the world, the largest proportion of GNP is consumed, with only a small amount saved. Thus, a small proportion of GNP is available for investment -- the "engine" of economic growth. Most experts agree that, with fairly constant costs per acceptor, expenditures on effective family planning services are generally one of the most cost effective investments for an LDC country seeking to improve overall welfare and per capita economic growth. We cannot wait for overall modernization and development to produce lower fertility rates naturally since this will undoubtedly take many decades in most developing countries, during which time rapid population growth will tend to slow development and widen even more the gap between rich and poor.
16. The interrelationships between development and population growth are complex and not wholly understood. Certain aspects of economic development and modernization appear to be more directly related to lower birth rates than others. Thus certain development programs may bring a faster demographic transition to lower fertility rates than other aspects of development. The World Population Plan of Action adopted at the World Population Conference recommends that countries working to affect fertility levels should give priority to development programs and health and education strategies which have a decisive effect on fertility. International cooperation should give priority to assisting such national efforts. These programs include: (a) improved health care and nutrition to reduce child mortality, (b) education and improved social status for women; © increased female employment; (d) improved old-age security; and (e) assistance for the rural poor, who generally have the highest fertility, with actions to redistribute income and resources including providing privately owned farms. However, one cannot proceed simply from identification of relationships to specific large-scale operational programs. For example, we do not yet know of cost-effective ways to encourage increased female employment, particularly if we are concerned about not adding to male unemployment. We do not yet know what specific packages of programs will be most cost effective in many situations.
17. There is need for more information on cost effectiveness of different approaches on both the "supply" and the "demand" side of the picture. On the supply side, intense efforts are required to assure full availability by 1980 of birth control information and means to all fertile individuals, especially in rural areas [emphasis added]. Improvement is also needed in methods of birth control most acceptable and useable by the rural poor. On the demand side, further experimentation and implementation action projects and programs are needed. In particular, more research is needed on the motivation of the poorest who often have the highest fertility rates. Assistance programs must be more precisely targeted to this group than in the past.
18. It may well be that desired family size will not decline to near replacement levels until the lot of the LDC rural poor improves to the extent that the benefits of reducing family size appear to them to outweigh the costs. For urban people, a rapidly growing element in the LDCs, the liabilities of having too many children are already becoming apparent. Aid recipients and donors must also emphasize development and improvements in the quality of life of the poor, if significant progress is to be made in controlling population growth. Although it was adopted primarily for other reasons, the new emphasis of AID's legislation on problems of the poor (which is echoed in comparable changes in policy emphasis by other donors and by an increasing number of LDC's) is directly relevant to the conditions required for fertility reduction.
POLITICAL EFFECTS OF POPULATION FACTORS - Index

19. The political consequences of current population factors in the LDCs -- rapid growth, internal migration, high percentages of young people, slow improvement in living standards, urban concentrations, and pressures for foreign migration -- are damaging to the internal stability and international relations of countries in whose advancement the U.S. is interested, thus creating political or even national security problems for the U.S. In a broader sense, there is a major risk of severe damage to world economic, political, and ecological systems and, as these systems begin to fail, to our humanitarian values [emphasis added]. 20. The pace of internal migration from countryside to over-swollen cities is greatly intensified by rapid population growth. Enormous burdens are placed on LDC governments for public administration, sanitation, education, police, and other services, and urban slum dwellers (though apparently not recent migrants) may serve as a volatile, violent force which threatens political stability.
21. Adverse socio-economic conditions generated by these and related factors may contribute to high and increasing levels of child abandonment, juvenile delinquency, chronic and growing underemployment and unemployment, petty thievery, organized brigandry, food riots, separatist movements, communal massacres, revolutionary actions and counter-revolutionary coups. Such conditions also detract from the environment needed to attract the foreign capital vital to increasing levels of economic growth in these areas. If these conditions result in expropriation of foreign interests, such action, from an economic viewpoint, is not in the best interests of either the investing country or the host government.
22. In international relations, population factors are crucial in, and often determinants of, violent conflicts in developing areas. Conflicts that are regarded in primarily political terms often have demographic roots. Recognition of these relationships appears crucial to any understanding or prevention of such hostilities.
GENERAL GOALS AND REQUIREMENTS FOR DEALING WITH RAPID POPULATION GROWTH - Index

23. The central question for world population policy in the year 1974, is whether mankind is to remain on a track toward an ultimate population of 12 to 15 billion -- implying a five to seven-fold increase in almost all the underdeveloped world outside of China -- or whether (despite the momentum of population growth) it can be switched over to the course of earliest feasible population stability -- implying ultimate totals of 8 to 9 billions and not more than a three or four-fold increase in any major region. 24. What are the stakes? We do not know whether technological developments will make it possible to feed over 8 much less 12 billion people in the 21st century. We cannot be entirely certain that climatic changes in the coming decade will not create great difficulties in feeding a growing population, especially people in the LDCs who live under increasingly marginal and more vulnerable conditions. There exists at least the possibility that present developments point toward Malthusian conditions for many regions of the world.
25. But even if survival for these much larger numbers is possible, it will in all likelihood be bare survival, with all efforts going in the good years to provide minimum nutrition and utter dependence in the bad years on emergency rescue efforts from the less populated and richer countries of the world. In the shorter run -- between now and the year 2000 -- the difference between the two courses can be some perceptible material gain in the crowded poor regions, and some improvement in the relative distribution of intra-country per capita income between rich and poor, as against permanent poverty and the widening of income gaps. A much more vigorous effort to slow population growth can also mean a very great difference between enormous tragedies of malnutrition and starvation as against only serious chronic conditions.
POLICY RECOMMENDATIONS - Index

26. There is no single approach which will "solve" the population problem. The complex social and economic factors involved call for a comprehensive strategy with both bilateral and multilateral elements. At the same time actions and programs must be tailored to specific countries and groups. Above all, LDCs themselves must play the most important role to achieve success. 27. Coordination among the bilateral donors and multilateral organizations is vital to any effort to moderate population growth. Each kind of effort will be needed for worldwide results.
28. World policy and programs in the population field should incorporate two major objectives:

(a) actions to accommodate continued population growth up to 6 billions by the mid-21st century without massive starvation or total frustration of developmental hopes; and
(b) actions to keep the ultimate level as close as possible to 8 billions rather than permitting it to reach 10 billions, 13 billions, or more.

29. While specific goals in this area are difficult to state, our aim should be for the world to achieve a replacement level of fertility, (a two-child family on the average), by about the year 2000 [emphasis added]. This will require the present 2 percent growth rate to decline to 1.7 percent within a decade and to 1.1 percent by 2000. Compared to the U.N medium projection, this goal would result in 500 million fewer people in 2000 and about 3 billion fewer in 2050. Attainment of this goal will require greatly intensified population programs [emphasis added]. A basis for developing national population growth control targets to achieve this world target is contained in the World Population Plan of Action. 30. The World Population Plan of Action is not self-enforcing and will require vigorous efforts by interested countries, U.N. agencies and other international bodies to make it effective. U.S. leadership is essential [emphasis added]. The strategy must include the following elements and actions:

(a) Concentration on key countries. Assistance for population moderation should give primary emphasis to the largest and fastest growing developing countries where there is special U.S. political and strategic interest. Those countries are: India, Bangladesh, Pakistan, Nigeria, Mexico, Indonesia, Brazil, the Philippines, Thailand, Egypt, Turkey, Ethiopia and Colombia. Together, they account for 47 percent of the world's current population increase. (It should be recognized that at present AID bilateral assistance to some of these countries may not be acceptable.) Bilateral assistance, to the extent that funds are available, will be given to other countries, considering such factors as population growth, need for external assistance, long-term U.S. interests and willingness to engage in self-help. Multilateral programs must necessarily have a wider coverage and the bilateral programs of other national donors will be shaped to their particular interests. At the same time, the U.S. will look to the multilateral agencies -- especially the U.N. Fund for Population Activities which already has projects in over 80 countries -- to increase population assistance on a broader basis with increased U.S. contributions. This is desirable in terms of U.S. interests and necessary in political terms in the United Nations. But progress nevertheless, must be made in the key 13 and our limited resources should give major emphasis to them.
(b) Integration of population factors and population programs into country development planning. As called for by the world Population Plan of Action, developing countries and those aiding them should specifically take population factors into account in national planning and include population programs in such plans.
© Increased assistance for family planning services, information and technology. This is a vital aspect of any world population program. (1) Family planning information and materials based on present technology should be made fully available as rapidly as possible to the 85% of the populations in key LDCs not now reached, essentially rural poor who have the highest fertility. (2) Fundamental and developmental research should be expanded, aimed at simple, low-cost, effective, safe, long-lasting and acceptable methods of fertility control. Support by all federal agencies for biomedical research in this field should be increased by $60 million annually.
(d) Creating conditions conducive to fertility decline. For its own merits and consistent with the recommendations of the World Population Plan of Action, priority should be given in the general aid program to selective development policies in sectors offering the greatest promise of increased motivation for smaller family size. In many cases pilot programs and experimental research will be needed as guidance for later efforts on a larger scale. The preferential sectors include:
- Providing minimal levels of education, especially for women;
- Reducing infant mortality, including through simple low-cost health care networks;
- Expanding wage employment, especially for women;
- Developing alternatives to children as a source of old age security;
- Increasing income of the poorest, especially in rural areas, including providing privately owned farms;
- Education of new generations on the desirability of smaller families.
While AID has information on the relative importance of the new major socio-economic factors that lead to lower birth rates, much more research and experimentation need to be done to determine what cost effective programs and policy will lead to lower birth rates.
(e) Food and agricultural assistance is vital for any population sensitive development strategy. The provision of adequate food stocks for a growing population in times of shortage is crucial. Without such a program for the LDCs there is considerable chance that such shortage will lead to conflict and adversely affect population goals and developmental efforts. Specific recommendations are included in Section IV© of this study.
(f) Development of a worldwide political and popular commitment to population stabilization is fundamental to any effective strategy. This requires the support and commitment of key LDC leaders. This will only take place if they clearly see the negative impact of unrestricted population growth and believe it is possible to deal with this question through governmental action. The U.S. should encourage LDC leaders to take the lead in advancing family planning and population stabilization both within multilateral organizations and through bilateral contacts with other LDCs. This will require that the President and the Secretary of State treat the subject of population growth control as a matter of paramount importance and address it specifically in their regular contacts with leaders of other governments, particularly LDCs.

