Graft vasculopathy in clinical hand transplantation.

Allogeneic hand transplantation is now a clinical reality. While results have been encouraging, acute rejection rates are higher than in their solid-organ counterparts. In contrast, chronic rejections, as defined by vasculopathy and/or fibrosis and atrophy of skin and other tissues, as well as antibody mediated rejection, have not been reported in a compliant hand transplant recipient. Monitoring vascularized composite allograft (VCA) hand recipients for rejection has routinely involved punch skin biopsies, vascular imaging and graft appearance. Our program, which has transplanted a total of 6 hand recipients, has experience which challenges these precepts. We present evidence that the vessels, both arteries and veins may also be a primary target of rejection in the hand. Two of our recipients developed severe intimal hyperplasia and vasculopathy early post-transplant. An analysis of events and our four other patients has shown that the standard techniques used for surveillance of rejection (i.e. punch skin biopsies, DSA and conventional vascular imaging studies) are inadequate for detecting the early stages of vasculopathy. In response, we have initiated studies using ultrasound biomicroscopy (UBM) to evaluate the vessel wall thickness. These findings suggest that vasculopathy should be a focus of frequent monitoring in VCA of the hand.

China's demographic dilemmas.

PIP: The year 2000 marks the end of a tumultuous century in China's population history, which weathered the demographic effects of devastating famines, wars, and epidemics and population growth and change. This paper examines the effect of population policies on the demographic dilemmas of China. In the 1950s, China had seen the fastest demographic transition in history, with a dramatic decline in mortality rates, followed by a decrease in fertility rates. However, in the 1970s, revisions in population control measures, changes in age structure, and fluctuations in age at marriage resulted in lower fertility rates. The struggles encountered by China in regulating fertility are described; these include the different methods of birth control, gender preference, marriage, population aging, and minority populations. Population and development issues within the context of urbanization, employment, education, health care, economy, and environment are also discussed. Future implications of these findings indicate the need for a systematic, effective, and complete environmental clean-up, as well as fertility and population policies.^ieng

China's demographic dilemmas.

PIP: China's demographic dilemmas are discussed as the demographic surge during the 20th century, the demographic transition, the struggle to regulate fertility, population and development, and prospects for the future. Brief accounts are given of China's household registration system and the efforts in entry into the global economy. There are references, suggested readings, and discussion questions. Ample figures and tables express population growth, birth and death rates, fertility, sex ratios, population projections for these older than 65 and total population, contraception (IUDs, sterilizations, and abortions), abortion ratios, ethnic minority groups, provincial population data for 1990, schools and enrollment, health care resources, selected economic indicators, and availability of selected consumer items (sewing machines, watches, bicycles, electric fans, washers, refrigerators, televisions, radios, and cameras). Population planning has been successful in reducing the birth rate from 35/1000 in the 1950s to 20/1000 in the 1990s. 17 million persons are added annually. The projection for 2000 is 1.3 billion persons. The emphasis of the discussion is on the development and consequences of strict population planning control measures instituted in the 1970s and strengthened in the 1980s. In addition to curbing numbers, the measures have also led to a rapid aging of the population, a marriage squeeze, charges of female infanticide, and international censure. Population pressure is felt in urban areas, and in the labor force, education, and health systems. Industrialization has led to serious deterioration of natural resources. The gap between rural and urban population has widened.^ieng

Potential causes for the revival of early marriage.

PIP: The discussion of the causes of recent trends for early marriage in China focuses on the definition of early marriage, a critical review of current views on the causes, and the effect of changes in the age structure. Fluctuations in the age of marriage have occurred over the past 15 years, but there has been no trend toward gradual reduction in the age of marriage. The explanation for the early marriage increases between 1981 and 1984 is related to the coming of age of men born between 1956 and 1958 who reached the age of late marriage and there was a shortage of women born between 1959 and 1961. The only possibility was to marry women younger than 20 years. The definition of early marriage varied between the 1950 Marriage Law and marriages in the 1980s. In 1950, marriage of women included women under 18 years, and did not include women 18-20 years. After 1980, early marriage included women older than 18 years but under 20 years. The 1980 Marriage Law contributed to some of the change in early marriage, but there must have been other influences, because early marriages declined between 1985 and 1988. Empirical examination is possible only when data become available on the first marriages of people born between 1956 and 1958. It is anticipated that 1996 will be another year when a large number of young men born between 1971 and 1974 will reach marriage age; plans need to be made to counterbalance the effects of too many marriageable men and too few women 2-3 years younger and to offer family planning. The explanations for the increasing trend to late marriage include 1) the increase in women's status, economic and cultural development and improvement in living standards; and 2) the marriage age had always been on the rise since the mid-1960s and was closely tied to implementation of family planning. 3) The turning point was in the early 1970s and closely related to family planning. 4) Early marriage was considered undesirable and people adopted the government recommendation of later, longer, fewer. These views are in contrast to theories which suggest a close correlation between socioeconomic development and the retention of traditional feudal ideology, and the prevalence of early marriage in rural areas. Both traditional and modern view attribute early and late marriage to development. Another view is that declines in economic conditions in rural areas and the 1980 Marriage Law promoted early marriage. Analyses lack an explanation for the role of men and women in marriage decision making.^ieng

