The sad realization is that we leave behind so many people who have no opportunity to enjoy the Good Life now. But the hope is that we can somehow transform this country into the tropical paradise that it has the potential to be. Infusions of medicines, food and building materials have not provided sustained success because when healthy well-nourished people enter their new dwellings, they have relations, and without dependable contraception, they create more people who will likely be just as dependent on outsiders for support. Without dependable contraception, Haiti (the size of Maryland) may have doubled in population size to 20 million people 30 years from now. Our aid may not be able to keep up. Haitian children need parents who read them bedtime stories and help them with homework and cheer for them in sports. If we establish the reputation of vasectomy as an easy (quick and painless) and attainable (available) procedure, we may slowly begin to see wider acceptance. We may see fathers playing greater roles in the the lives of their fewer children. It is difficult to read a story every night to 7 children in 4 households. It is difficult to pay for 7 educations on little or no income.

The shift to smaller families may require an in-your-face promotion campaign as has been done in Florida with billboards. It may require incentives until the social infrastructure (jobs, housing, sanitation, health care, education) can be improved. The man with no job, no income, no hobbies, no sport, and no particular special skill is very unlikely to give up his fertility when that's all he's got. And especially if his mother-oriented society puts no demands on his paternity. So what ... if he has 7 children by five different partners?! He's not taking care of them anyway! Why get a vasectomy? But with incentives, all that changes. In the Philippines, NSVI offers men US$12.00  "to cover travel expenses and time away from work". Actually, for the poorer men like putt-putt drivers, that may be two weeks' pay. Simply put, offer a man in a developing country an iPod and all his concerns about religion or macho or pain magically disappear. I know also from my experience in Florida that incentives work: I require a $100 non-refundable deposit to schedule a vasectomy. We are not universally strict in our policy, and we readily refund the deposits of young men with no children who are having second thoughts. But we would not refund the deposit of a man with 4 children. So the deposit becomes an incentive in itself, and it works VERY WELL. In fact, we receive far more compliments than complaints. "Doc, I was scheduled for this a year ago, but made up some excuse and procrastinated and bingo, my wife was pregnant a month later and had all sorts of complications. But I knew it was the right thing to do, and the deposit was just the incentive that I needed to see it through. A last minute excuse was not worth losing $100. Now I'm glad that I went through with it."

Obviously, loss of a deposit cannot be an incentive where we do not charge for vasectomies in poor countries. So our only option is to provide a positive incentive: a bag of rice, a pair of sunglasses, a T-shirt, an MP3 player, cash. Obviously, we are not even offering vasectomy to young men with no children. But why not sweeten the pie and make vasectomy more fun for men with two or more children?

One stumbling block to offering incentives is that US policy disallows incentives by organizations receiving financial assistance from USAID (United States Agency for International Development). In October 1998, Congress enacted an amendment initiated by Rep. Todd Tiahrt (R-KS), reaffirming and further elaborating standards for voluntary family planning service delivery projects to protect family planning "acceptors," that is, the individual clients receiving services. A summary of the Tiahrt Requirements is available in the USAID website, where you may also click a link to the Full Text of the Tiahrt Amendment. USAID monitors compliance with the Tiahrt Amendment and one such Assessment Report (of the USAID/Indonesia-Supported Family Planning Projects) suggests that "offering incentives ... was found to have little impact on increased utilization, it was difficult to administer, and it introduced distortions into the program". But it goes on to say that, "Today the challenge facing the Indonesia family planning program seems to be meeting existing demand rather than generating new demand for information and services." There is no doubt that incentives are of less value in societies where vasectomy is already commonplace enough that reputation alone can help programs be self-sustaining. Indeed the demand for vasectomy could actually rise when it is offered only to those who acknowledge its value by paying for it. But until vasectomy achieves acceptance through establishment of a good reputation in a locale where it is offered regularly, something is needed to break the ice. An outdoor billboard campaign can help, but nothing is as reassuring as a recommendation from a friend.

Receiving no funds from USAID, a non-profit organization such as NSVI could serve as the catalyst to start a program in a location where men have little incentive otherwise to have a vasectomy; that is, where fertility is a large part of one's identity, and where men currently play little role in child-rearing and therefore feel little burden as a result of siring large numbers of children with multiple partners.

Women are more receptive to long-term family planning, including sterilization, than are men, because it may be a matter of self-preservation. In some developing countries, the major cause of female mortality from ages 15-35 is pregnancy and childbirth. Complications such as eclampsia, placenta previa, and abruptio placenta can prove fatal where quick access to emergency care is not available. So one could make the case, "Why not simply focus on women and channel resources into providing long-term family planning methods, including bilateral tubal ligation, for women?" Indeed, given a hypothetical population of 10 women and 10 men and the resources to provide 9 sterilization procedures, it would make much more sense to sterilize 9 women, in which case the group could have only one offspring per year; whereas provision of 9 vasectomies still leaves open the possibility for 10 offspring per year. The appeal of vasectomy to family planning personnel is that it is so quick, painless, and safe in the hands of experienced providers. Under general anesthesia, bilateral tubal ligation (BTL) is painless but expensive and time-consuming - under local anesthesia, it is less expensive (though still more so than vasectomy) but much more risky and painful. And for women with pelvic scarring due to prior surgery or infection, BTL is not even an option.

So NSVI continues to promote vasectomy, but with strict respect for and compliance with US guidelines. When NSVI receives assistance from USAID (as was the case for this trip in which our transportation was supported by MSH), no incentives are offered. But when NSVI works independently, incentives may be offered in locations where vasectomy has not established a reputation with the local populace as a safe and painless form of contraception, the manly act of a responsible father and caring husband.