C. The Egyptian Case
Soheir A. Morsy documents the Norplant® trials in Egypt, which closely resemble the Brazilian experience in “Bodies of Choice: Norplant experimental trials on Egyptian Women” (Mintzes, Hardon, Hanhart, eds. 1993.). While the media and the Population Council provided glowing reports of the device, these reports were introduced into a critical attitude regarding population control policies among the public at large as well as state officials. Morsy sees Norplant® as the eerie realization of many of William Shockley’s policy recommendations for population control. Shockley supported cash inducements for an imagined subdermal “contraceptive time capsule” for women with low IQ’s, “a subcutaneous injection of a contraceptive time capsule which provides slow seepage of contraceptive hormones until it is removed” (Morsy 1993, 90). While the Norplant® experience differs markedly from Shockley’s vision, its provider-dependency, particularly in areas where removal is refused and population control is strongly advocated is a cause for consternation.
Egypt serves as another area of the world where these factors converged. Morsy notes that between 1975 and 1983, slightly over half (51.5%) of U.S. budgetary allocation to Egypt for health development was earmarked for population control (Morsy 1993, 92). Both the World Bank and USAID have pressured Egypt directly towards population control. The mid-eighties marked a shift in policy emphasis towards population control and Norplant® was introduced as a partial solution to the problem. The national media praised the device as “the magic capsule.” Yet, some criticisms of the Norplant® trials were mounted in the opposition press. Physicians in Egypt also became increasingly skeptical; noting that the device was not legal in the United States but was being tested on women other countries. Users’ criticisms of the device virtually mirror those presented in the above cases. While the Egyptian experience does bear some similarities to Brazil’s (side effects, public discourse regarding population control), policy changes have not emerged from criticisms raised by users, oppositional media, women’s groups, and concerned physicians.
It must be noted that from woman to woman and from country to country, the Norplant® experience is diverse. While there do seem to be problems built into the provider-dependent contraceptive technologies such as Norplant® and Depo-Provera, there are many cases where women who these technologies are pleased with their results. Thus, the Norplant® experience has as much, if not more, to do with political context than with the substance of the technology. Users’ experiences in Finland were less negative, due in part to greater access to information at the time of insertion, physician willingness to remove the device and greater access to general health care than in many Third World settings (Ollila, Kajesalo and Hemminki 1993, 47-69). While it may or may not have had any impact, it should be noted that Leiras Pharmaceuticals, the owner of Norplant®, is located in Finland. Oversight of research may be more comprehensive when the given site is in close geographic proximity. What is alluring about Norplant® is that many people are satisfied with it. This satisfaction is frequently used to minimize the real and existing experiences of those women who were not adequately informed of the risks of the technology and those who have experienced the side effects.
D. Norplant® in Bangladesh
In Bangladesh, Norplant was subjected to intense debate and scrutiny. While the Technical Advisory Board in Bangladesh never approved of Norplant® trials, the Bangladesh Fertility Research Program (BFRP) bypassed its evaluation. Advertisements were placed in newspapers for participating in the trials, calling the device “a wonderful innovation of modern science” (UBINIG 1988, 101). Yet, as many noted in Bangladesh, it seems that the very principles of science (neutral oversight) were averted in order to conduct these experiments. 151 doctors and pharmacists petitioned the end of the trials and the Population Council postponed the 1981 trial. However, in 1985 the trials commenced again through BFRP and funded by The Population Council and Family Health International. The UBINIG report charges that BFRP protocol focuses not upon the safety of the device, but rather upon its effectivity.
Moreover, the ideology of population control guided BFRP’s accounts of the device, through management of reproduction among the “semi-literate." In a February, 1985 report (which commenced the onset of the trials in Bangladesh), researchers had concluded:
This long lasting method has the potential advantage of not requiring day-to-day use and therefore may be particularly suitable for our semi-literate population...The effectivity question is mentioned and is specially targeted towards the semi-literate population, in other words, the poorer section of the population, so that population control can be ensured (UBINIG, citing BFRP 1988, 102; emphasis mine).
