Strategies for Funding Family Planning, Maternal Health Care, and Battles Against HIV/ AIDS in Developing Nations as Options Expand, Political Environments Shift, and Needs Grow: A Critique

Edition 5 - November 2009 (Updated August 2011)
by
Bruce Sundquist
bsundquist1@windstream.net

~Table of Contents -

Introduction

New Options:

~ ~ Mass Media Approaches

~ ~ Contraception Technology

~ ~ Options for Treating HIV/ AIDS

Changing Political Environments:

~ ~ The US

~ ~ Outside the US

~ ~ The Middle East

~ ~ The "Demographic" Rationale

~ ~ The "Health" Rationale

~ ~ The "Human Rights" Rationale

Growth in Needs

Critique

Recommendations:

~ ~ Social Content Serial Dramas

~ ~ The Changing Political Environment

References

Appendix A ~ Financial Support for International Family Planning: A Bottomless Pit for Money - or a Lucrative Investment? ~

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Previous Editions: Ed. 2, April 2005 // Ed. 3, August 2005 // Ed. 4, August 2007 // .

~ Introduction ~
The title above may suggest an excessively ambitious and needlessly complex scope for this document. However consider:

Strategies for funding family planning, maternal health care, and battles against HIV/ AIDS in the developing world have changed over the past four decades. This is to be expected in view of significant new options, major shifts in political environments, and large and growing needs in all three areas. The problem is that the changes have been in the direction that marginalizes those who support funding for these causes and minimizes their effectiveness in arenas of public discourse and in legislative chambers. The results have been tragic. This paper summarizes major changes in options, shifts in political environments and growing needs. It then critiques trends in funding strategies. Suggestions are made for regaining past influences in arenas of public discourse and funding-related legislation. A more comprehensive analysis of funding strategies, background material and closely related issues is presented in a larger document (09S2) by this author. This document is more narrowly focused and intended to serve mainly as a summary.

The most important new options and changes in the technological and political environments are described below. These will set the stage for a critique of strategies and some recommendations at the end of this document.

~ New Options ~ Mass Media Approaches ~
One of the more exciting and potentially strategy-influencing new options is the development of what are commonly referred to as "Social Content Serial Dramas" (SCSDs) a.k.a. "soap operas" or, in Latin America, "telenovelas". The developing world has changed in recent decades in terms of major increases in the availability of radios and TV sets, even in backward and remote regions. Radios have gotten cheap, and TV sets are often shared among large numbers of people, often in a community gathering-place with a power generator. What is so exciting is the much lower cost of selling the ideas that international family planning organizations are trying to promote. In one study the cost of selling family planning was found to be 80 US cents per new adapter. This probably translates to a cost of less than $10 per additional birth averted. (It is understood that further studies are under way to check these findings and put them on a firmer basis.) Research at the University of Sao Paulo Brazil studying TV-Globo's "telenovelas" and their impact, states that "telenovelas" have been the principle force driving Brazil's total fertility rate down from 3.4 in 1989 to 2.3 in 1996 (97P1). SCSDs have also focused on selling adult- and female education, the rights of women to control their sex lives, and other social issues that effectively, though indirectly, influence population growth rates (04R1).

The cost of getting developing world people to change behavior to avoid HIV/ AIDS via an SCSD approach was found to be 8 US cents per person making the necessary behavior change. This probably translates to a cost of averting one HIV/ AIDS-related death of roughly $10. More recent and comprehensive studies by Hogan et al (05H1) found that the cost of averting one HIV/ AIDS-related death is higher for seven media methods less expertly designed than SCSDs. This is to be expected. Preventing a HIV/ AIDS-related death via antiretroviral therapies is on the order of $11,000 / death averted in a developing world environment (05H1). The cost of wiping out the world's HIV/ AIDS pandemic via such therapies is therefore far beyond the available funding of $12 billion/ year.

The paper by Hogan et al (05H1) and a more recent paper by Hecht (09M1) add new data and insights on this issue. If one ignores the ethical/ moral issue of writing off all currently living, developing-world, AIDS victim and devote all HIV/ AIDS funding to selling the necessary behavior changes using SCSDs and/ or several other media-related strategies, then the cost of wiping out the HIV/ AIDS pandemic in the developing world falls to well within the limits imposed by current funding levels. These media-based strategies would produce major spillover benefits to family planning- and maternal health programs, since much of the funding that would otherwise go to these programs is being diverted to the HIV/ AIDS pandemic. Some data below illustrates:

Final Donor Expenditures for Population Assistance, by Category of Population Activity (in percentages) (05U1)

Year

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Family Planning Services

55

37

40

43

37

29

30

23

11

9

Basic Reproductive Health Services

18

33

27

22

30

29

24

25

28

25

STDs + HIV/ AIDS Activities

9

16

18

20

23

32

39

42

48

54

Basic Research + Development Policy Analysis

18

14

15

15

11

9

8

10

13

12

Millions of Current US$

1314

1511

1632

1681

1655

1781

2015

3162

3847

4907

In 1995, family planning received 55% of total worldwide population-assistance expenditures, while HIV/ STIs received 9%. In 2004, only 9 years later, HIV/ STIs received 54% of total worldwide population-assistance expenditures, while family planning services received only 12% (05U1) (05L1).

The direct economic effects of SCSDs on family planning services are equally impressive. The cost of averting a birth through a program of maternal health care combined with family planning services is something on the order of $100 (98B1). (Averting a birth via female education and other strategies costs something on the order of $600 (88C1).) The cost of averting a birth through family planning alone is not known but limited data (09S2) suggests a figure on the order of a half to a third of the $100 cost of the maternal-health-care-family-planning combination. The cost of averting a birth via SCSDs is not known either, but the above figure of 80 cents to sell someone on the idea of adopting modern family planning procedures would suggest a figure of perhaps $10 or less to avert a birth. A one-to-two order(s)-of-magnitude reduction in the cost of averting a birth in the developing world is easily comparable to discovering a cure for several major cancers in terms of the potential benefits to mankind, yet SCSDs are virtually unknown. One reason for the far greater economic efficiency of SCSDs, relative to providing family planning services, is that fewer than 3% of married women not practicing contraception report that contraceptive prices are the reason for their non-use (based on data from 56 countries with relevant Demographic and Health Surveys) (http://www.guttmacher.org/pubs/journals/3013404.html). The 2004 Guttmacher report showed that mass media communications is one of the most important interventions for increasing contraceptive prevalence in any country. Thus it is easy to see why selling people on the benefits of using modern contraceptives via the mass media is far more cost-efficient than providing free modern contraception.