The new census of China.

PIP: This article presents a brief introduction to the 1990 census of China and some provisional results. Particular attention is given to the implications of the results for Chinese population policy.^ieng

China's population planning after Tiananmen.

PIP: The author reports on the meeting of the China Demographic Society in Beijing in January 1990. The one-child policy is reviewed, and political changes that have taken place since the events in Tiananmen Square and their effect on the family planning policy are discussed.^ieng

Second thoughts on the second child: a talk with Peng Peiyun.

PIP: Peng Peiyun, the 4th person to head China's National Family Planning Commission during the 1980s, was chosen because of her substantial experience in education and the belief that it is important to emphasize education in implementing population planning programs. Acknowledging the existence and scope of controversies relating to the 1 child policy, she accepts the premises of the proponents of the policy and reiterates that, given the country's demographic base, population control is imperative and correct. Peng identifies the over a dozen categories of exemptions to the 1 child policy that have been allowed from the start and added to the provincial regulations. China's Strategic Demographic initiative continues to be based on administrative directives and ad hoc local regulations. Whether and how to enact a national family planning law continues to be disputed. The controversy surrounds primarily what the ideal family size should be for China as a whole. Family planning regulations such as those adopted by Tianjin Municipality in November 1988 call for fines for those couples who have a 2nd child without approval. Peng suggests greater reliance on education in family planning activities, that is, more systematic and comprehensive efforts should be made to convince the population of the need to control population growth in macroeconomic terms. Despite the fact that China's population most likely will reach 1.35 billion in the year 2000, rather than Peng's assessment of 1.27 billion, Peng maintains that through education, China can succeed in curbing population growth. The focus of China's Strategic Demographic Initiative has been redirected in recent months to reducing, or, where possible, eliminating, births of 3rd and higher parities and births among legally underage couples (15% and 10%, respectively, of some 25 million births in 1987).^ieng

As China's one-two fertility debate turns.

PIP: China's promotion of minimal reproduction has failed to result in exclusively 1-child couples despite great efforts. Findings from a large-scale sample survey in Shanghai, Hebei, and Shanxi in April 1985, for example, indirectly document a 2nd child present in a significant number of households. Participants at the China Demographic Society Fourth National Conference, meeting in November 1985, took 3 different approaches. 1 view deemed the present 1-child goal worth working for, even if not fully realized. Others favored preventing 2nd births outside population plans and all births of higher parities but endorsed the existing practice of permitting exceptions according to local circumstances. In these 2 views, acceptance of the 2nd child either was ambiguous or amounted to passive accommodation with reality. A 3rd view favoring 2nd children deserves special attention, for it may turn out to be the direction of possible modifications in China's population planning programs. As reproduced in a table, the projections based on 2 children per couple bear a 1984 date but had been prepared by Liang Zhontang for publication in an internally circulated journal in 1983. These figures apparently also served as the basis for discussion at the 1985 Conference. Of much interest is the fact that the making of projections of this kind began with, if not before, the start of the "1-child per couple" policy. At the Second National Conference on Population in December 1989, Liang voiced various reservations about the 1-child limit, including that it would lead to a too rapid process of population aging and too many people without children at their side in old age. Liaing proposed that the country adopt a plan based on the 2 principal ingredients -- "xi" and "shao," i.e., longer spacing and few children -- of the Zhou Enlai fertility model of the early 1970s. Specifically, for the next several decades each couple would be allowed 2 children, provided that the interval between the 2 births would be strictly kept at 8-10 years. His plan also called for 30% of the couples to have only 1 child, but this provision was not to take effect until 1990 and would probably be more easily realized by education and propaganda rather than by strong administrative measures. After a lapse of 10 years, with the actual survival of the 1st child, the family routine would crystalize around 1 child, and a proportion of the couples would voluntarily refrain from having a 2nd child. Liang calculated in 1979 that implementation of his plan would yield a stationary population of 1.11 billion between 2010 and 2020, a figure that is now obsolete. Included in Liaing's proposal were population projections for 1984-2020. In sum, the vigorous implementation of the 1-child policy during the recent past has not stifled dissent. The feedback from those affected may have fostered constructive debates in China.^ieng