The difficult and serious problem of population Norplant® programs in Bangladesh were not “for women,” as advertised but at best for the population, and at worst for the literate population. In the best scenario, women and men are confronted with a set of problematic and historically traditional assumptions about the role of women in society, which view women as bodily vessels, as essentially reproductive beings. In the worst scenario, the previous assumptions remain intact while classist and ethnocentric assumptions enter into the equation as well. It is better for the semi-literate not to reproduce because semi-literate people are poor. Putting aside for now the problems built into these very assumptions; both beg the question, better for whom?
UBINIG’s account of Bangladesh’s Norplant® trials also notes a similar pattern of disregard for the well being of the users. Additionally, a noteworthy criticism is raised. BFRP was wise to not distribute the device to women with contraindications. The device was not distributed to smokers, women with cardiovascular disease, diabetes, overweight women, women with liver disease (UBINIG 1988, 103). Yet, in the post-trial phase, has the device been given to any women with these conditions? The Norplant® experiments are then the results of the best possible case scenario, one that is arguably unrealistic. When combined with the plethora of side effects (menstrual disturbances, migraines, depression, weight loss, and in some reported cases, epilepsy), can one legitimately assert that for most women, the device is safe and effective or just effective?
All of the women interviewed for UBINIG’s study reported problems with Norplant®. These results parallel studies on Norplant® in Bangladesh by BBC (Cadbury 1994). In the literature, personal accounts by users put the experience in a painfully real context. Anwara Khatun, a 30-year-old test subject, spoke of her experiences: “I do not have any appetite, I am going to die. The menstruation is very irregular and during the last Shabe-Barat (a religious occasion). I had menstruation for two months at a stretch” (UBINIG 1988, 106). Moreover, these anecdotes put the notion of “side-effects” in another, more human light. The instrumental rationality of what one might term in Foucault’s language “the medico-political complex” eclipses the real, lived experiences of women and men. The device serves its purpose: it is highly effective. Yet the human costs of that effectivity (be they political, cultural, social, religious or personal), are in terms of policy implementation, insignificant. What is effective to BFRP, for example, may not be as effective for the semi-literate, impoverished woman who uses the device and is beset with migraines, depression, or irregular menstruation. Power relations produce a particular understanding of effectivity and safety for that matter – definitions that are arrived at through a logic that is, as Arendt cogently stated, “independent of the human condition” (Arendt 1994, 318). While I develop my critique of abstraction, reason and rationality in the following chapters, at this moment I want to emphasize that the very grounds upon which meaning is articulated (which I would say is the nature of politics itself), are produced through a veil of scientific neutrality, obscuring the lived human experiences of women and men throughout the world.
E. Norplant® in Colombia: A Medical Perspective or Who Is the Enemy?
Medical studies of Third World experiences with Norplant® trials are markedly different from accounts provided by critics. A noticeably different account of a Norplant® trial can be found in, “Two-Year Prospective Study in Columbia of Norplant® Implants” (Lopez, Rodriguez, Rengifo, and Sivin August 1986). While it is possible that the deciding factor here is that women’s experiences in Colombia are markedly different from those in Brazil, Egypt, Bangladesh, and other countries, it is also likely that the differences emerge from differences in methodology and focus. Norplant® was evaluated in the Colombian study in contrast to a copper IUD. Lopez et al sought to examine the “safety, effectiveness, and acceptability of Norplant implants” (Lopez et. al. 1986, 204). Lopez et al reported that Norplant® was highly effective, with no pregnancies in the study group and 1.1/100 in the IUD study group. Menstrual disturbances were reported as the most common side effect, with these effects diminishing for many as the study continued. Fourteen of the 100 users terminated Norplant® use as a result of these disturbances (Lopez et al, 1986, 206). Most did not experience pain at insertion (81%) and some experienced only minimal pain (18%) (ibid.). Medical follow-up was relatively consistent, though five percent “failed to make the required subsequent visits” and sixteen other women were not considered lost to follow-up even though they were not seen in the second year of the study. Continuation was reported at a high rate and no serious risks to health were reported. Lopez et al concluded that “given the effectiveness, acceptability of the method as indicated by the first two years of experience with the method in Colombia...the Norplant implants will provide and important addition to the contraceptive armamentarium” (Lopez et al, 1986, 207 emphasis added).
