[...] [Countdown leader on film] [Tone] [...] [Music] [Gentle reflective music] [Music] [Music] [Music] [A Question of Choice] [Music] [Malcom Potts:] I've been toapproximately 50 countries in the world, inthe past five years. And I've neverbeen anywhere where there was a goodsterilization program, which didn't have a lot ofpeople come in to get, either male orfemale sterilization. I've been to a lotof places where the experts have saidour men or our women don't want this operation. But they've alwaysbeen proved wrong, by the actualpractical experience of making a high qualityservice available. Without any compulsion,well-informed people of all cultures,all backgrounds, all socioeconomic groups,will choose this option, in very large numbers, whenthey have the number of children that they want. [Woman speaking Bengali] [Narrator:] The importantwords are well-informed. In Bangladesh,pre-sterilization interviews are commonly conductedby trained members of a responsible and respectedclan, the traditional birth attendants. [Background chatter] Their counseling must ofteninclude basic information about family health andwelfare, human reproduction, the principles of contraception. [Background chatter] Their listeners mayhave decided, simply, that they want to stopchildbearing once and for all. But they are entitled toknow more than the mechanics of the procedure. Full and candid counselingis not only the keystone to a successfulsterilization program, but the only courseof action commensurate with human dignity. [Woman speaking Tagalog] [Narrator:] In the Philippines, where private agency sterilization programs have spread deepinto the countryside, counseling is simple and direct. The counselor who will bethe surgeon speaks plainly. [Doctor continues explanation in Tagalog] [Narrator:] This is no time fordelicacies which could produce misunderstandings. These men have askedfor a permanent surgical contraception. It is best that they knowprecisely what that means. [Non-English speech] [...] [Man speaking Spanish] [Narrator:] The traditional distancebetween doctor and patient is something a sterilizationprogram must bridge. In El Salvador,the surgeon speaks to his vasectomy candidatesin their own idiom. It will be, he says, likehaving a river without fish. Only the fish will beeliminated, asks a patient. Yes, only the fish willbe eliminated. The river, he promises, willgo on flowing as before. These are simple men, who havemade an important decision. Such counseling ismost effective couched in images and concepts to whichthe campesinos can relate. [Non-English speech] [Speaker 1:] I'd like to talk with you. [Narrator:] In a southern cityof the United States, the counselor poses a questionof the utmost gravity. [Speaker 1:] We feelit's important that you understand thepermanence of this decision. For instance, how wouldyou feel if something were to happen to your wife? [Silence] [Speaker 2:] Well, I wouldn'thave any children, I mean, that would... if something did happen to her. To be honest withyou, I can't even imagine anythinghappening to her. We may all think about thatat one time or another. But uh, it boggles my mind tothink about it without her. In that event, uh thee,whoever I should meet, and perhaps remarry, would havejust had to accept the fact that there wouldn't beany children, that's all. [Narrator:] It is a question whichbelongs in every counseling session. [Music] [Paddles splashing water] [Music] Bangladesh is arelatively new country. It has ancient roots andconservative Islamic culture, and perhaps more than itsshare of modern problems. One problem, ofmassive overpopulation, is being confronted squarely. Sterilization is a recent entryin the family planning program. And Bangladesh is profitingby other nations experiences with the procedure. There is no compulsiontowards sterilization, however clear the needfor immediate solutions. [Music] [M.A. SATTAR:] Bangladeshis a poor country [Water splashing] with 40 percent of its people beinglandless, underemployed, or unemployed. These poor people are in agrim struggle for just survival. Once they have two orthree or four children, they accept family planning. [Children's voices] Just to brighten theprospect of their survival, they and their families. Unlike in Westerncountries, where people accept family planning toraise their standard of living, here these poor people,40 percent of our population, they accept familyplanning just for survival. [M.A. SATTAR:] I find, that in Bangladesh, these poor people, where they have very little privacy,where they are away from the supply depots,servicing facilities, [Crowd noise] the vast majority of them,want a simple, quick method of family planning. And that's what thesterilization vasectomy for men and tubectomy for women. We had, a couple of months ago,for nine weeks a sterilization campaign where we did 76,828cases of sterilization. [Indiscriminate chatter] And we found that, for everycase that we sterilized, we had to turn back five,whom we couldn't serve, because we didn'thave the facilities, medical and otherwise. And we have foundthat these people who have accepted sterilization,if they avert one birth, they contribute tonational service of $200. And at what cost? $10 to $12 per caseof sterilization. I don't think, interms of cost-benefit, there could be a betterinvestment in Bangladesh. [Energetic Bangladeshi music] [Narrator:] Theprivate agency which is most active in the field,offers a training program for doctors, paraprofessionals,and support staff. Most of the training isin mini-laparotomy. For women who have had all thechildren they want, or can afford, and have givenfully informed consent to the operation, permanentsurgical contraception is clearly the mostpractical course. There are, as yet,few male candidates. But that will come,experience has shown. [Bangladeshi