CHAPTER ELEVEN

CONCLUSION

The Program

 

In speaking of the need for population control in Asia, Myrdal says:

 

            In recorded history we have never seen birth control being spread widely in largely rural, tradition-bound, illiterate, and very poor populations (1970:150).

 

This is what we have been attempting among the Akhas living in Thailand.

 

                                                                                                     The Results

 

It has been possible for a full-time field worker, albeit with limited training, to inform and educate many Akhas in Thailand about family planning.  {footnote 1: I also aided in this, although I could not get to as many villages or give as much time as he.  The field worker had a travel companion who went with him, although he had no training.}  He has offered limited contraceptive and health aid in the villages, and provided a contact whereby more extensive services could be requested.

                                                                                                                                                                                                                        p.205

Some 325 Akha women living in Thailand have received reversible contraceptive aid, and 193 women (many from the above group), as well as on man, have received sterilization during this three and a half year program. {footnote 2: Many Akha couples from Burma, as well as other ethnic groups from Thailand and Burma were also helped.}  Since approximately half of the Akha women sterilized from Thailand were on reversible contraceptives before, this means that a total of 423 Married Women of Reproductive Age (MWRA) have accepted contraception.  I estimate that 20% of the Akha population is made up of married women (roughly 2,800), and that about 78% of these (2,184) are Married Women of Reproductive Age.  Almost 20% of the MWRA have accepted contraceptive aid.  It is estimated that when 30% of the MWRA accept contraception, the crude birth rate can be brought down to 30 births per year (the 30/30 condition, see Freedman and Berelson 1976:20).

 

Although too soon to be certain, the demographic picture of the Akhas seems to be changing, with a slight decline in the 0-4 age cohort.  There are various factors this could be attributed to, but considering that 20% of the MWRA have accepted contraception, the family planning program is undoubtedly among them.

 

It will be recalled that among the hill peoples of northern Thailand, the Akha were chosen for the study--as against the Lahu, Lisu, or Karen--because of their remoteness, their need, and the problems posed by their illiteracy.  The special character of the target group required special attention to communication.  We found that word of mouth communication is essential when introducing change to them, the ideal situation being when one who knows their culture and language goes directly to their village for purposes of education and service.

                                                                                                                                                                                                                        p.206

The particular parogram introduced is one that requires a choice exercised by family groups.  At the time it is affected by village mores, and thus by public opinion and example.  Although the records suggest that among Thailand Akhas a peak of enthusiasm for sterilization has been reached, with subsequent decline, there continues a steady but diminished traffic of women seeking this option.  Several Akha couples have received sterilization in Chiang Rai apart from our program, but influenced by it.

 

A side effect from the program has been the development of the Akha Advisory Committee.  This provided a responsible group which could recommend contraceptive practice to the villagers.  It also unlocked new possibilities of cooperation and achieving goals, as well as of regulating programs that intervene in the personal lives of the Akhas.  Educational, medical, and limited development programs have been begun as a result.

 

In their growing awareness of other groups and their programs, the Akhas have been seeking reference groups to use as possible models for their own behavior.  Programs among other tribal groups, such as the Lahus, are likely to be emulated, because these groups are seen to be on common footing with them, facing many of the same problems, so that their program may be a solution for the Akhas.  Just as the Lahu language is ceasing to be the lingua franca in the area and is being replaced by Northern Thai, the Thai ethnic group is becoming increasingly dominant, as the group the Akhas will imitate, replacing the model of other tribal groups.

                                                                                                                                                                                                                        207

                                                                                    What Can be Learned From the Program?

 

Special consideration had to be made for the Akha because of their illiteracy, their remoteness, and--as they themselves view it--backwardness, and their status as an ethnic minority not yet assured of citizenship.

 

1) The alternatives of contraceptive aid must be carefully presented (including the pros and cons), and then the couple should be allowed to accept of reject whatever method is best for their needs, in accordance with their own timing.  They must give informed consent for whatever method they choose, and not be pushed into making a decision they will later regret.

