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New York Review of Books
Monday, August 18th, 2008
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Fatal Misconception: The Struggle to Control World Population

by Matthew Connelly

The Strange History of Birth Control

A review by Helen Epstein

This review also covers Reproducing Inequities: Poverty and the Politics of Population in Haiti

In the 1920s it was illegal to advertise contraceptive diaphragms in the US or send them through the mail, and anyone who wrote about them risked imprisonment for indecency. The devices were entirely banned in some states, and in others doctors prescribed them only to women for whom pregnancy posed a clear health risk, if at all. Most couples relied on condoms, withdrawal, and douches, including the popular disinfectant Lysol, which was advertised in magazines along with "fountain syringes."

Margaret Sanger, the founder of the American Birth Control League, which became Planned Parenthood, and her allies eventually succeeded in making safe, reliable contraceptives -- including condoms, diaphragms, intrauterine devices (IUDs), and hormonal pills and injections -- accessible to millions of people throughout the world. But for years their campaign was opposed by two powerful forces. Eugenicists knew that white, middle-class women were more likely to use birth control than other ethnic groups or the poor. Making contraceptives more available would therefore only exacerbate what they saw as the problem: the swamping of the Nordic and Anglo-Saxon races by imbeciles, blacks, Asians, and eastern and southern Europeans. Meanwhile, the Catholic Church, bent on preserving its doctrine that procreation must be the primary purpose of sex, declared contraception sinful.

Two fascinating new books, Fatal Misconception: The Struggle to Control World Population by Matthew Connelly and Reproducing Inequities: Poverty and the Politics of Population in Haiti by M. Catherine Maternowska, show how this impasse was finally, if imperfectly, resolved. Today, family planning services are available throughout the US and even in remote parts of many developing countries. This is largely the result of an extensive, US-led effort during the 1960s, 1970s, and 1980s. Researchers invented cheap, easy-to-use contraceptives, and a global network of governmental and nongovernmental agencies, research centers, and think tanks developed the means to deliver them through specialized clinics, mobile vans, and door-to-door community distribution programs.

The family planning movement is one of the great success stories of public health. Birth control enables women to be more economically and socially independent, which may be crucial for sustainable development in general. It also enables them to lengthen the intervals between pregnancies, which improves child health and reduces the risk of fatal birth complications and abortion. However, the books under review remind us that at one time, these benefits were seen by many US family planning officials as secondary to the goal of reducing the absolute numbers of people in developing countries. The urgency of what came to be known as the "population control movement" contributed to a climate of coercion and led to a number of serious human rights abuses, especially in Asian countries. Family planning experts, in promoting the distribution of new contraceptives, sometimes failed to ensure their safety, and the staffs of local programs sometimes bullied people into using them, or even into being sterilized. Coercion was never a stated US family planning policy, but in their zeal to fight overpopulation, American policymakers, agency bureaucrats, and researchers often overlooked how local officials were interpreting their directives. They also did far too little to halt or at least distance themselves from the most abusive programs.

When I mentioned to friends who work in the family planning field that I was reviewing these books, nearly all of them expressed anger at Connelly in particular, for "dredging up" this history and for failing to emphasize the positive aspects of the population movement. After all, these events occurred decades ago, and today funding for international family planning programs is severely threatened by religious conservatives in the US Congress, some of whom equate taking birth control pills with "murder." These books only add "fuel to the furnace" in which the Christian right would like to incinerate family planning, one expert told me.

He had a point. Most family planning programs were not coercive and Connelly does dwell excessively on those that were and far too little on the benefits of contraceptives to individuals and even entire societies. But Connelly and Maternowska also have a point, which is not only about the unintended harm caused by well-intentioned but poorly run development programs. The mistakes those programs made -- and not Connelly or Maternowska, who merely report them—provided fuel for the religious right, and these books, though painful to read, contain many valuable lessons for anyone who cares about making development programs work, both technically and politically.

These writers arrive at similar conclusions from different perspectives. Catherine Maternowska is a feminist anthropologist who spent several years observing the collapse of a particularly disastrous family planning program in Haiti. Connelly, a historian of the cold war, is an outsider to the partisan strife in the population field. His only declared source of bias is that he comes from a family of eight children. Both authors endorse the right of women everywhere to control their own fertility and support US funding for family planning services overseas. But they both argue strongly that programs narrowly focused on cutting fertility rates alone often fail, even on their own terms, when they overlook the many other priorities in poor people's lives.

