Controlling Passions

Of all the 20th century’s great humanitarian ventures, none appears to have accomplished more than the campaign to control world population. Fertility rates have declined in every region of the world, and women now bear, on average, half as many children as they did 50 years ago. At a time when poor people are rioting over rising food prices, one could well imagine how many more hungry people there would be if the world’s population had continued to grow at its old rate.

Yet few of those who work in family planning today—almost no one uses the term “population control” ­anymore—­are rushing to claim credit for averting disaster. In part that’s because studies show that their efforts account for only a very modest share of the decline in fertility. The movement itself is largely becalmed. Aid levels for family planning have been flat or declining since the mid-1990s, even though birthrates remain high in many countries and tens of millions of women in ­sub-­Saharan Africa and other regions still lack access to birth control and safe abortion. Family planning workers in places such as Nigeria and India often find that the people they seek to help suspect their motives, doubt their assurances about the safety of contraceptives, and wonder whether they have a hidden ­agenda.

That skepticism, and the hesitation of family planning advocates to trumpet success, is in part the legacy of the movement’s own mixed history. As it gained momentum and a sense of urgency after World War II, the movement to reduce population growth encountered an unexpected array of complex practical and moral problems. What happens when a cause suddenly captures the public imagination and money pours in, along with demands for immediate action that can’t easily be satisfied? What should be done when ordinary people are reluctant to do what’s supposed to be good for them, or for humanity? What if they have more immediate needs that might impede achievement of the global goal? Especially in the 1960s and ’70s, the heyday of population control, the movement gave a lot of wrong ­answers.

Family planning was meant to help people take charge of their own lives, but in India and other developing countries it often came to mean applying varying degrees of coercion, from pushing risky contraceptives on reluctant clients to paying cash rewards to poor people who agreed to be sterilized. In the pursuit of their great goal, population controllers proved willing to sacrifice other efforts to improve the well-being of poor people around the world. And they were so persuaded of the necessity and rightness of their mission that they shielded much of their work from oversight and, more important, accountability to those they were supposed to serve. At a time when some are calling for a major new crusade against global poverty, their story provides a cautionary ­tale.

Family planning grew out of two somewhat contradictory movements. The eugenics movement, a creature of the 19th century, attracted those who were concerned not just about the numbers but the kind of people who might inherit the earth. Eugenicists aimed to breed better people by sterilizing the “unfit” and encouraging “fitter” parents to have more children. After World War I, feminists promoted birth control as a means of liberating women and preventing poverty and war. “No woman can call herself free who does not own and control her body,” declared birth control advocate Margaret Sanger. But Sanger, like many other progressives of the day, was sympathetic to eugenics, with its promise to attack the most basic causes of poverty and conflict, and in the 1930s she and others forged a broad alliance between feminists and eugenicists under the banner of “family planning”—a slogan that left unspecified who would do the planning.

At first, family planning involved purely voluntary efforts, but that approach looked increasingly inadequate as the Cold War began and national security arguments came to the fore. “We are not primarily interested in the sociological or humanitarian aspects of birth control,” wrote Hugh Moore, the cofounder of the Population Crisis Committee. “We are interested in the use which Communists make of hungry people in their drive to conquer the earth.” Even those who didn’t share in such calculations were alarmed by the brute demographic facts. High birthrates in the world’s poor countries combined with declining death rates due to improved nutrition and health pointed ineluctably to rapid increases in population.

This sense of crisis nudged orthodox family planning in the direction of population control: Now contraception and sterilization would need to be aggressively promoted in poor countries, and specific goals for fertility reduction would need to be set. Population control would take priority over other uses of foreign aid, from education to public health. Research by Rand Corporation economist Stephen Enke purported to prove that paying poor people to agree to sterilization or insertion of an intrauterine device (IUD) would be 250 times more effective in promoting economic development than other kinds of aid. In 1965 one of Enke’s studies landed on the desk of President Lyndon B. Johnson, and it convinced him to withhold food aid to India despite the threat of famine. “I’m not going to piss away foreign aid in nations where they refuse to deal with their own population problems,” LBJ insisted. India was already committed to controlling population growth. Now it agreed to begin paying incentives to those who accepted sterilization or ­IUDs.

