The NEW ENGLA ND JOURNAL of MEDICINE

Perspective August 1, 2019

Population and the Environment — Time for Another

Contraception Revolution
Deborah J. Anderson, Ph.D.​​

D
uring the second half of the 20th century, tions plummeted, and pharma-
ceutical companies and interna-
Population and the Environment

many political and academic thought leaders

were concerned about the rapid growth of
the human population, which had increased expo-
nentially from less than 1 billion
in 1800 to 5.5 billion by 1980.
Thomas Malthus, an 18th-century
English cleric and scholar, had
famously predicted that with geo-
metric population growth, human
need could eventually outstrip
Earth’s resources. Several popular
books were published in the 1970s
and 1980s forecasting dire con-
sequences of human overpopula-
tion. During this time, research on
contraception was relatively well
funded by private foundations and
government agencies, and research
on human reproduction was main-
stream and highly regarded in
respected academic institutions
such as the Harvard Medical
School Laboratory for Human Re-
production and Reproductive Biol-
ogy (LHRRB), where I worked.
At least half a dozen large U.S.
drug companies were spending
heavily on contraception research
and development.
By the end of the 20th century,
however, the mood had changed.
The fertility rate had peaked in
1962 and was declining, although
projections showed that popula-
tion growth would not level out
until at least the middle of the
21st century. Apocalyptic conse-
quences of overpopulation had not
materialized, and the agricultural
Green Revolution promised engi-
neered crops and other resources
to keep pace with population
growth.1 Activists voiced concern
about coercive and antifeminist
aspects of contraception. Funding
for contraception research from
government and private institu-
tional agencies with innovative
contraceptive methods in clinical
trials stopped their programs.2
Yet the Green Revolution and
continued population growth have
created serious problems that were
not clearly foreseen in the 1980s.
Scientists warn that dangerous
atmospheric levels of greenhouse
gases produced by human activity
are causing global warming and
climate disruption. Waste from
megacities and widespread agri-
culture and livestock industries
pollute the land, air, and water.
Rapid depletion of resources from
forests and oceans is destroying
natural habitats and further con-
tributing to climate change. Many
animal species are experiencing
catastrophic decline, and natural-
ists warn that as many as 50% of
species living today may be ex-
tinct by 2100 owing to human
activities.3
As the global population con-

