Note: The following is excerpted from Steven Mosher’s book, Population Control—Real Costs, Illusory Benefits.

When the government sterilization team arrived in their little town of La Legua, Peru, Celia Durand and her husband, Jaime, looked at each other and shook their heads. Although Celia had considered a tubal ligation in the past, she had begun to hear rumors of women damaged or even killed during the national tubal ligation campaign. She had decided that she didn’t want to be sterilized that way. Maybe sometime later I will do it, she told Jaime, maybe in a hospital. Certainly not in the little medical post down one of La Legua’s bare earth streets, with its windows opened wide to the dust, insects, and the smells from the pigs and other animals rooting and defecating in the nearby streets and yards. Certainly not in the middle of a Festivale de Ligaduras de Trompas [Tubal Ligation Festival], as the banner hastily hung in front of the clinic declared, with the doctors in a hurry to cut, snip, and sew their way through a long line of patients.¹

But then the campaign began in earnest. Ministry of Health “health promoters” descended upon her neighborhood, going door to door, house to house, pressing Celia and her neighbors to accept sterilization. Interviewed later, Jaime recalled the singular nature of their advocacy. It was sterilization or nothing. No other contraceptive method was offered. The promoturas, as they are called in Spanish, sought to allay Celia’s fears about having the procedure done during the campaign. “Do it now,” they told her. “You may have to pay [to have it done] later.” Ligation is “easy,” “safe,” and “simple,” they repeatedly reassured her. Nothing was said about possible side effects or risks. “All they told her was how easy it was, nothing more,” Jaime said later.

And the promoturas were relentless. Again and again they came to the family’s home, refusing to accept ”no” for an answer. Celia finally gave in. She would come in the following afternoon, she agreed, to have the procedure.

Her mother, Balasura, continued to worry. The two even quarreled about it. “Don’t go, daughter,” Balasura remembers saying. “There is always time later.” But Celia wanted the daily visits to end and, besides, the health promoters had convinced her that the procedure was safe and simple.

“Don’t worry, mama, I will be back in a couple of hours,” she said as she left for the post. That was the last time that her mother saw her alive.

Sometime during the procedure at the medical post, the surgeon caused enough damage to Celia that she slipped into a coma. Medical staff put off frantic visits from Celia’s brother-in-law, mother and husband. Then, as her condition worsened, they finally transferred her from the post to a larger clinic in the nearby city of Piura. It did no good. Celia Durand died without ever regaining consciousness. The date was July 3, 1997.

The sterilization campaign had begun the year before. President Alberto Fujimori, elected to a second term in mid-1995, had wasted no time in legalizing sterilization as a method of birth control. He ordered the country’s Ministry of Health, headed by Dr. Eduardo Yong Motta, to focus its efforts on family planning, specifically, on tubal ligations. To train Peruvian doctors and officials in how to structure and run a sterilization campaign, Dr. Motta brought in Chinese, Indian and Colombian doctors who had carried out such campaigns in their own countries.² To monitor the success of the campaign, Fujimori himself set national targets for the numbers of sterilizations to be performed—100,000 in 1997 alone—and demanded weekly progress reports.

Mobile sterilization teams, a fixture of such campaigns, were soon being assembled in the capital city of Lima. These teams of doctors and nurses, who often had no prior training in obstetrics or gynecology, were hurriedly taught how to do tubal ligations, and then sent to the countryside to conduct a series of one- or two-week “ligation festivals.” Prior to a team’s arrival in an area local Ministry of Health employees would hang banners announcing the forthcoming “Ligation Festival,” and fan out across the countryside to captar [ “bring in” or “capture” in English] women for tubal ligations. The effort was focused on the poorer provinces, home to a high percentage of Peruvians of Indian descent.

The teams themselves operated under very tight time constraints. Organizers sought to get as many women as possible under the knife in as short a time as possible. Celia Durand’s family discovered after her death that she had been the last of the 15 patients scheduled for that afternoon.³ And as soon as the last surgery was finished, the team moved out, heading for the next “Ligation Festival,” providing no follow-up care.