31. The World Population Plan of Action and the resolutions adopted by consensus by 137 nations at the August 1974 U.N. World Population Conference, though not ideal, provide an excellent framework for developing a worldwide system of population/family planning programs [emphasis added]. (The Plan of Action appears in Appendix 1.) We should use them to generate U.N. agency and national leadership for an all-out effort to lower growth rates. Constructive action by the U.S. will further our objectives. To this end we should:

(a) Strongly support the World Population Plan of Action and the adoption of its appropriate provisions in national and other programs.
(b) Urge the adoption by national programs of specific population goals including replacement levels of fertility for DCs and LDCs by 2000.
© After suitable preparation in the U.S., announce a U.S. goal to maintain our present national average fertility no higher than replacement level and attain near stability by 2000 [emphasis added].
(d) Initiate an international cooperative strategy of national research programs on human reproduction and fertility control covering biomedical and socio-economic factors, as proposed by the U.S. Delegation at Bucharest.
(e) Act on our offer at Bucharest to collaborate with other interested donors and U.N. agencies to aid selected countries to develop low cost preventive health and family planning services.
(f) Work directly with donor countries and through the U.N. Fund for Population Activities and the OECD/DAC to increase bilateral and multilateral assistance for population programs.

32. As measures to increase understanding of population factors by LDC leaders and to strengthen population planning in national development plans, we should carry out the recommendations in Part II, Section VI, including:

(a) Consideration of population factors and population policies in all Country Assistance Strategy Papers (CASP) and Development Assistance Program (DAP) multi-year strategy papers.
(b) Prepare projections of population growth individualized for countries with analyses of development of each country and discuss them with national leaders.
© Provide for greatly increased training programs for senior officials of LDCs in the elements of demographic economics.
(d) Arrange for familiarization programs at U.N. Headquarters in New York for ministers of governments, senior policy level officials and comparably influential leaders from private life.
(e) Assure assistance to LDC leaders in integrating population factors in national plans, particularly as they relate to health services, education, agricultural resources and development, employment, equitable distribution of income and social stability.
(f) Also assure assistance to LDC leaders in relating population policies and family planning programs to major sectors of development: health, nutrition, agriculture, education, social services, organized labor, women's activities, and community development.
(g) Undertake initiatives to implement the Percy Amendment regarding improvement in the status of women.
(h) Give emphasis in assistance to programs on development of rural areas.

Beyond these activities which are essentially directed at national interests, we must assure that a broader educational concept is developed to convey an acute understanding to national leaders of the interrelation of national interests and world population growth. 33. We must take care that our activities should not give the appearance to the LDCs of an industrialized country policy directed against the LDCs. Caution must be taken that in any approaches in this field we support in the LDCs are ones we can support within this country. "Third World" leaders should be in the forefront and obtain the credit for successful programs. In this context it is important to demonstrate to LDC leaders that such family planning programs have worked and can work within a reasonable period of time.
34. To help assure others of our intentions we should indicate our emphasis on the right of individuals and couples to determine freely and responsibly the number and spacing of their children and to have information, education and means to do so, and our continued interest in improving the overall general welfare. We should use the authority provided by the World Population Plan of Action to advance the principles that 1) responsibility in parenthood includes responsibility to the children and the community and 2) that nations in exercising their sovereignty to set population policies should take into account the welfare of their neighbors and the world. To strengthen the worldwide approach, family planning programs should be supported by multilateral organizations wherever they can provide the most efficient means.
35. To support such family planning and related development assistance efforts there is need to increase public and leadership information in this field. We recommend increased emphasis on mass media, newer communications technology and other population education and motivation programs by the UN and USIA. Higher priority should be given to these information programs in this field worldwide.
36. In order to provide the necessary resources and leadership, support by the U.S. public and Congress will be necessary. A significant amount of funds will be required for a number of years. High level personal contact by the Secretary of State and other officials on the subject at an early date with Congressional counterparts is needed. A program for this purpose should be developed by OES with H and AID.
37. There is an alternate view which holds that a growing number of experts believe that the population situation is already more serious and less amenable to solution through voluntary measures than is generally accepted. It holds that, to prevent even more widespread food shortage and other demographic catastrophes than are generally anticipated, even stronger measures are required and some fundamental, very difficult moral issues need to be addressed. These include, for example, our own consumption patterns, mandatory programs, tight control of our food resources. In view of the seriousness of these issues, explicit consideration of them should begin in the Executive Branch, the Congress and the U.N. soon. (See the end of Section I for this viewpoint.)
38. Implementing the actions discussed above (in paragraphs 1-36), will require a significant expansion in AID funds for population/family planning. A number of major actions in the area of creating conditions for fertility decline can be funded from resources available to the sectors in question (e.g., education, agriculture). Other actions, including family planning services, research and experimental activities on factors affecting fertility, come under population funds. We recommend increases in AID budget requests to the Congress on the order of $35-50 million annually through FY 1980 (above the $137.5 million requested for FY 1975) [emphasis added]. This funding would cover both bilateral programs and contributions to multilateral organizations. However, the level of funds needed in the future could change significantly, depending on such factors as major breakthroughs in fertility control technologies and LDC receptivities to population assistance [emphasis added]. To help develop, monitor, and evaluate the expanded actions discussed above, AID is likely to need additional direct hire personnel in the population/family planning area. As a corollary to expanded AID funding levels for population, efforts must be made to encourage increased contributions by other donors and recipient countries to help reduce rapid population growth.
POLICY FOLLOW-UP AND COORDINATION

39. This world wide population strategy involves very complex and difficult questions. Its implementation will require very careful coordination and specific application in individual circumstances. Further work is greatly needed in examining the mix of our assistance strategy and its most efficient application. A number of agencies are interested and involved. Given this, there appears to be a need for a better and higher level mechanism to refine and develop policy in this field and to coordinate its implementation beyond this NSSM. The following options are suggested for consideration:

(a) That the NSC Under Secretaries Committee be given responsibility for policy and executive review of this subject:
- Pros:
  - Because of the major foreign policy implications of the recommended population strategy a high level focus on policy is required for the success of such a major effort.
  - With the very wide agency interests in this topic there is need for an accepted and normal interagency process for effective analysis and disinterested policy development and implementation within the N.S.C. system.
  - Staffing support for implementation of the NSSM-200 follow-on exists within the USC framework including utilization of the Office of Population of the Department of State as well as other.
  - USC has provided coordination and follow-up in major foreign policy areas involving a number of agencies as is the case in this study.
- Cons:
  - The USC would not be within the normal policy-making framework for development policy as would be in the case with the DCC.
  - The USC is further removed from the process of budget development and review of the AID Population Assistance program.
(b) That when its establishment is authorized by the President, the Development Coordination Committee, headed by the AID Administrator be given overall responsibility:*
- Pros: (Provided by AID)
  - It is precisely for coordination of this type of development issue involving a variety of U.S. policies toward LDCs that the Congress directed the establishment of the DCC.
  - The DCC is also the body best able to relate population issues to other development issues, with which they are intimately related.
  - The DCC has the advantage of stressing technical and financial aspects of U.S. population policies, thereby minimizing political complications frequently inherent in population programs.
  - It is, in AID's view, the coordinating body best located to take an overview of all the population activities now taking place under bilateral and multilateral auspices.
- Cons:
  - While the DCC will doubtless have substantial technical competence, the entire range of political and other factors bearing on our global population strategy might be more effectively considered by a group having a broader focus than the DCC.
  - The DCC is not within the N.S.C. system which provides a more direct access to both the President and the principal foreign policy decision-making mechanism.
  - The DCC might overly emphasize purely developmental aspects of population and under emphasize other important elements.
© That the NSC/CIEP be asked to lead an Interdepartmental Group for this subject to insure follow-up interagency coordination, and further policy development. (No participating Agency supports this option, therefore it is only included to present a full range of possibilities).

Option (a) is supported by State, Treasury,
Defense (ISA and JCS), Agriculture, HEW,
Commerce NSC and CIA.** Option (b) is supported by AID.
Under any of the above options, there should be an annual review of our population policy to examine progress, insure our programs are in keeping with the latest information in this field, identify possible deficiencies, and recommend additional action at the appropriate level.***
SOME KEY POINTS FROM THE MAIN BODY OF THE REPORT - Index

All readers are urged to read the detailed main body of the report which is presented in full in Appendix Two. This will give the reader a better appreciation of the gravity of this new threat to U.S. and global security and the actions the many departments of our government felt were necessary in order to address this grave new threat -- a threat greater than nuclear war. These 20 important points will be discussed in the remaining chapters of this book. On the magnitude and urgency of the problem:

"...World population growth is widely recognized within the Government as a current danger of the highest magnitude calling for urgent measures." [Page 194]
"...it is of the utmost urgency that governments now recognize the facts and implications of population growth, determine the ultimate population sizes that make sense for their countries and start vigorous programs at once to achieve their desired goals." [Page 15]
"...population factors are indeed critical in, and often determinants of, violent conflict in developing areas. Segmental (religious, social, racial) differences, migration, rapid population growth, differential levels of knowledge and skills, rural/urban differences, population pressure and the spatial location of population in relation to resources -- in this rough order of importance -- all appear to be important contributions to conflict and violence...Clearly, conflicts which are regarded in primarily political terms often have demographic roots. Recognition of these relationships appears crucial to any understanding or prevention of such hostilities." [Page 66]
"Where population size is greater than available resources, or is expanding more rapidly than the available resources, there is a tendency toward internal disorders and violence and, sometimes, disruptive international policies or violence." [Page 69]
"In developing countries, the burden of population factors, added to others, will weaken unstable governments, often only marginally effective in good times, and open the way to extremist regimes." [Page 84]
The report gives three examples of population wars: the El Salvador-Honduras "Soccer War" [Page 71]; the Nigerian Civil War [Page 71]; and, the Pakistan-India-Bangladesh War, 1970-71. [Page 72]
"...population growth over the years will seriously negate reasonable prospects for the sound social and economic development of the peoples involved." [Page 98]
"Past experience gives little assistance to predicting the course of these developments because the speed of today's population growth, migrations, and urbanization far exceeds anything the world has ever seen before. Moreover, the consequences of such population factors can no longer be evaded by moving to new hunting or grazing lands, by conquering new territory, by discovering or colonizing new continents, or by emigration in large numbers. The world has ample warning that we all must make more rapid efforts at social and economic development to avoid or mitigate these gloomy prospects. We should be warned also that we all must move as rapidly as possible toward stabilizing national and world population growth." [Page 85]
Leadership is vital: - Index
"Successful family planning requires strong local dedication and commitment that cannot over the long run be enforced from the outside." [Page 106]
"...it is vital that leaders of major LDCs themselves take the lead in advancing family planning and population stabilization, not only within the UN and other international organizations but also through bilateral contacts with leaders of other LDCs." [Page 112]
"These programs will have only modest success until there is much stronger and wider acceptance of their real importance by leadership groups. Such acceptance and support will be essential to assure that the population information, education and service programs have vital moral backing, administrative capacity, technical skills and government financing." [Page 195] What must be done: - Index
"Control of population growth and migration must be a part of any program for improvement of lasting value." [Page 81]
"...the Conference adopted by acclamation (only the Holy See stating a general reservation) a complete World Population Plan of Action" [Page 87]
"Our objective should be to assure that developing countries make family planning information, education and means available to all their peoples by 1980." [Page 130]
"Only nominal attention is [currently] given to population education or sex education in schools..." [Page 158] "Recommendation: That US agencies stress the importance of education of the next generation of parents, starting in elementary schools, toward a two-child family ideal. That AID stimulate specific efforts to develop means of educating children of elementary school age to the ideal of the two-child family..." [Page 159]
"...there is general agreement that up to the point when cost per acceptor rises rapidly, family planning expenditures are generally considered the best investment a country can make in its own future," [Page 53] Contradiction of the Holy See's answer to the population problem: - Index
"Clearly development per se is a powerful determinant of fertility. However, since it is unlikely that most LDCs will develop sufficiently during the next 25-30 years, it is crucial to identify those sectors that most directly and powerfully affect fertility." [Page 99]
"There is also even less cause for optimism on the rapidity of socio-economic progress that would generate rapid fertility reduction in the poor LDCs, than on the feasibility of extending family planning services to those in their populations who may wish to take advantage of them." [Page 99]
"But we can be certain of the desirable direction of change and can state as a plausible objective the target of achieving replacement fertility rates by the year 2000." [Page 99] Abortion is vital to the solution: - Index
"While the agencies participating in this study have no specific recommendations to propose on abortion, the following issues are believed important and should be considered in the context of a global population strategy...Certain facts about abortion need to be appreciated: " -- No country has reduced its population growth without resorting to abortion". [Page 182]
" -- Indeed, abortion, legal and illegal, now has become the most widespread fertility control method in use in the world today." [Page 183]
" -- It would be unwise to restrict abortion research for the following reasons: 1) The persistent and ubiquitous nature of abortion. 2) Widespread lack of safe abortion techniques..." [Page 185]

