The population of Pakistan has more than quadrupled during my lifetime. When I went to the United States in 1971 for higher medical training, Pakistan was still made up of two parts. The western wing at that time had a population of around forty five million. Today the same part of the country that is now Pakistan has a population of more than two hundred million.

This is alarming for many including people like me who were brought up on the apocalyptic vision of population growth. The presumption has been that eventually population growth will outstrip resources available to sustain that population. And along the way it will also cause irreparable harm to the environment making all human life impossible. Fortunately, from a global perspective Pakistan is an outlier. Overall increase in population of the world is a lot less than that in Pakistan.

So looking at Pakistan, the country is not becoming ‘rich’ fast enough to provide the increasing population improved living conditions. That at least is an obvious impression based upon official statistic of esoteric concepts like Gross Domestic Product (GDP). But as I look around, compared to how things were a few decades ago, things do look a lot better. Economists will have a better idea but I suppose that the informal economy is responsible for this disparity. That said all is not well.

So far there is no widespread starvation or epidemics of major disease but there are less obvious but still important problems. Many estimates suggest that up to forty per cent of children in Pakistan are ‘stunted’ or smaller and less-developed for their age. That means that they are receiving inadequate nutrition. These children will become adults but with problems including small body size, generally poor health as well as decreased learning ability. This is clearly a problem of too many people to feed and not enough to feed them.

Besides the inadequate nutrition, as the population increases other major medical problems start becoming apparent. The existing infrastructure that provides healthcare to most of the poor is being overwhelmed and that adequate care cannot be made available without diverting resources from development projects that are necessary for poverty alleviation. This creates an interesting problem for the medical establishment. As better medical care is provided at the basic level, population will increase and as population increases the available economic pie will shrink.

Childhood immunisation, clean drinking water, better maternal and child healthcare are all quite low cost but have a major impact on survival during the two most vulnerable periods of life, early childhood for most people, and for women, pregnancy and delivery of a baby. Interestingly in developed countries, the increase in life expectancy in the early part of the last century was primarily from improvement in these two areas. Even though Pakistan is still lagging in these two areas but enough improvement has occurred to bump up life expectancy and also to increase the overall population.

The problems of increasing population are many and I have no intention to dwell upon them. Most people that study the environment around us as well as the resources available are of the opinion that population growth must be curbed especially in countries like Pakistan. The question is how to do it. Islam as a religion is clearly not an impediment to control of population. Iran, a theocracy, has managed to decrease the growth of its population as has Bangladesh that has a similar religious profile as Pakistan.

There have been historically severe steps to curb population growth. Perhaps the most famous was China’s one child policy. In our part of the world some might remember a few decades ago when in India relatively coerced sterilisations were being done. China was much more successful and now that policy has recently been relaxed. There have been eugenically propelled attempts at sterilisation of certain types of population but these were products of abhorrent political systems that have thankfully disappeared.

Frankly the only way to control population is to delink sexual activity and procreation. As a society becomes better educated the number of pregnancies per woman starts to go down. The reason for this is that educated women seek out ways to prevent unwanted pregnancies. And that brings me to methods used to prevent conception.

Condoms are a preferred method because they are inexpensive and obviously reversible but are also an important way to prevent sexually transmitted diseases. No, this is not just about things like gonorrhea and syphilis but includes many more. Chlamydia, Genital Herpes, Human Papilloma Virus (that can lead to cancer of the cervix), Hepatitis B and C viruses, HIV (the virus that leads to AIDS) and many other diseases. So condom use is extremely important for casual sex.

For a committed heterosexual relationship (marriage) that is also expected to lead to a planned family, a reliable but completely reversible method of contraception is needed. And that is where medical intervention becomes necessary.

First let me quickly mention two permanent methods of contraception. In men there is a minor operation called a vasectomy done under local aenesthesia. This operation involves small cuts on both sides of the groin where the tubes carrying sperm can be interrupted. In women a corresponding operation is called a tubal ligation but this requires entry unto the abdominal cavity. Women who have had multiple children are offered this procedure after delivery especially if multiple caesarian sections have been done. During such a section when the abdomen is already open, the tubal ligation can be quickly performed.

For men the only temporary method of contraception is the condom. Women have a few more options available. The most famous is the ‘pill’, a hormonal concoction that prevents the step necessary in women to become pregnant. The major problem with the pill is that it has to be taken regularly. Other types of hormone delivery systems have been developed that can be inserted under the skin and their effect is reversed once they are removed. Most of these systems are convenient but relatively expensive especially for mass use in a country like Pakistan.

Probably the best and the safest method is what is called an Intra Uterine Device (IUD) that is essentially a small plastic ‘T’ with a thread that can be inserted into the uterus and reliably prevents pregnancy. It can be easily removed but requires some expertise in placement and removal. A few decades ago, IUDs got a bad rap due to some manufacturing types but today it is definitely one of the most reliable methods of contraception in women.

Sadly one of the commonly used methods of population control in many countries like China and India has been termination of early pregnancy (abortion). This procedure is unfortunately often combined with fetal ultrasound to determine the sex of the fetus. Female fetus can then be aborted preferentially. Abortion on demand is a major political issue even in western countries like the US. And many religions including Islam forbid abortions. There are however good medical reasons to go ahead with the termination of pregnancy especially when the life of the mother is at risk.

Most people that study the environment around us as well as the resources available are of the opinion that population growth must be curbed especially in countries like Pakistan. The question is how to do it.