How were tens of thousands of Peruvian women induced to submit to sterilization? In some cases, like Celia’s, harassment by repeated home visits, along with false assurances of safety, was sufficient to bring them in. Those who resisted official “invitations” found that the encounters all too often turned ugly. Women in the Ayacucho region, which PRI investigator David Morrison visited in 1998 and again in 1999, routinely reported being subjected to harsh forms of verbal abuse. If they objected to sterilization, officials shouted that they were no better than “cats” and “dogs,” or called them “animals” or “beasts.” The women, mostly Quechua-speaking Indians, were repeatedly told how “ignorant” or “stupid” they were for wanting to have more children.⁴

Browbeating didn’t work with everyone. Some had to be bribed with promises of government benefits, while still others were threatened with punishment unless they complied. Ernestina Sandoval, poor and badly in need of assistance after a string of weather-related problems cost her husband his job and then their home, was told about a government program that would help feed her family. When she went to enroll, however, she was told by officials that she would first have to undergo sterilization. “They told me I had to bring a card from the hospital saying I had been ligated,” Mrs. Sandoval reported. “If I didn’t agree to do this they wouldn’t give me anything.”

Maria Elena Mulatillo enrolled her daughter, a sickly child, in a food supplement program. Two months later government officials told her that, unless she agreed to a tubal ligation, her little girl could not continue in the food program. Maria refused and the officials followed through on their threat. There were no more monthly cans of protein powder for her daughter.⁵ Using food to coerce a poor, hungry women into surrendering her fertility is bad enough, but there is something particularly despicable in threatening to let her children go hungry unless or until she agrees.

Why were doctors, nurses, and other officials so insistent? Because they themselves were being judged—and rewarded or punished—on the basis of the number of women they “captured.” Dr. Hector Chavez Chuchon, president of the regional medical federation of Ayacucho, testified before the U.S. Congress that the central government was imposing sterilization quotas on medical workers throughout Peru. He produced Ministry of Health documents stating that each medical worker had to bring in (captar) two women for sterilization each month or risk losing their jobs.

“The Ministry of Health denies that there are campaigns and quotas for sterilizations,” Dr. Chavez testified. “[But] doctors work under pressure from their superiors, are given quotas, and are subjected to other, more subtle, forms of pressure. It is also true that doctors work under very unstable employment conditions, and could easily lose their posts.”⁶ Peruvian officials neatly corroborated Dr. Chavez’s testimony by summarily firing his wife, a government dentist, after he returned to Peru from his whistle-blowing expedition to the United States. He himself would have been terminated from his government posts had U.S. Congressman Christopher Smith (R, N.J.) not intervened. Maria Lopez, the administrator of a local medical sub-post, was also among those who went on record to say that she, and others like her, would be demoted or fired if their posts consistently failed to meet its family planning targets.⁷

Those who exceeded their quotas were routinely rewarded. Stories appeared in major Peruvian dailies like El Comercio and La Republica about “health promoters” who were rewarded with special prizes for bringing in more than their quota of women for sterilization. A young medical student by the name of Javier Chavez told PRI investigators that, while working with a group of “family planning promoters,” whoever gained the most new “clients” in a month received a special bonus of 20 Peruvian Soles (about US$6) and sports clothes.⁸

Doctors and nurses struggling to meet quotas or eager for bonuses often ignored the wishes of the women, simply refusing to take no for an answer. Sterilization during a caesarean section delivery—with or without the woman’s consent—was a favorite tactic. Victoria Vigo Espinoza went into pre-term labor when she was 7 months pregnant, and was rushed to the hospital on 23 April 1996. One of the first questions the obstetric nurse asked was “How many children do you have?”

“This is the third,” responded the petite brunette, in considerable pain.

“Are you going to be sterilized?” the nurse then asked.

Victoria, worried about her unborn baby and with waves of pain washing over her body, didn’t bother to answer. It had been difficult for her to conceive children because of an irregular menstrual cycle and infertility. She had only gotten pregnant this time after undergoing months of hormone therapy. Being sterilized was the last thing she was interested in. She scribbled her name on a consent form without reading it, thinking that she was giving her permission for a caesarean section, and was prepped for surgery.

When Victoria woke up the next day, her first thought was for her child. “Please bring my baby to me,” she smiled at the nurse. Instead, the intern who had attended her surgery and the doctor on duty somberly filed into the room. Her son had died during the night, they told her.

Victoria burst into tears.

At this, the intern became agitated as well. “She is very, very sad because of her child’s death,” he said to the doctor. “Very sad,” he repeated helplessly

“I want to go home now,” Victoria finally choked out through her tears, struggling to sit up.

The doctor attempted to calm her down before she hurt herself. It was too soon after the surgery to release her. “You will have another child,” he said softly

“No, she won’t,” Victoria heard the intern whisper to the doctor. “She is ligated.”

The intern came back later that afternoon, this time alone. “Have I been sterilized?” Victoria asked him directly.

“Yes, Ma’am,” he responded. “The doctor performed a ligation on you.” He hesitated for a minute and then added, “Forgive me. I feel guilty over what has happened.”