* AID expects the DCC will have the following composition: The Administrator of AID as Chairman; the Under Secretary of State for Economic Affairs; the Under Secretary of Treasury for Monetary Affairs; the Under Secretaries of Commerce, Agriculture and Labor; an Associate Director of OMB; the Executive Director of CIEP, STR; a representative of the NSC; the Presidents of the EX-IM Bank and OPIC; and any other agency when items of interest to them are under discussion.) ** Department of Commerce supports the option of placing the population policy formulation mechanism under the auspices of the USC but believes that any detailed economic questions resulting from proposed population policies be explored through existing domestic and international economic policy channels.
*** AID believes these reviews undertaken only periodically might look at selected areas or at the entire range of population policy depending on problems and needs which arise.

PART ONE. ANALYTICAL SECTION

CHAPTER I - WORLD DEMOGRAPHIC TRENDS

INTRODUCTION

The present world population growth is unique. Rates of increase are much higher than in earlier centuries, they are more widespread, and have a greater effect on economic life, social justice, and -- quite likely -- on public order and political stability. The significance of population growth is enhanced because it comes at a time when the absolute size and rate of increase of the global economy, need for agricultural land, demand for and consumption of resources including water, production of wastes and pollution have also escalated to historically unique levels. Factors that only a short time ago were considered separately now have interlocking relationships, inter-dependence in a literal sense. The changes are not only quantitatively greater than in the past but qualitatively different. The growing burden is not only on resources but on administrative and social institutions as well. Population growth is, of course, only one of the important factors in this new, highly integrated tangle of relationships. However, it differs from the others because it is a determinant of the demand sector while others relate to output and supply. (Population growth also contributes to supply through provision of manpower; in most developing countries, however, the problem is not a lack of but a surfeit of hands.) It is, therefore, most pervasive, affecting what needs to be done in regard to other factors. Whether other problems can be solved depends, in varying degrees, on the extent to which rapid population growth and other population variables can be brought under control.
HIGHLIGHTS OF CURRENT DEMOGRAPHIC TRENDS

Since 1950, world population has been undergoing unprecedented growth. This growth has four prominent features:

It is unique, far more rapid than ever in history.
It is much more rapid in less developed than in developed regions.
Concentration in towns and cities is increasing much more rapidly than overall population growth and is far more rapid in LDCs than in developed countries.
It has a tremendous built-in momentum that will inexorably double populations of most less developed countries by 2000 and will treble or quadruple their populations before leveling off -- unless far greater efforts at fertility control are made than are being made.

Therefore, if a country wants to influence its total numbers through population policy, it must act in the immediate future in order to make a substantial difference in the long run. For most of man's history, world population grew very slowly. At the rate of growth estimated for the first 18 centuries A.D., it required more than 1,000 years for world population to double in size. With the beginnings of the industrial revolution and of modern medicine and sanitation over two hundred years ago, population growth rates began to accelerate. At the current growth rate (1.9 percent) world population will double in 37 years.

By about 1830, world population reached 1 billion. The second billion was added in about 100 years by 1930. The third billion in 30 years by 1960. The fourth will be reached in 1975.
Between 1750-1800 less than 4 million were being added, on the average, to the earth's population each year. Between 1850-1900, it was close to 8 million. By 1950 it had grown to 40 million. By 1975 it will be about 80 million.

In the developed countries of Europe, growth rates in the last century rarely exceeded 1.0-1.2 percent per year, almost never 1.5 percent. Death rates were much higher than in most LDCs today. In North America where growth rates were higher, immigration made a significant contribution. In nearly every country of Europe, growth rates are now below 1 percent, in many below 0.5 percent. The natural growth rate (births minus deaths) in the United States is less than 0.6 percent. Including immigration (the world's highest) it is less than 0.7 percent. In less developed countries growth rates average about 2.4 percent. For the People's Republic of China, with a massive, enforced birth control program, the growth rate is estimated at under 2 percent. India's is variously estimated from 2.2 percent, Brazil at 2.8 percent, Mexico at 3.4 percent, and Latin America at about 2.9 percent. African countries, with high birth as well as high death rates, average 2.6 percent; this growth rate will increase as death rates go down.
The world's population is now about 3.9 billion; 1.1 billion in the developed countries (30 percent) and 2.8 billion in the less developed countries (70 percent).
In 1950, only 28 percent of the world's population or 692 million, lived in urban localities. Between 1950 and 1970, urban population expanded at a rate twice as rapid as the rate of growth of total population. In 1970, urban population increased to 36 percent of world total and numbered 1.3 billion. By 2000, according to the UN's medium variant projection, 3.2 billion (about half of the total) of world inhabitants will live in cities and towns.
In developed countries, the urban population varies from 45 to 85 percent; in LDCs, it varies from close to zero in some African states to nearly 100 percent in Hong Kong and Singapore.
In LDCs, urban population is projected to more than triple in the remainder of this century, from 622 million in 1970 to 2,087 in 2000. Its proportion in total LDC population will thus increase from 25 percent in 1970 to 41 percent in 2000. This implies that by the end of this century LDCs will reach half the level of urbanization projected for DCs (82 percent) (See Table 1).
The enormous built-in momentum of population growth in the less developed countries (and to a degree in the developed countries) is, if possible, even more important and ominous than current population size and rates of growth. Unlike a conventional explosion, population growth provides a continuing chain reaction. This momentum springs from (1) high fertility levels of LDC populations and (2) the very high percentage of maturing young people in populations. The typical developed country, Sweden for example, may have 25% of the population under 15 years of age. The typical developing country has 41% to 45% or its population under 15. This means that a tremendous number of future parents, compared to existing parents, are already born. Even if they have fewer children per family than their parents, the increase in population will be very great.
Three projections (not predictions), based on three different assumptions concerning fertility, will illustrate the generative effect of this building momentum.
a. Present fertility continued: If present fertility rates were to remain constant, the 1974 population 3.9 billion would increase to 7.8 billion by the hear 2000 and rise to a theoretical 103 billion by 2075.
b. U.N. "Medium Variant": If present birth rates in the developing countries, averaging about 38/1000 were further reduced to 29/1000 by 2000, the world's population in 2000 would be 6.4 billion, with over 100 million being added each year. At the time stability (non-growth) is reached in about 2100, world population would exceed 12.0 billion.
c. Replacement Fertility by 2000: If replacement levels of fertility were reached by 2000, the world's population in 2000 would be 5.9 billion and at the time of stability, about 2075, would be 8.4 billion. ("Replacement level" of fertility is not zero population growth. It is the level of fertility when couples are limiting their families to an average of about two children. For most countries, where there are high percentages of young people, even the attainment of replacement levels of fertility means that the population will continue to grow for additional 50-60 years to much higher numbers before leveling off.)
It is reasonable to assume that projection (a) is unreal since significant efforts are already being made to slow population growth and because even the most extreme pro-natalists do not argue that the earth could or should support 103 billion people. Famine, pestilence, war, or birth control will stop population growth far short of this figure.
The U.N. medium variant (projection (b)) has been described in a publication of the U.N. Population Division as "a synthesis of the results of efforts by demographers of the various countries and the U.N. Secretariat to formulate realistic assumptions with regard to future trends, in view of information about present conditions and past experiences." Although by no means infallible, these projections provide plausible working numbers and are used by U.N. agencies (e.g., FAO, ILO) for their specialized analyses. One major shortcoming of most projections, however, is that "information about present conditions" quoted above is not quite up-to-date. Even in the United States, refined fertility and mortality rates become available only after a delay of several years.
Thus, it is possible that the rate of world population growth has actually fallen below (or for that matter increased from) that assumed under the U.N. medium variant. A number of less developed countries with rising living levels (particularly with increasing equality of income) and efficient family planning programs have experienced marked declines in fertility. Where access to family planning services has been restricted, fertility levels can be expected to show little change.
It is certain that fertility rates have already fallen significantly in Hong King, Singapore, Taiwan, Fiji, South Korea, Barbados, Chile, Costa Rica, Trinidad and Tobago, and Mauritius (See Table 2). Moderate declines have also been registered in West Malaysia, Sri Lanka, and Egypt. Steady increases in the number of acceptors at family planning facilities indicate a likelihood of some fertility reduction in Thailand, Indonesia, the Philippines, Colombia, and other countries which have family planning programs. On the other hand, there is little concrete evidence of significant fertility reduction in the populous countries of India, Bangladesh, Pakistan, etc.1
Projection © is attainable if countries recognize the gravity of their population s...