While the full implications of the dilemmas posed by the instrumental rationality of the Norplant® Condition are elaborated upon below, several points must be touched upon before continuing. First, I assume that everything that Lopez et al have asserted is true. There are no grounds to challenge the reliability of this data. However, the parameters of the authors’ truth-claims are likely to be constrained and mediated by other factors, other truth-claims. What were the experiences of the fourteen- percent of women who had the device removed because of menstrual disturbances? Is this the reason why they reached the conclusion that the device was effective and acceptable (again begging the question, to whom?) but did not state in conclusion that the device was safe? This seems particularly noteworthy as the safety of the device was to be evaluated in this report. Were there women who were refused removal or pushed not to remove the device? No adequate account of medical counseling to ensure that women could have the device removed at any time was provided. Of what does “lost-to-follow-up” consist? Writing from the perspective of a medical researcher, this constitutes missing data and it is. But it is also a life at-risk. The device loses its effectivity over time and can lead to ectopic pregnancy, which can be fatal. It is also a life with an economic and social context. Some may be too poor to return. Others may have not been fully informed as to the necessity of returning. Lastly, why were the sixteen missing women not considered lost to follow-up? In many cases, the effectivity of the device is of greater importance than the “side-effects” or its actual, physical dangers to some people. These questions lead to a consideration of the assumptions built-in to the Norplant® study in Colombia. Norplant® is considered to be a tool, a tool in a battle. Considerations of safety tend to drop out of view in battle. “The contraceptive armamentarium” is an armory, a “place where arms and instruments of war are kept” (Webster 1972, 102-103). Some may argue that this is just a turn-of-phrase, a nice way for Lopez et al to close an essay, and it is. Yet, the model of war dominates much of the medical profession’s assessment of biological challenges. And, if Norplant® is part of an armamentarium, then who is the Enemy?
3. Norplant® in America: Less for the Unfit?
In 1992, the Kaiser Forums, sponsored by the Henry J. Kaiser Family Foundation, held a two-day conference in the United States on the issues surrounding Norplant® and poor women. This conference is of particular interest because it brought together divergent perspectives from members of the health profession, researchers, contraceptive experts, and policymakers. Six of the essays presented were published in a volume, Norplant and Poor Women (Samuels and Smith 1992). The conclusions that were reached in this conference point to the potential for interdisciplinary collaboration on this topic. Participants concluded:
1) that the device should be readily available;
2) that free consent is mandatory, as is full information on all options, including teens and incarcerated women;
3) that every step should be taken to prevent any harm to any woman;
4) that the device only be prescribed when there are clear benefits to the individual;
5) that health care is mandatory;
6) removal on all requests; and
7) “Economic incentives should not be so great as to be coercive”
(Samuels and Smith 1992, xiii-xiv).
While some may take issue with the specifics of these recommendations, it is worth noting that short of those who favor banning Norplant®, Depo-Provera, and other injectables, this marks an attempt to integrate considerations of women’s well being into Norplant® policy. What would the Colombian study look like, for example, had these standards of “success” been adopted?
While the Kaiser Forums indicate a viable avenue for feedback on the Norplant® experience, is this site of democratic communication indicative of the United States’ reproductive policies? A closer examination reveals divisions between women’s health advocates, researchers, and practitioners within the Forum. While the Senior Associate for the Center for Biomedical Research of the Population Council, Irving Sivin, announced that the main obstacles to Norplant® were “price, provider attitudes and the cost to governments and public-sector providers,” Julia Scott of the National Black Women’s Health Project and Feringa, Iden and Rosenfield of Columbia University’s School of Public Health reiterated the history and potential for abuse of contraceptive devices (Sivin 1992, 1-19; Scott 1992, 39-52; Feringa, Iden, and Rosenfield 1992, 53-64).