Until the late 1940s, world population growth was a concern mainly for eugenicist cranks. Demographers were aware that population was soaring -- it had doubled in the previous three hundred years and they rightly predicted it would triple in the next sixty -- but most maintained there wasn't much you could, or should, do about it because population would stabilize on its own. Improved living standards, including better nutrition, health care, and education, led to the survival of more children. But at the same time, urbanization and wage employment, along with a growing culture of individualism, consumer aspirations, and secular patterns of thought, created a general desire for smaller families.

The fastest route to lower birthrates was therefore through development and modernization, and the best way for governments to reduce population growth was by investing in human welfare, especially in health care, education, and the reduction of poverty. Promoting birth control and opening clinics would certainly help those mainly white, middle-class women who were already trying to practice family planning by whatever folk methods (withdrawal, Lysol, etc.) were available. But the overall birthrate was held to be determined by social conditions and the spread of ideas, religious beliefs, and attitudes concerning the value of having children, women's role in the family, and so on. Already, birthrates were plummeting in many Western countries, with or without Margaret Sanger's clinics. It seemed likely that they would soon begin to fall in the rest of the world, too, as it developed and modernized.

Then, sometime around 1950, the demographers changed their minds. Their articles and reports increasingly referred to rising world population as a "Frankenstein" monster, as demographer Kingsley Davis put it, threatening economic chaos, ecological disaster, and wars over food. Suddenly population control was the leading edge of development, not the other way around, and the fate of the planet seemed to hinge upon the rapid expansion of family planning programs, especially in Asia. In 1966, President Lyndon Johnson declared that five dollars spent on population control was worth one hundred dollars spent on economic and social development. He was particularly concerned about the situation in India, where reporters and academics, including Paul Ehrlich, author of the 1968 best-seller The Population Bomb, were dispatching accounts of squalid, teeming slums, mass starvation, and imminent political collapse.

According to these observers, India's population was soaring because colonialism had trapped it in a "low mortality high fertility" phase of development. The British had installed public health reforms and improved nutrition in the subcontinent, but in seeking to preserve markets for their own manufactured goods, they had discouraged industrialization. Thus the changes in norms and values and the consequent shift to be expected in an industrial society toward individualism and small nuclear families had not occurred. India's "rigid caste system" and "other-worldly religion" made it especially resistant to modernization, according to Kingsley Davis.

While famine loomed, Johnson used food aid to pressure the Indian government to meet its family planning targets. When Johnson's adviser Joseph Califano suggested increasing relief in advance of a visit by Indira Gandhi to the US, Johnson replied, according to Califano, "Are you out of your fucking mind? I'm not going to piss away foreign aid in nations where they refuse to deal with their own population problems."

By the early 1970s, Bangladesh was spending one third of its entire health budget on family planning and India was spending 60 percent. These programs brought services to many people who wanted them, but sometimes did so while ignoring other needs, like the safety of those services, as well as other health care, food education, dignity, and humane treatment.

Connelly shows that between the 1960s and 1980s, millions of people in India and other Asian countries were sterilized or had IUDs, as well as other contraceptives, inserted in unhygienic conditions. Numerous cases of uterine perforation, excessive bleeding, infections, and even death were reported, but these programs made little effort to treat these conditions, or even determine their frequency, so we don't know precisely how common they were. However, Connelly's account gives us some idea.

One way to increase the use of contraceptives was to promote devices that required as little decision-making and technical skill as possible on the part of the user. In the 1960s, researchers came up with new IUDs and hormonal methods of contraception such as Depo-Provera and Norplant that could prevent conception for months or years; but not all of them were safe. Some of the early IUDs posed significant risks of infection, sterility, and death. During the 1960s, the US Population Council, a private organization supported by foundations and the US government, sent large shipments of unsterile IUDs to India, with too few inserters. The council officials involved must have known how difficult it is to sterilize equipment in rural India, and that contaminated inserters would undoubtedly be reused. When American patients sued A.H. Robbins Corporation in the 1970s because its defective "Dalkon Shield" IUD heightened the risk of infection and uterine perforation, USAID quietly bought up thousands of the devices at a discount for distribution overseas. As Connelly shows, they were inserted into nearly half a million women in forty-two developing countries before they were finally recalled in 1975.