PART TWO. POLICY RECOMMENDATIONS

I. Introduction - A U.S. Global Population Strategy

There is no simple single approach to the population problem which will provide a "technological fix". As the previous analysis makes clear the problem of population growth has social, economic and technological aspects all of which must be understood and dealt with for a world population policy to succeed. With this in mind, the following broad recommended strategy provides a framework for the development of specific individual programs which must be tailored to the needs and particularities of each country and of different sectors of the population within a country. Essentially all its recommendations made below are supported by the World Population Plan of action drafted at the World Population Conference. A. Basic Global Strategy

The following basic elements are necessary parts of a comprehensive approach to the population problem which must include both bilateral and multilateral components to achieve success. Thus, USG population assistance programs will need to be coordinated with those of the major multilateral institutions, voluntary organizations, and other bilateral donors. The common strategy for dealing with rapid population growth should encourage constructive actions to lower fertility since population growth over the years will seriously negate reasonable prospects for the sound social and economic development of the peoples involved.
While the time horizon in this NSSM is the year 2000 we must recognize that in most countries, especially the LDCs, population stability cannot be achieved until the next century. There are too many powerful socio-economic factors operating on family size decisions and too much momentum built into the dynamics of population growth to permit a quick and dramatic reversal of current trends. There is also even less cause for optimism on the rapidity of socio-economic progress that would generate rapid fertility reduction in the poor LDCs than on the feasibility of extending family planning services to those in their populations who may wish to take advantage of them. Thus, at this point we cannot know with certainty when world population can feasibly be stabilized, nor can we state with assurance the limits of the world's ecological "carrying capability". But we can be certain of the desirable direction of change and can state as a plausible objective the target of achieving replacement fertility rates by the year 2000.
Over the past few years, U.S. government-funded population programs have played a major role in arousing interest in family planning in many countries, and in launching and accelerating the growth of national family planning programs. In most countries, there has been an initial rapid growth in contraceptive "acceptors" up to perhaps 10% of fertile couples in a few LDCs. The acceleration of previous trends of fertility decline is attributable, at least in part, to family planning programs.
However, there is growing appreciation that the problem is more long term and complex than first appeared and that a short term burst of activity or moral fervor will not solve it. The danger in this realization is that the U.S. might abandon its commitment to assisting in the world's population problem, rather than facing up to it for the long-run difficult problem that it is.
From year to year we are learning more about what kind of fertility reduction is feasible in differing LDC situations. Given the laws of compound growth, even comparatively small reductions in fertility over the next decade will make a significant difference in total numbers by the year 2000, and a far more significant one by the year 2050.
The proposed strategy calls for a coordinated approach to respond to the important U.S. foreign policy interest in the influence of population growth on the world's political, economic and ecological systems. What is unusual about population is that this foreign policy interest must have a time horizon far beyond that of most other objectives. While there are strong short-run reasons for population programs, because of such factors as food supply, pressures on social service budgets, urban migration and social and political instability, the major impact of the benefits - or avoidance of catastrophe - that could be accomplished by a strengthened U.S. commitment in the population area will be felt less by those of us in the U.S. and other countries today than by our children and grandchildren.
B. Key Country priorities in U.S. and Multilateral Population Assistance

One issue in any global population strategy is the degree of emphasis in allocation of program resources among countries. The options available range from heavy concentration on a few vital large countries to a geographically diverse program essentially involving all countries willing to accept such assistance. All agencies believe the following policy provides the proper overall balance. In order to assist the development of major countries and to maximize progress toward population stability, primary emphasis would be placed on the largest and fastest growing developing countries where the imbalance between growing numbers and development potential most seriously risks instability, unrest, and international tensions. These countries are: India, Bangladesh, Pakistan, Nigeria, Mexico, Indonesia, Brazil, The Philippines, Thailand, Egypt, Turkey, Ethiopia, and Colombia. Out of a total 73.3 million worldwide average increase in population from 1970-75 these countries contributed 34.3 million or 47%. This group of priority countries includes some with virtually no government interest in family planning and others with active government family planning programs which require and would welcome enlarged technical and financial assistance. These countries should be given the highest priority within AID's population program in terms of resource allocations and/or leadership efforts to encourage action by other donors and organizations.
However, other countries would not be ignored. AID would provide population assistance and/or undertake leadership efforts with respect to other, lower priority countries to the extent that the availability of funds and staff permits, taking into account of such factors as : long run U.S. political interests; impact of rapid population growth on its development potential; the country's relative contribution to world population growth; its financial capacity to cope with the problem; potential impact on domestic unrest and international frictions (which can apply to small as well as large countries); its significance as a test or demonstration case; and opportunities for expenditures that appear particularly cost-effective (e.g. it has been suggested that there may be particularly cost-effective opportunities for supporting family planning to reduce the lag between mortality and fertility declines in countries where death rates are still declining rapidly); national commitment to an effective program.
For both the high priority countries and the lower priority ones to which funds and staff permit aid, the form and content of our assistance or leadership efforts would vary from country to country, depending on each nation's particular interests, needs, and receptivity to various forms of assistance. For example, if these countries are receptive to U.S. assistance through bilateral or central AID funding, we should provide such assistance at levels commensurate with the recipient's capability to finance needed actions with its own funds, the contributions of other donors and organizations, and the effectiveness with which funds can be used.
In countries where U.S. assistance is limited either by the nature of political or diplomatic relations with those countries or by lack of strong government desire. In population reduction programs, external technical and financial assistance (if desired by the countries) would have to come from other donors and/or from private and international organizations, many of which receive contributions from AID. The USG would, however, maintain an interest (e.g. through Embassies) in such countries' population problems and programs (if any) to reduce population growth rates. Moreover, particularly in the case of high priority countries, we should be alert to opportunities for expanding our assistance efforts and for demonstrating to their leaders the consequences of rapid population growth and the benefits of actions to reduce fertility.
In countries to which other forms of U.S. assistance are provided but not population assistance, AID will monitor progress toward achievement of development objectives, taking into account the extent to which these are hindered by rapid population growth, and will look for opportunities to encourage initiation of or improvement in population policies and programs.
In addition, the U.S. strategy should support in these LDC countries general activities (e.g. bio-medical research or fertility control methods) capable of achieving major breakthroughs in key problems which hinder reductions in population growth.
C. Instruments and Modalities for Population Assistance

Bilateral population assistance is the largest and most invisible "instrument" for carrying out U.S. policy in this area. Other instruments include: support for and coordination with population programs of multilateral organizations and voluntary agencies; encouragement of multilateral country consortia and consultative groups to emphasize family planning in reviews of overall recipient progress and aid requests; and formal and informal presentation of views at international gatherings, such as food and population conferences. Specific country strategies must be worked out for each of the highest priority countries, and for the lower priority ones. These strategies will take account of such factors as: national attitudes and sensitivities on family planning; which "instruments" will be most acceptable, opportunities for effective use of assistance; and need of external capital or operating assistance. For example, in Mexico our strategy would focus on working primarily through private agencies and multilateral organizations to encourage more government attention to the need for control of population growth; in Bangladesh we might provide large-scale technical and financial assistance, depending on the soundness of specific program requests; in Indonesia we would respond to assistance requests but would seek to have Indonesia meet as much of program costs from its own resources (i.e. surplus oil earnings) as possible. In general we would not provide large-scale bilateral assistance in the more developed LDCs, such as Brazil or Mexico. Although these countries are in the top priority list our approach must take account of the fact that their problems relate often to government policies and decisions and not to larger scale need for concessional assistance.
Within the overall array of U.S. foreign assistance programs, preferential treatment in allocation of funds and manpower should be given to cost-effective programs to reduce population growth; including both family planning activities and supportive activities in other sectors.
While some have argued for use of explicit "leverage" to "force" better population programs on LDC governments, there are several practical constraints on our efforts to achieve program improvements. Attempts to use "leverage" for far less sensitive issues have generally caused political frictions and often backfired. Successful family planning requires strong local dedication and commitment that cannot over the long run be enforced from the outside. There is also the danger that some LDC leaders will see developed country pressures for family planning as a form of economic or racial imperialism; this could well create a serious backlash.
Short of "leverage", there are many opportunities, bilaterally and multilaterally, for U.S. representations to discuss and urge the need for stronger family planning programs. There is also some established precedent for taking account of family planning performance in appraisal of assistance requirements by AID and consultative groups. Since population growth is a major determinant of increases in food demand, allocation of scarce PL 480 resources should take account of what steps a country is taking in population control as well as food production. In these sensitive relationships, however, it is important in style as well as substance to avoid the appearance of coercion.
D. Provision and Development of Family Planning Services, Information and Technology

Past experience suggests that easily available family planning services are a vital and effective element in reducing fertility rates in the LDCs. Two main advances are required for providing safe and effective fertility control techniques in the developing countries:
1. Expansion and further development of efficient low-cost systems to assure the full availability of existing family planning services, materials and information to the 85% of LDC populations not now effectively reached. In developing countries willing to create special delivery systems for family planning services this may be the most effective method. In others the most efficient and acceptable method is to combine family planning with health or nutrition in multi-purpose delivery systems.
2. Improving the effectiveness of present means of fertility control, and developing new technologies which are simple, low cost, effective, safe, long-lasting and acceptable to potential users. This involves both basic developmental research and operations research to judge the utility of new or modified approaches under LDC conditions.
Both of these goals should be given very high priority with necessary additional funding consistent with current or adjusted divisions of labor among other donors and organizations involved in these areas of population assistance.
E. Creating Conditions Conducive to Fertility Decline

It is clear that the availability of contraceptive services and information is not a complete answer to the population problem. In view of the importance of socio-economic factors in determining desired family size, overall assistance strategy should increasingly concentrate on selective policies which will contribute to population decline as well as other goals. This strategy reflects the complementarity between population control and other U.S. development objectives, particularly those relating to AID's Congressional mandate to focus on problems of the "poor majority" in LDC's. We know that certain kinds of development policies -- e.g., those which provide the poor with a major share in development benefits -- both promote fertility reductions and accomplish other major development objectives. There are other policies which appear to also promote fertility reduction but which may conflict with non-population objectives (e.g., consider the effect of bringing a large number of women into the labor force in countries and occupations where unemployment is already high and rising).
However, AID knows only approximately the relative priorities among the factors that affect fertility and is even further away from knowing what specific cost-effective steps governments can take to affect these factors.
Nevertheless, with what limited information we have, the urgency of moving forward toward lower fertility rates, even without complete knowledge of the socio-economic forces involved, suggests a three-pronged strategy:
1. High priority to large-scale implementation of programs affecting the determinants of fertility in those cases where there is probable cost-effectiveness, taking account of potential impact on population growth rates; other development benefits to be gained; ethical considerations; feasibility in light of LDC bureaucratic and political concerns and problems; and timeframe for accomplishing objectives.
2. High priority to experimentation and pilot projects in areas where there is evidence of a close relationship to fertility reduction but where there are serious questions about cost-effectiveness relating either to other development impact (e.g., the female employment example cited above) or to program design (e.g., what cost-effective steps can be taken to promote female employment or literacy).
3. High priority to comparative research and evaluation on the relative impact on desired family size of the socio-economic determinants of fertility in general and on what policy scope exists for affecting these determinants.
In all three cases emphasis should be given to moving action as much as possible to LDC institutions and individuals rather than to involving U.S. researchers on a large scale.
Activities in all three categories would receive very high priority in allocation of AID funds. The largest amounts required should be in the first category and would generally not come from population funds. However, since such activities (e.g., in rural development and basic education) coincide with other AID sectoral priorities, sound project requests from LDC's will be placed close to the top in AID's funding priorities (assuming that they do not conflict with other major development and other foreign policy objectives).
The following areas appear to contain significant promise in effecting fertility declines, and are discussed in subsequent sections.

providing minimal levels of education especially for women;
reducing infant and child mortality;
expanding opportunities for wage employment especially for women;
developing alternatives to "social security" support provided by children to aging parents;
pursuing development strategies that skew income growth toward the poor, especially rural development focussing on rural poverty;
concentrating on the education and indoctrination of the rising generation of children regarding the desirability of smaller family size.