Debate over women’s reproductive rights has raged within the United States, long before the Food and Drug Administration’s 1990 approval of Norplant®. At the core of this debate is a long-standing critique of traditional medicine that pre-dates criticisms by radical feminists (e.g. Corea, Rowland, Klein). Barbara Ehrenreich and Deirdre English provide a comprehensive history of women’s health, with a particular focus on America since the mid-nineteenth century (Ehrenreich and English 1978). For Her Own Good: 150 Years of the Experts’ Advice to Women details the professionalization of health care and its sexist biases. To generalize broadly, care of women’s reproductive needs once fell into the hands of midwives and healers, who emphasized the care of the individual. The modern, masculinist rise of medical “expertise” posited the mother as intrinsically pathological (Ehrenreich and English 1978, 211-265). Concomitant to this rise was the delegitimization of midwifery, which in turn, eliminated women as primary health care providers. While Ehrenreich and English’s piece is limited in its assessment of the dangers of modern medicine (detail on ethnic diversity, class bias, and the complexity of power relations are missing here), it provides a superlative historic account of gender biases intrinsic to medical knowledge and practice. In Chapter Five, I elaborate on contemporary forms of women’s health care informed by feminist readings of modern medicine, as in the case of lay midwife Abigail Odam.
To follow Ehrenreich and English into the eighties and nineties, it is unsurprising that a contraceptive device would be posited by U.S. policymakers as a solution to drug abuse (or “fetal drug abuse”), child abuse, poverty, or the growth of certain sectors of the population. In 1870, Professor M.L. Holbrook had addressed a medical society, asserting that it was “as if the Almighty, in creating the female sex, had taken the uterus and built up a woman around it” (Ehrenreich and English 1978, 120 emphasis in original text). In 1883, G.L. Austin wrote in his book that ovaries “give woman all her characteristics of body and mind” (ibid.). American culture has a long tradition of focusing on individual responsibility for social dysfunctions and it also has a long misogynist tradition of sexualizing the essence of a woman’s personhood. Thus it is not surprising that when women are held accountable for social dysfunctions such as poverty, policymakers focus on women’s sexuality. It is through this biological and ethical reductionism that many in the United States have managed to look to control of women’s reproductivity to solve problems of abuse, poverty, and over-consumption of non-renewable resources.
Yet, how does Ehrenreich and English’s work fit into the specific context of the political history of birth control? James W. Knight and Joan C. Callahan, in what is arguably the most comprehensive text in English on birth control address this topic contextually in Preventing Birth: Contemporary Methods and Related Moral Controversies. During the nineteenth-century, contraception in the West was often subjected to intense moral criticism. This criticism often found its basis in Victorian mores that suggested that birth control would engender sex for the purpose of pure pleasure, which was deemed obscene. These mores were bolstered by Jewish and Christian heritages that “associate(d) nonreproductive sexual interaction with moral evil” (Knight and Callahan 1989, 37). Some advocated expanding reproductive freedom for the purpose of sexual equality (Robert Dale Owen) and reducing poverty (Charles Knowlton). Yet, most in the medical profession found these opinions reprehensible. A Lancet editorial from 1869 stated that contraception for women “brought into the condition of mind of a prostitute” and that for men, sex with contraception was inseparable from masturbation (Knight and Callahan 1989, 31-32; emphasis mine).
By the latter part of the nineteenth century, attention turned to the dangers of population growth, and “Malthusians” articulated an international movement to legitimate contraception for Malthusian and/or economic purposes. While this provided some currency to contraception as a rational activity, the Malthusian movement lost popularity by the 1920s, due to a decline in populations worldwide. It is within this context that an emphasis on birth control emerged, from the likes of Marie Stopes and Margaret Sanger. Knight and Callahan note that for them, birth control was about care: “health, family life, and women’s reproductive freedom” (Knight and Callahan, 1989, 33). The tension between these two “schools” of thought has never completely dissipated and has returned in recent years.