It is worth noting that there are different methodologies being used under the banner "entertainment-education", or "social-content serial dramas" or "behavior change communications." These methodologies, like family planning technologies, are constantly being improved to achieve better results per dollar spent. Also, like family planning technologies, the effectiveness of different methodologies has been found to vary widely (as should be expected at this early stage of development). For example, there was an opportunity in Tanzania to compare the effects of a Sabido-style soap opera with a serial drama using a strategy developed by Johns Hopkins University which placed more emphasis on the "what" of family planning methods, and less on the "why." The John Hopkins program was listened to by 25% of the adult population and was cited by 4% of new family-planning adopters at Ministry of Health clinics as their reason for coming in. The Sabido style program was listened to by 58% of the adult population and was cited by name by 41% of the new family planning adopters at the same clinics. So there was a ten-to-one ratio of the effects of the Sabido style methodology vs. the Johns Hopkins methodology (06R1).

To put these numbers in a broader perspective, the infrastructure costs (educational-, industrial-, commercial-, and transportation- infrastructure, plus housing, land development, utilities etc.) of providing developing-world-class infrastructure for a one-person-growth in population in the developing world is currently on the order of $16,400, for a total cost of about $1.2 trillion/ year to the developing world as a whole. This is a cost that few developing nations can afford, since the median developing world income is less than $2/ capita/ day (09S2) - an income level barely sufficient to cover food, clothing, etc. The result is an endless cycle of ever-increasing wretchedness, hopelessness, warfare, terrorism, religious fundamentalism, environmental degradation, external debt and diminishing safety of financial capital and what it is invested in. Yet developed world leaders (mainly those in the US) keep wondering out loud why their $640 in annual foreign aid per new developing-world inhabitant (97% spent on accommodating population growth, and 3% spent on reducing population growth) doesn't seem to be doing much good. What they fail to recognize is that this $640 is being thrown at a $16,400 problem. Also, 97% of that $640 is being spent on the symptoms of the problem, while only 3% is being focused on the root cause of the problem. If they would just reduce their growth accommodation/ reduction ratio from 97/ 3 to 90/ 10 they would have been delighted by the results (08S3).

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~ New Options ~ Contraceptive Technology ~
Modern contraception technology is constantly improving in terms of reliability, safety and cost. All three of these benefits increase the usage of modern contraception, make family planning services more beneficial to the recipient, reduce birth rates, and reduce maternal mortality and maternal health care costs. However, expressing these benefits quantitatively is difficult. For each additional contraceptive method that is widely available in a country, contraceptive "prevalence" - the percentage of married women using contraception - increases by 3.3 percentage points, (based on data from Demographic and Health Surveys in 44 countries) (96B1), (96R1). Reducing fertilities to replacement levels requires at least a 70% usage of modern methods of contraception by women wanting to prevent or postpone pregnancy. Current usage of a method of contraception in the developing world is 59%.** A UN report of early 2005 stated that contraception usage in the developing world was 40%. This latter figure apparently pertains to the usage of modern methods of contraception. The cost of infrastructure growth needed to accommodate population growth in the developing world is about US$1.2 trillion per year (09S2). This would suggest that a single new modern contraception method would save the developing world roughly $120 billion per year. However much of that benefit would come in the form of reduced unmet needs for additional infrastructure and reduced wretchedness, hopelessness, warfare, terrorism, religious fundamentalism, environmental degradation, and greater safety of financial capital and what it is invested in. Spillover cost savings to the developed world would also be sizeable (09S2). Thus only an unknown fraction of this $120 billion/ year comes in the form of additional cash going into people's pockets.
** See the wall chart on World Contraceptive Use 2003, issued by the UN Department of Economic and Social Affairs' Population Division.

Quinacrine Sterilization:

A significant development in contraception technology is the International Service Assistance Fund's (ISAF's) Phase III clinical trial of a non-surgical method of female sterilization known as QS (quinacrine sterilization) (06I1). Successful completion of the Phase III trial is expected to reduce maternal mortality and morbidity by 40%, reduce the number of abortions worldwide by 40%, and reduce the number of unwanted births by more than 50%. This reduction in unwanted births would amount to over 25 million births per year out of the 78 million or so annual surplus of births in excess of deaths, and out of the 136 million births per year - a major change in global population growth trends. Some 25 million fewer births per year (virtually all in the developing world) would represent a savings in infrastructure costs to developing nations of $325 billion/ year. These savings would come largely in the form of a reduction in unmet needs for new infrastructure, plus reduced wretchedness, hopelessness, warfare, terrorism, religious fundamentalism, environmental degradation, and greater safety of financial capital and what it is invested in. An unknown fraction of this $325 billion/ year comes in the form of additional cash going into people's pockets.

QSs have been performed in 50 countries on more than 175,000 women. They are so simple and low-cost that they can be performed by nurses instead of doctors (06B1). They can even be done in peoples' homes in the developing world using a simple, cheap, plastic, disposable tool (06B1). A QS costs about $5 (06B1) in the developing world. This is a tenth of the cost of a normal laparoscopic surgical female sterilization, a procedure that has long been the leading contraceptive method worldwide. This popularity is in spite of the fact that less than half of the developing world has access to it, due either to the absence of surgical facilities, or to the inability to afford a $50 surgical procedure. In the poorest ("least developed" 50 or so) nations, total fertility rates remain at roughly 4-6 children. Making QS available there could avert roughly two births and a like number of illegal abortions for each QS performed. For a far more complete analysis of the QS issue see Reference (09S1).

Female Sterilization Today and Tomorrow: By far the most popular contraceptive, globally, is female sterilization (05U3). The popularity of surgical sterilization and the potential of QS is all the more impressive when one considers that most of the developing world does not have access to surgical contraception (in terms of either physical access or affordability), and will not have such access for the foreseeable future. (http://www.quinacrine.com) Female sterilization currently requires surgery and a surgeon, and these resources are something that most people in the developing world find much harder to afford than oral or trans-dermal contraceptives. Even more importantly, most women in the developing world do not have access to a surgeon at any price, and this is likely to continue to be the case for the foreseeable future. QS would eliminate the need for surgery and a surgeon, and reduces the cost of female sterilization by about 90% (from about $50 to about $5 in a developing world environment). QS has 1/50th the complication rate of laparoscopic surgical sterilization (03B2).