In 1968, Paul Ehrlich’s The Population Bomb made population control a national issue. (Ehrlich wrote the book on commission from the Sierra Club in just four weeks—not enough time to confirm some of his data or to notice that the cover’s image of a bomb with a burning fuse was captioned, “The population bomb keeps ticking.”) With its warning that hundreds of millions of people would starve to death during the 1970s, the book terrified many Americans. Money began pouring in to support population control. In 1969 Congress boosted the U.S. Agency for International Development’s budget for family planning to $50 million (about $275 million in today’s dollars), a 20-fold increase in three years. The USAID administrator, William Gaud, complained that his agency could not possibly spend this sum, but two years later Congress doubled the budget ­again.

As other Western governments, foundations, and nongovernmental organizations (NGOs) rushed to create programs, they looked to the new United Nations Fund for Population Activities (UNFPA) as the natural leader. Because family planning faced popular resistance in many poor countries, along with widespread suspicion that it was designed to limit the size and power of the Third World, it was thought that the UN imprimatur would show that population control was a worthy objective for all humanity. UNFPA got most of its money from foreign-aid donors such as USAID, and it was governed by an independent board rather than the UN member states, an arrangement that gave it great freedom of action. Rafael Salas of the Philippines was named the first UNFPA director, in no small part because he had been nominated by the philanthropist and population control advocate John D. Rockefeller 3rd and because the top UN development official wanted a front man who was “Catholic and brown.” Salas had only a single deputy, who, like him, had no experience organizing family planning programs.

By 1970, a total of 27 countries had announced that they aimed to cut birthrates. But only South Korea, Taiwan, Malaysia, India, and Pakistan had substantial programs. Everywhere, proponents claimed that there remained enormous “unmet need” for contraceptives. Sweden quad­rupled its aid for family planning between 1971 and 1977. Starting at a lower level, Norway, Japan, and the Netherlands increased their budgets eightfold. “I traveled around with tens of millions of kroner in my pockets,” one Norwegian official recalls, “and I had to find a way of spending them.”

The biggest challenge was to establish and rapidly scale up programs in countries that lacked even rudimentary public-health services. “We are undertaking a virtually unprecedented effort at deliberate social change of a very great magnitude,” said Bernard Berelson, president of the Population Council. He lamented that some of the beneficiaries were slow to get with the program, blaming “illiterate and uninformed villagers” and “peasant resistance to change.”

Consultants tended to promote standardized techniques. In India, Indonesia, Tunisia, and the Dominican Republic, ­truck-­borne mobile clinics were sent into the countryside, dispensing condoms and pills to anyone who would take them. But the consultants failed to reckon with inadequate roads that wreaked havoc on the trucks, not to mention the lack of interest in what the clinics had to offer. In poor rural societies, children provided parents with their only security in old age, and many died young in places where the water was alive with harmful microbes and the mosquitoes carried malaria. In the Punjab, anthropologist Mahmood Mamdani found parents grumbling that aid workers didn’t help childless couples with their “family planning” or offer other kinds of health ­care.

Critics pointed out that better health care for mothers and infants, clean drinking water and improved nutrition, and other public-health services might have changed the equation for many poor people, but the aid givers were bent on their ­single-­minded vision. Funding for already neglected public-health services was to be redirected toward population control, while other forms of aid were restricted. World Bank president Robert McNamara, recently arrived from the Pentagon, said in 1969 that the bank would not finance health care “unless it was very strictly related to population control, because usually health facilities contributed to the decline of the death rate, and thereby to the population explosion.” USAID kept spending more on population control even as it cut other kinds of aid. The head of its population program, Reimert Ravenholt, argued that helping women avoid unwanted childbirth in places with high maternal mortality rates would by itself save many lives. Some officials in the field didn’t bother with such niceties. “It becomes increasingly important to show progress in the only terms which ultimately matter,” Ravenholt’s man in Manila declared, “births averted.”

The big question confronting leaders of the population control movement was whether they would need to resort to incentives and disincentives in order to persuade poor people to stop having so many children. Some contemplated going further. A Ford Foundation report speculated in 1967 about the potential of a technological breakthrough: “an annual application of a contraceptive aerial mist (from a single airplane over India), neutralized only by an annual antidotal pill on medical prescription.” Berelson favored research on a “mass involuntary method with individual reversibility.”