music continues] The logistical problems ofordinary life in Bangladesh are disheartening. There are too few sourcesof supply for medication, too few doctorsand health centers. Even primary healthcare remains out of reach for mostpeople of Bangladesh. It would be difficult tofind a more suitable setting for a fullsterilization program. [Music] [Soothing music] In the hills ofNorthern Thailand, are tribal people whoseaccess to health care is more limited still. Their lives are almostunimaginably remote and sheltered behind ritual. But when they began to learn,through Thai government representatives, and amissionary anthropologist, of the possibility oflimiting their fertility, they accepted the whole ideaas a strange and unexpected blessing. The women come to the hospitalfrom as far as two days away. Much of the journey on foot. Most of them have had littleor no prior experience with modern medical care. But they have been wellcounseled and embark on this venturewithout misgivings. They live in aconservative society, where the ultimateauthority of the husband is rarely questioned. But they have arrived atthis decision jointly, and many of thehusbands cheerfully make the trip alongwith their wives to help care forthe little ones. Most of them concede that thevalue of smaller families, and wives released from theburden of multiple births is too great to be ignored. [Music] [Women remove silver headdresses] [Women undressing for medical procedure] [Music] For women who couldhardly be less accessible to contraceptiveservices requiring re-supply orperiodic examination, sterilization would seemthe only feasible method. Accordingly, a Thaigovernment hospital provides a facility forsterilizations once a month. The operations are performed bya surgical team from McCormick hospital in Chiang Mai,headed by Dr. Aroni Fonsi, who has done as many as 75laparoscopic sterilizations in a single visit. Advances in the technologyof sterilization procedures have dramaticallyreduced complications and shortened recovery time. [Surgical room preparation for procedure] Exciting and successfulas this project has been, it is only one small part of acomprehensive national program, one of the best andboldest in the world. Thailand plans to perform150,000 sterilizations in the current year. Insix regional centers, 150 first-c class health centers, and20 mobile sterilization teams. [Soft music] The tribal women usuallyspend one night of rest in the hospital, and theday following the operation, begin the long bus ride,which will take them to the foothills oftheir mountain homes. There they will starta climb, lasting a day or more, before they areback in their settlements. [Music] They are, to be sure,of hardy stock, but the speed of theirrecovery from surgery attests to the current stateof the laparoscopic art. [Music] [Montage of family on journey home] [Music transitions to hopeful mood] On the other side of theworld, in more than a geographic sense, is El Salvador, the smallest country inthe Western hemisphere, rich in volcanic soil,warmth, and rainfall. And all too rich in people,with one of the hemisphere's highest growth rates. Superficially, it seemsan unusual setting for a thrivingsterilization program. Conservative, religiouslyand politically, with strong Spanish and Indiantraditions, and a deeply rural character,it has still taken an unusually forthright attitudetoward permanent surgical contraception. The farmers who tillthe tiny hillside plots, from which El Salvadortakes most of its food, have the good sense,or the good luck to be members of a union,which equates the land-use problem with thepopulation problem. It has a thriving familyplanning program which has moved into sterilization. In this, an unusual conditionfor a society traditionally devoted to theprinciple of machismo, the men have taken the lead. In concert with TheDemographic Society, the union has an activevasectomy program. Like their brotherson other continents, the Salvadorenos recognizethe economic hazards of raising a large family today. The nation's hospitals,the Ministry of Health, and a group of far-sighted doctors, carry on a lively concernwith developments in female sterilization. And developments therehave assuredly been. [Music] [Angel Quan:] The demand forvoluntary sterilization at the maternityhospital of El Salvador has greatly increasedin the past few years. In the decade 1956 to 1965,approximately 2,900 sterilizations were performed. In contrast, in the fiveyears from 1972 to 1976, approximately 18,000sterilizations were performed. In a review of three consecutiveyears in our hospital, in a series of over12,000 sterilizations, we had not a single death. [Narrator:] The emphasisthroughout the national campaign is on therelative simplicity and fundamental safety ofthe sterilization procedures. [Gentle music] In the rural Philippines, oneof the most interesting phases has been the growing tendencyto regard both male and female sterilization as, undercurrent conditions, and with the technologynow available, outpatient procedures. For a long time, vasectomyhas been so regarded. Now there are programs to carrylaparoscopy into the same area. [...] A mobile team fromMary Johnston Hospital in Manila travels intothe outlying provinces. Sets up in available quarters,and with every visit, serves an increasing number ofcandidates for sterilization. [Music] [...] A team member acts ascounselor, and makes certain that the women understand thenature of the laparoscopy. That it is irreversible, andthat they have examined, and in most cases,employed other methods, before deciding upon this one. This time, the setting is anunused room in a local bank. The team has used comparablefacilities in a social welfare office or a community hall. A local sponsoringagency has found the room for the mobile clinic,and has brought