The World Population Plan of Action includes a provision (paragraph 31) that countries trying for effective fertility levels should give priority to development programs and health and education strategies which have a decisive effect upon demographic trends, including fertility. It calls for international information to give priority to assisting such national efforts. Programs suggested (paragraph 32) are essentially the same as those listed above. Food is another of special concern in any population strategy. Adequate food stocks need to be created to provide for periods of severe shortages and LDC food production efforts must be reenforced to meet increased demand resulting from population and income growth. U.S. agricultural production goals should take account of the normal import requirements of LDC's (as well as developed countries) and of likely occasional crop failures in major parts of the LDC world. Without improved food security, there will be pressure leading to possible conflict and the desire for large families for "insurance" purposes, thus undermining other development and population control efforts.
F. Development of World-Wide Political and Popular Commitment to Population Stabilization and Its Associated Improvement of Individual Quality of Life.

A fundamental element in any overall strategy to deal with the population problem is obtaining the support and commitment of key leaders in the developing countries. This is only possible if they can clearly see the negative impact of unrestricted population growth in their countries and the benefits of reducing birth rates - and if they believe it is possible to cope with the population problem through instruments of public policy. Since most high officials are in office for relatively short periods, they have to see early benefits or the value of longer term statesmanship. In each specific case, individual leaders will have to approach their population problems within the context of their country's values, resources, and existing priorities. Therefore, it is vital that leaders of major LDCs themselves take the lead in advancing family planning and population stabilization, not only within the U.N. and other international organizations but also through bilateral contacts with leaders of other LDCs. Reducing population growth in LDCs should not be advocated exclusively by the developed countries. The U.S. should encourage such a role as opportunities appear in its high level contact with LDC leaders.
The most recent forum for such an effort was the August 1974 U.N. World Population Conference. It was an ideal context to focus concerted world attention on the problem. The debate views and highlights of the World Population Plan of action are reviewed in Chapter VI.
The U.S. strengthened its credibility as an advocate of lower population growth rates by explaining that, while it did not have a single written action population policy, it did have legislation, Executive Branch policies and court decisions that amounted to a national policy and that our national fertility level was already below replacement and seemed likely to attain a stable population by 2000.
The U.S. also proposed to join with other developed countries in an international collaborative effort of research in human reproduction and fertility control covering bio-medical and socio-economic factors.
The U.S. further offered to collaborate with other interested donor countries and organizations (e.g., WHO, UNFPA, World Bank, UNICEF) to encourage further action by LDC governments and other institutions to provide low-cost, basic preventive health services, including maternal and child health and family planning services, reaching out into the remote rural areas.
The U.S. delegation also said the U.S. would request from the Congress increased U.S. bilateral assistance to population-family planning programs, and additional amounts for essential functional activities and our contribution to the UNFPA if countries showed an interest in such assistance.
Each of these commitments is important and should be pursued by the U.S. Government.
It is vital that the effort to develop and strengthen a commitment on the part of the LDC leaders not be seen by them as an industrialized country policy to keep their strength down or to reserve resources for use by the "rich" countries. Development of such a perception could create a serious backlash adverse to the cause of population stability. Thus the U.S. and other "rich" countries should take care that policies they advocate for the LDC's would be acceptable within their own countries. (This may require public debate and affirmation of our intended policies.) The "political" leadership role in developing countries should, of course, be taken whenever possible by their own leaders.
The U.S. can help to minimize charges of an imperialist motivation behind its support of population activities by repeatedly asserting that such support derives from a concern with:
(a) the right of the individual couple to determine freely and responsibly their number and spacing of children and to have information, education, and 1means to do so; and
(b) the fundamental social and economic development of poor countries in which rapid population growth is both a contributing cause and a consequence of widespread poverty.
Furthermore, the U.S. should also take steps to convey the message that the control of world population growth is in the mutual interest of the developed and developing countries alike.
Family planning programs should be supported by multilateral organizations wherever they can provide the most efficient and acceptable means. Where U.S. bilateral assistance is necessary or preferred, it should be provided in collaboration with host country institutions -- as is the case now. Credit should go to local leaders for the success of projects. The success and acceptability of family planning assistance will depend in large measure on the degree to which it contributes to the ability of the host government to serve and obtain the support of its people.
In many countries today, decision-makers are wary of instituting population programs, not because they are unconcerned about rapid population growth, but because they lack confidence that such programs will succeed. By actively working to demonstrate to such leaders that national population and family planning programs have achieved progress in a wide variety of poor countries, the U.S. could help persuade the leaders of many countries that the investment of funds in national family planning programs is likely to yield high returns even in the short and medium term. Several examples of success exist already, although regrettably they tend to come from LDCs that are untypically well off in terms of income growth and/or social services or are islands or city states.
We should also appeal to potential leaders among the younger generations in developing countries, focusing on the implications of continued rapid population growth for their countries in the next 10-20 years, when they may assume national leadership roles.
Beyond seeking to reach and influence national leaders, improved world-wide support for population-related efforts should be sought through increased emphasis on mass media and other population education and motivation programs by the U.N., USIA, and USAID. We should give higher priorities in our information programs world-wide for this area and consider expansion of collaborative arrangements with multilateral institutions in population education programs.
Another challenge will be in obtaining the further understanding and support of the U.S. public and Congress for the necessary added funds for such an effort, given the competing demands for resources. If an effective program is to be mounted by the U.S., we will need to contribute significant new amounts of funds. Thus there is need to reinforce the positive attitudes of those in Congress who presently support U.S. activity in the population field and to enlist their support in persuading others. Public debate is needed now.
Personal approaches by the President, the Secretary of State, other members of the Cabinet, and their principal deputies would be helpful in this effort. Congress and the public must be clearly informed that the Executive Branch is seriously worried about the problem and that it deserves their further attention. Congressional representatives at the World Population Conference can help.
An Alternative View

The above basic strategy assumes that the current forms of assistance programs in both population and economic and social development areas will be able to solve the problem. There is however, another view, which is shared by a growing number of experts. It believes that the outlook is much harsher and far less tractable than commonly perceived. This holds that the severity of the population problem in this century which is already claiming the lives of more than 10 million people yearly, is such as to make likely continued widespread food shortage and other demographic catastrophes, and, in the words of C.P. Snow, we shall be watching people starve on television. The conclusion of this view is that mandatory programs may be needed and that we should be considering these possibilities now.
This school of thought believes the following types of questions need to be addressed:
Should the U.S. make an all out commitment to major limitation of world population with all the financial and international as well as domestic political costs that would entail?
Should the U.S. set even higher agricultural production goals which would enable it to provide additional major food resources to other countries? Should they be nationally or internationally controlled?
On what basis should such food resources then be provided? Would food be considered an instrument of national power? Will we be forced to make choices as to whom we can reasonably assist, and if so, should population efforts be a criterion for such assistance?
Is the U.S. prepared to accept food rationing to help people who can't/won't control their population growth?
Should the U.S. seek to change its own food consumption patterns toward more efficient uses of protein?
Are mandatory population control measures appropriate for the U.S. and/or for others?
Should the U.S. initiate a major research effort to address the growing problems of fresh water supply, ecological damage, and adverse climate?
While definitive answers to those questions are not possible in this study given its time limitations and its implications for domestic policy, nevertheless they are needed if one accepts the drastic and persistent character of the population growth problem. Should the choice be made that the recommendations and the options given below are not adequate to meet this problem, consideration should be given to a further study and additional action in this field as outlined above.
Conclusion

The overall strategy above provides a general approach through which the difficulties and dangers of population growth and related problems can be approached in a balanced and comprehensive basis. No single effort will do the job. Only a concerted and major effort in a number of carefully selected directions can provide the hope of success in reducing population growth and its unwanted dangers to world economic will-being and political stability. There are no "quick-fixes" in this field. Below are specific program recommendations which are designed to implement this strategy. Some will require few new resources; many call for major efforts and significant new resources. We cannot simply buy population growth moderation for nearly 4 billion people "on the cheap".
II. Action to Create Conditions for Fertility Decline: Population and a Development Assistance Strategy

II. A. General Strategy and Resource Allocations for AID Assistance

Discussion:

1. Past Program Actions

Since inception of the program in 1965, AID has obligated nearly $625 million for population activities. These funds have been used primarily to (1) draw attention to the population problem, (2) encourage multilateral and other donor support for the worldwide population effort, and (3) help create and maintain the means for attacking the problem, including the development of LDC capabilities to do so. In pursuing these objectives, AID's population resources were focussed on areas of need where action was feasible and likely to be effective. AID has provided assistance to population programs in some 70 LDCs, on a bilateral basis and/or indirectly through private organizations and other channels. AID currently provides bilateral assistance to 36 of these countries. State and AID played an important role in establishing the United Nations Fund for Population Activities (UNFPA) to spearhead multilateral effort in population as a complement to the bilateral actions of AID and other donor countries. Since the Fund's establishment, AID has been the largest single contributor. Moreover, with assistance from AID a number of private family planning organizations (e.g., Pathfinder Fund, International Planned Parenthood Foundation, Population Council) have significantly expanded their worldwide population programs. Such organizations are still the main supporters of family planning action in many developing countries.
AID actions have been a major catalyst in stimulating the flow of funds into LDC population programs - from almost nothing ten years ago, the amounts being spent from all sources in 1974 for programs in the developing countries of Africa, Latin America, and Asia (excluding China) will total between $400 and $500 million. About half of this will be contributed by the developed countries bilaterally or through multilateral agencies, and the balance will come from the budgets of the developing countries themselves. AID's contribution is about one-quarter of the total - AID obligated $112.4 million for population programs in FY 1974 and plans for FY 1975 program of $137.5 million.
While world resources for population activities will continue to grow, they are unlikely to expand as rapidly as needed. (One rough estimate is that five times the current amount, or about $2.5 billion in constant dollars, will be required annually by 1985 to provide the 2.5 billion people in the developing world, excluding China, with full-scale family planning programs). In view of these limited resources AID's efforts (in both fiscal and manpower terms) and through its leadership the efforts of others, must be focussed to the extent possible on high priority needs in countries where the population problem is the most acute. Accordingly, AID last year began a process of developing geographic and functional program priorities for use in allocating funds and staff, and in arranging and adjusting divisions of labor with other donors and organizations active in the worldwide population effort. Although this study has not yet been completed, a general outline of a U.S. population assistance strategy can be developed from the results of the priorities studied to date. The geographic and functional parameters of the strategy are discussed under 2. and 3. below. The implications for population resource allocations are presented under 4.
2. Geographic Priorities in U.S. Population Assistance