But most of the leading people in the field, including Berelson, doubted this would prove feasible. They demanded instead that family planning programs set numerical targets, either in terms of birthrates or the number of “acceptors.” By 1977 Bangladesh, Egypt, India, South Korea, Pakistan, Taiwan, and Tunisia were all paying family planning personnel according to the numbers of IUDs inserted. (In principle, clients were supposed to be offered a range of choices. But since administrators could not be sure people would use the condoms and pills they were given, they pushed IUDs and sterilization.) USAID was also offering to pay hospitals in Indonesia, Pakistan, and the Philippines a fee for each sterilization performed. In many countries, freelance “motivators” were paid to recruit ­patients.

In their haste to get the job done, many providers cut corners. India’s national program was the most closely studied because it had been the first country to commit to population control and absorbed the lion’s share of international aid. In the state of Maharashtra, a 1971 government study produced the surprising finding that ­three-­quarters of husbands, who many supposed would object to having fewer children, were initially happy with their wives’ decision to adopt the IUD. But more than half changed their minds. Almost 58 percent of the women experienced pain after IUD insertion, and 43 percent had “severe” and “excessive” bleeding. Most fieldworkers, the study reported, had no training in family planning. Peace Corps volunteers in the state of Bihar saw ­first­hand one reason why so many women suffered side effects: Rather than sterilize the inserter after each procedure, workers would simply wipe it on their saris. When the volunteers alerted Ford Foundation consultants, they were told to stay focused on program targets. Indian women began refusing IUDs; it took nearly 20 years to restore the device’s ­popularity.

When programs failed to meet targets, consultants working for the UN, the World Bank, and the International Planned Parenthood Federation (IPPF) advised governments to provide “incentives” worth up to a month’s wages directly to “acceptors” who agreed to sterilization. In some areas, government officials were offered what amounted to bounties for finding volunteers, prompting some of them to mobilize the police and tax collectors. In the state of Kerala, local officials set up a sterilization camp and carried out some 60,000 procedures in a single month in 1971. It was hard to overlook the fact that many of those recruited were desperately poor people tempted by the cash incentives—the numbers of “acceptors” rose and fell with the level of incentive payments, and shot up in times when famine threatened.

Often, the programs attracted the wrong “acceptors.” In Uttar Pradesh, In­dia’s most populous state, one study found that the ages of those undergoing vasectomies had been systematically ­falsified—­almost half were more than 50 years old. But bribing people to agree to sterilization was not merely ineffective. It made family planning seem like an imposition, rather than something that served clients’ own ­interests.

In the 1970s, many more national governments adopted numerical targets, and a few went beyond incentives to disincentives. Indonesia denied public servants rations for younger children in large families. Anyone in Singapore who had more than three children was kicked out of public ­housing.

No government went further than India during the Emergency Period (1975–77). By 1975 Prime Minister Indira Gandhi’s corrupt Congress Party was becoming increasingly unpopular. Faced with mass demonstrations, Gandhi suspended the constitution and imprisoned more than 100,000 opponents. Her ­ne’er-­do-­well son Sanjay took charge of population control and other initiatives, raising incentive payments, ratcheting up disincentives, and encouraging states to consider compulsory sterilization for Indians with more than three children. “Our real enemy is poverty,” explained health minister Karan Singh, but to many the population effort looked like a war on the poor. Sanjay Gandhi launched an aggressive slum clearance program, and displaced Indians were told they would not be allowed to build new homes elsewhere unless they consented to sterilization. In several towns and cities, the police and army had to fire on crowds to keep the sterilization camps ­running.

McNamara flew to Delhi to offer his support. “At long last,” he wrote, “India is moving to effectively address its population problem.” Donors were well aware of what was happening. “Obviously the stories . . . on how young and unmarried men more or less are dragged to the sterilization premises are true in far too many cases,” a Swedish official acknowledged. He advised against compulsion, but suggested that “civilized and gentle pressure should be used.” The World Bank, Sweden, and the IPPF all decided to increase funding. Over 12 months, the government carried out more than eight million sterilizations. According to official statistics, 1,774 people died because of botched ­operations.

A chastened Indira Gandhi finally reined in the population control program, but it was too late. When she ended the Emergency and called elections in 1977, voters routed the Congress Party, ending its 30-year reign. In the states with the largest increase in the number of sterilizations, the party lost 141 out of 142 ­seats.