Victoria left the hospital on the third day. “I felt completely defeated,” she later testified. “I was depressed about never having more children, and went to see a psychiatrist to overcome my depression. And I still have faith that I may one day have more children.”⁹

If agents of the state combed American communities, attempting to harass women into accepting sterilization, issuing verbal insults and threats to those who resisted, the outcry would be deafening. Add to this already volatile mix the kinds of bribes and sanctions that were imposed on Peruvian women and riots might well result. How many American women would quietly suffer the kinds of injuries, indignities, and coercion that the Peruvian state inflicted upon tens of thousands of women over the course of the mid-to late nineties?

Yet neither Peru nor China is an isolated case. Women in dozens of developing countries have suffered the kinds of human rights abuses reported in Peru’s sterilization campaign, from lack of informed consent to out-and-out coercion. For the use of bribes, sanctions and bullying on both “acceptors” (women) and “promoters” (doctors, nurses, and other government agents) is commonplace in family planning programs, as are targets and quotas.

In Bangladesh, for example, a system of bribes was begun in 1976, with those who agreed to sterilization receiving a sum equal to about the week’s earnings. In addition, women are given a saree and men a lungi. Such inducements may seem trivial compared to the gravity of permanently giving up one’s fertility, but against a background of extreme poverty they loom large. Population control workers were assigned a monthly target of two sterilizations and one IUD.¹⁰

In El Salvador, hospitals, clinics and fieldworkers have been given monthly targets for the number of sterilizations they are to carry out, and women have been sterilized without their knowledge or consent.¹¹

In South Africa under apartheid, Black South African women were given Depo-Provera shots by health care workers who told them that the injections will "help their milk supply." Black women were often unable to apply for jobs unless they could present a family planning card showing that they were on some type of birth control.¹²

Vietnam has a two-child policy, but in other respects its rigorous laws on birth control could have been copied verbatim from its giant neighbor to the north. The country denies third children a birth certificate and offers a reward of $20 to women who have a hysterectomy. Punishment for having a third child exists across Vietnam, but it appears the policy, which began in 1985, is most strict among the subsistence farmers who make up the poorer echelons of society. Families who violate the policy are denied land to grow rice—and thus effectively starved—until they fall back into line. They are also fined about $80, a seemingly paltry amount that is in fact the equivalent of 10 months’ income. The government encourages women to undergo a hysterectomy following the birth of her second child, a procedure to which approximately half of all village women have been subjected.¹³

Mexico has used similarly draconian methods to cut its birth rate. Following the passage of a national population law, the first in Latin America, in 1974, government doctors were told that they must either sterilize or insert an IUD in every woman who comes in to give birth. From the moment a woman in labor enters a government-run clinic, she is bombarded with questions about which method she wants: “temporary” (an IUD) or “definitive” (sterilization). Even if she rejects both, she is often ligated or has an IUD implanted anyway.¹⁴

Sometimes the deception is even more complete, as in the case of the mobile medical clinics of Guatemala. The clinics travel about the countryside offering free medical examinations to all comers, but those who take advantage of the offer often get more than they bargained for. Senora Flores went in for a free physical, but after the exam she began to hemorrhage. The bleeding and discomfort grew as the days passed. Finally, in desperation, she undertook a journey to the nearest town to see a doctor. He soon discovered the source of her troubles: An IUD had been secretly inserted in her during the medical examination, and it had led to a severe case of Pelvic Inflammatory Disease (PID). The doctor removed the IUD, but warned her that, because of the damage to her reproductive system, she may never be able to have children.¹⁵

For sheer brutality the North Korean population control program cannot be outdone. The policy is even stricter for the millions of inmates of that country’s Gulag, where pregnancy is a crime and births are absolutely forbidden. One former prisoner reported that “While I was there, it was commonly known that pregnant women were taken to a hospital outside the camp for forced abortion and that babies born alive were killed. One day when we came back from our work outside the camp, prisoners told us that a police doctor had inspected the female prisoners in the morning and had found out that two of them were pregnant . . . Both were ordered to run around the camp yard with a heavily loaded stretcher. The first woman had [a] miscarriage and collapsed. Then, two prisoners were ordered to kick the swollen belly of Kim Son-hi. She miscarried about one or two hours later . . ."¹⁶

China, Bangladesh, Guatemala, Pakistan, Cambodia, South Africa, Sri Lanka, Indonesia: The roll call of countries where human rights have been abused in the cause of limiting fertility is entirely too long. Many of these countries received U.S. funding for their programs, others were encouraged and financed by U.S.-funded international organizations. Many received both.

You can read more in Steve's book, Population Control: Real Costs, Illusory Benefits, available here.

Endnotes