Family planning program under fire in Bangladesh

Not everyone applauded when Bangladeshi President Hussain Muhammad Ershad received the fifth United Nations Population Award last year. Mr. Ershad, who was commended by the UN for ``strong personal leadership'' in reducing his country's birthrate, has come under fire in recent months for being too strong in his government's approach to population control.

Groups both inside and outside Bangladesh are charging that the safety of women, their right to free choice, and sometimes even their lives, are being sacrificed to a birth control program that puts national reduction quotas ahead of all else.

By 1997, the government hopes to bring down Bangladesh's annual population growth from the current 2.6 percent to 1.8 percent. This effort is encouraged by such donors as the United States Agency for International Development (AID) and the World Bank. Together, they contribute much of the $270 million that will be spent on the five-year population control plan, begun in 1985.

The government's main strategy to achieve this goal is to offer incentives of food, cash, and saris to poor women if they will agree to be sterilized - and to give similar cash incentives to government ``health workers'' for persuading woman to be sterilized. Doctors are also paid bonuses for each sterilization.

According to critics of this strategy, especially womens' groups, many of these ``health workers'' are not trained in health care. Many are hired for their powers of persuasion.

Although this gung-ho approach to population control has succeeded in reducing the birth rate - from 43 births per 1,000 people in 1980 to 32 per 1,000 in 1985 - critics say the method is at least tacitly coercive and does not give women free choice.

``When you offer a poor woman a new sari, when you offer her extra rice, when you offer her 100 takas (about $1.90), it is a pressure, and voluntary decisions become difficult,'' says Zafulla Chowdhury, a Bangladeshi physician who, in the early '70s, helped introduce sterilization as a family-planning option here.

Dr. Chowdhury says, ``It is mainly because of pressure from the donor countries - especially the US - that the government pursues this program.''

A Dacca-based women's group, Naripoko (meaning ``for women'' in Bengali), recently launched a campaign calling on the government to make the family-planning program safer and more voluntary, and to drop incentives and quotas.

``We're really concerned with the lack of emphasis on safety in the government program,'' says Shareen Hoq, a member of the group. ``Money spent on incentives is money that should be spent on improving health care for women who choose to be sterilized. Now, the government seems to think a form of birth control is `safe' if it's effective - in other words, that the woman definitely won't get pregnant. In that sense, sterilization is considered `safest.' But we're talking about real safety - about not jeopardizing women's lives for the sake of reaching a quota.''

Naripoko first became embroiled in the population control issue more than a year ago after learning about a poor urban woman's death following a sterilization operation. The woman did not receive a set of tetanus shots, which are usually given 21 days apart. The shots are considered necessary prior to such operations because villages often do not have properly sterilized surgical instruments. Apparently, Naripoko workers say, the health workers thought they would lose the recruit as part of their quota if they waited.

Naripoko representatives say women should be fully informed of all their options before they are given irreversible operations. In many cases, other birth-control methods may be very effective and more appropriate. And they want male sterilization to be encouraged more.

But some foreign donors to the Bangladesh family-planning program say a higher degree of compulsion should be used. Back in 1984, when the current program was being planned, the UN Family Planning Association's representative in Dacca, Walter Holzhausen, said in a letter ``Most donor representatives here greatly admire the Chinese for their achievements - a success story brought about by massive direct and indirect compulsion.'' The letter was leaked at the time to a London-based group that campaigns against foreign aid and intervention that is socially harmful to Bangladesh.

The letter, addressed to Nafis Sadik, then assistant executive director and now director of UNFPA, said: ``No one really doubts the need for massive direct or indirect intervention by government to limit the size of families; nor does anyone seriously believe that Bangladesh has the money or the time to establish better (mother-child health care) services and better educational facilities as a precondition for making voluntary family planning more successful. ... Massive incentive schemes, including disincentives and other measures of pressure, still deserve international support.''

With a current population of more than 100 million people and a 2.6 percent annual growth rate, Bangladesh will likely have twice as many inhabitants within 30 years. The country already imports food and relies on foreign aid to feed its people.

But critics of the current approach to population control say that until inequalities in the existing social order are resolved, no amount of sterilization and population control will solve Bangladesh's economic and social woes. In the meantime, they say, womens' rights to free choice and safe family planning should not be ignored.