POPULATION PATROL: BANKERS, BABIES, AND BANGLADESH

...In a dramatic move, it withdrew from Population III because of its longstanding concern about sterilization incentives...

...According to AID, the incentives were really "compensation payments" designed to cover transportation, food costs, and wages lost due to the sterilization operation...

...Children are a vital source of agricultural labor, and adult sons are the only source of financial support in old age...

...One of the most important findings of the Bank report is that the payment to sterilization acceptors "acts as a positive incentive in a substantial minority of cases— disproportionately men, the very poor, and those suffering a particular economic crisis...

...Less than a third is literate or has access to basic health care...

...A hungry person can buy many meals for 175 taka and a piece of clothing is a powerful inducement for a person who owns only one worn-out garment...

...The emphasis on sterilization distorts the health-care needs of the people of Bangladesh...

...The report's findings were serious enough to persuade AID to stop financing incentives in 1988, although the Bangladesh government and other aid donors stepped in to foot the bill...

...almost half the rural population is landless and chronically underemployed...

...new...

...Even when women want to control their fertility, family-planning services of good quality are few and far between...

...It blames many of Africa's problems on rapid population growth, ignoring its own role in setting back development through structural adjustment...

...In 1984, for example, large parts of Bangladesh suffered serious summer flooding which made the lean season even leaner than usual for the poor...

...Numerous studies have shown that sterilization clients in Bangladesh come disproportionately from the poorest sections of the rural population...

...In a situation where only one-fifth of the children born in a year grow up healthy and fit, parents need to have many children to ensure that a few survive to adulthood...

...She is director of the Population and Development Program at Hampshire College in Amherst, Massachusetts...

...Although there is a divergence of opinion within the institution, the dominant Bank view of population is neo-Malthusian...

...In Bangladesh, the World Bank has gone one step further to support a coercive sterilization-incentive scheme...

...Forcing down birth rates through population-control programs will thus help the poor help themselves...

...Once an incentive system is in place, it also opens the way to other, even more coercive methods of population control...

...When she approached a local official for food relief, he told her, "If you have the operation, you will get wheat...

...Ironically, this emphasis on family planning over health is counterproductive even in narrow population-control terms, since one of the chief causes of high birth rates in Bangladesh is the high level of infant and child mortality...

...Almost half of infant deaths and one-third of childhood deaths are caused by illnesses which could be prevented or readily cured...

...It has also pressured them to relax prescription guidelines for contraceptives and aggressively push those considered most "effective"—intrauterine devices, pills, injecta-bles, and now the implants—in the absence of adequate screening and treatment for side effects, which can be serious and even life-threatening...

...In many countries, the World Bank has urged governments to make population control a higher priority than basic health care...

...At the time, negotiations were under way for a five-year, $270 million World Bank-coordinated "Population HI" project for Bangladesh...

...In rural Bangladesh, where chronic hunger and unemployment are realities for much of the population, the distinction between compensation and incentives is dubious...

...The World Bank is among the largest donors...

...No more foreign exchange, the agencies insist, unless the government devalues its currency, denationalizes its industries, opens its doors to foreign imports and investment, freezes wages, raises food prices, and slashes its budget for social services...

...The harmful effects of World Bank population policies are not limited to Bangladesh...

...As a result, many women have become disillusioned with these methods and dropped out of family-planning programs altogether...

...Bangladesh is a country of gross inequalities...

...The Bangladesh government responded quickly, instituting a crash program to reduce the birth rate, including enhanced incentives and punitive measures against family-planning personnel who fail to meet monthly sterilization quotas...

...Another dilemma faced by reproductive-rights activists is the extent to which they should ally with reformers in the population field, who would like to see improvements in the "quality of care" provided by family-planning programs...

...Regarding Nepal, one of the poorest countries in the world, a 1989 confidential Bank report says that nation's population problem calls for a Chinese-type solution "although something less than this is probably the best that can be expected...

