The business of avoiding babies

Bela Malik Delhi

Population control is ensconced in ideology, technology, industry and, of course, health, but at the cost of women's well-being.

The billion mark of a fecund nation worries arithmeticians who simply divide India's national income by its population and yearn for a total fertility rate (TFR) down to a replacement-level of 2.1. India's obsession with population control has traversed coercive birth control, family welfare, and now embraced "reproductive and child health" that ostensibly empowers women by providing them with a menu of contraceptive products. To dispel any doubt about the bottom line, a two-child norm was introduced for participation in panchayati raj institutions by an amendment to the decade-old panchayati raj act. The United Progressive Alliance (UPA) in its national common minimum programme declared war on high fertility in some districts, creating a conducive atmosphere for non-informed consent to controversial women's contraception by NGOs, private players and other interested agents (DKT International-India presenting what it calls "alternative business models for family planning" is active in districts in Bihar). The National Population Policy, 2000, maintained that India has 1 billion (100 crore) people, i.e. 16 per cent of the world's population on 2.4 per cent of the globe's land area, and if this trend continues, then resource endowment and environment are likely to suffer. A stable population remains the goal. The policy document points out that females in India tend to reproduce "too early, too frequent, too many".
Causal connections established between population and poverty found easy route from the mighty alarmists in the North (encirclement, extinction, immigration concerns, arising from differential fertility rates as between the global North and South) to India. Mohan Rao, public health academic, in a scathing critique of this Malthusian perspective pointed out that these proponents will not say that a household is poor because it has little control over productive resources. What they say is that it is poor because relative to the resources it owns it has too many people. Ample research has been brought to bear against demography zealots to point to lack of sufficient cause-and-effect relationship between a growing population, economic development and the environment.
Despite the evidence mounted against neo-Malthusians and the opposition of women in the health movement, the emphasis on population stabilisation rests less on total health and more on contraceptives. There is a touching belief in the ability of reduced births to bring about revolutionary changes in the bulk of a nation's population. Efforts to induce a demographic transition through birth reduction require intervention. Apart from awareness (brainwashing children in schools through textbooks and media campaigns), abortions and sterilisations, the goodies roll out: injectables, vaccines, patches, emergency contraception, spermatocides, implants, pills and others (condoms, vaginal rings and intrauterine devices). Birth control fundamentalists are obviously comfortable with a war against birth rates. Ashis Bose, founder member of the Indian Association for the Study of Population is on print with, "The main reason for the success of the Indonesian model is the excellent military style logistic in naming the programme. In India we have an overdose of democracy." (Financial Express, January 4, 1994) Coercion did not meet its objectives. The emergency in India smoothened the way for 8.26 million sterilisations between April 1976 and March 1977, more than the number done in the previous five years and more than the number done at any time in any other country in the world. Still the Fifth Plan birth rate targets were unmet. Most of those sterilised were poor, Muslim, dalit, illiterate and lower caste. The easiest way to reduce poverty has been to reduce the number of poor, the non-entitled section that makes the least demands on resources, but is unfortunately the most unseemly.
A study by Malini Karkal disclosed that the National Family Health Survey (NFHS), (International Institute for Population Sciences, 1995, National Family Health Survey 1992-93) which collected data from 99 per cent Indian population, found that the TFR has declined from 5.1 in 1971 to 3.39 in 1992-93. It found that 84 per cent of the total users used terminal methods such as sterilisation and that of the total sterilised, 88 per cent were female (average age in some states being 24-26 years). Majority of the sterilised were found not to have used any temporary method before (http://www.gendwaar. India's prevalence of modern methods in 2000 was 42.8 of which 36.1, the bulk, was sterilisation (oral contraceptives 2 per cent; injectables, implants and intrauterine devices are officially low at 1.6).
After the political fallout of male sterilisation in post-emergency India (1975-77), gentler ways were sought to be devised, but with little success. Population control agendas rode on prettier-sounding concerns of reproductive health, women's empowerment and choice. Striking is the sex bias in offering choice to the "target" to control population through invasive reproductive technologies under the cover of mother and child health. The all-new improved packaging for women's contraception paved the way for profiteers. The largest segment, hormonal contraceptives, is dominated by hundred-odd "big boys", mostly North-based (including Pfizer with a $3.5 billion turnover), who are able to hold the world, including the World Health Organisation (WHO) and the United States Food and Drug Administration (US FDA), to ransom. In general the contraceptive trade is big. UNFPA, according to its procurement officer, David Smith, does an annual $155 million worth of business, of which contraceptives make up about half (it was higher earlier). The global contraceptives business is $4 billion, of which, because of high prices, the US makes up half ($2 billion). There is disproportionate weight on women's contraception by international agencies and pharmaceuticals. For example, UNFPA, the world's largest supplier of contraceptives to developing nation governments, deals with only 22 per cent of condoms. The rest is made up of pills (27), implants and trochars (2.12), and injectables (the largest at 45 per cent).