Tempest in China's population pyramid?

PIP: The returns of China's 3rd National Census confirmed its estimated size of over 1 billion people. China's age sex structure for 1982 has now been published from a computer tabulation of a 10% sample of the population. For the 1st time the issue of China's demographic future can be argued on a factual basis. Figuratively speaking, the country's 1982 population pyramid takes the form of a giant wasp. The narrow "waist" reflects extraordinarily high mortality in 1959-61, and the wider shoulders and abdomen result from a surge of relatively rapid growth in the 1940s and the baby boom of the 1960s. At the bottom, the wasp's tapered tail shows the impact of the intensified family planning program since the early 1970s. These recent age groups are smaller than their predecessors, but they are still quite large. The large number of China's parents-to-be between now and 2000 could still produce enough births to dwarf the previous baby boom no matter how low a fertility level they have. Of the total population increase of 467 million from 1949-82, about 190 million, or 41%, took place during 1964-73. China has worked hard to limit total population to 1.2 billion by the end of the century. The 1 child per couple policy epitomizes the country's effort to halt rampant population growth in the interest of national and individual welfare. The degree to which the 1.2 billion population goal has been realistic can now be based on more solid projections of the shape and development of China's demographic structure. Of China's approximately 463 million women and men below age 20 in 1982, 225 million are women who will turn 20 (the minimum age for marriage under the 1982 Marriage Law) during the next 2 decades. As of 1982, their older sisters had a total fertility rate (TFR) of 2.8. Series A of the projections assumes that China will be able to persuade the younger women to have, on average, just 1 child. The projection assumes that this will take 10 years from 1982 so that the TFR drops from its 1982 level of 2.8 to 1.0 in 1992 where it remains ever after. Under this projection, China's population would peak at just under 1.2 billion about 2007 and then begin to decline. Series B shows the results of a medium projection in which the TFR drops to 1.4. The high projection of Series C assumes that the 1 child fertility policy is largely unsuccessful and that the TFR declines to 2.1, the approximate level needed for natural, longterm "replacement" of the population. In Series D the TFR drops to 1.0 in 1992, stays there for 2 decades, and then rises in 10 years to 2.1.^ieng

Demography in China: from zero to now.

PIP: After 20 years of neglect the study of population and demography in China have come to be considered imperative. China has even accepted $50 million from the UN Fund for Population Activities to defray the cost of the 1982 census and help pay for action, training, and research programs. Institutions directed toward population studies have been established in many provinces during the 1970s. The principal types are population training and research institutes and offices within institutions of higher learning. In addition institutes outside the system of higher education and special units of population studies in various medical colleges were initiated. Between 1957-77 the large increase in population began to cause economic problems which were not admitted until the late 1970s. Since 1979 the country's efforts to lower the level of fertility have been organized in major policy statements calling for 1 child/couple and a rate of natural increase causing zero population growth by the year 2000. The Institute of Population Research was created in 1974 and it has provided population projections that have helped form population policy with a major focus on historical stages of growth in China as well as counteracting the lopsided population optimism which existed earlier. In 1978 a conference was held on the science of population theory which identified areas for study such as: 1) population and economics, 2) capitalist population theories, 3) population policies, 4) family planning and economics, and 5) population problems in foreign countries. The author describes some of the literature which was published after the 1978 conference and the reappearance of academic journals in 1979 as well as the 1979 conference. 1980 and 1981 studies dealt with such topics as debates on Malthusian theory, zero population growth, urban and rural populations, historical demography, housing, employment, health improvement of the population, minorities, and fertility determinants. Chinese scholars have also begun to cooperate with their foreign colleagues in a variety of studies. In order to illustrate the wide variety of directions which Chinese population studies are taking the author provides a bibliography of population studies from 1977-81.^ieng

China's experience in population control: the elusive model.