Could QS reduce Total Fertility Rates to Replacement Level? The number of women aged 15-49 years married or in union in 2005 was 947 million in the less developed regions of the world (05U3). Some 59% of these 947 million women use any method of contraception, and 53% use modern methods of contraception. Some 22.3% of these 947 million women use female sterilization. Only the IUD (14.5%) comes anywhere close to sterilization (05U2). If these developing world women had access to QS in addition to surgical contraception ($25 in developing nations), this 22.3% would increase significantly - perhaps to 25%. Less than half of the women in the developing world have access to sterilization. So if QS were to be introduced into the half of the developing world without any access to sterilization, the percent of developing world women using sterilization would at least double, i.e. to 50%. This would increase the percent of developing world women using modern methods of contraception from 53% to 81% (53% + (25%-22.3%) +25%).

A common rule-of-thumb says that total fertility rates can drop to replacement level only after the percentage of women (married or in union) using modern contraceptives reaches 70%. This suggests that the population growth rate in the developing world could drop to replacement level, or below, after momentum effects wear off as a result of broad-scale introduction of QS. Maternal death rates and abortion rates would see huge declines in developing nations. A stable developing world population would eliminate the $1.4 trillion need for infrastructure growth required to accommodate population growth. This, in turn, would eliminate the dire scarcity of financial capital and human capital that now plagues the developing world. This scarcity is largely responsible for the bulk of the other serious problems plaguing the developing world. A major component of the reduction of unmet needs for new infrastructure (a result of reducing population growth rates) would come in the form of reductions in unmet needs for "human capital" (education - one component of "infrastructure"). This is essential for the transition to developed world status, and something that increases awareness of, availability of, and affordability of, contraceptives. These effects further decrease the global number of births per year, and hence further reduce the unmet needs for new infrastructure.

QS in the US: In the U.S., the cost of a QS is about $100 (03B2). In the U.S. the cost of a laparoscopic surgical sterilization is $4,000 to $6,000 (03B2). So with approximately 600,000 laparoscopic surgical sterilizations per year in the U.S., the savings to the U.S. health care system from converting laparoscopic surgical sterilizations to QS could reach $2 billion/ year (02L1). QS could revolutionize contraceptive provision worldwide.

Harsh Realities - Cost: A Phase III clinical test of QS is going to cost about $8 million. This is a large sum when quinacrine is off-patent (because it is already an anti-malarial drug) and costs only pennies for the quinacrine pellets needed for a QS procedure - not a high-profit-margin drug. Currently about $1 million has been raised.

Harsh Realities - Politics: A number of politically active organizations oppose essentially any contraceptive that works. For these organizations, an inexpensive, simple, safe contraceptive that even the poorest of developing world women can afford has got to be their worst nightmare. The possibilities for QS to eliminate population growth in the developing world make that nightmare even worse. One must expect, then, that these organizations will become active in the arenas of public discourse and federal legislation when the time is right. Some of history of past activities aimed at slowing, or halting, introduction of QS into common usage in developing nations are described in Ref. (09S1). When financier Warren Buffett funded Phase II clinical tests of QS, he incurred much nasty criticism from religious fundamentalists who tend to oppose any means of contraception that works. The potential benefits of a Phase III clinical test of QS vastly outweigh the test's costs as noted above. So what seems to be needed most now is a greater public understanding of QS, its history (that spans more than half a century), its science, and its politics. Ref. (09S1) provides this.

Effects of QS on the US: About 76% of pregnancies to poor women in the US are unintended (95G1). Title X program (the federal program that provides family planning services to poor women in the US) saw its funding drop (in inflation-corrected terms) by about 55% during 1980-2000 (01D1). This was in spite of the fact that every public (Title X) dollar spent for family planning services saves $4.40 - over $3 in medical costs alone - that otherwise would be spent over the next two years to provide medical care, welfare benefits and other social services to pregnant women (99A1). Further benefits would result from reducing the poverty caused by families having more children than they can afford, reduced crime rates and similar benefits. A 90% reduction in the cost of female sterilization would make already badly stretched Title X funding go farther. Also, the $325 billion/ year benefit to the developing world translates to a higher probability that the external debts of developing nations ($2.45 trillion in 1999, and increasing by $1 trillion every 10-15 years) will ever be repaid. An aggressive family program in Mexico during recent decades has reduced total fertility rates significantly, resulting in the beginnings of a Mexican middle class and hints of the trend spreading beyond Mexico (06K1). A 90% reduction in the cost of a female sterilization could make such procedures far more accessible to the average Mexican. This would promote further growth in Mexico's middle class, thereby reducing the rate illegal immigration of Mexicans into the US. For the US this would mean a reduction in the high social, economic and political costs of such immigration. For Mexico this would reduce the economic costs of the "brain-drain" of human capital exiting Mexico. Brazil and Chile also have been actively involved in promoting family planning over the past decade or two. The results in these two countries have also included the early beginnings of a middle class - something that has been rare throughout the entire history of Latin America.

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~ Options for, and Costs of, Treating HIV/ AIDS in the Developing World ~
In recent years new drugs and procedures (called anti-retroviral therapy) have come out that seem capable of putting AIDS into a state of remission - at least in developed nations. There is always the risk that the AIDS virus will evolve into drug-resistant forms. The problem is that the price of such drugs is far in excess of what the overwhelming majority of people in the developing world can afford. However there is some indication that some drug companies may be willing to reduce their prices for developing world customers. Doing so would not significantly reduce their cash sales. Also, production costs of typical drugs tend to be extremely small. The main costs are in research, development, testing, marketing, etc. So large-scale distribution in the developing world at very low prices would not necessarily represent a loss to AIDS drug makers. The current worldwide expenditure on treating and preventing HIV/AIDS is roughly $12 billion/ year (09M1). These expenditures have come largely at the expense of various population-related expenditures, mainly family planning services as the table above (05U1) shows.

One recent study (05H1) examined the costs of treating HIV/AIDS by a range of options that can be divided into two categories: prevention and cure. The options in each category are listed below.