together the patients. Evidence indicates thatwhile a clinic is always a preferable location,it is not mandatory. Interestingly, theoperating group began as a demonstrationteam, traveling around to show provincialdoctors and clinics the laparoscopic procedure. But the demandfor sterilizations became so urgent,that they have moved into the delivery of services. [Surgical room and procedure] After the operation, the womenrest for two or three hours in companionable closenessto their neighbors on the sleeping mats, whichthey brought from home. Then they get up andgo back to their homes, usually without anyattendant complications. The growing refinementof surgical techniques for tubal ligation, and thereduction of the operating area, have brought aboutan impressive record of operations,without complications. [Music] The very fact thatsterilization service has been broughtto the community, contributes to anatmosphere of familiarity, which the womenof the countryside appreciate and trust. [Music] [...] [Barge horn sounds on Mississippi River] [Upbeat music] [Memphis panoramic city landscape] [Upbeat music] [Narrator:] Memphis, is a cityof the southern United States, on the Mississippi River. It is representative,not only of the nation, but of the nation'smany programs of surgical contraception. Almost as many Americancouples of reproductive age have chosen permanentsurgical contraception as have chosen the pill. [Light guitar music] Memphis is one of 59 PlannedParenthood affiliates. Here, vasectomies areoffered one night each week. Men are counseledon the first visit, then asked to returnafter an interval of time, to allow them to considertheir decision fully. [Speaker 1:] Wellat this point, it might be a good idea forme to go ahead and explain the procedure toyou a little bit. Let you know-- [Speaker 2:] Might be a good idea. [Speaker 1:] the way wedo the procedure here. On this diagram,this is a diagram of the penis andthe scrotal sac. And you can seeit like an X-ray, where you see the inside ofthe tubes and the scrotum. OK. What we do, duringthe vasectomy, is cut the vas deferens. This is where the spermis stored normally. During an ejaculationyou have a combination-- [Narrator:] There arerecent surveys indicating that in more than a quarterof all American couples of childbearing age, eitherthe husband or the wife has chosen sterilization. And the number isgrowing each year. [Speaker 1:] What we're doingis cutting the sperm out, so that your ejaculationjust consists of-- [Narrator:] On one thing,all programs depend... the fully-informedconsent of the candidate for sterilization. The nature of the operation, thefact that it is, at this point, almost certainly permanent, andthat all possible alternatives have been considered. All of this must be confronted and examined. The chart is universal. [Diagram of procedure held up] The message is universal. [Speaker 3:] You mightfeel some pressure, but you won't feelany discomfort. Now I want to know ifit hurts, at this point because, you shouldnot have any pain. Does that hurt at all like that? [Speaker 4:] No, it doesn't. [Speaker 3:] OK. That's all the discomfortyou should feel. At this point youfeel me touching you. But you shouldn't feel any pain. If I bother you at all I wantto know from this point on. [Speaker 4:] Ok. [...] [Speaker 4:] Years ago, it wasn'tso bad to have a large family, but today, due to theeconomic situation... [Speaker 3:] Well, that'san individual decision I think everybody hasto make themselves. I tend to agree. I had my vasectomy after two. [Speaker 4:] I wouldn't takea million dollars for the two I've got, though. [Speaker 3:] All right. We're just about through. You feel all right? [Speaker 4:] Great. [Speaker 5:] When I was pregnant,both of us, my husband and I both decided, it would-- that something would have tobe done about sterilization. It would be cheaperand easier for him to have it donethan it was for me, because it takesmore from a woman. It takes a lotlonger to get well. When he went to work the nextday, and he has a hard job. And he wasn't hurt at all. It didn't seem to affect him whatsoever. [Baby fussing] And it was, in a way, better. We lost the fear of pregnancy. We no longer have to worry abouthaving to support another one, when we've already got twothat's hard enough to support. [Speaker 6:] Like she said, I'min the construction trade. I've never had any problemswhatsoever out of it. And my love life hasreally gotten a lot better than it's ever been. Because my wife, like shesays, is not scared anymore of becoming pregnant again. [Instrumental flute music] [Narrator:] Permanentsurgical contraception may well be thecontraception of the future. There is no countryin today's world where surgicalcontraceptive services are able to meet the demandfor the permanent solution. We inhabit anuncertain world, where nothing is as it was,or will ever be again. There is one certainty. We have a clear choice overour reproductive status. We can still say wechoose to interrupt the pattern ofprocreation, because it is of us, but only part of us. There is more to lifethan to make life. We can bear thechildren we want. We can live with thosechildren in a world which we may, perhaps, make better. It is a question of choice. [Music] [An AIRLIE production] [...] [Executive producer, Murdock Head, M.D.] [...] [Producer, Douglas Larson; Director, Paul Noonan; Writer, Miriam Bucher] [...] [Film crew: Michael Barrett, Robert Fennell, James Reid, David Nash] [...] [We express our appreciation to the individuals and organization who assisted in the production] [while on location in Thailand, Bangladesh,] [the Philippines, El Salvador, Memphis, Tennessee, USA] [...] [Produced by, George Washington University School of Medicine] [and Health Sciences, Department of Medical and Public Affairs] [Music fades out] [...]