US is key player in Salvador's controversial birth control plan

By , Special to The Christian Science Monitor

A major controversy here - one that has gone largely unreported in the United States - concerns the key role played by the US in El Salvador's family planning program.

Believing that a high population growth rate is ''a principal causal factor of social-political tension'' in El Salvador, the US Agency for International Development (AID) has pumped nearly $5 million into family planning here over the past five years and named population control as one of its four main objectives here.

AID helped to start the Salvadorean Health Ministry's Family Planning Coordination Office and has sunk more than $4 million into the other key family planning organization here, the Salvadorean Demographic Association (ADS). Both of these organizations distribute contraceptives nationwide and perform surgical sterilizations on women. Between them, the Family Planning Coordination Office and ADS have spent well over $10 million promoting population control.

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The family planning programs are successful, US AID and ADS officials say. AID estimates that about 25 percent of the women of child-bearing age in El Salvador use some type of contraception - a dramatic increase since AID became involved in family planning here.

Nonetheless the program has come in for heavy criticism. Many physicians and local health workers argue that the US is not attacking the really pressing health needs of El Salvador and that there have been some serious abuses in the surgical sterilization program.

''What this country needs is basic pharmaceutical supplies and fundamental medical equipment,'' says Jose Rodolfo Iraheta, administrator of the Rosales Hospital in San Salvador.

And the director of San Salvador's maternity hospital, Dr. Luis B. Duarte, says, ''You cannot solve the social problems here through family planning. These problems are not demographic problems. Unless the family planning program is coupled with other changes in the social structure, it will fail to bring the promised better conditions to the poor.''

Some groups suggest the US has not just grabbed a wrong end of the health problem here but is involved in an effort to try to change El Salvador's social structure. The Roman Catholic Church and many relief and health workers charge that the goal of the family planning effort is to limit the number of poor people.

US AID provides contraceptives to El Salvador - which are available for sale at approximately 800 pharmacies and are given to ADS and the Ministry of Health for distribution. The proceeds from contraceptives that are sold support ADS, which is the primary recipient of AID family-planning funds. AID also donated 47 jeeps to ADS in 1981, allowing teams to travel throughout the country to promote family planning.

AID officials say the intent of this effort is to make contraceptives available to those who normally do not have access to pharmacies or cannot afford birth control. The head of ADS, Dr. Enrique Enriques, says the contraceptive program is focused on Salvadoreans in the countryside. ''Improverished families habitually have large numbers of children,'' he says.

The most explosive aspect of the family programs in El Salvador, however, is not the distribution of contraceptives, but the surgical sterilizations performed on some 21,000 Salvadorean women a year.

A health official says that strict norms and procedures are adhered to in El Salvador's family planning programs. But relief workers charge that is not always the case. They say, for example, that food has been offered to women in displaced persons camps in Santiago de Maria if they will agree to be sterilized. Some workers also say that many expectant women who go to state-run hospitals are pressured by medical staffs to have sterilization operations after they give birth. Sometimes, these workers say, the mothers are sterilized without prior consultation or consent.

''My wife went into the hospital on Oct. 2, 1982, to have our last child,'' says a man who lives just outside San Miguel. ''We had heard the rumors about sterilization and asked both the nurse and doctor not to perform the sterilization operation. My wife was in the operating room to have a Caesarean. They told her to sign a piece of paper or she would lose the child. Unable to read the paper and scared, she signed. It was a request for sterilization.''

However, Dr. Jose Adah Montes, the director of the Ministry of Health's Division of Maternity and Childhood, Nutrition, and Family Planning, says: ''All patients who are sterilized do so voluntarily and without pressure. These patients are provided with complete information about all family planning methods and their consequences. . . .

''All patients who request sterilization sign a form,'' he says. ''A witness must also sign, certifying that the sterilization was requested by the patient.''

AID officials have promised to conduct an investigation into alleged abuses of sterilization procedures. They say they do not condone sterilizations that are performed as a result of pressure or that are done against the will of the patient.

It appears, however, that AID has violated at least one tenet of its own guidelines set out in Washington. According to those guidelines, surgical sterilization cannot be more economical than other forms of birth control. But in El Salvador, sterilization is often provided without cost.

The structure of the ADS lends it to a campaign for surgical sterilizations. ADS has 1,900 contraception distribution centers nationwide and four clinics that provide free surgical sterilization. The distribution centers are run by women who work out of their own homes. The centers provide temporary contraception to women at a minimal cost and serve as contacts to refer women for sterilization. ADS provides conceptive services to approximately 8 percent of the nation's 935,000 women of child-bearing age. The organization sterilizes 7,000 people a year.

The temporary contraception measures promoted at the distribution centers are primarily pills and IUDs, Dr. Enriques says. These centers, run by women who may themselves have been surgically sterilized, registers women in the family planning program.

ADS officials say the ADS teams, which include a nurse, make home visits and explain the advantages of sterilization.

''We expect each nurse in the field to sign up an average of one women for sterilization a day,'' says Martin Caballero Reyes, the director of information and education at ADS, ''and if a nurse does not find 300 women a year for surgical sterilization, they fall below what we consider average.''

In Santa Tecla ADS has two clinics. One, which only makes referrals for surgical sterilizations, is located in the center of a camp for some 1,000 displaced persons. The clinic provides contraceptives and offers the only form of medical assistance available to the displaced people here.

The nurse at the clinic, Maria Elizabeth Argueta, has made 80 referrals for surgical sterilization since April, a figure Caballero considers ''very low, especially since she visits other camps in the area.''

In displaced centers ADS often promotes contraceptives that do not require daily attendance, such as IUDs and Depo-Provera. Depo-Provera is an injectable contraceptive and is considered effective for three months. More than 10 percent of the women in this camp receive Depo-Provera injections. The drug is banned in the US because of possible negative side effects. US AID officials say they do not provide Depo-Provera to ADS.

AID says it does have plans to move ahead in other medical areas besides family planning. It recently initiated a $25 million program that is intended to reduce the shortage of supplies and to replace some medical equipment.

The $25 million project, AID officials say, will strengthen El Salvador's ability to maintain regular supplies of drugs and other equipment to health facilities throughout the country. The program will also provide some new equipment, help to repair old equipment, and maintain vehicles used for medical purposes.

''The problem with this program, like all the aid programs here,'' says Mr. Iraheta, ''is that what is sent to us passes through many hands. We wonder how many of these supplies will ever make their way to our hospital.''

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