Prevention:

  1. Mass media - TV and radio episodes and inserts into newspapers,
  2. Voluntary counseling and testing performed in primary care clinics for anyone requesting the services,
  3. Peer education for sex workers,
  4. Peer education combined with treatment of sexually transmitted infections for sex workers
  5. School based education targeted at youths aged 10-18 years,
  6. Treatment of sexually transmitted diseases for the general population provided in primary care facilities and available to anyone who requests it,
  7. Prevention of mother-to-child transmissions,

Cure:
Highly active anti-retroviral therapy using several categories of drugs.

These options were tested in sub-Saharan African countries with high adult mortality and high child mortality. They were also tested in Southeast Asian countries with high adult- and child mortality. In both the African study and the Southeast Asian study it was found that the lowest cost of achieving a given benefit via a cure (anti-retroviral therapy) option was about 180 times greater than the lowest cost of achieving that same benefit via one of the prevention options listed above. This would suggest that the bulk (if not all) of the available funding for addressing the HIV/AIDS pandemic should be spent on prevention options. In the African study, the lowest-cost prevention option was Option (1) (Mass media). In the Southeast Asian study the lowest-cost prevention option was a tie between Options (3) and (4).

The benefit units used in the above-mentioned study are confusing, but it would appear that roughly 20 of these benefit units are equivalent to one human life saved. If this were the case, the cost of averting a death via anti-retroviral therapy would be about $11,000, and the cost of averting a death via the cheapest prevention measure studied by Hogan et al (05H1) would be about $11,000/180 = $60.

Elsewhere in this document a study (06R1) involving social content serial dramas (SCSDs) was alluded to that suggested that the cost of achieving a behavior change that would prevent being infected by HIV/AIDS was about $0.80. Converting this behavior-change cost to the cost of averting a death would suggest a cost of roughly $10. This seems to be at odds with the $60 cost from the above-mentioned study by Hogan et al, but this is not necessarily so. The Hogan et al study represents the best result of the seven forms of mass media listed above. The SCSD results come from a carefully researched and designed media campaign based on the Sabido style methodology. Even other methodologies with formats similar to the Sabido style, such as that developed at Johns Hopkins University, was only about 10% as cost-effective. The effectiveness of newspaper articles on HIV/ AIDS avoidance would be expected to be far less cost-effective that even the Johns Hopkins methodology (06R1). Given the uncertainties involved, it seems best to estimate the cost of averting a death via a good prevention strategy lies somewhere between $10 and $60.

The number of new HIV/ AIDS infections in low- and middle-income countries in 2004 was about five million (05H1). Other data give 2.3 million new HIV/AIDS infections in 2007 in only the poor countries of the world (09M1). The number of HIV/AIDS-related deaths in 2004 was about three million (05H1) (presumably in the low- and middle-income countries combined). So bringing the HIV/ AIDS pandemic under control in just the poor countries would require curing roughly three million HIV/ AIDS victims per year via antiretroviral therapy, or preventing the occurrence of roughly three million new infections per year via some mass-media-based prevention strategy. If one used a prevention strategy (by far the cheapest) the cost would be between $30 million ($10 x 3 million) and $180 million ($60 x 3 million). Both of these sums are well within the amounts of money that are available for fighting HIV/ AIDS, i.e. roughly $12 billion/ year (09M1). The cost for an antiretroviral therapy strategy for bringing the HIV/AIDS pandemic under control would be vastly larger, and outside the limits of currently available funding.

Recent work on the costs of halting the spread of HIV/AIDS (09M1) predicted that, by 2031 (50 years after the first cases of AIDS were identified) poor countries would need $35 billion/ year to (1) treat AIDS patients, (2) care for orphans and (3) do prevention work. This $35 billion is about three times the amount of money that is spent now, i.e. about $12 billion/ year. Even under the best case foreseen, more than one million people will be newly infected each year. (About 2.3 million were infected in 2007.) Achieving that outcome would cost $722 billion over 22 years ($32 billion/ year), or nearly $8,000 for each infection prevented (09M1). Based on the analysis above, it is clear that a pure mass media approach for preventing infection would cost far less than the $8000 per infection prevented and bring the cost of bringing the HIV/AIDS pandemic under control to within the limits imposed by the current $12 billion/ year available for fighting HIV/AIDS.

~ Changing Political Environments - The US ~
US advocates of increased support for international family planning (IFP) have grown increasingly frustrated during the past two decades as they witness the ever-increasing political power of religious fundamentalism with its thinly veiled contempt for modern methods of contraception and the UN - a contempt that apparently exceeds even its hatred of abortion. (Virtually every time the Vatican has had to choose between increasing contraception use and increasing abortion rates it has chosen increased rates of abortion.) The perceived successes of family planning might have led to some of its recent loss of visibility in the US, as policy-makers and the public view "the population problem" to have been largely solved (05L1). The remainder of the developed world apparently does not see it this way - see below.

Another problem with antiretroviral therapy, aside from its relatively high cost, is the fact that the virus causing HIV is capable of evolving so as to develop immunity to antiretroviral therapy (10H1). This means that the antiretroviral therapy drug must be constantly changed to remain effective. This, in itself, is an expensive process. Combating HIV is only going to become trickier and more expensive to implement as drug resistance spreads (10H1). All this underlines the increasingly urgent need to develop an effective HIV vaccine or to make increasing use of relatively inexpensive mass media approaches to slow the spread of HIV/AIDS.

~ Changing Political Environments ~ Outside the US ~
In virtually all other regions of the globe, the opposite trend grows increasingly evident. A record 180 countries contributed to UNFPA in 2006, for total contributions of $360 million, the highest in the 37-year history of the world's largest international source of funding for IFP and reproductive health programs ("Record Number of Countries Contribute Record Amount to UN Population Fund," UN News Center, 1/22/07.). African nations that viewed the "demographic" rationale for family planning with dark suspicions in the 1970s (e.g. at the 1974 Bucharest Population Conference) have gradually turned around (e.g. at the 1984 Mexico City Population Conference) and now embrace it completely, or nearly so (UNFPA press release in 2002).

