I think that few of those over 50, would have believed at the beginning of the 21st century, that in a short time we will end up living in a period of deep crises: the energy crisis, the food crisis, the financial crisis, the climate crisis, the crisis of the health, the demographic crisis, etc. However, some current crises were predictable. In the scientific and academic circles, predictions have been made and are being made that later come true. One of these concerns is referred to the worrisome demographic situation, especially in developed and developing countries. Although the Republic of Moldova is far from being a well-developed country from an economic and social point of view, it has a dramatic demographic situation with direct existential connotations, and I can say that we have entered and are deepening into an obvious demographic crisis. The population of the country in the last 2 decades decreased by about 1/3, from over 4 million inhabitants to 2 million 800 thousand, with tendencies to continue the negative trend with another 20-30% towards the year 2035. 

            The definition of the demographic crisis encompasses the notions of declining birth rates, increased mortality and accelerated ageing with the decrease in natural population growth, along with uncontrolled emigration. All these components are commonplace in the Republic of Moldova. Of course the state authorities are aware of the situation and are trying to manage it. But unfortunately, very often the demographic situation, as well as other society problems, have been approached by the ostrich method (hiding the head in the sand so that maybe the tail cannot be seen) or unilaterally, without a broad, interdisciplinary involvement, of all those on whom the finding of solutions depends. And while in recent years the seriousness of the problem and the involvement of international institutions which have funded the development of projects have highlighted the situation, the approach still raises many questions. I have carefully studied recent reports on the demographic situation in Moldova. They are very comprehensive and up-to-date from a statistical, economic and social point of view. At the same time, the medical aspects of the problem are addressed briefly and somewhat unilaterally. Some timid solutions are also proposed, in various dimensions, but without a clear, multidimensional, state-level strategy for redressing the situation. I agree that the economic, financial and social aspects are very important in managing a demographic crisis, but they are not the only ones. The examples of France, Italy, and Spain, countries that are economically overdeveloped but with clearly negative demographic trends are eloquent. The improvement of the economic situation will contribute to the migration aspect of the problem. Other mechanisms, including medical and psycho-social ones, need to be put in place to solve the problem. Birth rate and fertility rates are the cornerstone of demography. Population numbers can only be increased by increasing the number of births. Then comes health maintenance, health being the main factor in social and economic development. There can be no social evolution without human beings, just as there can be no proper development when human beings are sick. Increasing life expectancy, reducing morbidity and mortality are important aspects because they can increase demographic indices, factors following birth. At the same time, social and economic factors influence the state of a country's sanitary system and directly affect health. Most medical demographic studies, until relatively recent ones, have paid more attention to mortality than to birth rates. It was and it is a salutary method of maintaining the health of the existing population. Most strategies in sexual and reproductive health were and are focused on the prevention of sexually transmitted infections, and in family planning on the use of contraception or safe abortion. This has been and still is the society demand. This is acceptable, but not enough. Everyday reality and my own medical experience over 30 years show other trends. About 15-20% couples or families cannot have children, or have fewer than they would want. The causes, mostly medical, are evenly divided between men and women. There are increasingly paradoxical situations when the couple uses contraceptive methods, including hormonal ones, for many years, and later it is found that they are in fact infertile. Therefore, there are situations of prescribing and using contraceptives without a basic evaluation, one of the causes being the small number of medical offices and specialists in the field or the lack of access to quality medical services. Unfortunately, in most sexual-reproductive health policies the focus is only on women's health and only in the last decade in some countries are state doctrines and policies emerging for men. The average time from the detection of the problem to the visit to an andrologist in the Republic of Moldova is about 1.5-2 years. The state sector in the field of sexual and reproductive health is practically absent. In the private sector services are expensive and there are often doubts about their quality. There are many gaps in the sexuality education system, and the younger generation is educated with the idea that sexual activity is mostly for pleasure and can start early, pregnancy must and can be prevented, sexually transmitted diseases can be avoided by using condoms, and planning the birth of their own children is somewhere in the very distant future, if at all. This doctrine has positive sides, by reducing the frequency of sexually transmitted diseases (not the papilloma virus) and the number of abortions, but at the same time it leads to an increase in the level of promiscuity (a large number of sexual partners), the decrease to complete disappearance of the phases a sexual act and the importance of a heterosexual family. This leads to the fact that people focus more on themselves, increase in the number of divorces and the tendency to have the first child after the age of 40. 

            A new approach to demographic policies at national level is obvious and imperative, with direct coordination of state bodies and the involvement of all those who can change the situation, not only formally but in reality. The first concrete steps that can be taken are to increase access to quality reproductive health services for both women and men. The Ministry of Health and the Nicolae Testemițanu SUMPh can get involved by training medical staff and carrying out scientific research, the National Health Insurance Company by funding programs for the diagnosis and treatment of infertile couples, including invitro fertilization, the Ministry of Labor and Social Protection by creating appropriate instruments to support young mothers and children, etc... In addition, of course, national and international financial institutions by providing real funding according to needs and not through derisory allocations. 

            We must remember! As long as the focus of any demographic approach is not on people and human health, any population growth initiative is doomed to failure.

Ion Dumbraveanu, MD, PhD, Leading research project „Male infertility - systemogenesis of risk factors, study of pathological mechanisms and optimization of prevention, monitoring and treatment strategies in the population of the Republic of Moldova”.