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PERS PE C T IV E
tinues to grow, these pressures
will increase and become more
critical. Currently there are 7.7 bil-
lion people on earth. The United
Nations (U.N.) predicts that the
human population will reach
9 billion by 2050, and probably
11.2 billion by the end of the
century. Estimates of the number
of human beings the Earth can
support range from fewer than
2 billion to more than 100 billion
(median, 8 billion). The actual
number depends on variables
such as acres of arable land,
amount of fresh water, and hu-
man dietary habits. If the sustain-
ability of ecosystem health and
biodiversity are factored into the
equation, modern estimates of
the planet’s carrying capacity be-
come much lower — 1.5 billion
to 5 billion people1 — and have
already been exceeded.
The U.N., the World Health
Organization (WHO), and others
are increasingly sounding the
alarm, and action is being taken
on multiple fronts. The Paris
Agreement within the U.N. Frame-
work Convention on Climate
Change has provided an ambi-
tious global road map for the re-
duction of greenhouse gases. Or-
ganic farming and calls for less
animal-intensive diets are gain-
ing traction. Conservationists are
working hard to protect the envi-
ronment and animal species. In
the United States, energy-efficiency
policies and programs initiated
at the state level and the Green
New Deal promise to jump-start
sustainable-energy projects and in-
troduce new environment-friendly
regulations.
The population-growth side of
the equation is also receiving at-
tention. London Family Planning
Summits in 2012 and 2017 set
an ambitious goal of expanding
access to voluntary family plan-
398
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ning services in the lowest-income
countries, where 222 million
women have an unmet need for
family planning. The Gates Foun-
dation recently prioritized the em-
powerment of girls and women,
with an initiative expected to have
a major moderating effect on hu-
man population growth.1
The contraception revolution of
the 20th century produced several
effective birth-control methods
that reshaped society. The lead-
ing methods used today are male
and female sterilization, hormonal
methods, long-acting methods
such as intrauterine devices and
implants, and male and female
barrier methods. However, many
men and women still cannot find
a method to meet their needs.
Sterilization is not suitable for
people who desire to have chil-
dren in the future; hormonal
methods have side effects that
many women find unacceptable;
and barrier methods have a high
failure rate when used inconsis-
tently. Furthermore, all methods
except for male condoms normal-
ly require medical prescriptions or
interventions that put them out
of reach of many people because
of cost and lack of access.
Population watchers report that
of the approximately 210 million
human pregnancies that occur
each year worldwide, at least 40%
(more than 80 million) are unin-
tended; of these, about 30 mil-
lion end in abortion or miscar-
riage and 50 million result in
unplanned live births.2 Notably,
the rates of unintended pregnan-
cies are high in both high-income
countries (47%) and low-income
countries (39%). A disproportion-
ate number of unintended preg-
nancies occur in young, unmarried
women, who often lack access to
comprehensive sexuality education
and modern contraception; the
n engl j med 381;5 nejm.org  August 1, 2019
Population and the Environment
WHO has pointed out that un-
planned pregnancies in this group
are a major contributor to mater-
nal and child mortality and to
intergenerational cycles of poverty
and poor health. More accessible,
effective contraception choices are
needed to ensure that all children
are planned and wanted. Such an
advance could significantly reduce
population growth to meet real-
istic goals for sustainable devel-
opment.1
The time seems ripe for an-
other contraception revolution to
provide options for the diverse
populations that are not current-
ly being served by modern con-
traception. Appropriate leadership
and an infusion of funding could
reignite contraception research,
education, and services. This in-
vestment would be quickly offset
by savings in health care and
other costs attributable to pollu-
tion and global warming, whose
U.S. costs currently total $240
billion per year and are expected
to increase to $350 billion per
year in the next decade if drastic
mitigation steps are not taken.
Globally, the health costs of cli-
mate change are projected to ex-
ceed $1 trillion per year.4
New products are in the pipe-
line that could help fill the re-
maining contraception gap. Vagi-
nal gels and films with powerful
spermicidal activity could prove
to be popular as over-the-counter,
on-demand methods for women.
Male hormonal birth-control pills,
gels, and patches that act on the
hypothalamus–pituitary–testis axis
to suppress spermatogenesis, and
other drugs that temporarily in-
hibit sperm production or sperm
function, are being developed for
male contraception. The concept
of a new approach called multi-
purpose prevention technology
(MPT) that offers dual protection
 PE R S PE C T IV E
against unintended pregnancy and
highly prevalent sexually trans-
mitted infections (STIs), such as
human immunodeficiency virus
type 1 (HIV-1) and herpes sim-
plex virus type 2, has been en-
thusiastically endorsed by women
and could boost the popularity
of contraceptive methods.5 MPT
products under development in-
clude a combination of antiretro-
viral therapy and hormonal con-
traception, as well
An audio interview
with Dr. Anderson
as topically delivered
nonhormonal agents
is available at NEJM.org
such as monoclonal
antibodies that specifically target
sperm, HIV-1, and other STIs.
Saving the Endangered Physician-Scientist
Saving the Endangered Physician-Scientist
— A Plan for Accelerating Medical Breakthroughs
Mukesh K. Jain, M.D., Vivian G. Cheung, M.D., Paul J. Utz, M.D., Brian K. Kobilka, M.D., Tadataka Yamada, M.D.,
and Robert Lefkowitz, M.D.​​
O n July 1, 1968, at the height
of the Vietnam War, four
young physicians with little to no
background in research reported
for duty at the National Institutes
of Health (NIH) to begin fulfill-
ing their draft obligation as com-
missioned officers in the U.S. Pub-
lic Health Service (USPHS). This
intensive, 2-year experience ulti-
mately led each of them to incor-
porate scientific research into their
career plans as physicians. Their
future accomplishments would in-
clude the discovery of oncogenes;
research that led to the develop-
ment of statins; the discovery of a
family of receptors that now serve
as the targets for one third of all
drugs approved by the Food and
Drug Administration; and, as a
bonus, four Nobel Prizes. The four
physician-scientists were Harold
Varmus, Michael Brown, Joseph
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A new contraception initiative
could promote innovative strate-
gies by leveraging recent advanc-
es in well-funded scientific fields
such as HIV prevention, molecular
biology, nanotechnology, and bio-
informatics, among others. New
contraceptive discoveries could im-
prove the health and well-being
of women and their families and
could help to further reduce and
stabilize human population num-
bers globally, offering an addi-
tional step toward rebalancing
the planet and preserving its natu-
ral treasures for future generations.
Disclosure forms provided by the author
are available at NEJM.org.
Goldstein, and one of us (R.L.),
and their efforts would forever
change science and medicine.
Physician-scientists have been
a driving force in biomedical re-
search and have made broad con-
tributions in both the private and
public sectors. Their research has
led to mechanistic understanding
of diseases and the development
of therapies, devices, and technol-
ogies that enable current medical
practice. They account for 37% of
the winners of Nobel Prizes in
Physiology or Medicine and nu-
merous winners of Nobel Prizes
in Chemistry. An outsized share
of leaders in industry and gov-
ernment, including about 70% of
chief scientific officers at top 10
pharmaceutical companies and
NIH institute directors, hold M.D.
degrees. In the past four decades,
however, the proportion of U.S.
Population and the Environment
From the Departments of Obstetrics and
Gynecology, Microbiology, and Medicine,
Boston University School of Medicine, Boston.
1. Crist E, Mora C, Engelman R. The inter-
action of human population, food produc-
tion, and biodiversity protection. Science
2017;​356:​260-4.
2. Bongaarts J, O’Neill BC. Global warm-
ing policy: is population left out in the cold?
Science 2018;​361:​650-2.
3. Intergovernmental Science–Policy Plat-
form on Biodiversity and Ecosystem Services.
IPBES-UN global assessment report on biodi-
versity and ecosystem services. May 2019.
4. Universal Ecological Fund. The economic
case for climate action in the United States.
2018 (https://feu​-­us​.org/​case​-­for​-­climate​-­action​
-­us/​).
5. IMPT for Reproductive Health. MPT prod-
uct development database (http://mpts101​
.org/​mpt​-­database).
DOI: 10.1056/NEJMp1906733
Copyright © 2019 Massachusetts Medical Society.
Population and the Environment
physicians engaged in research
has dwindled from a peak of 4.7%
of the overall physician work-
force in the 1980s to approxi-
mately 1.5% today.1,2 There are
numerous reasons for this trend,
some of which are outlined in
Table 1. Because of these changes,
aspiring young physician-scientists
see careers combining research
and patient care as unattainable.
As more people abandon this ca-
reer path, the loss of role models
for trainees further exacerbates
the problem.
The decrease in the number of
physician-scientists comes at a
time when we particularly need
innovations in medicine, as the
population ages and communi-
cable diseases spread more rap-
idly and widely. Many diseases
still have unknown origins and
pathways, and for precision med-
399