~ Changing Political Environments ~ The Middle East ~
The changing attitudes toward family planning and contraception in the Muslim world suggest a more peaceful Middle East in the future. The Muslim world of the Middle East has the world's second highest population growth rate. (Sub-Saharan Africa has the world's highest population growth rate.) But Muslim attitudes toward family planning and contraception are changing rapidly. For a detailed analysis and data compilation on this issue see this author's web page (08S2).

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~ Changing Political Environments ~ The Demographic Rationale ~
The original (post WWII) motives in the developed world for supporting IFP were based on "demographic" concerns (concerns about the negative economic, social, political and military effects of population growth and over-population). It has become clear from statements made by political leaders in the developing world that they too are now very much concerned about these same "demographic" issues. Also they have become increasingly aware of the huge benefits achieved by the five "Asian Tiger" economies, Tunisia, the Barbados, the Bahamas and Ireland as a result of active family planning programs in recent decades. Also they note that countries with high population growth rates also suffer the most negative and unstable economic, social, political and military conditions (e.g. Niger with an estimated slave population of 800,000 (05A1), mass starvation, and the world's highest fertility rate - 8 children per woman).

It is also becoming increasingly apparent to the developed world that the economic, social and political problems of the developing world have grown increasingly likely to spill over into the developed world. Globalization, the growing mobility of information, technology, natural resources, goods, people, labor content and capital are making the ills of developing nations increasingly real (08S4), if not also frightening, to Americans. Virtually the entire developed world is being invaded by huge numbers of wretched folk from developing nations seeking to escape the miseries of their homeland as they overwhelm the welfare-, education-, and health-care systems of their new hosts. Immigration rules are being tightened throughout the developed world - except for the US. This is making refugee status much harder to achieve. Despite the beefing up border patrols, the wretched keep pouring into developed nations. The connection between immigration and population growth has become increasingly easy to see.

Only two developed-world nations remain with leaderships that are in denial about the legitimacy of "demographic" concerns - the U.S. and the Vatican. In December 1983, the Vatican's Congregation for Catholic Education issued a document to all governments which stated "It is the task of the state to safeguard its citizens against injustice and moral disorders such as the . . . improper use of demographic information." In other words, it is the responsibility of the government to censor demographic information that suggests the existence of population-related problems (86M1). In the US the issue of US support for IFP has been transformed from a quiet bipartisan one to one of the most contentious foreign policy issue the Congress confronts. The changeover happened around 1980. This is when the Reagan administration proclaimed that the global scale of human activity is negligible relative to the scale of natural systems. This effectively denies the legitimacy of demographic concerns, in accord with long-held views of the Vatican. It has been noted that all, or nearly all, of Reagan's top advisors were Irish Catholics (86M1). The Reagan view that demographic concerns are not legitimate formed the basis of the "Mexico City Policy", enunciated by the Reagan administration at the 1984 UN population conference:

  1. Population growth is a "neutral" phenomenon.
  2. To the extent that population growth could be considered a problem, "market forces" would solve it.

The obvious conclusion is that there is no need for the US to support international family planning, and that to support it would be a de-facto acceptance of the legitimacy of demographic concerns. This partly explains why Republicans tend to oppose US support for international family planning even though such support significantly reduces abortion rates. The other part of the explanation is opposition to contraception, but few outside the Vatican oppose modern contraception. In fact, most within the Vatican favor modern contraception (86M1). Opposition to both abortion and modern contraception becomes harder to defend when demographic concerns are in vogue.

All subsequent Republican US presidents have repeated the Mexico City Policy. Numerous opinion polls find that about 70% of Americans disagree with this position (See Appendix B of (09S2)). That percentage is almost certainly far higher in the rest of the world. The scientific evidence against this position is overwhelming, and few, if any, in the scientific community would accept this position. The denial of legitimacy of demographic concerns largely explains the Republican Party's views on environmental issues generally. That same denial also forces the Party to explain the ills of the developing world in terms of "bad leadership." This too can easily be shown to be a tragic misconception (09S2). Unfortunately this misconception has formed much of the basis of foreign and military policies of Republican presidents since 1980. It has also been instrumental in widening the ideological split between the US and the remainder of the developing world - a world that sees the ills of the developing world as a consequence of demographic effects rather than bad leadership. (Bad leadership is actually an effect of developing-world ills, not a cause (09S2).)

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~ Changing Political Environments ~ The "Health" Rationale ~
During the 1980s a shift toward the "health" rationale occurred among the community of US advocates of US support for international family planning (IFP) (02S1). They were driven by concerns over the effects of high fertility on maternal, infant, and child mortality. This shift was perhaps driven by a desire to broaden the base of popular support for IFP aid. As a result, arguments on behalf of US support for IFP were framed in more family-oriented terms, such as:

This was a tragic strategic blunder in that, by abandoning the demographic rationale, it narrowed the base of popular support for IFP aid. The developing world is full of ills - hundreds of them - and most are at least as heart-wrenching as those mentioned above. The developed world tends to see this massive array of ills as a bottomless pit for money, and thus tends to be little impressed by pleas for funds to address just a few of these ills. Almost certainly, few if any of the developing world's leaders who have come out strongly in favor of family planning were motivated by the "health" rationale. They were motivated by the massive, widespread effects of overpopulation and population growth on the overall economic, social, political and military ills of their country - a scope vastly larger than the scope of the "health" rationale. The "demographic" rationale addresses the entire scope of these ills. It would almost appear that the community of US advocates of US support for IFP is tacitly accepting the Republican view that the demographic rationale has no legitimacy. They are thus abandoning a huge array of arguments that a large fraction of the US public would find compelling. Demographic problems like globalization, immigration, terrorism, US peacekeeping efforts, and countless others can be easily linked to problems that support for IFP would address. A broad philosophical structure could be developed that could form the bulk of the Democratic Party's platform, each plank of which could have broad public support.

~ Changing Political Environments - The "Human Rights" Rationale ~
In the 1990s, the "human rights" rationale for IFP was added to the "demographic" and "health" rationales (02S1). It focused on women's rights, principally reproductive rights and the reproductive health of women and men. According to some feminists, governments have a "responsibility" to ensure reproductive rights, and to provide family planning services (02S1). If the "health" rationale was a tragic strategic blunder, the "human rights" rationale was worse. The developing world is in no financial or political position to ensure "reproductive rights" (whatever that means). To say that developed world governments have the "responsibility" to protect reproductive rights (or any other rights) and to provide family planning services (or any other services) to citizens in developing nations strains at credulity. Any candidate for public office in the US would suffer embarrassment by taking such a position.