PIP: A critique of a report prepared for the Committee on Foreign Affairs of the U.S. House of Representatives titled "China's experience in population control: the elusive model is presented. The title is criticized, pointing out that the Chinese have done nothing "elusive," but, instead, have used methods familiar to family planning experts the world over. They have brought services close to home, used a variety of paramedical and lay people drawn from the community, have made services free, have offered a choice of services, and have used people from within the community for family planning education. Neither have the Chinese been secretive about it, as the report implies. It is the American refusal to admit that the People's Republic of China was the accepted government of the region which made Americans ignorant of developments. The report's author also seems unwilling to admit that the reason for the success of the program is that it has been integrated into a total plan for the improvement of socioeconomic conditions for the average person. Since 1949 some 200 million people have been added to the population of China, nearly the population of the U.S. Despite this large population growth, conditions have improved and the starvation which used to be common has been eliminated. Population growth has not been a bar to development. Any country which tries to reduce family size without putting it in a total context of development will find it difficult to succeed. Other developing nations cannot borr ow China's experience in toto as circumstances vary from country to country, but the essence is that no viable solution to population problems can be brought be fertility reduction invest as such. Meaningful socioeconomic change is also essential.^ieng

Marital moratorium and fertility control in China.

Abstract Since 1949, the issue of marital postponement has been extensively discussed in China. Unlike some other means of fertility control (e.g. abortion and oral contraception), marital postponement has been welcomed with the fewest misgivings. Lately, marital postponement has also been given renewed emphasis by those outside China who see a weak link between various current national family planning programmes based on improved technology and the goal of fertility reduction. One aim of this paper is to render a comprehensive account of the marital postponement programme in China in the course of the birth control campaign during the last two decades. The second objective is to discuss the lessons that may be learned from it, and its implications for the current fertility controversy in the United States. Four general conclusions emerge from a careful analysis of the available documents: (1) in China, proponents of delayed marriage were divided on the question of how to secure its general acceptance. One issue dividing them was whether or not China's Marriage Law of 1950 should be amended in order to achieve it. Those who favoured raising the minimum legal age disagreed on the details of the presumably needed change. There is enough evidence to suggest that medical personnel were the chief advocates of compulsory postponement of marriage. The government rejected this legalistic approach and, in so doing, agreed with Chen Ta (a noted demographer) and others who sought to achieve postponement of marriage through appropriate social and economic measures. (2) Decisions to delay matrimony in different socio-cultural settings are not necessarily identical sociological phenomena. In some societies, (e.g. the United States), they may amount to no more than a course of action that enables individuals involved to realize or develop alternate goals in life. In others (e.g. China), they are literally acts of rebellion. (3) The fertility policy dispute has been carried on in a context of revolutionary change, and involved persons who have committed themselves to transforming the Chinese family. This prior commitment was mainly responsible for the relative lack of controversy about marital postponement as a means of fertility control. (4) Use of contraception is private, hidden from open view. But postponement of marriage is public and may be a source of inter-generational and interpersonal conflict. In China and other parallel situations, a decision to delay marriage is in itself against tradition. In this sense, a full-scale marital moratorium cannot but be more than a partial assault on the hold that the family has over its offspring. This must be unequivocally reflected in discussions of fertility control policy everywhere.

Mobility, non-familial activity, and fertility.

In this analysis of fertility data from a sample of non-Catholic faculty couples in an American university, temporal patterns and variations in education, employment, marriage, and parenthood of the husbands and wives are discussed in reference to (1) the social mobility-fertility hypothesis and (2) a non-familial activity-fertility hypothesis.The couples are divided into four groups on the basis of family size and mobility status: (1) mobile-small, (2) non-mobile-small, (3) mobile-large, and (4) non-mobile-large. Whatever their mobility status, the four groups of husbands successfully completed requirements for the doctoral degree at about the same age and became established at about the same time in life and within the profession. Whatever their husbands' social origins, the wives also differ little with respect to educational attainment and in their work experiences in prematrimonial days. However, a different pattern is found in the work experiences of the wives since marriage. Those with two children are more likely to be employed after marriage and parenthood.On the other hand, a good many more wives with four or more children not only never worked before marriage but also remained outside the labor force after marriage (in the earlier years of marriage as well as after the tenth anniversary). The present data thus seem to support an analytically useful distinction between the "working wives" and the "working mothers."