 

2) There must be cultural sensitivity throughout the program.  Aspects of the program which require behavior at variance with the norm should be presented to them in terms of their own culture.  {footnote 3: When the Akha women were disturbed to learn that they would have to remove their headdresses for the sterilization operation, for example, I explained it to them in cultural terms that they could understand.}

                                                                                                                                                                                                                        p.208

3) Involvement of local leaders increases the potential effectiveness of the program, while at the same time guarding against serious cultural backlash.  People are not going to respond to "exhortation from afar" (McNicoll 1975:1), especially when it comes to changing something as intimate as their reproductive behavior.

 

4) The requirements of the receptor group must be given primary consideration.  As Foster points out (1976:16), the common practice with some medical practitioners is to put their own convenience first.  We found that the service must be taken to the people in the villages, and when certain needed services could not be given there, special arrangement for the tribal people had to be made in hospitals and health centers in town.

 

5) Funding is a special problem, both in obtaining the grant initially, and then using the money in the most productive way.  Some funding agencies only want to take on huge projects with a minimum amount of paperwork per acceptor (Korten 1975:180).  This will not usually work with preliterate minority people in Southeast Asia.

 

6) When possible, family planning programs should be integrated with health delivery and community development programs.  This reaches a larger group with more effective service, at a reduced cost per acceptor.

                                                                                                                                                                                                                        p.209

                                                                                                The Weaknesses

 

Throughout the program we found weaknesses, which we tried to remedy as the program progressed.

 

1) Service to a village only twice a year is not sufficient.  The field worker could not get to know people and their individual needs in that time.  Shortness of funds and personnel put this limitation on our program.

 

2) The education we gave the villagers regarding family planning was insufficient.  The faster such education can reach all Akhas, the earlier their positive response will be, and the more effect it will have on the demographic picture.

 

3) There was the problem of how to help those couples who were too poor to pay for service.  If a program is to serve a group effectively, the service must be available to all.

 

4) Viewed narrowly in terms of the program alone, certain decisions of the Akha Advisory Committee may seem to be weaknesses, such as the fee set for DMPA injections.  In the larger perspective of developing an effective leadership body among the Akha for this and other programs, the individual decisions such as that concerning injections, which can always be reconsidered, are relatively minor losses.

                                                                                                                                                                                                                        p.210

5) So far the program has been too dependent upon non-national personnel (myself especially).  Although this was necessary at the beginning, Akhas and other Thai nationals should increasingly take over the burden of the program.

 

                                                                                    Resolving the Weaknesses

 

As the Tribal Family Planning Project progressed, constant thought was given to improving the service and remedying weaknesses.  Reviewing these matters, the Akha Advisory Committee (along with the Lahu Advisory Committee) developed the concept of an enlarged program which will start January 1978, and will be called the Integrated Health Project.

 

1) There will be three teams of Akha men (two to a team) who will travel to each Akha village in their area four times a year.  These six men have been selected by the Akha Advisory Committee. {There will also be five teams of Lahus, but I am only considering the Akha sector of the program here.}

 

2) The field workers will give the following services in the villages: preventive medicine (including inoculations), simple curative aid, education about health and nutrition, and family planning services (including reversible contraceptive aids).  They will also seek to find persons suffering from such chronic illnesses as TB and leprosy so as to help them get outside help.  In those villages that ask for aid in solving their opium addiction problem, the paramedics will try to help the villagers find practical and safe means of detoxifying and rehabilitating addicts.

                                                                                                                                                                                                                        p.211

3) There will be a supervisor for the Akha sector of the project, to serve under the project supervisor.  He will give special attention to the Tribal Family Planning Center in Namlat, and will also aid Akha and other tribal people who wish to get medical care in Chiang Rai, as well as furnish support to the teams in the field.

 

4) Each village will form its own health committee which will prepare the villagers for the team's arrival, assist the team while it serves their village, and give follow-up attention after the team has left. 

 

5) A Lahu nurse will become supervisor of the project beginning January 1979.  In the meantime, I will serve in that capacity, with the Lahu nurse giving aid in: a) training programs, and b) sterilization trips.