It is interesting to speculate on the origins of the "health" and "human rights" rationales that have marginalized US advocates of increased funding for IFP, maternal health care and the battle against HIV/ AIDS in the developing world. Opponents of IFP funding have engaged in a well-orchestrated attack on the validity of the demographic rationale. They will note, for example, that food prices in the global marketplace have been in decline for some decades. Arguments like these have intimidated advocates of increased funding for IFP into abandoning the demographic rationale and substituting new rationales at the margins of the overall debate. IFP funding advocates would not be so intimidated by their opponents if they would just do some homework. Agriculture is a large part of the economies of the developing world. Agricultural experts now agree that the developing world's inventories of undeveloped cropland-grade land are now essentially depleted. Also developing world croplands are undergoing a transformation from labor-intensive agriculture to capital-intensive agriculture, meaning that the need for agricultural labor (a large fraction of the developing world's labor force) is dropping rapidly. This fact, plus population growth, is marginalizing family farmers onto steep, rocky hillsides where erosion rates are extreme and where farming is non-sustainable. As a result, the agriculture labor force is migrating to huge, wretched slums that now ring virtually all the urban areas in the developing world. There they must buy food on the open global market, a far cry from growing their own fruits, vegetables and livestock in traditional, labor-intensive ways. For these people, food price trends are not downward - they are jumping dramatically as a result of the change in origins of their food source. For more detailed analyses of the numerous arguments over the demographic rationale, see Reference (09S2) and the last sections of Reference (08S4). This author foresaw problems of this nature back in the early 1980s and so initiated reviews of the global literature on the degradation of the world's soils, croplands, forests, grazing lands, irrigated lands, and fisheries. These reviews have now grown to large compilations of facts, figures and summaries of analyses and arguments. These can be seen on the author's web site, http://home.windstream.net/bsundquist1/. Analyses of the sustainability of the outputs of the world's croplands, forests, grazing lands, irrigation systems, fisheries, aquifers and surface waters are also available on this website.

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~ Growing Needs ~
Of the 41 countries designated as "heavily indebted poor countries" by the World Bank, 39 fall into the category of high-fertility nations, where women, on average, bear four or more children. Similarly, the 48 countries identified by the UN as "least developed" are expected to triple their populations by 2050 (02C3). These nations are where the costs of family planning supplies and services and maternal health care are the least affordable and thus where funding of family planning and maternal health care is most important. This would suggest a rate of growth in the need for funding for these services of at least 3%/ year. Other figures support this. Over the next 20 years, the number of couples wanting to use contraception will almost double (95G1). By 2020, the number of couples in the reproductive age group will double to 1.6 billion (99U1).

In developing countries, the percentage of couples using contraception increased by at least 1 percentage point per annum in 68% of the countries, and by at least 2 percentage points per annum in 15% of the countries (02C2). This would suggest that the average rate of increase in the percentage of couples using contraception for the developing world as a whole must be about 1 percentage point per year. This would suggest that another three decades will be required before modern methods of contraception are used by at least 70% of developing world couples and fertility rates might reach replacement level. Several additional decades will be required for population momentum effects to wear off, suggesting that global population growth is not likely to become zero until around 2050. All of this data suggests that rapid growth in the need for international funding for family planning and maternal health services will be a fact of life for some decades.

~ Critique ~
The expanding options, the shifting political environments, and the growing needs outlined above would appear to suggest that strategies for funding IFP in the developing world ought to be in a constant and rapid state of flux. However the newer strategies (rationales) appear to be virtually oblivious to all of these major changes. Even worse, they are evolving in the wrong direction. The bottom is dropping out of the costs of marketing and providing family planning services and dealing with the HIV/ AIDS pandemic. Government attitudes toward family planning have become dramatically more positive in all but a few of the world's 190 or so governments. Religious leaders are becoming increasingly supportive of all manner of contraception and family planning services. The laity is increasingly ignoring those religious leaders that are not falling into line. Fertilities are dropping rapidly nearly everywhere. Females are getting better educated and are seeking and seeing an increasingly broader range of life-shaping options. Opponents of funding IFP are complaining that family planning programs are getting too successful. The adverse effects of demographic changes in the developing world are increasingly spilling over into the developed world as a result of exploding mobilities of virtually ever component of economic output. These spillovers are providing major possibilities for advancing the agenda of IFP funding supporters in political arenas throughout the developed world. Unfortunately proponents of funding IFP remain oblivious to all of this.

A recent paper by Robert Lalasz of the Population Reference Bureau (05L1) notes a common perception that, in the developing world as a whole - although not necessarily in every individual country - women's motivation to control fertility is so strong (and the social norm of family planning so well established) that contraceptive use will continue to rise no matter what happens to family planning programs (05L1). The problem with this perception is that it is false in the very regions of the world where fertility rates have barely dropped from their values in the 1960s. There the affordability of (and access to) contraceptives and sterilization is minimal at best; external debts are staggering; and the Vatican holds powerful sway among the political leadership. Spillover effects (emigration, warfare, demographic aggression, terrorism, and social-, political-, economic- and military instabilities) can spread misery far outside the borders of these problem nations. (For example, see the long list of military actions along the border of the Muslim- and non-Muslim worlds in Ref. (08S2).) Also, the implicit assumption in all of this is that the outputs of the world's croplands, forests, grazing lands, irrigation systems, fisheries, aquifers and surface waters are sustainable and even capable of accommodating the anticipated 50% growth in global population over the next half-century (at which time populations are expected to start falling). A massive body of evidence challenges this perceived sustainability, not to mention the potential for output growth (11S1).

The Lalasz paper has compiled the views of those with an active involvement in family planning issues. Suggestions for recasting the central message of family planning centered on three areas (05L1):

  1. Addressing the unfinished agenda of unmet contraceptive needs, unwanted fertility, stalled fertility decline, and shortages of contraceptive supplies;
  2. Highlighting family planning's benefits in terms of reducing abortion and improving women's status and health;
  3. Demonstrating family planning's relevance in reducing social inequality.

All this is well and good, but it ignores a massive body of data and deep-felt public concern over the countless harms and growing risks posed by the demographic effects of population growth. Self-marginalization and a reluctance to do homework seems to be a persistent problem in the community of those involved in advocacy on behalf of funding IFP.