The words and actions of Margaret Sanger embody this tension between Malthusian population control advocacy and birth control advocacy. Understanding Sanger is important not only as an indicator of these distinctions, but also because she embodies the complexity of (disciplinary) liberalism. Sanger alternately argued for birth control (better care for individuals, more individual autonomy) and for eugenics (stating “more children from the fit, less from the unfit” and advocating sterilization of “the whole dysgenic population”) (Knight and Callahan 1989, 40). The form and type of care she advocated was contingent upon class and social standing. She was pro-natalist for the “fit” and anti-natalist for the “unfit,” a policy perspective that has its closest corollary in the Nazi regime (Knight and Callahan, p. 1989, 39-41). This is not a contradiction, but a form of eugenics. The liberal doctrine of autonomy exists, perhaps even in an exaggerated form, but it only exists for the fit, which is to say the members of the socially and economically dominant classes. The unfit are subjected to the “freedoms” or Liberties of the fit. Contra Marx, the contradictory nature of this relationship serves to perpetuate, rather than eliminate it. Freedom and autonomy exist on an unparalleled level, as long as one understands that this means total freedom, which includes the freedom to oppress. In Sanger’s case, the unfit are disciplined into literal sterility. Yet, disciplining of the unfit is freedom, and of equal importance, it is Good. This notion of the Good is born of a utilitarian impulse in eugenic ideologies.
Twentieth century western political history has witnessed the emergence of vigorous contention over reproductive rights. In the realm of contraception, this is characterized generally by three schools of thought: 1) pro-natalist, 2) anti-natalist, and 3) hybrids of the former two. None of these positions is “safe” from extremism. Pro-natalist extremism has been manifested in American abortion clinic bombings (and shootings) as well as Mussolini’s proclamations of repopulation. Anti-natalism governs China’s population policy positions. And, as has been discussed, both Nazi population control policy and the work of Margaret Sanger underscore the potential dangers of natalist and anti-natalist hybrids. United States contraceptive policy in the twentieth century has been marked by natalist and anti-natalist tendencies. While it is easy to assume this results from competing interest groups’ attempts to influence policy-making, Margaret Sanger’s poignant story signifies the possibility that natalism and anti-natalism have been intentionally combined in a synoptic policy model.
Was Margaret Sanger’s “more children for the fit, less for the unfit,” a personal inconsistency or did it signify dominant attitudes among policymakers, health officials, and the public at large? “By 1932, twenty-seven states had laws allowing involuntary sterilization of the feeble-minded, insane, criminal, and physically defective” (Knight and Callahan 1989, 40). This was the era where Oliver Wendell Holmes could declare from the United States Supreme Court that “three generations of imbeciles are enough” (Knight and Callahan 1989, 10). Yet, reproduction was limited not because it was inherently problematic (as in the Malthusian construct), but because reproduction of the unfit was problematic. United States policy at least sought to maintain the reproduction of the fit, while reducing drastically the reproduction of the unfit.
These policies did not die out with the realization of the dangers of totalitarianism, but continued unabated until the early 1960s. When combined with the tenuous legalization of elective abortion in 1973, it is unsurprising that United States’ contraceptive policy has been met with considerable skepticism among many women, the poor, minorities, and advocates for each of these groups. When one considers the blight of racism in American society combined with eugenic sterilization of “unfit” women and men, that the Norplant® experiment has particular implications for minority groups is undeniable.
Dorothy Roberts provides a superlative analysis of race and reproduction in Killing the Black Body. Roberts makes the acute observation that racial issues and reproductive issues are inextricably linked:
Scientific racism explained domination by one group over another as the natural order of things: Blacks were biologically destined to be slaves, and whites were destined to be their masters. It also forged an indelible link between race and policies governing reproduction. Because race was defined as an inheritable trait, preserving racial distinctions required policing reproduction. Reproductive politics in America inevitably involves racial politics (Roberts 1997, 9).
Policies that may not be explicitly intended to do damage to blacks are racialized not out of some suspected conspiracy but because reproduction, genetics and race are connected.
White control over black slaves’ reproduction was an essential component of slavery. Social regulation of reproduction is not a part of some imagined history, but a foundational component of black women’s political history in America. Women in slavery existed to work, to reproduce, and for the sake of sexual abuse. This very literal objectification of black women in America has had far reaching consequences. While slave women’s personal “housework” has been identified by Angela Davis (and Roberts) to be a site of resistance, marking a space where white oppression was dimmed, the power of the whip and the auction block is not merely “historical background.” It is part of the cultural memory that has produced reproductive policy. It has made it easier to racialize what Sanger and other eugenicists called “the unfit.” Indeed, it made it easier for reproductive control to be linked to genetic supremacy. Americans were hardly foreign to the notion of breeding individuals for the purpose of social betterment. Breeding had been normalized in America, long before Sanger’s appearance. In this historical context, that Sanger’s feminist vision of birth control, which indicated a strong sense of bodily autonomy, managed to slip into eugenic versions of population control is unsurprising.
