The headlines from India are chilling, and as if from a time long gone: botched sterilizations in a government program to curb population growth. Twelve women dead, more than 60 hospitalized, community members outraged.
This had trouble written all over it from the get-go: poor, illiterate women in Chhattisgarh, one of the most impoverished states in India, were given incentive payments of a more than a week’s wages to undergo tubal ligation at a mobile health clinic. The health workers, too, received an incentive based on the number of procedures performed, possibly to reach a monthly target. And the conditions were nothing short of appalling: no alternative birth control methods, rusty instruments, poor infection control, tainted medicines (which it now appears may have caused the women’s deaths), and a lack of follow-up care once the surgery was done.
While this terrible incident has come to international attention because of its sensational elements, it fits a troubling, longstanding pattern. For many decades India has pursued an aggressive population control policy that seems far more focused on the interests of the state than those of the women and their families. Incentive payments that are hard for poor women to refuse, combined with numerical targets and an emphasis on permanent contraception, have added up to a family planning program that’s at odds with global norms.
The numbers tell the tale: More than 4.6 million women are sterilized in India every year, and sterilization accounts for more than 80 percent of contraceptive use in the country. Female sterilization is more than twice as prevalent in India than in places where the Pill, injectables, implants, IUDs, and other methods are offered, like China and Latin America. Many of the procedures are done in temporary camps, set up for quantity rather than quality. The doctor performing surgery on these women, for instance, had been honored by the state government earlier this year for performing more than 50,000 tubal ligations.
Surely, it’s time for this to stop.
Even the Indian government has said so. I was in the audience, along with Melinda Gates, Dr. Raj Shah from USAID, and many others, at the London Family Planning Summit in July 2012 when a representative of the Indian Government promised that, “Through the largest public health program in the world, the National Rural Health Mission and the upcoming National Urban Health Mission, addressing equity, ensuring quality, including adolescents and integration into the continuum of care are slated to be the cornerstones of the new strategy. The centerpiece of its strategy on family planning will be a shift from limiting to spacing methods, and an expansion of choice of methods, especially IUDs.” Those are all the right words. Then, just two weeks ago when the FP2020 2013-2014 Progress Report was released, I was impressed to read that “Family planning in India has undergone a paradigm shift, away from the old sterilization-centric emphasis on population control.”
If the paradigm truly has shifted, some people haven’t gotten the memo.
It’s not as if we don’t know what, in principle, a family planning program would look like if it were doing the right things, the right way. In 2013, under the auspices of FP2020, the Futures Group and EngenderHealth developed “Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights: A Conceptual Framework.” And just this year the World Health Organization published “Ensuring Human Rights in the Provision of Contraceptive Information and Services: Guidance and Recommendations.” Those documents contain an exhaustive list of the shoulds and should nots—from good governance to respectful services to monitoring for violations of human rights, and everything in between.
Despite all that good thinking, though, the job is clearly not done—and maybe it’s barely begun. I’m sure there are health authorities in India, as elsewhere, who are horrified by the current situation and would like nothing better than to promote change. But those who are trying to improve conditions in tough environments have to figure out how to put into operation the complex concepts promoted in those documents—things like “ensur[ing] that respecting and protecting rights is built into performance monitoring and accountability, indicators, procedures and practices.” That’s going to take hard work at all levels of government, paired with organized actions by citizens to hold government to account. Along the way, the international community—funders, technical partners and everyone else—should offer support and celebrate progress.
But more than that, we should all be brave enough at times like this to publicly condemn repressive policies and call for an immediate halt to lethal practices.