The U.S. strategy should be to encourage and support, through bilateral, multilateral and other channels, constructive actions to lower fertility rates in selected developing countries. Within this overall strategy and in view of funding and manpower limitations, the U.S. should emphasize assistance to those countries where the population problem is the most serious. There are three major factors to consider in judging the seriousness of the problem:
The first is the country's contribution to the world's population problem, which is determined by the size of its population, its population growth rate, and its progress in the "demographic transition" from high birth and high death rates to low ones.
The second is the extent to which population growth impinges on the country's economic development and its financial capacity to cope with its population problem.
The third factor is the extent to which an imbalance between growing numbers of people and a country's capability to handle the problem could lead to serious instability, international tensions, or conflicts. Although many countries may experience adverse consequences from such imbalances, the troublemaking regional or international conditions might not be as serious in some places as they are in others.
Based on the first two criteria, AID has developed a preliminary rank ordering of nearly 100 developing countries which, after review and refinement, will be used as a guide in AID's own funding and manpower resource allocations and in encouraging action through AID leadership efforts on the part of other population assistance instrumentalities. Applying these three criteria to this rank ordering, there are 13 countries where we currently judge the problem and risks to be the most serious. They are: Bangladesh, India, Pakistan, Indonesia, Philippines, Thailand, Egypt, Turkey, Ethiopia, Nigeria, Brazil, Mexico, and Colombia. Out of a total 67 million worldwide increase in population in 1972 these countries contributed about 45%. These countries range from those with virtually no government interest in family planning to those with active government family planning programs which require and would welcome enlarged technical and financial assistance.
These countries should be given the highest priority within AID's population program in terms of resource allocations and/or leadership efforts to encourage action by other donors and organizations. The form and content of our assistance or leadership efforts would vary from country-to-country (as discussed in 3. below), depending on each country's needs, its receptivity to various forms of assistance, its capability to finance needed actions, the effectiveness with which funds can be used, and current or adjusted divisions of labor among the other donors and organizations providing population assistance to the country. AID's population actions would also need to be consistent with the overall U.S. development policy toward each country.
While the countries cited above would be given highest priority, other countries would not be ignored. AID would provide population assistance and/or undertake leadership efforts with respect to other countries to the extent that the availability of funds and staff permits, taking account of such factors as: a country's placement in AID's priority listing of LDCs; its potential impact on domestic unrest and international frictions (which can apply to small as well as large countries); its significance as a test or demonstration case; and opportunities for expenditures that appear particularly cost-effective (e.g. its has been suggested that there may be particularly cost-effective opportunities for supporting family planning to reduce the lag between mortality and fertility declines in countries where death rates are still declining rapidly).
3. Mode and Content of U.S. Population Assistance

In moving from geographic emphases to strategies for the mode and functional content of population assistance to both the higher and lower priority countries which are to be assisted, various factors need to be considered: (1) the extent of a country's understanding of its population problem and interest in responding to it; (2) the specific actions needed to cope with the problem; (3) the country's need for external financial assistance to deal with the problem; and (4) its receptivity to various forms of assistance. Some of the countries in the high priority group cited above (e.g. Bangladesh, Pakistan, Indonesia, Philippines, Thailand) and some lower priority countries have recognized that rapid population growth is a problem, are taking actions of their own to deal with it, and are receptive to assistance from the U.S. (through bilateral or central AID funding) and other donors, as well as to multilateral support for their efforts. In these cases AID should continue to provide such assistance based on each country's functional needs, the effectiveness with which funds can be used in these areas, and current or adjusted divisions of labor among other donors and organizations providing assistance to the country. Furthermore, our assistance strategies for these countries should consider their capabilities to finance needed population actions. Countries which have relatively large surpluses of export earning and foreign exchange reserves are unlikely to require large-scale external financial assistance and should be encouraged to finance their own commodity imports as well as local costs. In such cases our strategy should be to concentrate on needed technical assistance and on attempting to play a catalytic role in encouraging better programs and additional host country financing for dealing with the population problem.
In other high and lower priority countries U.S. assistance is limited either by the nature of political or diplomatic relations with those countries (e.g. India, Egypt), or by the lack of strong government interest in population reduction programs (e.g. Nigeria, Ethiopia, Mexico, Brazil). In such cases, external technical and financial assistance, if desired by the countries, would have to come from other donors and/or from private and international organizations (many of which receive contributions from AID). The USG would, however, maintain an interest (e.g. through Embassies) in such countries' population problems and programs (if any) to reduce population growth rates. Moreover, particularly in the case of high priority countries to which U.S. population assistance is now limited for one reason or another, we should be alert to opportunities for expanding our assistance efforts and for demonstrating to their leaders the consequences of rapid population growth and the benefits of actions to reduce fertility.
In countries to which other forms of U.S. assistance are provided but not population assistance, AID will monitor progress toward achievement of development objectives, taking into account the extent to which these are hindered by rapid population growth, and will look for opportunities to encourage initiation of or improvement in population policies and programs.
In addition, the U.S. strategy should support general activities capable of achieving major breakthroughs in key problems which hinder attainment of fertility control objectives. For example, the development of more effective, simpler contraceptive methods through bio-medical research will benefit all countries which face the problem of rapid population growth; improvements in methods for measuring demographic changes will assist a number of LDCs in determining current population growth rates and evaluating the impact over time of population/family planning activities.
4. Resource Allocations for U.S. Population Assistance

AID funds obligated for population/family planning assistance rose steadily since inception of the program ($10 million in the FY 1965-67 period) to nearly $125 million in FY 1972. In FY 1973, however, funds available for population remained at the $125 million level; in FY 1974 they actually declined slightly, to $112.5 million because of a ceiling on population obligations inserted in the legislation by the House Appropriations Committee. With this plateau in AID population obligations, worldwide resources have not been adequate to meet all identified, sensible funding needs, and we therefore see opportunities for significant expansion of the program. Some major actions in the area of creating conditions for fertility decline, as described in Section IIB, can be funded from AID resources available for the sectors in question (e.g., education, agriculture). Other actions come under the purview of population ("Title X") funds. In this latter category, increases in projected budget requests to the Congress on the order of $35-50 million annually through FY 1980 -- above the $137.5 million requested by FY 1975 -- appear appropriate at this time. Such increases must be accompanied by expanding contributions to the worldwide population effort from other donors and organizations and from the LDCs themselves, if significant progress is to be made. The USG should take advantage of appropriate opportunities to stimulate such contributions from others.
Title X Funding for Population

+----------------------------------------------------+
| Year Amount ($ million) |
+----------------------------------------------------+
| FY 1972 - Actual Obligations 123.3 |
| FY 1973 - Actual Obligations 125.6 |
| FY 1974 - Actual Obligations 112.4 |
| FY 1975 - Request to Congress 137.5 |
| FY 1976 - Projection 170 |
| FY 1977 - Projection 210 |
| FY 1978 - Projection 250 |
| FY 1979 - Projection 300 |
| FY 1980 - Projection 350 |
+----------------------------------------------------+

These Title X funding projections for FY 1976-80 are general magnitudes based on preliminary estimates of expansion or initiation of population programs in developing countries and growing requirements for outside assistance as discussed in greater detail in other sections of this paper. These estimates contemplated very substantial increases in self-help and assistance from other donor countries. Our objective should be to assure that developing countries make family planning information, educational and means available to all their peoples by 1980. Our efforts should include:
Increased A.I.D. bilateral and centrally-funded programs, consistent with the geographic priorities cited above.
Expanded contributions to multilateral and private organizations that can work effectively in the population area.
Further research on the relative impact of various socio-economic factors on desired family size, and experimental efforts to test the feasibility of larger-scale efforts to affect some of these factors.
Additional bio-medical research to improve the existing means of fertility control and to develop new ones which are safe, effective, inexpensive, and attractive to both men and women.
Innovative approaches to providing family planning services, such as the utilization of commercial channels for distribution of contraceptives, and the development of low-cost systems for delivering effective health and family planning services to the 85% of LDC populations not now reached by such services.
Expanded efforts to increase the awareness of LDC leaders and publics regarding the consequences of rapid population growth and to stimulate further LDC commitment to actions to reduce fertility.
We believe expansions in the range of 35-50 million annually over the next five years are realistic, in light of potential LDC needs and prospects for increased contributions from other population assistance instrumentalities, as well as constraints on the speed with which AID (and other donors) population funds can be expanded and effectively utilized. These include negative or ambivalent host government attitudes toward population reduction programs; the need for complementary financial and manpower inputs by recipient governments, which must come at the expense of other programs they consider to be high priority; and the need to assure that new projects involve sensible, effective actions that are likely to reduce fertility. We must avoid inadequately planned or implemented programs that lead to extremely high costs per acceptor. In effect, we are closer to "absorptive capacity" in terms of year-to-year increases in population programs than we are, for example, in annual expansions in food, fertilizer or generalized resource transfers.
It would be premature to make detailed funding recommendations by countries and functional categories in light of our inability to predict what changes -- such as in host country attitudes to U.S. population assistance and in fertility control technologies -- may occur which would significantly alter funding needs in particular geographic or functional areas. For example, AID is currently precluded from providing bilateral assistance to India and Egypt, two significant countries in the highest priority group, due to the nature of U.S. political and diplomatic relations with these countries. However, if these relationships were to change and bilateral aid could be provided, we would want to consider providing appropriate population assistance to these countries. In other cases, changing U.S.-LDC relationships might preclude further aid to some countries. Factors such as these could both change the mix and affect overall magnitudes of funds needed for population assistance. Therefore, proposed program mixes and funding levels by geographic and functional categories should continue to be examined on an annual basis during the regular USG program and budget review processes which lead to the presentation of funding requests to the Congress.
Recognizing that changing opportunities for action could substantially affect AID's resource requirements for population assistance, we anticipate that, if funds are provided by the Congress at the levels projected, we would be able to cover necessary actions related to the highest priority countries and also those related to lower priority countries, moving reasonably far down the list. At this point, however, AID believes it would not be desirable to make priority judgments on which activities would not be funded if Congress did not provide the levels projected. If cuts were made in these levels we would have to make judgments based on such factors as the priority rankings of countries, then-existing LDC needs, and divisions of labor with other actors in the population assistance area.
If AID's population assistance program is to expand at the general magnitudes cited above, additional direct hire staff will likely be needed. While the expansion in program action would be primarily through grants and contracts with LDC or U.S. institutions, or through contributions to international organizations, increases in direct hire staff would be necessary to review project proposals, monitor their implementation through such instrumentalities, and evaluate their progress against pre-established goals. Specific direct hire manpower requirements should continue to be considered during the annual program and budget reviews, along with details of program mix and funding levels by country and functional category, in order to correlate staffing needs with projected program actions for a particular year.
Recommendations