Roberts proceeds to detail the horrors of the eugenics movement in America. In addition to her comprehensive account of eugenics in America, Roberts provides a needed history of blacks’ experiences of birth control and eugenics. Many black leaders (e.g. Marcus Garvey) were critical of birth control, with the experience of oppressive reproductive policies being a guiding factor. Du Bois, however, adamantly supported birth control - sometimes with an elitism that mirrored Sanger’s (Roberts 1997, 85). However, according to Roberts, black birth control advocates differed significantly from their white counterparts. Black advocates saw birth control as one tool in a fight for social justice. Sanger and many other white advocates viewed birth control as the tool in this fight. That birth control was a singular device in the fight against poverty and poor health conditions often led to more extreme measures being considered, such as sterilization. Du Bois and other black activists opposed these measures. Additionally, black advocates opposed eugenic arguments of racial superiority. While some of their statements and actions reflect elitism, that elitism tended to be social, rather than hereditary in nature. These distinctions are significant because a majority of those who were involuntarily sterilized during the rise of the eugenics movement in America were black. In the 1930s and 1940s, the North Carolina Eugenics Commission sterilized 8,000 “mentally deficient” people, of which 5,000 were black (Roberts 1997, 90). In 1955, a South Carolina State hospital reported 23 sterilizations - all of which were of black women.
Roberts notes that while these are significant events, most black women were not sterilized under eugenics laws. The 1970s signified a period of great increase of sterilization for the purpose of birth control. Many women, black and white - particularly black women in the South, have reported incidents of lack of informed consent and/or sterilization for no medical reason. Roberts’ text is replete with horrifying accounts of these incidents, mirroring the experience of women in developing countries during the Norplant® experiments. Included in her anecdotes, are the experiences of fourteen-year-old Minnie Lee Relf and twelve-year old Mary Alice Relf, two of six black children living with their parents in Montgomery, Alabama in 1973. The Relf parents were asked if they would volunteer their two youngest daughters for experimental use of Depo-Provera. Mrs. Relf signed the informed consent form with an “X” because she could not read. In actuality, all governmental programs involving Depo-Provera had been stopped due to it being linked to cancer. Minnie and Mary Relf had been actually been intentionally sterilized and their family had been deliberately misinformed by the federally funded Montgomery Community Action Agency (Roberts 1997, 93).
The Relfs went to the Southern Poverty Law Center for help and a class action lawsuit was filed, as this procedure (and many like it) was common during the 1970s among poor women, particularly minorities. Roberts, a professor at Rutgers University School of Law, examines Judge Gerhard Gessell’s conclusion that “an estimated 100,000 to 150,000 poor women like the Relf teenagers had been sterilized annually under federally funded programs” (ibid. emphasis mine). Moreover, half of these women and children were black. Some were threatened with loss of benefits. These actions circumvented the failure of equally radical sterilization legislation proposed in the House of Representatives during the 1960s. Through this history, Roberts provides a significant, alternative perspective on the “war on poverty.” Liberalism, in its modernist variation, does not entail liberation or autonomy. It may, as I shall discuss later, provide the illusion of autonomy as a mechanism for discipline and coercion.
Federal guidelines for government-subsidized sterilization emerged directly from these tragic incidents. These guidelines do provide some basic protection against future abuses of sterilization. Unfortunately, hundreds of thousands of women in poverty were involuntarily sterilized before any such action was taken. That such a social experiment on women and children in poverty, fifty percent of whom were black, transpired in the 1970s substantiates Roberts’ point that race and reproductive policy are integrally related in America. While the auction block and the whip may have disappeared, the white clinical gaze of disciplinary liberal Progress continues to do its work within a rhetoric of free choice.