These should be times of exuberance and shifts to increasingly aggressive stances. Yet in the face of all this, some advocates of greater funding for IFP have withdrawn into marginally relevant shells of "health" and "human rights" rationales that make countless opportunities largely invisible. Even timid advances have become all but impossible. The abilities of IFP advocates to deal with the demographic rationale are limited to making a few glib statements about basic resources. That glibness exposes them to the risk of powerful, though false, criticisms and considerable embarrassment. The cause of IFP funding is suffering from a sickening, tragic leadership vacuum. The Lalasz paper notes this frequently (05L1). This author has yet to see a substantive discussion of funding strategy issues in any document from any IFP-oriented organization. All this would be comical if it weren't so tragic and important in determining the future of mankind.

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~ Recommendations ~ Social Content Serial Dramas ~
SCSDs ought to be seen as the marketing departments for the overall effort to provide family planning services and maternal health care, and to battle the HIV/ AIDS pandemic. As noted above, SCSDs offer the only known affordable approach to eliminating the global HIV/AIDS pandemic. The drain on family planning funds that this pandemic has created (See above) represents the most serious threat to hopes of reducing the developing world's total fertility rates. Organizations like Marie Stopes International, DKT International, Population Services International, and IPPF should be seen as service providers. Marketing and service providing operations need to be coordinated. Marketing a product in an area where the service is not available, or setting up a service outlet where there is no marketing, is not efficient. The relative amounts of money allocated to marketing and service-providing should be based on the criterion of equal marginal rates of return as measured in births averted per dollar spent. Greater effort should be expended on determining marginal rates of return. SCSD organizations contend that their marginal rates of return are far greater than those of service-providing organizations. If so, donor agencies ought to reallocate funding accordingly. One might at first suspect that this would lead to SCSDs operating in the richer regions of the developing world, while service providing agencies operate mainly in the poorest regions where contraception availability is the crucial issue. But the issue is far more complex. Even in the absence of family planning services, SCSDs can promote delayed age of marriage, smaller desired family sizes, use of the rhythm method, education of daughters, the rights of women to work outside the home, and other steps that will likely lead to reduced fertility. And in countries where people don't have the capability to purchase family planning services, but the government or service providers make them available at low or no cost, SCSDs can play a major role in doing away with the fatalism or belief that pre-determination that causes many to accept the number of children that "God gives them," regardless of the number they might desire (06R1).

~ Recommendations ~ The Changing Political Environment ~
The world's leaders and the public are so much more attuned to the demographic rationale than the health- or human rights rationale that nothing can be gained by advocates of IFP funding focusing on the latter two rationales and largely ignoring the demographic rationale. This is not to say that one should stop arguing that reducing IFP funding by X dollars would produce Y unintended pregnancies and Z abortions. But it is to say that such statements ought to be but one part of a far larger analysis of the IFP funding issue. There are countless powerful demographic arguments that the voting public would find compelling and that would aid candidates for public office who support funding for IFP. Retreating to the margins of the issue is to cede the center of the issue to opponents of IFP funding. This is not a wise strategy.

One problem is that some of the organizations involved in IFP have not done any homework on the demographic rationale since around 1980. Also the relevant demographic issues are slightly complex and constantly evolving. But a massive amount of well-documented information is available from this author's web site (equivalent to about a thousand pages of hardcopy). Also there are hundreds of well-qualified experts who would be willing to help with specific tasks.

Presently many advocates of IFP funding operate mainly on a preach-to-the-choir level because their "health" and "human rights" rationales resonate so little with the public-at-large that costs of mass-media approaches overwhelm benefits. Once messages that resonate are developed, mass media approaches become viable, and public officials who support IFP funding get the voter support that they badly need. Opponents of IFP funding frequently argue against the demographic rationale, and many supporters of IFP funding pretend they didn't hear anything. Candidates for public office that feign deafness tend to lose elections. Combatants in arenas of public discourse who feign deafness tend to be marginalized.

Many advocates of US support for IFP seem to have lost touch with the "demographic rationale". They have long forgotten, if they ever knew, any of the relevant facts, figures, logic or analyses. So returning to any sort of IFP advocacy using the demographic rationale may appear to be risky. So in order to diminish any hesitancy, Appendix A ("Financial Support for International Family Planning - A Bottomless Pit for Money or a Lucrative Investment?") gives an example of how the demographic rationale might be put forth in the arenas of public discourse and the mass media. Appendix A should not be seen as a complete compilation of compelling arguments, facts and figures. Such a compilation would occupy a document far larger than anything the average voter would be willing to read.

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~ References ~
86M1 Stephen D. Mumford, "The Pope and the New Apocalypse: The Holy War Against Family Planning", Center for Research on Population and Security, Research Triangle Park, NC (1986) 82 pp.
88C1 Susan H. Cochrane, "The Effects of Education, Health and Social Security on Fertility in Developing Countries", Policy, Planning and Research Working Paper No. 93, World Bank, Washington DC (1988).

95G1 Alan Guttmacher Institute, "The Cairo Consensus: Challenges For US Policy at Home and Abroad", (1995).
96B1 Bhushan, I. "Understanding Unmet Need", Baltimore, Johns Hopkins School of Public Health. Center for Communication Programs, Working Paper #3 (1996) 50 pp.
96R1 Robey, B., Ross, J., and Bhushan, I., "Meeting Unmet Need: New Strategies". Population Reports, Series J, #43. Baltimore, Johns Hopkins School of Public Health, Population Information Program, 9/96. 36 pp.) (UN, "World Contraceptive Use, 1998" (a wall chart) New York, UN (1999).
97P1 David Poindexter, "Population Realities and Economic Growth," Population Press, 4(2) (Nov./ December 1997) http://www.popco.org/irc/essays/essay-poindexter.html.
98B1 Rodolfo A. Bulatao, "The Value of Family-Planning Programs in Developing Countries", RAND MR-978-WFHF/RF/UNFPA (1998) 79 pp.

99A1 Alan Guttmacher Institute report of January 1999.
99G1 Georgie Ann Geyer, "Population Growth Is the Pivotal Issue in Economic Development", The Salt Lake Tribune (From the UN web site, 6/4/99).
99U1 Ushma Upadhyay, Bryant Robey, "Why Family Planning Matters", Population Reports, Johns Hopkins Population Information Program, Sept. 1999 (See
http://www.jhuccp.org/pr/j49edsum.stm).