...In Indonesian-occupied East Timor, where human-rights activists charge the Indonesian army has killed almost one-third of the population, the Bank has financed the highly controversial construction of family-planning facilities...

...On Ali's way back home, a sterilization agent accosted him, promising a free sarong and cash payment of 175 taka—the equivalent of several weeks' wages—if Ali agreed to a vasectomy...

...Their numbers spread scarce agricultural and environmental resources too thin, keep wages low, and cost governments too much money in social services...

...This is especially true in sub-Saharan Africa, the region hardest hit by economic reversal...

...According to World Bank figures, only 2 per cent of children in Bangladesh had been immunized by 1987 against the common infectious diseases...

...Sterilization effectively ended her chances of remarriage, for in Bangladesh few men will marry a sterile woman...

...emergency food aid from destitute women unless they agreed to be sterilized...

...moreover, it actively allies itself with the same Third World elites who monopolize resources within their countries and thus prevent real development...

...Agency for International Development financed 85 per cent of these incentive and referral fees, despite the fact that Congress explicitly prohibits the use of U.S...

...The capital city of Dhaka rises from the flat, fertile river delta of Bangladesh like an oasis of affluence...

...The stage was set for abuse...

...More prosperous couples tend to choose such reversible methods of birth control as the IUD and the pill...

...Under the government's revised incentive system, each person—man or woman—who agrees to be sterilized receives 175 taka and a free sari or sarong...

...A vital part of his battle plan is "curbing excessive population growth...

...As a result, incentives, coupled with pressure from health and family-planning workers, are instrumental in persuading many poor people to be sterilized...

...It has acted under direct pressure from the World Bank and other international agencies...

...First, it obscures the real cause of poverty in the Third World: the unequal distribution of resources and power within individual countries and between the developed and underdeveloped worlds...

...In the face of grinding poverty, poor people in Bangladesh, as in many other Third World countries, are forced to rely on children as their only form of economic security...

...Today, the World Bank and the International Monetary Fund are engaged in a full-scale attack on the Third World's poor people through "structural adjustment," applying the screws to Third World economies already burdened by massive foreign debt...

...Mother and Child Health, supposedly a cornerstone of Bangladesh's population policy, has consistently taken a back seat to sterilization, with tragic consequences...

...While quality of care is a noble goal, too often its advocates fail to recognize the basic contradiction between population control and the reforms they would like to see...

...The four-volume report, written by John Cleland and W. Parker Mauldin, is an excellent example of the way the Bank manages to ignore or misinterpret its own findings...

...Agency for International Development, and the United Nations Fund for Population Activities circulated a position paper in Dhaka calling for a "drastic" reduction in population growth, the creation of an autonomous National Population Control Board with emergency powers, and an increase in sterilization incentives...

...The agent instructed Osman Ali to tell the people at the family-planning clinic that he had two wives aged thirty-six and twenty-two although, in fact, his only wife had already reached menopause...

...The report downplays socioeconomic inequalities and asserts that fertility reduction "must be the single most important objective of Nepal's health and population sectors...

...In male-dominated Bangladesh, Rohima's personal history is not unusual...

...The rich residential areas of Gulshan and Dhanmondi, home to high government officials, businessmen, diplomats, and aid agency personnel, boast sprawling houses maintained by retinues of servants...

...Ten per cent of rural households own more than 50 per cent of the land...

...Inevitably, the payment of a fixed sum to all will act as an incentive to some," Cleland and Mauldin summarize their argument in a recent article...

...Answering charges that the East Timor population program has used coercion, a Bank official recently stated, in language reminiscent of Bangladesh, that there may have been "isolated cases of overzealousness on the part of family-planning workers...

...Today three-quarters of Bangladesh's population is malnourished...

...The Swedish government went one step further...

...Today, the international women's health and reproductive-rights movement is gaining momentum, as activists in both Western and Third World countries share information and organize campaigns...

...The affluence of Dhaka is a world away...

