[tt] NYTBR: Matthew Connelly: Fatal Misconception

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Matthew Connelly: Fatal Misconception
http://www.nytimes.com/2008/03/23/books/review/Kristof-t.html

Birth Control for Others
By NICHOLAS D. KRISTOF

FATAL MISCONCEPTION
The Struggle to Control World Population.
By Matthew Connelly.
Illustrated. 521 pp. Harvard University Press. $35.

The first large-scale scientific test of family planning took place
in Khanna, India, beginning in the early 1950s. Backed by the
Rockefeller Foundation and the Harvard School of Public Health,
researchers asked 8,000 villagers how often they had sex, whether
they wanted to conceive and the details of the women's menstrual
cycles. The researchers met the villagers monthly and provided
contraceptives, while closely monitoring another group that was
given no contraceptives. After five years, the women given
contraceptives had a higher birth rate than those who hadn't
received any assistance.

That initiative was an early warning that population policy can be
very difficult to get right. In "Fatal Misconception," Matthew
Connelly, an associate professor of history at Columbia University,
carefully assembles a century's worth of mistakes, arrogance,
racism, sexism and incompetence in what the jacket copy calls a
"withering critique" of "a humanitarian movement gone terribly
awry."

Efforts to control population have long been ferociously
controversial, and the United States under George W. Bush refuses to
provide a penny of funding for the United Nations Population Fund
because of its supposed (but in fact nonexistent) links to forced
abortion in China. Critics of family planning programs will seize
gleefully upon this book, and that's unfortunate, because two
propositions are both correct: first, population planners have made
grievous mistakes and were inexcusably quiet for too long about
forced sterilization in countries like India and China; and second,
those same planners have learned from past mistakes and today are
fighting poverty and saving vast numbers of lives in developing
countries.

"Fatal Misconception" is to population policy what William
Easterly's "White Man's Burden: Why the West's Efforts to Aid the
Rest Have Done So Much Ill and So Little Good" (2006) was to foreign
aid: a useful, important but ultimately unbalanced corrective to
smug self-satisfaction among humanitarians. Connelly scrupulously
displays a hundred years of family planners' dirty laundry, but
without adequately emphasizing that we are far better off for their
efforts. One could write a withering history of medicine, focusing
on doctors' infecting patients when they weren't bleeding them, but
doctors are pretty handy people to have around today. And so are
family planners.

One of the movement's early sins was a fondness for eugenics, the
belief that contraception was perfect for "dull-minded natives," as
one enthusiast put it, or for curbing the share of melanin in the
admixture of humanity. Activists sometimes seem to have had
antifreeze in their veins. Connelly cites a crusader named William
Vogt, author of a best-selling environmental diatribe called "Road
to Survival," who in 1948 described tropical diseases like sleeping
sickness as "advantages" because they helped curb population growth
and scolded the medical profession for believing it "continues to
have a duty to keep alive as many people" -- read: brown and black
people -- "as possible." Margaret Sanger, who courageously pioneered
the cause of birth control, icily promoted contraception "to be used
in poverty-stricken slums, jungles and among the most ignorant
people."

In the 1960s, the United States began to pour money into population
control, pushing nations to adopt family planning as a condition of
foreign aid. One result was extensive campaigns to insert IUDs, with
little or no follow-up care for the many women who developed pelvic
inflammatory disease and other problems. When the manufacturer of
the Dalkon Shield was hit with lawsuits over dangerous
complications, it offered the device at a big discount (and
unsterilized) to the United States Agency for International
Development, which happily shipped it abroad to be used by less
litigious dark-skinned women. As Connelly writes, "Scientists and
activists worldwide had agreed that high fertility was to be treated
as a disease, and that birth control for nations made individuals
expendable."

In fairness, while IUDs were dangerous, so was pregnancy. The
planners reasoned that while many people would suffer or die from
botched sterilizations or contraception, tens of thousands fewer
women would die in childbirth. Unfortunately, they showed little
interest in maternal health care, and they often mixed an admirable
impulse to serve humanity with a blithe contempt for individual
humans.

It didn't help that the planners were virtually all Western men who
had little understanding of life in the villages. At the 1974 World
Population Conference, 127 of the 130 national delegations were led
by men. The planners had far too much confidence in their own
wisdom. Paul Ehrlich's best-selling book "The Population Bomb" had
warned that the world was on the verge of terrible famines and urged
the United States to cut off food aid to areas beyond hope. At the
World Bank, Robert McNamara discouraged financing of 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."

Planners always assumed their programs would lower fertility. The
reality, however, was more nuanced. Evidence from careful,
randomized studies suggests that well-designed, intensive birth
control programs can reduce fertility somewhat, but that simply
shoveling pills or condoms at peasants has little or no impact. Poor
and uneducated people often want lots of children, so to be
successful, family planning has to focus as much on reducing desired
family size as on curbing ovulation. "Even according to the most
favorable contemporary studies," Connelly writes, "family planning
efforts explained less than 5 percent of fertility levels in
developing countries."

In 1983, the United Nations disgraced itself by giving its
Population Award gold medal to Qian Xinzhong, head of the Chinese
government's brutal quasi-military campaign of forced sterilizations
and abortions as part of a crackdown under its one-child policy. Yet
gradually the population movement became aware that women had rights
as well as uteruses. This awareness coincided with the rise of women
in the movement in the United States and abroad, including the
appointment of Nafis Sadik as head of the United Nations Population
Fund in 1987. Under Sadik, a Pakistani gynecologist known for
promoting women's rights, the fund expanded its scope to tackling
maternal mortality and the spread of AIDS. It has also become a huge
positive force in China, taming coercive policies and pushing for
replacement of the traditional Chinese IUD, which was ineffective
and painful (but which the government favored because it was cheap).
More broadly, planners have embraced education for girls -- now
recognized as the single most effective means of contraception in
poor countries -- as well as programs like microcredit that empower
women and reduce fertility, too. They are also leading the fight to
lower maternal mortality, which continues to take more than half a
million lives a year.

It's certainly fair of Connelly to dredge up the forced
sterilizations, the casual disregard for injuries caused by IUDs,
the racism and sexism and all the rest -- but we also need to
remember that all that is history. The family planning movement has
corrected itself, and today it saves the lives of women in poor
countries and is central to efforts to reduce poverty worldwide. If
we allow that past to tarnish today's efforts by family planning
organizations, women in poor countries will be doubly hurt.

Nicholas D. Kristof is a columnist for The Times. He is writing a
book with his wife, Sheryl WuDunn, about women in the developing
world.

You are invited to comment on this book or the issues raised in the
review on Mr. Kristofs blog.