1. The U.S. strategy should be to encourage and support, through bilateral, multilateral and other channels, constructive action to lower fertility rates in selected developing countries. The U.S. should apply each of the relevant provisions of its World Population Plan of Action and use it to influence and support actions by developing countries. 2. Within this overall strategy, the U.S. should give highest priority, in terms of resource allocation (along with donors) to efforts to encourage assistance from others to those countries cited above where the population problem is most serious, and provide assistance to other countries as funds and staff permit.
3. AID's further development of population program priorities, both geographic and functional, should be consistent with the general strategy discussed above, with the other recommendations of this paper and with the World Population Plan of Action. The strategies should be coordinated with the population activities of other donors countries and agencies using the WPPA as leverage to obtain suitable action.
4. AID's budget requests over the next five years should include a major expansion of bilateral population and family planning programs (as appropriate for each country or region), of functional activities as necessary, and of contributions through multilateral channels, consistent with the general funding magnitudes discussed above. The proposed budgets should emphasize the country and functional priorities outlined in the recommendations of this study and as detailed in AID's geographic and functional strategy papers.
II. B. Functional Assistance Programs to Create Conditions for Fertility Decline

Introduction

Discussion

It is clear that the availability of contraceptive services and information, important as that is, is not the only element required to address the population problems of the LDCs. Substantial evidence shows that many families in LDCs (especially the poor) consciously prefer to have numerous children for a variety of economic and social reasons. For example, small children can make economic contributions on family farms, children can be important sources of support for old parents where no alternative form of social security exists, and children may be a source of status for women who have few alternatives in male-dominated societies. The desire for large families diminishes as income rises. Developed countries and the more developed areas in LDCs have lower fertility than less developed areas. Similarly, family planning programs produce more acceptors and have a greater impact on fertility in developed areas than they do in less developed areas. Thus, investments in development are important in lowering fertility rates. We know that the major socio-economic determinants of fertility are strongly interrelated. A change in any one of them is likely to produce a change in the others as well. Clearly development per se is a powerful determinant of fertility. However, since it is unlikely that most LDCs will develop sufficiently during the next 25-30 years, it is crucial to identify those sectors that most directly and powerfully affect fertility.
In this context, population should be viewed as a variable which interacts, to differing degrees, with a wide range of development programs, and the U.S. strategy should continue to stress the importance of taking population into account in "non-family planning" activities. This is particularly important with the increasing focus in the U.S. development program on food and nutrition, health and population, and education and human resources; assistance programs have less chance of success as long as the numbers to be fed, educated, and employed are increasing rapidly.
Thus, to assist in achieving LDC fertility reduction, not only should family planning be high up on the priority list for U.S. foreign assistance, but high priority in allocation of funds should be given to programs in other sectors that contribute in a cost-effective manner in reduction in population growth.
There is a growing, but still quite small, body of research to determine the socio-economic aspects of development that most directly and powerfully affect fertility. Although the limited analysis to date cannot be considered definitive, there is general agreement that the five following factors (in addition to increases in per capita income) tend to be strongly associated with fertility declines: education, especially the education of women; reductions in infant mortality; wage employment opportunities for women; social security and other substitutes for the economic value of children; and relative equality in income distribution and rural development. There are a number of other factors identified from research, historical analysis, and experimentation that also affect fertility, including delaying the average age of marriage, and direct payments (financial incentive) to family planning acceptors.
There are, however, a number of questions which must be addressed before one can move from identification of factors associated with fertility decline to large-scale programs that will induce fertility decline in a cost-effective manner. For example, in the case of female education, we need to consider such questions as: did the female education cause fertility to decline or did the development process in some situations cause parents both to see less economic need for large families and to indulge in the "luxury" of educating their daughters? If more female education does in fact cause fertility declines, will poor high-fertility parents see much advantage in sending their daughters to school? If so, how much does it cost to educate a girl to the point where her fertility will be reduced (which occurs at about the fourth-grade level)? What specific programs in female education are most cost-effective (e.g., primary school, non-formal literacy training, or vocational or pre-vocational training)? What, in rough quantitative terms, are the non-population benefits of an additional dollar spent on female education in a given situation in comparison to other non-population investment alternatives? What are the population benefits of a dollar spent on female education in comparison with other population-related investments, such as in contraceptive supplies or in maternal and child health care systems? And finally, what is the total population plus non-population benefit of investment in a given specific program in female education in comparison with the total population plus non-population benefits of alternate feasible investment opportunities?
As a recent research proposal from Harvard's Department of Population Studies puts this problem: "Recent studies have identified more specific factors underlying fertility declines, especially, the spread of educational attainment and the broadening of non-traditional roles for women. In situations of rapid population growth, however, these run counter to powerful market forces. Even when efforts are made to provide educational opportunities for most of the school age population, low levels of development and restricted employment opportunities for academically educated youth lead to high dropout rates and non-attendance..."
Fortunately, the situation is by no means as ambiguous for all of the likely factors affecting fertility. For example, laws that raise the minimum marriage age, where politically feasible and at least partially enforceable, can over time have a modest effect on fertility at negligible cost. Similarly, there have been some controversial, but remarkably successful, experiments in India in which financial incentives, along with other motivational devices, were used to get large numbers of men to accept vasectomies. In addition, there appear to be some major activities, such as programs aimed to improve the productive capacity of the rural poor, which can be well justified even without reference to population benefits, but which appear to have major population benefits as well.
The strategy suggested by the above considerations is that the volume and type of programs aimed at the "determinants of fertility" should be directly related to our estimate of the total benefits (including non-population benefits) of a dollar invested in a given proposed program and to our confidence in the reliability of that estimate. There is room for honest disagreement among researchers and policy-makers about the benefits, or feasibility, of a given program. Hopefully, over time, with more research, experimentation and evaluation, areas of disagreement and ambiguity will be clarified, and donors and recipients will have better information both on what policies and programs tend to work under what circumstances and how to go about analyzing a given country situation to find the best feasible steps that should be taken.
Recommendations:

1. AID should implement the strategy set out in the World Population Plan of Action, especially paragraphs 31 and 32 and Section I ("Introduction - a U.S. Global Population Strategy") above, which calls for high priority in funding to three categories of programs in areas affecting fertility (family-size) decisions: a. Operational programs where there is proven cost-effectiveness, generally where there are also significant benefits for non-population objectives;
b. Experimental programs where research indicates close relationships to fertility reduction but cost-effectiveness has not yet been demonstrated in terms of specific steps to be taken (i.e., program design); and
c. Research and evaluation on the relative impact on desired family size of the socio-economic determinants of fertility, and on what policy scope exists for affecting these determinants.
2. Research, experimentation and evaluation of ongoing programs should focus on answering the questions (such as those raised above, relating to female education) that determine what steps can and should be taken in other sectors that will in a cost-effective manner speed up the rate of fertility decline. In addition to the five areas discussed in Section II. B 1-5 below, the research should also cover the full range of factors affecting fertility, such as laws and norms respecting age of marriage, and financial incentives. Work of this sort should be undertaken in individual key countries to determine the motivational factors required there to develop a preference for small family size. High priority must be given to testing feasibility and replicability on a wide scale.
3. AID should encourage other donors in LDC governments to carry out parallel strategies of research, experimentation, and (cost-effective well-evaluated) large-scale operations programs on factors affecting fertility. Work in this area should be coordinated, and results shared.
4. AID should help develop capacity in a few existing U.S. and LDC institutions to serve as major centers for research and policy development in the areas of fertility-affecting social or economic measures, direct incentives, household behavior research, and evaluation techniques for motivational approaches. The centers should provide technical assistance, serve as a forum for discussion, and generally provide the "critical mass" of effort and visibility which has been lacking in this area to date. Emphasis should be given to maximum involvement of LDC institutions and individuals.
The following sections discuss research experimental and operational programs to be undertaken in the five promising areas mentioned above.
II. B. 1. Providing Minimal Levels of Education, Especially for Women

Discussion

There is fairly convincing evidence that female education especially of 4th grade and above correlates strongly with reduced desired family size, although it is unclear the extent to which the female education causes reductions in desired family size or whether it is a faster pace of development which leads both to increased demand for female education and to reduction in desired family size. There is also a relatively widely held theory -- though not statistically validated -- that improved levels of literacy contribute to reduction in desired family size both through greater knowledge of family planning information and increasing motivational factors related to reductions in family size. Unfortunately, AID's experience with mass literacy programs over the past 15 years has yielded the sobering conclusion that such programs generally failed (i.e. were not cost-effective) unless the population sees practical benefits to themselves from learning how to read -- e.g., a requirement for literacy to acquire easier access to information about new agricultural technologies or to jobs that require literacy. Now, however, AID has recently revised its education strategy, in line with the mandate of its legislation, to place emphasis on the spread of education to poor people, particularly in rural areas, and relatively less on higher levels of education. This approach is focused on use of formal and "non-formal" education (i.e., organized education outside the schoolroom setting) to assist in meeting the human resource requirements of the development process, including such things as rural literacy programs aimed at agriculture, family planning, or other development goals.
Recommendations

1. Integrated basic education (including applied literacy) and family planning programs should be developed whenever they appear to be effective, of high priority, and acceptable to the individual country. AID should continue its emphasis on basic education, for women as well as men. 2. A major effort should be made in LDCs seeking to reduce birth rates to assure at least an elementary school education for virtually all children, girls as well as boys, as soon as the country can afford it (which would be quite soon for all but the poorest countries). Simplified, practical education programs should be developed. These programs should, where feasible, include specific curricula to motivate the next generation toward a two-child family average to assure that level of fertility in two or three decades. AID should encourage and respond to requests for assistance in extending basic education and in introducing family planning into curricula. Expenditures for such emphasis on increased practical education should come from general AID funds, not population funds.
II. B. 2. Reducing Infant and Child Mortality

Discussion

: High infant and child mortality rates, evident in many developing countries, lead parents to be concerned about the number of their children who are likely to survive. Parents may overcompensate for possible child losses by having additional children. Research to date clearly indicates not only that high fertility and high birth rates are closely correlated but that in most circumstances low net population growth rates can only be achieved when child mortality is low as well. Policies and programs which significantly reduce infant and child mortality below present levels will lead couples to have fewer children. However, we must recognize that there is a lag of at least several years before parents (and cultures and subcultur...

Magda - more excellent work. Thank you! :handkiss:

The use of a chemical sclerotic sterilization agent on poor women in developing countries, in field conditions, needs to be seen through the lens of NSSM200.

Below is the transcript of the part the BBC2 Horizon film, The Human Laboratory, which investigated quinacrine use.

Quote:BETSY HARTMANN: It's not just in the United States case the government, but there are also a whole range of private foundations that are funding the building of a population control movement.

NARRATOR: One private organisation is run by two doctors from America's southern states who believe they've found the answer for Third World women in a drug called Quinacrine.

DR. STEPHEN MUMFORD: Quinacrine is the most important development in contraception since the birth control pill. It has an enormous potential for preventing births and we're talking about literally billions of births.

DR. ELTON KESSEL: We have trials of the Quinacrine method going in some 17 countries like India, China, Bangladesh, and the trials are going very well. 100,000 women have had this method without a single fatality being reported.

