703 Women in the world SiR-Your July 22 editorial criticises the International Conference on Population and Development (ICPD), together with UNFPA’s most recent report on the state of the world’s population, "for placing women and their reproductive needs at the top of the international health agenda", and for defining health "in a surprisingly one dimensional manner" so that "it seems to exist in a reproductive context only". The statement that "when seen through the lens of fertility control health is distorted beyond all control" shows that these criticisms are based on several false assumptions. First, neither the UN nor ICPD are determined, as you claim, "to coerce women into adopting fertility control". Both are seeking to obtain "recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so" (ICPD Programme for Action, para 7.3). Second, you assume that reproductive health is concerned only with family planning and fertility control. It is not. The definition contained in the ICPD Programme for Action states very clearly that reproductive health "includes a state of complete physical and social wellbeing (and not merely the absence of disease of infirmity) in matters relating to the reproductive system and to its functions and processes" (para 7.2). The provision of reproductive health information and services advocated by ICPD is crucial to controlling sexually transmitted diseases (WHO estimates that a million women were newly infected with HIV/AIDS last year), and of many other conditions adverse to health, including cancers of the genital tract (carcinoma of the cervix is increasing and appearing at an earlier age), complications of pregnancy (from which half a million women die each year, most of which are avoidable deaths), and female genital mutilation (which 84 million girls and women are estimated to have undergone). The consequences of reproductive ill health cause endless misery, and your editorial does women, or for that matter, men as well, no service at all by playing them down-still less by its ill-judged suggestion that the provision of reproductive health services would have to be at the expense of rural primary-care facilities, which should, of course, provide reproductive health information and services in any case. Third, you clearly fail to appreciate that, unlike the two previous UN population conferences, ICPD was concerned with development as well as with population. Women’s health, and particularly their reproductive health, is crucial to development in the third world. In a developing country infertility resulting from reproductive tract infection, complicated delivery, or unsafe abortion is just as damaging to the health and wellbeing of women as the unwanted pregnancies with which you seem to think that both ICPD and UNFPA are solely concerned. The low health status of women in developing countries is closely associated with their environment, more particularly with the discrimination that they suffer from birth onwards. The elimination of this discrimination, and the priority that should be given to reproductive health services is not, as you claim, a matter of placing "western utopianism before local pragmatism". John Havard Commonwealth Medical Association, BMA House, London WC1H 9JP, UK SiR-I was most impressed by your editorial on the United Nation’s Population Fund report on the world’s population. In this postmodern era of the politics of knowledge, in which the language of human rights has been abused beyond all recognition, it is particularly encouraging to know that some parts of the medical establishment still maintain a sense of fair play and justice. You refer to the dangerous strategy of "the new colonialism of the international women’s health agenda" and the fact that "gender equality is the social tool by which the UN sees its aim of population control being met". I was especially pleased that you question the assumptions of the reproductive health and family planning movement and the role of Halfdan Mahler, Secretary General of the International Planned Parenthood Federation (IPPF), in that movement. The fact that the UNFPA together with the IPPF have contributed more than US$100 m to China’s brutal population control programme since 1984, may partly explain the incongruity of holding a women’s rights conference in Beijing. Seamus Grimes Department of Geography, University College Galway, Ireland SiR-Your July 23 editorial distorts the findings of the UN Population Fund’s State of World Population report, which I edited. The report explains very clearly that: . reproductive health is only one aspect of health considered as a whole; . coercion in any form is morally and practically unacceptable; . its conclusions on reproductive health, like those of the 179 countries atending last year’s International Conference on Population and Development, are firmly based on experience over a quarter of a century; . women in most cultures are treated as second-class citizens. It is time this was ended; and the first step is to give women control over their reproductive function; . this will also help achieve the universally desired goal of slowing high rates of population growth. Choice for women means smaller families. As you say, the facts are unchallengeable and the conclusions self-evident. Tortured arguments about "new colonialism" and semantic discussions of the nature of equality are beside the point. Alex Marshall UN Population Fund, 220 East 42nd Street, New York, NY 10017, USA SIR-In your July 22 editorial you attribute to the United Nations-and by implication to the International Planned Parenthood Federation (IPPF)-the aim of population control, camouflaged by apparent concern for women’s equality and reproductive health. Such accusations are part of the stock-in-trade of Vatican spokesmen but are surprising in a Lancet editorial. It is bizarre to suggest that the UN (or IPPF) does not fully recognise the importance of women’s proper access to primary health care, clean water and sanitation, food, education, security, and so on. Just to give one instance, both we and many other international agencies have repeatedly stressed the importance of girls’ education in improving family health and women’s status, as well as in lowering fertility. To talk of international agencies "coercing women into adopting fertility control" betrays an extraordinary ignorance of the unmet need for family planning and reproductive health services in many countries. There are at least 150 million women (probably twice as many) who would like to control their childbearing but lack the information and means to do so. To us, it smacks more of "new colonialism"