Upping the ante

Refusing to admit the implications of these findings, many governments and international agencies have responded to the marginal impact of family planning programs by upping the ante: designing ever tougher programs involving long-term injected or implanted contraceptives, sterilization, and financial incentives and penalties.

One example is the injectable contraceptive Depo-Provera. Although considered too hazardous for general use in the United States, it has been widely distributed in third world countries. Known short-term side effects include menstrual disorders, skin disorders, headaches, weight gain, depression, hair loss, abdominal discomfort, loss of libido, and delayed return to fertility. And while long-term side effects will not be known for some time, preliminary studies suggest that Depo-Provera is probably linked to an increased risk of cervical cancer.⁵⁴ The World Health Organization (WHO) and the International Planned Parenthood Federation (IPPF) approved Depo-Provera for use in the third world while it was banned in the United States, arguing that overpopulation requires an "entirely new set of medical standards for developing countries."⁵⁵ Another example is the hormonal implant Norplant, which is increasingly being used in the third world despite side effects being reported in 64.7 percent of users.⁵⁶

The sterilization of women continues to be the preferred course of birth control in much of the third world, usually funded by Western donors. In many countries doctors, nurses, and paramedics have numerical sterilization targets they have to meet. Studies in India and Bangladesh show how in their urgency to meet their targets, nurses and doctors act hastily and hazardously, often disregarding their patients' needs and complaints. Furthermore, a variety of material incentives are used to induce patients to undergo sterilization or to use contraception.⁵⁷ Defenders of incentive programs stress that they are voluntary, but when you are hungry, how many choices are voluntary?

Sri Lankan scholar Dr. Asoka Bandarage reports that "not only do poor people lack all relevant information, but, in many cases, the desperation of poverty drives them to agree to accept contraception or sterilization in return for payments in cash or kind. In such cases, choice simply does not exist. Direct force has reportedly been used in some countries . . . however, coercion does not pertain to simply the outright use of force. More subtle forms of coercion arise when individual reproductive decisions are tied to sources of survival like the availability of food, shelter, employment, education, health care and so on."⁵⁸ In Thailand, for example, roads, transportation, and latrines have been tied to the acceptance of contraception.⁵⁹

The use of heavy-handed publicity campaigns, numerical targets, and subtle coercion had perhaps their saddest consequences in Puerto Rico. After the United States seized the island from Spain in 1898, U.S. sugar companies rapidly set up vast plantations while engaging in the wholesale eviction of small farmers. By 1925, less than 2 percent of the population owned 80 percent of the land, and 70 percent of the population was landless. With so many people out of work and livelihood, Puerto Rico suddenly had a problem that U.S. colonial officials labeled "overpopulation."⁶⁰

In the 1940s light manufacturing industries began to move in from the U.S. mainland, attracted by cheap labor and low taxes. Young women were a key and "docile" part of that labor force, but subject to "loss" (from the employer's point of view) due to pregnancy. The result was a massive sterilization campaign carried out by the local government and the IPPF, with U.S. government funding. Women were cajoled and coerced into accepting sterilization, often not even being told that the process wasn't reversible. The result was that by 1968 one-third of the women of childbearing age had been sterilized.⁶¹ The combination of mass sterilization and heavy out-migration due to a declining economy caused the population of Puerto Rico to actually drop-with no resultant improvement in living standards, or the environment.⁶²

The television documentary La Operación vividly portrays the anguish of now middle-aged, childless women in depopulated Puerto Rican towns.⁶³ It is impossible to witness their tearful testimony of lives filled with loneliness and not sympathize with Asoka Bandarage and reproductive rights activist Betsy Hartmann when they characterize such programs as violations of the most basic of human rights.⁶⁴

We may be witnessing a similar tragedy-in-the-making in Mexico, along the northern border with the United States. There many of the U.S.-owned maquiladora factories employing young women demand negative pregnancy tests as a condition of employment. Some even go so far as to require that female employees show their menstrual pads to a supervisor every month in order to keep their jobs.⁶⁵

Here in the United States we face the specter of similar programs. Economic incentives for women on welfare to use Norplant inserts have been proposed by various state legislators including David Duke of Ku Klux Klan infamy. While such bills haven't yet passed, Norplant has been introduced into public school health clinics in several cities.⁶⁶ In fact, the attack on minority "teenage pregnancies" in the United States smacks of racism and misinformation in the same way as do many of the arguments about third world overpopulation.⁶⁷

Can investment in birth control bring down fertility rates without broad socioeconomic change taking place? The case of La Operación suggests that it can, though no one should want to repeat that experience. Many family planning advocates today point to the experience of the Matlab region in Bangladesh as an example to be replicated.⁶⁸

The most famous "social experiment" in family planning was carried out in Matlab by the International Center for Diarrheal Disease Research with funding from Western donors. The region was chosen because it was "uncontaminated" by any mother and child care system prior to the experiment's inception.⁶⁹ The project began in 1977 by providing half the villages in the region with intensive family planning services, including fortnightly home visits by a health and family planning promoter. The other half of the villages received no special services. By 1990 contraceptive use in the intensive villages was more than double that of the control villages, and fertility was a less impressive quarter lower.⁷⁰ This experiment does prove that intensive family planning alone, in the absence of any other change, can reduce fertility. But the financial costs were so high-$120 per "birth averted," or 120 percent of the per capita gross domestic product⁷¹-that the results are "not replicable at a national scale, let alone everywhere in the developing world."⁷²

Such concerns led researchers to cost-cutting experiments, which showed that with a minimal package it is still possible to raise contraceptive use rates. They concluded, for example, that prenatal care and midwife training were superfluous, and that teaching about oral rehydration therapy for infants suffering from diarrhea actually interfered with contraceptive education and thus should be tossed as well.⁷³ The implications are grave. As Betsy Hartmann put it: "By holding up Bangladesh as a model, the population establishment is turning the whole concept of development on its head: it's all right if the poor stay as poor as ever, just as long as there are fewer of them born."⁷⁴ This is what we earlier called a "negative way that fertility can decline."