How do the controversial products of this lucrative business find themselves in women's bodies? The pharma-donor-government links are becoming a nexus. NGOs distribute the products through vertically delivered, unaccountable and scattered social marketing, which is outside public regulatory gaze. NGOs that work directly with international organisations such as DKT International, Population Service International include hormonal contraceptives as part of their "reproductive health package". A representative of Janani/DKT International-India, Bihar, observed that Depot Medroxy Progesterone Acetate (DMPA) was less painful to women to take as an intramuscular injection in a 3 ml dose than a 1 ml dose. Saheli activists recounted that Parivar Seva Sanstha (PSS), an Indian NGO active for over 20 years in distribution, post-marketing surveillance and building a body of information in favour of injectable contraceptives, organised a meeting in Manesar, Haryana, in October 2004, supported by MoHFW, Packard Foundation and UNFPA. Senior managers of Pfizer, producer of DMPA, were present at the meeting. Here the "Forum for Expanding Contraceptive Choices" was rechristened "Advocating Reproductive Choices" (ARC) and many NGOs were reportedly joining the forum with its secretariat at PSS. ARC with its representatives of health professionals, service delivery organisations, manufacturers and suppliers of contraceptives, international reproductive health experts, called on the Indian government to "strengthen the availability of injectables", deemed to be a safe method. "It is indeed manufactured consent," said Saheli's spokesperson.
The menu offered to Indian women was not broadened to include their rights to food, employment, education, security, equality, and dignity. In a health landscape dominated by medical care, most of which is provided by the private sector (82 per cent as against 55.7 per cent in the US and 28 per cent in Canada of total health is private, as per Dilip Shah, Indian Pharmaceutical Alliance), this array of women's contraceptive choices has little meaning, argued Sama, a Delhi-based women's health forum. Most of these contraceptive technologies require an infrastructure that India simply lacks (sophisticated medical equipment, diagnostic facilities and skilled medical personnel). They also shift dependence of women from sexual partners for their own reproductive rights to predominantly male medical practitioners.
Health activists have had to keep a vigilant eye on these contraceptive technologies as they were pushed by enthusiastic funding agencies in alliance with powerful global pharmaceutical interests through the Government of India (potential market for the expensive DMPA is thousands of million dollars in India alone). The campaign against Depo Provera (DMPA), produced by Upjohn (later bought by Pfizer, which refused to accept any legal liabilities of the company it took over) and Net En (Nortesteone Enenthate) was based on inadequacy of research and trials, ethics of trials, informed consent, high potential for abuse, and the complete lack of accountability of the government, its agencies and the multinational drug companies towards people. Norplant, a hormonal implant, and an anti-fertility vaccine are similarly controversial. An over-the-counter "emergency contraceptive" (read medical abortion) RU486 does away with the need for medical advice to terminate pregnancy. An All India Democratic Women's Association (AIDWA) activist pointed out that even registered medical practitioners, such as those in a clinic run by JK Jain (former member of parliament, Bharatiya Janata Party, and owner of Jain TV), captured on film by Jamia Millia students, confessed to using quinacrine, a synthetic anti-malarial with the ability to chemically sterilise women, on unwary patients despite a supreme court injunction against its use. Privatisation and NGO-isation of health reduces the role of the drug controller or the Indian Council of Medical Research (ICMR). The complexities involved with these technologies are immense, and there are few experts in the field. These technologies are nonetheless sought to be generalised.
Donors leverage a disproportionate share of influence in the government's health policy despite giving only a fraction of its total funds, argue health activists. In the 1990s, USAID financially assisted India with $325 million for decreasing the total fertility and mortality levels and increasing couple protection rates. This was the largest programme of foreign assistance for reducing population growth rates in India, reported Karkal. India found it convenient to pick up only the reproductive health component of the International Conference of Population and Development (ICPD), Cairo, 1994. Now World Bank (the $350 million loan in reproductive health is the largest constituent), DFID, European Commission, USAID, UNFPA, KFW (a German Bank), and technical support from WHO, UNICEF and UNFPA (who preferred to be called "development partners") are new players added to the powerful Rockefeller Foundation, the Population Council, Ford Foundation and USAID, the neo-Malthusians who were the first to fund the Indian population control programme embarked on in the 1950s. Funding agencies contributed largely to the reproductive health, to HIV/AIDS/ malaria/tuberculosis programmes (health components of the Millennium Development Goals), and came as either loan or grants. Notwith-standing changes in the vocabulary, women rights groups remain concerned that for population controllers, the best way to reduce maternal and infant mortality is by warding off birth.
A senior official in the MoHFW agreed that the total external funding is 8-10 per cent of the total spent in reproductive and child health (including efforts to bring down maternal and infant mortality rates), but denied that there was any pressure on the government, believing instead that it brought with it "knowledge, information, innovations, good practices and critical appraisals that the government system itself lacked". Birth control, the senior health official insisted, formed a small component of the overall health programme.
The Tenth International Women and Health Meeting (IWHM) held in Delhi on September 21-25, 2005 bore the imprint of donor-led health agendas, with the venue in an exclusive hotel, and a complex and costly process of registration that ensured that many activists were kept out. Paul Hunt, UN Special Rapporteur on Health, and Jane Cottingham of the WHO, were prominent in the closing session, and given their due coverage in the media.
The stated aim of the meeting, of movement building, could not take place. The grand narrative has been successful in using the language of opposition to sabotage resistance.
In the early years (1950-80), women rights activists were sought to be silenced with the argument that population control was a national priority. Now, UNFPA and WHO, largest procurers of contraceptives, find that the "big boys" are too expensive for sourcing hormonal contraceptives and are seeking to expand their supply base with Indian generic drug manufacturers. India can do with strengthening its pharma market, and hereby is introduced another stakeholder in the big game of curbing births. Population stabilisation can be achieved through the contraceptive of rights and development. It does not need more hormonal contraceptives for women that are long-acting, invasive, untested, hazardous and provider-controlled all in the name of offering a "choice" that results in anything but women's well-being. Women's health
is much more than reproductive health, and cannot be subordinated to the population control enterprise.

Bela Malik Delhi
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