...As in Bangladesh, this policy is likely to have disastrous human consequences...

...Recently, referral payments to health and family-planning workers, as well as to public agents, were abolished...

...In the government budget, military spending has a much higher priority than either health or education...

...In the spring of 1983, the World Bank, the U.S...

...Cleland and Mauldin ignore the serious ethical questions raised by a survey cited in the report which indicated that more than one-third of women who said that money was their motive for being sterilized regretted their decision after a few years...

...In Indonesia, the Bank has supported the government's program of aggressively pushing the IUD, pill, and injectables through "acceptor clubs," in which women who agree to use contraception (usually without adequate health backup) receive preferential access to credit and training...

...Payments to sterilization acceptors remain in place today...

...The payment of referral fees to health and family-planning workers has also undermined freedom of choice...

...Moreover, government statistics show that the number of sterilizations tends to increase dramatically during the lean autumn months before the rice harvest, when many landless peasants are unemployed and destitute...

...His story was brought to light by the Catholic Commission for Human Rights in Bangladesh...

...Other donors viewed the report as a whitewash...

...Members of the public acting as sterilization agents have been even more unscrupulous, as in the case of Osman Ali...

...Ignoring these realities, the Bangladesh government has tried to force down birth rates in the absence of any real improvements in people's lives...

...They are not opposed to family planning—on the contrary, they are fighting to make safe birth control, including abortion, accessible to women as a part of a more comprehensive health-care system and larger social reforms...

...POPULATION PATROL Bankers, Babies, and Bangladesh BY BETSY HARTMANN On August 11, 1987, in Bangladesh, an eighty-year-old peasant named Osman Ali traveled to the town of Mymensingh to see his brother...

...The societies in which population is growing very fast must accept that many— perhaps most—of these new lives will be miserable, malnourished, and brief," he said...

...Population control has done much to harm the quality of life for millions of poor people—by, for example, undermining basic health services...

...In financial terms alone, population control now absorbs a full third of the government's health budget...

...Smaller incentives were also offered to women who agreed to use IUDs...

...Political power is concentrated in the hands of a military government, which annually receives more than $1.5 billion in foreign aid...

...funds to "provide any financial incentive to any person to undergo sterilization...

...There was no mention of the misery that population control has brought to poor people like Osman Ali...

...She worked for a wealthy family husking rice, but when the floods came there was no more work and she had nothing to eat...

...Not only have workers tended to promote sterilization at the expense of other contraceptive methods, but many also failed to give adequate information on the possible side effects of sterilization, for fear of losing clients...

...This is a major reason why there is "a strong link between poverty and sterilization...

...This is the countryside of Bangladesh, home to most of the nation's 100 million people...

...In 1986, the Bank announced that population assistance was its "highest priority" in Africa and called for massive increases in foreign population aid...

...Improving care in family-planning programs is a step forward, but it is not enough...

...A confidential 1985 Bank report on Population III, circulated among co-financers of the project, endorsed the government's goal of increasing sterilization rates and contained nothing critical about the incentive system...

...Until recently, doctors and clinic staff received a special payment for each sterilization they performed, and government health and family-planning workers, as well as village midwives and members of the public, received a referral fee for each sterilization client they brought to the clinic...

...Three of the donors that chose to remain in the project—the British, Dutch, and Norwegian governments—made their participation contingent on the Bank's commissioning a thorough study of incentives, which was completed in 1987...

...Second, the emphasis on population control distorts social policy and undermines the delivery of safe, voluntary family-planning services...

...By procreating too often, the logic goes, the poor help to create and perpetuate their own poverty...

...As big landowners, businessmen, and corrupt politicians line their pockets, the situation of the poor deteriorates...

...While monitoring food relief, field workers from British voluntary agencies discovered that local government officials had withheld U.N...

...But the allurement of cash is only a spur to action for couples who want no further children and this does not raise serious ethical questions...

...The result, according to the United Nations Children's Fund, has been increasing malnutrition, decreasing school enrollment, and a tragic rise in child deaths in many Third World countries...