India was only the most dramatic instance of a growing international backlash against population control. In Pakistan, opponents of Prime Minister ZulÞkar Ali Bhutto bitterly criticized contraception as “a Þlthy business and against the spirit of Islam.” When Bhutto was overthrown in a military coup in 1977, Pakistan’s family planning program was immediately suspended. From the Ayatollah Kho­meini in Iran to Daniel Ortega in ­Nicaragua, revolutionaries attacked family planning as a form of imperialism. The Vatican seized the opportunity to organize conservative Muslims and Third World revolutionaries in a worldwide campaign against it. (Cardinal Alfonso López Trujillo of Colombia, a key adviser to Pope John Paul II, condemned one ­USAID-­funded project as part of a program of “global castration.”) A crowning blow came in 1984, after UNFPA and the IPPF blundered into China and helped Communist leaders implement their draconian ­one-­child policy, which in some cases led to forced abortions. President Ronald Reagan now had the excuse he needed to cut off U.S. funding to the two organizations and to put all others on notice that they would lose support if they helped make even voluntary abortion ­available.

Meanwhile, the movement was being transformed from within, as feminists working in international NGOs found their voice and women began to gain power within some of the leading organizations. At the UNFPA, Salas was succeeded in 1987 by a woman, Nafis Sadik, who insisted on a broader agenda devoted to the ­well-­being of women, including efforts against female genital mutilation and the emerging plague of ­HIV/AIDS.

Feminists assailed abusive population control programs along with traditional means of coercing women into bearing unwanted children. It had been well known since the early 20th century that women with schooling and jobs overwhelmingly elected to have fewer children. But it was a lesson that few chose to hear in the post–Population Bomb crisis atmosphere, not only because it threatened to complicate the simpler prescriptions of population control but because it contradicted the eugenicist strand of the population movement, which saw the lower birthrates of educated people as something to be ­combated.

Population control finally met its formal end in 1994 at a ­UN-­sponsored conference in Cairo. In what is now called the “Cairo Consensus,” 162 states rejected the use of population targets as well as the incentives and disincentives used to reach them, embracing instead a new focus on the ­well-­being of individuals, including full reproductive rights, education for women, and health care for mothers and ­infants.

Family planning remains a gigantic enterprise. Through USAID, the United States gives more than $400 million to such efforts worldwide, still more than any other country. But the younger people who are passionately committed to the cause today tend to care most about extending reproductive rights—the idea that women everywhere should have the same freedom to control their fertility, regardless of what size family they choose to have. The tainted history of population control has bred a degree of ambivalence, while experience has brought more realistic attitudes about how much social change can be engineered.

At most, studies suggest, family planning programs account for about a quarter of the worldwide decline in fertility rates since the 1950s. Women can now choose from many methods of ­contraception—­pills, IUDs, implants, and ­injectables—­that might not exist had family planning organizations not pushed to develop them. But women had the means to regulate the number of children they bore long before these methods were available. What was lacking was the economic security, education, and basic health needed to persuade couples to have smaller families. Where those conditions occur, birthrates typically decline. Brazil, Algeria, and Turkey, for example, all made minimal efforts in family planning in the second half of the 20th century, yet fertility rates in all three declined ­dramatically.

But enthusiasm for the old ideas hasn’t died. Economist Jeffrey Sachs, a leader of the campaign to “make poverty history” and combat global warming by implementing a crash program to achieve the UN’s Millennium Development Goals, has cited “population control” as a model, calling it “one of the great success stories of modern times.” Sachs says he favors purely voluntary methods, but he and his allies are playing with a dangerous formula. Declaring a “global crisis” can attract media attention and don­ors. It can also create pressure for quick results while increasing the temptation to resort to extraordinary measures. These sorts of pressures are already manifest in the current worldwide efforts to eradicate malaria and stop HIV/AIDS. The governments and organizations pouring money into these two great causes are insisting on short-term numerical ­targets—­medications delivered, bed nets ­distributed—­and those involved in combating HIV/AIDS are pondering the idea of compulsory ­testing.

Humanitarian challenges rightly create a sense of urgency. The problems begin when those who set out to save the human race refuse to be accountable to any humans in particular. Acting in the name of an abstract “humanity,” population controllers found it easier to think of the world as a laboratory populated by potential “acceptors,” and to believe they could manipulate millions in pursuit of a global goal. Rather than accept that the causes of poverty are many and complex, including the bad choices some people insist on making, they preferred to focus on neat technical fixes.

Global crises do not necessarily have global solutions. ­Would-­be humanitarians must listen to what people actually want and develop answers appropriate to each need, without simply assuming they know best. A campaign to make poverty history will lead nowhere or worse if it starts with an impoverished understanding of the ­past.