It takes more than a village to depopulate one

International | Contraceptive family planning and abortion advocacy mark the kind of "relief" international relief organizations energetically import to East Africa

Issue: "Passing of a peacemaker," Feb. 20, 1999

in Nairobi, Kenya - A large, dusty sign hovering over the used-clothing stalls of Kenyatta Market reads, "Marie Stopes International-family planning/laboratory services, maternal health, counseling services, curative services, gynecological consultation." Steps beckon to a second-floor clinic. It offers extended hours, six days a week, and the door is always open. Inside, an American woman can inquire about receiving an abortion, if she will be discreet. "Do you have all forms of family planning here, or do you refer patients to a hospital or somewhere else?" "Yes, all forms," replies a friendly African receptionist. "If a person were pregnant, but wasn't sure she could go through with it ..." "You have to just say what it is you want," the receptionist interjects, leaning into the counter and lowering her voice. "Could a pregnancy be terminated or would that have to done somewhere else?" "It can be done here." Never mind that abortion in Kenya is illegal. Overseas charity organizations like the British organization Marie Stopes are the vanguard in changing Kenya's cultural reticence to killing unborn babies and limiting family size. They use enticing come-ons promoting "maternal health" and "comprehensive family planning." In East Africa and other developing regions of the world, they receive outsized budgets from multilateral agencies in the name of empowering women, improving health conditions, and preserving the environment. At the behest of the UN Family Planning Association (UNFPA) and international groups including Marie Stopes, the International Planned Parenthood Federation (IPPF), and others, Kenya is embarking on an aggressive family planning program. The UNFPA was denied funding by the United States from 1985 until 1993 for support of China's coercive one-child policy. Its allocation from Washington restored in 1993 by the Clinton administration, the UNFPA is in the middle of a five-year, $20 million program to control Kenya's population. Not content with the dramatic reduction in Kenya's birth rate-which modern contraceptives already have achieved (from 8 children per woman in 1979 to just over 4 children per woman today)-the UNFPA and others are looking to reduce fertility further, to 2 children per woman by 2010. "We have a two-child policy except in law," said Margaret Ogola, a Nairobi physician. "Practically the only kind of health care you get in this country centers on reproductive health and family planning." UNFPA papers refer to a "decentralized" national population policy driven by the Kenyan government's National Council for Population and Development. But local direction is not the case, according to Dr. Ogola, who, as a representative for Kenya's Catholic Secretariat, is involved in regular consultations with NCPD. Funding for the NCPD, as for all Kenya's population projects, begins with funding from UNFPA, the World Bank, the World Health Organization, and overseas developers like the State Department's U.S. Agency for International Development (USAID). From those sources also flow grant and contract awards to groups like Marie Stopes and to Kenya's IPPF affiliate, Family Planning Association of Kenya (FPAK). USAID does not list Marie Stopes as one of its beneficiaries, but FPAK received direct funding by USAID until 1997, according to FPAK director Stephen K. Mucheke. Mr. Mucheke told WORLD, "We work in collaboration with other organizations, and sometimes we may be funded by the same donor that is funded by USAID. We share the same implicit plans." A little noticed amendment to last year's congressional budget bill should have put U.S. funding for UNFPA's quota-based program out of bounds. The Tiahrt amendment forbids U.S.-funded family planning programs from setting targets or quotas for number of births, sterilizations, or contraceptive prevalence. Abortion, according to Mr. Mucheke, "is happening down the street.... From an official point of view, I am not supposed to say that there are groups like Marie Stopes performing abortions. What I would say is, if you want to know about products and procedures, ask a consumer." In the UN lexicon, so-called private groups like FPAK are referred to as NGOs, or non-governmental organizations. The NGO consensus holds that most of the problems in the developing world can be solved with more contraceptives. Private pharmaceutical companies also get a piece of the action by contracting with NGOs and government agencies to supply the contraceptives. Groups like IPPF, which cried foul when U.S. judges tried to force Norplant on convicted drug users and child abusers, don't have a problem when it is women in the developing world under not government coercion, but their persuasion. Common among NGOs, particularly in controversial issues involving family planning, is a practice of "stripping off" portions of a large grant to other organizations, in effect subcontracting services in a way that makes following the money a challenge. More common, contraceptive programs reside in programs