The population police are at it again. With much hand-wringing and a strong dose of humbug a British medical journal warns us this month of a world sexually out of control, with epidemics of syphilis, chlamydia, and gonorrhoea, and millions of unintended pregnancies of which millions, again, end in dangerous terminations.
This apocalyptic message is presented by The Lancet, casting a gloomy eye on the global burden of ill health in the reproductive arena and focusing in turn on four key points: sexual behaviour, family planning, unsafe abortion, and sexually transmissible infection. Editor Richard Horton, launching the journal’s investigation, claims that sexual and reproductive health has been "utterly marginalised from the global conversation about health and well-being during the past decade."
Utterly marginalised? This is a hard claim to substantiate. At United Nations level and even more so within the European context these issues are rarely off the agenda. Perhaps what Horton should be saying is that the Lancet viewpoint has become somewhat marginalised in recent years as the world, thankfully, struggles to develop more civilised responses to the problems many people are facing, particularly in the developing world.
In the United Kingdom reproductive health is far from marginalised. It is a very rare day, indeed, when Brits are not treated to a shock-horror front page relating to reproductive issues. Sexually transmitted diseases are certainly rampant, appearing in younger and younger patients. Half the women of reproductive age seem unable to get pregnant and the other half seems unwilling not to. If the protagonist of the latest tabloid drama is not a teenage mum on her third pregnancy trying to get a bigger council flat or a "shameless Mick" (as the Daily Mail recently described a Catholic delinquent) with 15 children from five different relationships, then it is a post-menopausal grandmother seeking egg donors so she can fulfill her open-ended reproductive rights, or a career woman freezing her eggs when they are young on the off-chance that she might meet Mr Right later on.
Arguments as to how many cycles of IVF should be provided from the health budget for those who desperately want children contrast ironically with abortion figures, which continue to rise as more ways are proposed to get rid of desperately unwanted pregnancies. Other questions with which we torture ourselves include: Should we allow social sex selection? Do IVF babies need fathers? Is it permissable to create animal/human hybrids? The issues multiply.
In recent months we have discussed the appropriateness of vaccinations for cervical cancer for very young girls, the provision of the morning after pill and condoms by school nurses (again, to under-age children) and the police this week are arguing about what exactly constitutes under-age sex. It may be less of a crime if the girl is between 13-16, a senior officer suggests.
The BBC is currently showing yet another television series on assisted reproduction, A Child Against All Odds, looking at prenatal testing, freezing of embryos, anonymous sperm donation, and all the other controversies in a six-part special. This is accompanied by online debates, storylines in most of the current soap operas, phone-ins on radio shows, and endless emotional stories in the daily newspapers.
Nor are we alone in the developed world in this obsessional interest in human reproduction. Every year in Europe and in the USA fertility mega-conferences take place, attracting thousands of practitioners, drug companies and biotech representatives, and of course journalists. For weeks before and after these events we are primed about everything that is novel or terrifying.
This is certainly not my definition of "marginalized".
But let us return to the Lancet worldview and see if there is anything we can agree about. Drawing attention to the need for equitable medical services on a worldwide basis is commendable, if obvious, and nobody disputes the need for better maternal healthcare. Such suggestions get my vote. And there is, hopefully, total consensus on the duty to combat the practice of genital mutilation and any other abuses of women, which contribute to poor physical or mental health. So, credit to The Lancet for its coverage of these issues, and its attempt to deal intelligently with sexually transmitted diseases.
But good proposals come with the predictable, and we are too soon immersed in facile rhetoric. The bogeymen in the battle for better health for the developing world are, inevitably, the "conservative political, religious, and cultural forces around the world" who threaten "to undermine progress in sexual and reproductive health". According to most contributors, the biggest sinners are -- you guessed -- the United States and the Catholic Church. If only those two players would fund more abortions and distribute condoms and contraceptive pills the length and breadth of Africa, we would be half-way to solving our problems: third world poverty would be defeated, HIV/AIDS would be significantly reduced, and altogether there would be "substantial impact on fertility rates". Impacting fertility rates is undoubtedly the key factor in the Lancet approach, and it is very sad how frequently concerns about access to abortion precede or trump concerns about good maternity and childcare.
The exaggerated focus on population control in the Lancet papers seriously diminishes the credibility of the overall series. It often makes for very uncomfortable reading, evoking uneasy racist or eugenic associations, particularly as so much time is spent concentrating on the African continent. One article even suggests that "family planning should have a higher priority than investment in HIV prevention and treatment in most poor countries, because population growth poses a greater threat to development." More money for abortion and condoms than for treating or preventing AIDS? More for the fit, less for the unfit?
With the US clearly not playing the Lancet ball, we read in the same article the recommendation that, "Europe, rather than the US, should take the lead in revitalising global commitment to family planning." This, I believe, justifies my earlier accusation of "humbug". How is it possible that The Lancet considers it appropriate to endorse a European model of reproductive health? "Physician, heal thyself," is my answer to such a proposal.
 
Despite all our money and expertise and propaganda, we Europeans (particularly those of us in the UK) are making little impact on levels of sexually transmitted diseases and we face increasing rates of infertility and abortion. And we never will deal with them successfully within the current framework because they are all by-products of the birth control culture we espouse -- the culture we are so anxious to foist on the developing world in the interests of stabilizing world population.

Stabilising numbers, however, destabilises other things. The decline in birthrates across the developed world is creating top-heavy population towers and contributing to economic earthquakes across most European countries. Italy and Germany in desperation are turning at last to pro-natal social policies. France already had them. With a current average of 1.5 children per woman and an ideal replacement level of 2.1, many western European nations are in effect committing suicide. Not a happy role model for Africans, Asians and Latin Americans.

I believe that Europe today has very little, if anything, to teach the world about reproductive health, and should start putting its own home in order – if it survives long enough to do so. There are undoubtedly problems in developing countries that involve reproductive health, and these must be addressed by a compassionate world, committed to equity. I cannot help thinking, though, that clean running water, adequate food, anti-malarial drugs and the like, are more vital to their well-being than Richard Horton’s family planning projects.

Despite the missionary fervour behind it, this series of articles has contributed very little to solving the world's problems. Their relentless message of increased population control in an ageing world seems curiously old-fashioned, and the suggestion that abortion and condoms should come before economic or medical aid is immoral.
 
Solutions to the reproductive health problems of developing countries must be found, but they must be solutions which respect the cultural identities of the people involved, and we must be prepared to support these countries economically. Above all we must sit down and listen to what they want; not tell them what we think they need. Two African health workers told me recently that one of the biggest problems they were dealing with in their respective countries was the societal repercussion of infertility for African women. Now there’s a problem I bet never occurred to The Lancet.

Josephine Quintavalle is the current director of CORE (Comment on Reproductive Ethics), a non-profit organisation in the UK which focuses on the many controversial issues associated with human reproduction. The group was founded in 1994 and is a key contributor to ethical debate at national and international level. Mrs Quintavalle is an ex-pat New Zealander living in London.