...These are the standard incentives offered by the government's population-control program, which is funded by the World Bank and a consortium of other foreign donors...

...Until 1988, the U.S...

...Solidarity work has been made more difficult by the anti-abortion movement, which would like to capture the population-control issue for its own narrow purposes...

...The latest Japanese cars cruise along its wide, smooth boulevards, the hum of their air conditioners mixing with the beat of stereo cassette recorders...

...Pressure intensified several months later when World Bank Vice President W. David Hopper sent a letter to a senior government minister instructing him to "outline necessary measures to strengthen the program so that agreed national population objectives could be met on time...

...She was only twenty at the time, and her only child, a four-month-old son, was surviving on barley water...

...More than half of the appallingly high number of maternal deaths could also be prevented by basic care—yet most health facilities are inaccessible to poor, pregnant women (unless they come for sterilization) and traditional midwives have been encouraged to spend most of their time recruiting sterilization candidates and women who will accept IUDs...

...Pursuit of population control by the World Bank has not gone unchallenged...

...A year later, at the 1988 annual meeting of the World Bank and the International Monetary Fund, Bank President Barber Conable pledged that his institution is "dedicated to attacking poverty and beating it back...

...Christopher Allison, population adviser to the British Overseas Development Administration, told the Bank that the report "may be interpreted as providing a tacit endorsement" of the incentive system, which he argued "has potentially greater negative than positive effects on worker attitudes, practices, and performance...

...Yet the Bank continued to press the government to improve its population-control performance...

...Structural adjustment gives the Bank even greater leverage to promote population control in countries starved for foreign exchange...

...The Bank's population strategy for Africa looks distressingly similar to its programs elsewhere...

...After the operation, the agent collected his referral fee from the clinic staff and then proceeded to steal the sarong and cash from Osman Ali...

...Rohima agreed to be sterilized...

...It can do this by virtue of its leverage over other forms of development aid...

...Foreign aid flows primarily to the rich...

...The free clothing was justified as "surgical apparel...

...Cleland and Mauldin were at first reluctant to see the agents go, since they were "an important source of information" for poor men...

...There are two main problems with this analysis...

...In a 1985 position paper, the Swedish International Development Authority charged that the system may lead to "indirect coercion," contravene the principle of "free and informed choice as to contraceptive method," and "compete with other health services...

...When news of the food-aid incidents started hitting the international press, the World Bank passed them off as isolated cases of "over-zealous local officials" taking "undue advantage of food shortages to improve their family-planning records...

...Just outside the city limits stretches a patchwork of lush rice fields edged by footpaths and rivers and clusters of thatch-roofed huts...

...For more than twenty years, the World Bank has played a strategic role in pressuring Third World governments to implement population-control programs...

...The agent system, which was only recently abolished, accounted for almost half of the male sterilizations in Bangladesh...

...Despite this evidence, however, the report goes on to recommend that incentives be continued, since they allow poor people to meet the costs of sterilization...

...Rohima was one of these women...

...The Bank has always turned a blind eye to inequality...

...She was married at an early age to a poor man, who divorced her when she was seven months pregnant and sent her back to her mother's house...

...Although the soil is rich, many of its cultivators are desperately poor...

...Conable's pronouncement was nothing Betsy Hartmann is the author of "Reproductive Rights and Wrongs: The Global Politics of Population Control and Contraceptive Choice" (Harper & Row, 1987) and co-author with Hilary Standing of "The Poverty of Population Control: Family Planning and Health Policy in Bangladesh " (distributed in the United States by the Boston Women's Health Book Collective...

...It encourages governments to set population-control targets, to promote the pill, injectable contraceptives, and IUD in the absence of adequate health backup, and if necessary use incentives and disincentives...

...The old man suffered an immediate stroke and died the next day...

...Regret was also high among women who had only one or two children at the time of sterilization, or who had subsequently lost a child...