As side effects made IUDs and long-acting hormonal contraceptives increasingly unpopular, locally run and US-supported family planning programs kept up their quotas by urging men and women to be sterilized. During India's "State of Emergency" in the 1970s, sterilization was made a condition for receiving land allocations and water for irrigation, as well as electricity, rickshaw licenses, and medical care. Connelly quotes a Swedish diplomat touring a joint Swedish/World Bank population program at the time who admitted, "Obviously the stories...on how young and unmarried men are more or less dragged to the sterilization premises are true in far too many cases." Indian officials recruited many men and women for sterilization programs by paying them nearly three times the annual wage of the average Indian at the time. Especially in the poorest areas where food was scarce, large numbers of people volunteered for sterilization, including a sizable number of women in their fifties and men in their seventies and eighties.

Even China's draconian population programs received some support in the 1980s from the US-funded International Planned Parenthood Federation and the UN Population Fund. Before China launched its infamous "One Child Policy," concerns were being raised about its "voluntary" family planning program. In 1981, Chinese and American newspapers reported that "vehicles transporting Cantonese women to hospitals for abortions were 'filled with wailing noises.' Some pregnant women were reportedly 'handcuffed, tied with ropes or placed in pig's baskets.'"

After 1983, coercion became official Chinese policy. "All women with one child were to be inserted with a stainless-steel, tamper-resistant IUD, all parents with two or more children were to be sterilized, and all unauthorized pregnancies aborted," according to the One Child Policy. During this time, the International Planned Parenthood Federation and the UN Population Fund continued to support China's nongovernmental Family Planning Association, even though some of its top officials also worked for the government.

Outside of Asia, family planning programs were not nearly so coercive, but in their single-minded quest to boost the numbers of contraceptive users, many were inhumane in other ways. In Reproducing Inequities, Catherine Maternowska describes one such program in great detail. If ever there were a place in need of family planning services, it would be Cite Soleil, a vast slum in the Haitian capital of Port-au-Prince. As Maternowska describes it, the burdens of overpopulation are everywhere to be seen there: in the filthy streets, the air choked with exhaust fumes; in the dark, crowded shacks; in the faces of feverish, bloated children in rags.

Many of the people who live in Cité Soleil are migrants from the Haitian countryside, where the legacy of the exploitation of the peasantry, first by French colonists and then, after independence in 1804, by mulatto elites, created a Malthusian nightmare. Peasants produced large families so they could grow more crops on their small parcels of land; but the more children they produced, the more the land was depleted. Today, this once lush island nation is almost entirely deforested, and some thirty-six million tons of fertile topsoil are lost through erosion each year. Eighty percent of the population lives under the official poverty line and only half of all adults can read. At the time of Maternowska's study, the women of Cité Soleil bore an average of 4.7 children each.

In 1983, a family planning clinic supported by USAID opened in Cité Soleil. Its staff of doctors, nurses, and pharmacists—all relatively privileged Haitians—conducted physical examinations and helped women choose a contraceptive method, placing particular emphasis on long-acting contraceptives such as Norplant and Depo-Provera. The clinic also employed a team of family planning "promoters" who went from door to door in the slums urging women to attend the clinic. The clinic staff and the promoters were in the unenviable position of having to mediate between their American funders, who measured their success in numbers—prescriptions filled, people sterilized, etc. -- and their potential clients, often very poor people whose desire for children was rooted in the complexities of their daily lives.

By the early 1990s, regular use of contraceptives in Cité Soleil had reached a meager 10 percent, and the birthrate had risen slightly since the program began. One reason the program failed was that the precarious economic situation in Cité Soleil had made fairly regular childbearing a virtual necessity for many women. In order to survive, poor women had to rely on men, and the only way to secure a man's loyalty was by bearing his children. But Haitian men had problems of their own. Most were unemployed or were forced to compete for the small number of day-labor jobs working on building sites or hauling charcoal in the slums. These difficulties, rather than discouraging the men from having children, apparently challenged their sense of masculinity, sometimes prompting macho demands that their women not use contraception because it would make them "loose" or promiscuous.