01D1 Cynthia Dailard, "Challenges Facing Family Planning Clinics and Title X", The Guttmacher Report on Public Policy (April 2001).

02C2 Joseph Chamie (now retired), UN Press Release of 5/16/02 (Further information may be obtained from the Director, Population Division, UN, New York NY 10017, 1-212-963-3179.) (See the wall chart entitled "World Contraceptive Use 2001", issued by the UN Population Division pertaining, on average, to the year 1997 for women aged 15-49.)
02C3 Win Carty, senior journalist, PRB. "Poverty Fuels Developing World's High Birth Rate", 2002 World Population Data Sheet, August 2002 authored by Carl Haub. Copies of the 2002 World Population Data Sheet are available online from the PRB store for US$4.50/ copy. Copies are free to audiences in developing countries.
02L1 Jack Lippes, "Quinacrine Sterilization: the imperative need for American clinical trials," Fertility and Sterility 77(6) (June 2002) pp. 1106-1109.
02S1 Judith R. Seltzer, "The Origins and Evolution of Family Planning Programs in Developing Countries, RAND, Santa Monica, CA (2002) 185 pp.
02T1 Allison Tarmann, " Iran Achieves Replacement-Level Fertility," (Population Today, May/ June 2002).

03B2 Mandeep Brar, Ida Campagna et al, "Quinacrine Sterilization," a presentation at the triennial FOGO meeting in Santiago Chile (11/4/03).
03N1 Gautam Naik, "As Tunisia Wins Population Battle, Others See a Model", Wall Street Journal (8/8/03).

04R1 William Ryerson, "PMC-Ethiopia's two radio serial dramas are causing great behavior changes", Ethiopian Reporter (6/16/04). Contact William Ryerson, President, Population Media Center, 145 Pine Haven Shores Road, Suite 2011, P.O. Box 547, Shelburne VT 05482.

05A1 Antislavery International, Estimates of the world population of slaves as reported on Nightline, 6/2/05.
05H1 D. R. Hogan, R. Baltussen, C. Hayashi, J. A. Lauer, Joshua A. Salmon, "Cost Effectiveness Analysis of Strategies to Combat HIV/AIDS in Developing Countries," British Medical Journal 331 (11/10/05) pp. 1431-1437.
05L1 Robert Lalasz, "The Future of the International Family Planning Movement", Population Reference Bureau (July 2005),
www.prb.org/Template.cfm?Section=PRB&Template=/Content/ContentGroups/05_Articles/The_Future_of_the_International_Family_Planning_Movement.htm
05M1 Valentine Moghadam, Farzaneh Roudi-Fahimi, "Reforming Family Laws to Promote Progress in the Middle East and North Africa," Population Reference Bureau (PRB) (December 2005) http://topics.developmentgateway.org/population/rc/ItemDetail.do~1062629?intcmp=700
05O1 Statement by UNFPA executive director Thoraya Ahmed Obaid ("Record Year for UNFPA Donors and Donations", UN News Centre, 1/27/05).
05U1 United Nations, "The Flow of Financial Resources for Assisting in the Implementation of the Program of Action of the International Conference on Population and Development," Report of the Secretary General E/CN.9/2005/5 (New York: United Nations, 2005)
05U3 UN, "Contraception Prevalence 2005" http://www.un.org/esa/population/publications/contraceptive2005/2005_World_Contraceptive_files/WallChart_WCU2005.pdf (Visited 5/19/09)

06A1 Mohamed Ayad and Farzaneh Roudi, "Fertility decline and reproductive health in Morocco: new DHS figures," Washington, DC, Population Reference Bureau (May 2006) (Web site visited 5/22/06).
http://www.prb.org/Content/NavigationMenu/PRB/DataFinder/New_Country_Data/Fertility_Decline_and_Reproductive_Health_in_Morocco__New_DHS_Figures.htm
06B1 Dr. Tim Black, Chief Executive of Marie Stopes International, in a personal communication to this author of 11/23/06.
06I1 International Service Assistance Fund, press release of 6/22/06. (Contact ISAF at 919-990-9099 or visit www.quinacrine.com)
06K1 June Kronholz, John Lyons, "Smaller Families in Mexico May Stir U.S. Job Market," Wall Street Journal (4/28/06) p. A1.
06R1 Bill Ryerson, President, Population Media Center, private communications via his critique of an earlier edition of this document in April of 2006.
06U1 UNFPA Global Population Policy Update Issue # 64 (6/1/06)
http://www.un.org/esa/population/cpd/comm2006.htm

07S2 Michael Slackman, "A Quiet Revolution in Algeria: Gains by Women," The New York Times (5/26/07).

08S2 Bruce Sundquist, "The Muslim World's Changing Views toward Family Planning and Contraception," Edition 2 ( March 2008)  http://home.windstream.net/bsundquist1/muslim.html
08S3 Bruce Sundquist, "Could Family Planning Cure Terrorism?" Edition 7 (March 2008) 33 pp. http://home.windstream.net/bsundquist1/terror.html 
08S4 Bruce Sundquist, "Globalization: The Convergence Issue", Edition 16 (April 2008) http://home.windstream.net/bsundquist1/gci.html

09M1 Donald G. McNeil Jr., "AIDS: Panel Warns That Without New Direction, Epidemic will Remain Out of Control at 50," (Based on a paper by Robert Hecht et al in the journal, Health Affairs (11/03/09).)
09S1 Bruce Sundquist, "Quinacrine Sterilization - The Controversy and the Potential," Edition 2 (June 2009) 13 pp. http://home.windstream.net/bsundquist1/qs.html 
09S2 Bruce Sundquist, "The Controversy over US Support for International Family Planning: An Analysis", Edition 9 (June 2009)  http://home.windstream.net/bsundquist1/ifp.html.

10H1 Eben Harrell, "New Study Raises Concerns About HIV-DRUG Resistance," Time (based on a study in the Journal Science) (January 2010).

11S1 Bruce Sundquist, "Sustainability of the world's Outputs of Food, Wood and Freshwater for Human Consumption" Edition 2 (Jan. 2011) http://home.windstream.net/bsundquist1/su0.html 

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