 

6) The program has already been promised funding by Family Planning International Assistance.  The first year's budget comes to over $60,000, and the help will continue through 1980.  It is hoped that by that time the program can be incorporated into some national health program so that it will be part of a long-term health service.

                                                                                                                                                                                                                        p.212

7) Along with regular in-service training of all the field workers, there will also be special training sessions in which it is hoped that members of the village health committees can come together once a year to take part in a health training program.  Preventive care (including family planning) will be the main emphasis.

 

                                                                                                            The Future

 

What lies ahead for the Akhas, and for Southeast Asia?  If the population is to be stabilized (and all are agreed that that day must come sooner or later), each woman must only have two children (Caldwell 1975:429, Hauser 1972:413, Keyfitz 1971:648), nor can the world go on doubling its population every thirty-five years (King 1974:22).

 

                                                                                                Royal Thai Government

 

In the long run, the government of any nation is responsible for its people, and whatever the Akhas are able to accomplish will be in the context of the national setting.  The government of Thailand must be praised both for its excellent, people-centered family planning goals, and for the relatively quick improvement in the population situation it has brought about.

                                                                                                                                                                                                                        p.213

Since the national program gives continuing service through government hospitals and health centers, as well as continued backing to such private programs as the McCormick Family Planning Program, the demographic picture for Thailand should steadily improve.  There is debate about whether or not voluntary family planning programs will actually solve the population problem (see especially Davis 1967).  If they cannot, the government of Thailand may someday be faced with the question, "Should force be used to make certain changes in the fertility rate so as to stabilize the population within a reasonable period?"  I would make three comments regarding such a program among the tribal people.

 

1) Coercion will not work.  No matter how essential the need for coercion may seem to be, the feeling of the tribal people will be that it is genocide, and it will simply lead to violence.

 

2)Tribal people should be encouraged to solve this problem in their own way, with government aid.  One way the government can help is to work with the tribal group to see that all of their children have a chance for an education.  This, among other things, will postpone the age of marriage, and thus help cut down on the population growth.  There must be many other alternatives provided as well, for just as the problem is complex, so must the answer be complex.

                                                                                                                                                                                                                        p.214

3) Immigration from Burma is a major problem facing Thai officials, as well as the tribal people living in the border area.  Such immigration should be controlled, which will take full cooperation between the government and the tribal people currently living on the border.

 

                                                                                                  The Akha People

 

Much has been written about the demographic transition that has taken place in the West (see especially Polgar 1972, Masnick and Katz 1976, Teitelbaum 1975, Demeny 1974, Dumond 1975).  This model, which at best is not ideal for the West, is very poor for the Akhas (Zubrow 1976:16-18, Caldwell 1976).

 

There is another model which has been developed by the People's Republic of China which appears to have made dramatic demographic changes in a relatively short time (Chen 1975).  There the age of marriage has been raised, women put to work, and education made available to everyone--all factors which help cut down on fertility.  Besides this, each commune sets a goal for the number of births per 1,000 it will have in the coming year.  Then the people themselves decide which couples will have children during that period.

 

Although this has been reportedly effective in China, almost certainly this model would not work for the Akhas and other tribal groups in Thailand without considerable adaptation.  Each group and sub-group must find its own way of making the demographic transition.  There are four things I would suggest to the Akhas:

                                                                                                                                                                                                                        p.215

1) Each village should meet and discuss the matter, first to encourage the people to air their own needs and problems, and to express their opinions as to causes and possible solutions.  Village authorities must take increased responsibility in both the discussion and the implementation of the decisions.

 

2) Data prepared with the help of an expert showing the rate of growth of that village, past, present and future should be presented to the villagers so they can see what is actually happening to them, both because of immigration and because of excessive births.

 

3) The villagers (or village elders) should work at finding a practical solution that is best for them, and which will fit into the goals of the nation as well.  I would suggest that they should consider trying to bring the birth level down to not more than 20 per 1,000 population as quickly as possible, using whatever practical means are available to reach that goal.  At the same time they must do everything possible to better the quality of life of both the children and adults presently living in that village.

                                                                                                                                                                                                                        p.216