"You just keep having children. This is how you keep a man," Sylvia, mother of twelve, told Maternowska. "If you don't give [children] to him, he doesn't give [money] to you.... And sometimes even if you do give, you lose anyhow. Life is hard."

Women would do anything to keep a man. There was a brisk trade in sexy outfits and wild rumors circulated about love potions, some from voodoo healers, some home-made, including rice and beans cooked in water in which a woman had washed her underwear. The only way a man could resist the owner of the underwear, it was said, was by eating rice and beans cooked in water in which his mother's underwear had been washed.

Maternowska found that the relatively elite, and overwhelmed, staff at the Cite Soleil family planning clinic had no time or inclination to fathom their clients' problems. The long-acting hormonal contraceptives they promoted sometimes caused alarming and dangerous side effects, such as bloating, dizziness, and excessive bleeding, a considerable hardship in a slum where sanitary pads were nonexistent and where even rags came at a premium. When women expressed fears or complained, the doctors and nurses were often gruff and dismissive. One woman, wishing to have her Norplant removed, was called an animal by her doctor while Maternowska looked on. When another doctor advised a very poor young woman to feed her baby eggs and vegetables, the woman asked, "Where am I going to find these things?" The doctor changed the subject and advised her to go to the pharmacy for contraceptive pills.

As political tensions in Haiti increased during the late 1980s, the clinic, already unpopular in the community, came to be seen as a den of political intrigue. Rumors circulated that USAID was using it as a front for a violent paramilitary group opposed to then presidential candidate Jean-Bertrand Aristide. On October 15, 1995, a motorcade taking Tipper Gore, wife of the US vice-president, on a tour of Port-au-Prince was stoned by protesters, shattering the windows of two of the cars. The assailants were aiming at the Haitian director of the family planning clinic, not Mrs. Gore, but the event marked a low point in US–Haitian relations.

For Maternowska, the only way out of this impasse is through economic development and the protection of human rights. During her research, she discovered that family planning programs can work in Haiti if they are linked to broader efforts to improve people's lives. In the 1960s, a project that combined pig farming, small business loans, and family planning resulted in 40 percent of couples using contraception, a rate four times higher than that achieved by the program she was studying. But by the 1970s, such broad development programs were rare as US-funded programs became increasingly narrowly focused on raising the numbers of family planning "users."

In September 1994 a broad coalition of women's rights activists, public health experts, academics, and family planning advocates came together at the UN International Conference on Population and Development in Cairo, Egypt, and committed itself to ending all population programs that were "target-based," i.e., with specific numerical goals. From then on, programs were to support the right of all women to make their own family planning decisions, and services were to be provided in ways that supported women's health and human rights in general. By then it was clear that coercive family planning programs were unnecessary. During the previous two decades, birthrates had declined across the developing world as people adjusted their expectations and desires to changing livelihoods and social norms. This occurred just about as rapidly in places with limited population programs as in those with very aggressive programs. This is what the demographers had predicted in the 1940s, before they lost their sense of social and historical perspective during the panic and political turmoil of the 1950s.

Unfortunately, by the 1990s the abuses of the past were well known, and this emboldened the American Christian right, which had its own agenda. In November 1994, just two months after the Cairo population conference, the Democrats lost control of Congress to a Republican majority that included a number of powerful conservative Christians. Their very first act was to slash USAID's family planning budget by 35 percent. Claiming to be defenders of human life and dignity, they then proceeded to launch a crusade to curtail abortion rights, install "abstinence only" programs in schools, and otherwise promote what they considered "family values" but what many others considered an attack on women's rights. As a result, millions of poor women throughout the world still lack access to safe, voluntary family planning services. Having at one time urged contraception on many poor people who may not have wanted it, the family planning movement now finds that many people who do want it still can't get it.

Recently, a number of family planning advocates have resumed warning us about the dangers of overpopulation. Wars in the Middle East and Africa, food shortages throughout the developing world, and even global climate change have all recently been attributed to "population pressure." Some of these groups use language that is worryingly similar to that of the "population bomb" alarmists of the 1950s and 1960s.