with blander names. Thus, even when the Christian relief organization World Vision surveyed its health officers worldwide on family planning issues last year, it found: "All responding NOs [national offices] are engaged in some type of family planning-related activity, either as a straightforward family planning or reproductive health project or buried within child survival, maternal health or women's health activities." As a result of the contraceptive campaign, Nairobi residents are streetwise about birth control. Women who wear Norplant are teased on city buses for the "battery pack"; the six-capsule implant, just inside a woman's upper arm, is revealed when a woman reaches for an overhead strap during crowded commutes. Shoppers at Kenyatta, a busy nexus between the slum area of Kibera and lower-to-middle class neighborhoods near the downtown area, know where to go for an abortion. They know about the "copper T" and "the loop," two different kinds of IUDs. And, like people everywhere, they dismiss much-touted condoms as impractical. Even Christian women looking for inexpensive, safe, and acceptable contraceptives may be unknowingly referred to Marie Stopes, because it has been known to do some procedures, like tubal ligation, free of charge. The London-based organization gained a reputation for increasing the availability of both sterilization and abortion services in Bosnia and Croatia, countries that now report negative fertility rates. In addition to performing actual abortions, Marie Stopes and other clinics, along with up to 90 percent of private OB-GYNs, peddle an abortifacient procedure called "menstrual regulation." Similar to what is known in the United States as dilation and curettage (D & C), in Kenya menstrual regulation can be performed as an office or clinic procedure. It is done when a woman misses a menstrual period but without benefit of a pregnancy test. No one knows how many abortions result from menstrual regulation. Even without that tally, in Kenya, according to UN statistics, "40 percent of all documented schoolgirl pregnancies terminate in abortion." But none of that means that women who need help are well informed, according to Stephen Karanja, a long-time Nairobi gynecologist. Dr. Karanja, a Roman Catholic, served as secretary of the Kenya Medical Association and has practiced obstetrics and gynecology at Kenyatta National Hospital, Nairobi's largest public facility, as well as at Mather Hospital, a smaller, private, and Catholic facility. Dr. Karanja helped organize the city's Family Life Counseling Center and has been an activist in upholding Kenya's law banning abortion. In 1992 he opened a clinic at Kenyatta Market-50 yards from the entrance to Marie Stopes. He named it St. Michael's, in honor of the patron saint that does battle with forces of evil. Most of the women Dr. Karanja sees at St. Michael's have been given no information and little follow-up in connection with the methods of birth control they are using. Last year at the clinic, he removed approximately 200 IUDs. "Word of mouth has spread, and when women begin to have problems with IUDs, someone tells them to go to 'that crazy man on the hill and he will remove it,'" he said. He keeps a sampling of those reclamations in a screwtop jar, and when he wants to give a graphic depiction of how women are served by Nairobi birth control providers, he spills the jar's contents across his desk. To a trained medical eye, the devices are throwbacks, copper coiled or loop-shaped IUDs that were taken off the U.S. market at least five years ago. The T-shaped devices had an extremely high failure rate; another IUD, copper 385, contained enough copper wire to be deadly toxic to a developing, tiny unborn child. Dr. Karanja's patients tell him, in most cases, that the birth-control clinics that inserted the devices are not willing to remove them. "The services encouraged for poor women are those that are not repetitive," he said. "They are not something the women can decide themselves to change." Catholics and evangelical Protestants disagree on where to draw the line on contraceptives. Both, however, see the pitfalls of a national family planning plan. "In our culture, that is why the message and the messenger have to go together. The church is still custodian of morality in Africa. These are deep-seated issues, and people need to be able to trust the messenger," said Peter Okaalet, Africa director of MAP International, a Christian medical relief group based in Brunswick, Ga. "NGO work has come into acceptance because the government has let us down," Mr. Okaalet told WORLD. "We talk about Kenya as a country with 10 millionaires and 10 million beggars. With half the population living below the poverty line, NGOs are perceived as an answer." Dr. Ogola agrees: "No individual, not even combined force of the churches-and it is a force to be reckoned with in this country-can compete with the massive propaganda and funding. The government has to wake up to the fact that its people are important and its policies have to be home-grown. "We have to tell the government to resist. That is very hard when the government is broke and the donors are offering millions for family planning."

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