NARRATOR: Dr. Elton Kessel was the founding director of Family Health International. He now researches Quinacrine in a worldwide operation, masterminded from Dr. Mumford's basement in Chapel Hill, North Carolina. Quinacrine is inserted into the top of the womb where it causes inflammation and scarring in the Fallopian tube, in theory blocking the tube with scar tissue and preventing the sperm from reaching the egg.

STEPHEN MUMFORD: It's a very simple procedure, takes only a few minutes. It can be done in very primitive settings by people who do not necessarily have a lot of clinical skills. Quinacrine is clearly the cheapest method available in the world and in fact the second cheapest method would probably be more than 100 times as expensive as the Quinacrine method. For $10,000's worth of Quinacrine pellets, 70,000 women can be sterilised.

INTERVIEWER: Is that a lot of women?

STEPHEN MUMFORD: That's a lot of women, and a lot of grateful women.

DR. AMY POLLACK: The story of Quinacrine is very unusual. It amazes many people that, despite the fact that this drug has not been approved by any major regulatory body for use in women, it's been used and distributed to over, you know, 80,000, maybe 100,000 women around the world who've been told that it's a safe and effective method and therefore agreed to use the method. How's it been done? Just a couple of guys out there running around with suitcases full of the drug who distribute the drug to doctors, primarily, and there's an appeal because it's inexpensive and it's easy to use.

NARRATOR: But some scientists believe the drug could put women's lives at risk - from cancer and ectopic pregnancy. And they question this entire approach to sterilisation.

PROF. SHREE MULAY: This method of producing scar tissue is extremely barbaric. to try to damage the tissue so that you produce inflammation and block the tubes that way I think is extremely crude. It is imprecise for sure because one does not know where exactly that is going to take place and it causes a tremendous amount of pain because of the inflammation. There has been a long history of chemical sterilisation research and this history is really an ugly one and it's quite a shocking one because all kinds of agents have been used - sulphuric acid, formaldehyde - all of these agents which actually burn the tissue and cause production of scar tissue. Chemical sterilisation was first tried out by the Nazis in their very first experiments in the death camps. That it has been picked up in the 60s, 70s and the 80s and been promoted as rescue for the women of the Third World I think is quite extraordinary.

STEPHEN MUMFORD: We're seeing 500,000 women die per year. Every day women die because of unwanted fertility that could be treated with this method.

INTERVIEWER: And you're going to save them?

STEPHEN MUMFORD: That's... I'm not going to save them, they're going to save themselves by electing this if the thing is made available, if the method is made available. We know these women want this method.

AMY POLLACK: What kills women in childbirth is horrible obstetrical services totally inadequate services that exist around the world. Not only are they bad services, but they're services provided for women who want to have children, and those women are not going to choose sterilisation. So women who don't choose sterilisation and choose to get pregnant are not going to be saved by Quinacrine. The numbers that are presented to us don't take that into account at all.

NARRATOR: The World Health Organisation has stated that no further Quinacrine research in women is justified until further laboratory tests have been completed.

AMY POLLACK: We don't have answers to critical questions about the long-term impact of Quinacrine on women, and until we have those answers, and we can find those answers, we should not be using this drug in women, period.

NARRATOR: So who is funding the research?

BETSY HARTMANN: A student of mine was examining who was funding the anti-immigration movement in the United States and searching through the tax records of various foundations, when she chanced upon the tax records of the Leland Fikes Foundation and found to her amazement that that Foundation was not only funding the Federation for American Immigration Reform, which is very anti-immigrant, but Mumford's work on Quinacrine. It's very scary that you have a private foundation funding both an anti-immigration group and a form of unethical contraception. I think there's a racial fear involved in this politics.

STEPHEN MUMFORD: My God this is they call this an anti-immigrant organisation. I think that the Federation of American Immigration Reform is a highly patriotic institution, that is correct. I mean very few Americans agree that we should have open borders and FAIR's position is that we should not have open borders and that has been the focus of their efforts since they were created. I'm very happy to identify with the Federation for American Immigration Reform.

ELTON KESSEL: You know, if you open the borders of the United States, the United States will become a developing country.

STEPHEN MUMFORD: That's correct. Most Americans do not want to live in these conditions, including myself.

NARRATOR: They've had sympathisers for their philosophy in high places.

STEPHEN MUMFORD: I've just completed a book and George Bush was just leaving the directorship of the CIA at that time. George Bush read the synopsis again, which said over-population is a graver threat to US security than the nuclear threat. George Bush says I agree with everything you're saying here in this synopsis and I can assure you that the people at the CIA agree with you too, so at that point I knew that at the highest levels of our government this issue was being discussed.

The full transcript can be seen at the DPF thread below:

http://www.deeppoliticsforum.com/forums/....php?t=620

Here's a 1999 article by Betsy Hartmann which provides some more of the history of quinacrine.

Quote:Women's Health Advocates Win a Victory in the Fight Against Chemical Sterilization

December, 02 1999

Betsy Hartmann

On November 13, the Board of Directors of Planned Parenthood of America (PPFA) turned down a motion from its own Medical Committee which have put the organization in the position of supporting unethical human experimentation. The drug in question was quinacrine chemical sterilization. The Medical Committee was prepared to involve PPFA affiliates in human trials of quinacrine before sufficient toxicology laboratory studies were completed. The Board voted that participation in trials would be considered if and only when the FDA gave the go-ahead. The vote is a victory for women's health advocates, whose timely intervention helped prevent Planned Parenthood from making a wrong and very dangerous decision. Coercive medical research on concentration camp inmates and prisoners of war during World War II gave rise to the Nuremberg codes and later the Helsinki Declaration on human experimentation. This declaration states that "In any research on human beings, each potential subject must be adequately informed of the aims, methods, anticipated benefits and potential hazards of the study and the discomfort it may entail." Furthermore, subjects should be free to withdraw from participation at any time and be advised of alternatives, including non-treatment, in language they can understand. Doctors should obtain their freely given informed consent, preferably in writing.

At the Nuremberg trials Nazi doctors were taken to task for their chemical sterilization trials on women, which included intrauterine instillation of formaldehyde and phenol. Now over 40 years later, over 100,000 women in 19 countries, most of them in the Third World, have been sterilized with quinacrine pellets. These trials have largely taken place in the absence of adequate informed consent, medical screening and follow-up, in violation of the Helsinki Declaration.

The main promoters of the quinacrine method are two population control and anti-immigrant extremists from the United States, Drs. Stephen Mumford and Elton Kessel, who have the backing of wealthy donors. These include Donald Collins, Sally Epstein, and Leland Fikes, all supporters of the conservative Federation for American Immigration Reform. Donald Collins is also on the board of the right-wing Scaife Family Foundation.

Previously developed as an anti-malarial treatment, quinacrine is a known mutagen and preliminary laboratory studies point to potential risks of cancer, birth defects and toxicity. In addition, quinacrine may be less effective than surgical sterilization and may increase the risk of ectopic pregnancy. Injected into the uterus with a modified IUD inserter, quinacrine works by burning the fallopian tubes, resulting in scar tissue that blocks the egg's passage into the uterus. Quinacrine is much cheaper than surgical sterilization, and thus is viewed by its promoters as a cost-effective weapon in the war against population growth. The Wall Street Journal quotes Mumford as saying that the drug is "essential to population growth-control;" Mumford, in fact, believes that overpopulation is a more serious national security threat than nuclear weapons.

Quinacrine has not been approved for sterilization purposes by any drug regulatory agency, including the World Health Organization and the FDA. Nevertheless, Mumford and Kessel have carried the pellets around the world in suitcases, recruiting local doctors willing to engage in their vast unethical experiment. In Viet Nam alone, over 30,000 women were sterilized until the government finally stopped the trials. In India more than 10,000 quinacrine sterilizations have been performed in the state of West Bengal alone. The two most zealous quinacrine supporters in India espouse openly anti-Muslim politics; poor Muslim women, in fact, are their preferred target.

The international family planning community now widely accepts that many quinacrine trials have violated based medical and informed consent protocols. Press reports, including an award-winning piece by Alix Freedman in the Wall Street Journal, have helped to document the extent of quinacrine abuse. Last year women's groups and public health specialists in India succeeded in getting the Supreme Court of India to ban further trials there, and women activists in Chile secured a similar ban from national health authorities in that country. Yet Mumford and Kessel continue to operate with impunity. Their latest strategy is to target the United States.

Extolling themselves as 'pro-choice' and falsely depicting the women's health opposition as "handmaidens of the Vatican," Mumford and Kessel have set out to woo abortion and family planning providers in the U.S. This past April, for example, they showed up at the National Abortion Federation meeting in Atlanta.

Unfortunately, given the intersection between population control and family planning interests in this country, quinacrine is being taking seriously as a potential method. With private population control funding, Family Health International in North Carolina is now performing the laboratory tests required for the official FDA process. Without that funding, it is doubtful such tests would have ever taken place since the results of earlier lab studies were not promising.

The more cautious among quinacrine's supporters urge that these tests be completed before any further human trials are conducted. The motion put before the PPFA Board of Directors would have jumped the gun, endorsing human trials at PPFA sites before sufficient toxicology results were in.

The motion might have passed if a number of prominent pro-choice women's health advocates and organizations had not organized a major campaign to alert the Board to the serious consequences of such an action. Their letter to the Board not only opposes human trials in the absence of completed laboratory tests, but also makes the point that even if the lab results indicate no specific toxicity, the "drug is already so tainted in the minds of so many women, that the credibility of those institutions embarking upon clinical trials would suffer severely." In addition, it remarks on quinacrine's easy potential for abuse and calls for scarce research funds to be redirected to more promising technologies, such as microbicides which could prevent sexually transmitted diseases.

While the PPFA Board heeded the message and voted the right way for now, the quinacrine battle is far from over. Currently,in Chile the Ministry of Health is considering rescinding its ban and allowing a new human trial of quinacrine in public hospitals. Because they have big money behind them, Mumford and Kessel will no doubt continue their campaign to win support for quinacrine in the U.S. Approval here would help give them legitimacy overseas; they hope, for example, that it would help lift the Supreme Court ban in India.

Further research on quinacrine, including the present laboratory tests, only serves to legitimize the illegitimate process by which the drug has been used to experiment on poor women. It sends a message that there is no punishment for those who conduct unethical drug experiments on human subjects. Instead of further research, the priority now should be to use the Helsinki Declaration and other internationally accepted codes of conduct to hold Stephen Mumford and Elton Kessel accountable for their actions.

-- Betsy Hartmann is the Director of the Population and Development Program at Hampshire College and a founding member of the Committee on Women, Population and the Environment (CWPE) and the Quinacrine Alert Network. For further information on quinacrine, visit CWPE's web page, http://www.cwpe.org.

http://www.zmag.org/zspace/commentaries/269

Magda Hassan

Magda Hassan

Jan Klimkowski

Jan Klimkowski