In fact, population growth alone probably isn't the political or economic threat that so many people feared. In the 1950s, demographers produced studies showing a modest correlation between economic growth and reduced fertility, but these were largely refuted in the 1980s. In any case, it is debatable whether Congo and Kenya would be more stable and prosperous if there were half as many Congolese and Kenyans. The 1994 Rwanda genocide has sometimes been attributed partly to overpopulation, but the brutal eviction of the Tutsis from many of their farms -- which was later seen as a major cause of the genocide -- occurred in 1959, when there were only one third as many Rwandans. Likewise, attributing crises in the Middle East to population growth, as The Economist recently did, overlooks underlying issues of politics and justice.

The greatest threats to the global climate come from China and the West, where birthrates are extremely low. The future of the planet depends less on the number of babies born in Uganda than on the choices we in the West make, which, at the moment, are not good ones. As recently as 2004, a Japanese study found that when shopping for cars, Americans cared more about the size of the cup holder than fuel efficiency. Our habits may be shifting, but ever so slowly.

Even the food shortages now causing so much suffering in the developing world would be more effectively addressed by pragmatic policy changes in rich countries than by aggressive population control in poor ones. We could, for example, end the boondoggle of rich-country farm subsidies, especially those for corn-based ethanol "biofuels" which aren't more energy-efficient than ordinary gasoline. We could also devote more foreign aid to agriculture in developing countries, something that development agencies have long neglected; such aid might include encouraging poor farmers to use new technologies, including genetically modified seeds. We could also do more to improve access to comprehensive education and primary health care, including voluntary family planning, in developing countries. If we did all these things, we could vastly improve the quality of life for millions of people, while population took care of itself.

As Amartya Sen pointed out in these pages fourteen years ago, the key to lowering birthrates and improving "population quality" -- as the eugenicists would say -- lies not in contraception alone but in education, health care, and in empowering women. Educated women have fewer, healthier children, and healthier children generally grow up to be stronger, taller, and more intellectually capable adults, who themselves have smaller families. Unfortunately, during the heyday of the population control movement, donor governments, including the US, seemed inclined to do as little as possible to improve the health and education of the children people did have.

As funding for population control programs soared in the 1980s, other development programs were slashed. In the aftermath of the debt crisis of the 1970s, rich country donors made development loans conditional on civil service cuts. Thousands of teachers, doctors, and nurses throughout the developing world saw their salaries dwindle and their jobs disappear. Agricultural support programs vanished and the very walls of clinics and schools crumbled to the ground. In those clinics that remained, many poor patients would find that contraceptives were the only subsidized and thus affordable medical assistance available to them. The message this conveyed about the perceived value of their lives must have been clear.

It would be all too easy to attribute these development policies to eugenicist tendencies lingering from bygone days, but fortunately neither Connelly nor Maternowska does so. What really set off the "population alarm" in the 1950s probably had more to do with fear of the turmoil of decolonization and development itself. Western policymakers knew from the history of their own societies that while political independence, industrialization, the growth of towns, and the expansion of trade created new forms of wealth, they also brought urban unemployment, rootlessness, overcrowding, strained gender relations, inequality, racial tension, environmental pollution, and epidemics of tuberculosis, cholera, and other diseases. Particularly after the Communist takeover of China in 1949, Washington policymakers began to fear the rise of an increasingly resentful -- and rapidly proliferating -- global population of poor people who were easily susceptible to radical ideas and militaristic leaders. But in the end such people, if they threatened anyone, were mainly a danger to themselves.

Today we face a set of problems in some respects similar to those we faced in the 1950s: political and religious movements we don't fully comprehend; a global economy that currently excludes vast numbers of poor people; a sense that sacrifices need to be made somewhere to save the planet. Meanwhile, just as in the past, our policymakers sometimes regard human rights, especially those of non-US citizens, as a luxury we can't afford right now because addressing terrorism and other threats is more important. The population control movement was a small part of US foreign policy, but its history reminds us of the point American policymakers keep missing: universal human rights are not a luxury. They are themselves the goals we should be seeking.

Helen Epstein's book book The Invisible Cure: Why We Are Losing the Fight Against AIDS in Africa was published last year.


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