When the first sterilization campaign arrived in their little town of La Legua, Peru, Celia Durand and her husband Jaime were unsure they wanted to participate. Although they had discussed Celia’s having the operation in the past, and had even researched its availability, they had begun to hear rumors about women damaged and even killed during the campaigns and Celia had decided she didn’t want to be sterilized that way. Maybe sometime later she would do it; maybe in a hospital. Certainly not in the little medical post down one of La Legua’s bare earth streets, with its windows opened wide to the dust, insects, and the smells from the pigs and other animals rooting and defecating in the nearby streets and yards.
But then the campaign began and the Ministry of Health “health promoters” began to work her neighborhood. Going door to door, house to house, they repeatedly pressed the sterilization option. Interviewed later, her husband Jaime would recall the singular nature of the workers’ advocacy. They wouldn’t offer Celia any other contraceptive method, he reported. It was sterilization, nothing else. Many of the conversations centered around minimizing Celia’s fears about having the procedure during the campaign. “Do it now,” they said. “You may have to pay [to have it done] later.” Other lines of argument included how “easy,” “safe,” and “simple” the procedure would be. And the workers persisted. Again and again they came to the family’s home, refusing to accept ‘no’ for an answer, until finally Celia gave in and made an appointment. On the afternoon of July 3, 1997, she agreed, she would have the procedure.
Her mother, Balasura, worried and the two even quarreled about it, “Don’t go, daughter, there is always time later,” Balasura remembers saying. But Celia wanted the daily visits to end and, besides, the health workers emphasized the procedure’s easy nature. “Don’t worry, mama, I will be back in a couple of hours.” she said as she left. That was the last time her mother saw her alive. Sometime during the procedure at the medical post, the surgeon caused enough damage to Celia that she slipped into a coma. Medical staff put off frantic visits from Celia’s brother-in-law, mother and husband, finally moving her entirely out of the post and into a larger clinic in nearby Piura. It did no good. Celia died without ever regaining consciousness.
Celia’s story is just one of many which have resulted from a nationwide campaign which aggressively targets poor, working class and lower middle class women for surgical sterilization in often filthy circumstances and without adequately trained medical personnel. Although estimates of how many women may have been hurt in these campaigns are difficult to tabulate, a survey of reports about women who have suffered some injury, indignity, or coercion reveals a pattern stretching across Peru ‘s length and breadth. Methods of coercion have included repeated harassing visits until women consent, verbal insults and threats, offers of food and other supplies made conditional upon accepting sterilization and making appointments for women to have the procedure before they have agreed to do so. Further, none of the Peruvian women interviewed by a PRI investigator reported having been adequately informed as to the nature, permanence, possible side-effects or risks of the procedure. “All they told her was how easy it was,” Jaime said later. “No more.”
According to both high-and-low level Peruvian sources, the Ministry of Health’s family planning program was a mostly quiet and somewhat moribund affair prior to 1995. ‘“It was just one of those things [the ministry] did,” recalled one former high level official who served in the MOH when the sterilization campaign began. “They would give their pills, maybe make some IUD’s and give some shots and that was it.” Everything changed, sources agree, when the Peruvian legislature changed the National Population Control Law to allow sterilization as a means of family planning.
According to Peruvian legislators, the Fujimori administration used a mixture of pressure and dirty tricks to change the law. Long-standing supporters of Fujimori, even if they did not want to vote in favor of a broad sterilization mandate, were told they had to support the administration or face political reprisal. Then some of the measure’s key opponents, particularly female legislators, were sent to Beijing part of the Peruvian delegation to the UN Womens’ Conference. Although these legislators were promised, both verbally and, in one ease, in writing, that the sterilization issue would not be debated in their absence, President Fujimori’s supporters took up the issue the evening before he left to address the Conference. The result was the passing of the bill that amended one sentence in the National Population Control Law. Formerly the law disallowed both abortion and sterilization as means of “family planning,” now it would disallow only abortion.
A former high-ranking official who served in the MOH at that time described what happened next as a “transformation.” It wasn’t so much that the administration began to put greater amounts of money into actually starting the campaigns, he said, at least not at first. Rather it was that the family planning component of the Ministry’s portfolio moved from being merely one among the eight or nine other activities that the Ministry did to being the first or “most publicized” among them. And within the family planning program itself, sterilization became the most publicized birth control method.
Anatomy of the campaign
Peruvian Ministry of Health officials structured the sterilization campaign in a way remarkably similar to the way other government and non- governmental authorities have structured similar campaigns in other countries. This in itself is not surprising as doctors from Colombia and India are reported to have been brought in to train Peruvian doctors and officials in how to run campaigns.1 Familiar elements include:
l. Using mobile sterilization teams.
According to PRI interviews with women and their families and accounts in the Peruvian media, the Ministry of Health assembles “teams” of doctors and nurses elsewhere in the country, usually in Lima, and then brings the team to a local area to complete the campaign. In most cases doctors and nurses actually performing the surgery are not those most familiar to the local people but are instead strangers brought in for the procedure, who depart quickly when the campaign is over. Similar approaches have been seen in other places, particularly in India.2 Bringing in a team tends to cut the campaign’s expense since it removes the requirement that every doctor in the country be trained in sterilization procedures. However, it also tends to lead to a very aggressive surgical schedule as organizers seek to get as many women as possible under the knife in as short a time as possible. Although none of the witnesses reported a pace as rapid as has been seen in India (48 women in 128 minutes in one example)3 Celia Durand’s family discovered after her death that she had been the last of the afternoon’s 15 patients.
2. Using incentives to till sterilization quotas.
As with women in India, Bangladesh and Pakistan, Peruvian women also reported being offered food, clothing and other things for themselves or for their children as a condition or an inducement to sterilization. Ernestina Sandoval, poor and badly in need of assistance after a string of weather problems cost first her husband’s livelihood and eventually her home, reported being offered food in a government hospital but then being told in order to qualify for the food she would have to accept a sterilization. “They told me I had to bring a card from the hospital saying I had been ligated,” she told a PRI investigator. “If I didn’t agree to do this they wouldn’t give me anything.” Maria Emilia Mulatillo, another woman, reported that her daughter’s participation in a program that supported children of low birth weight was made conditional upon her acceptance of a sterilization procedure. Likewise, Peruvian papers like El Comercio and La Republica have published stories of how “health promoters” have been paid or rewarded with special prizes if they manage to bring more than their quota of women for the procedure.
3. Lack of informed consent.
None of the over thirty sterilized Peruvian women whom a PRI investigator interviewed, which included a number of women who said they were happy they had the procedure, reported having given anything like informed consent. None of them were told of the procedure’s possible side effects, particularly when performed under the time and other constraints that mark the campaigns. None were told of the risks. Universally what the women reported was being told over and over again about the procedure’s eventual benefits, speediness and ease. But, as critics have pointed out, merely being told one set of facts about a potential medical procedure cannot be considered as having been adequately informed about the procedure.
4. Sterilization the only method offered.
Although supposedly committed to offering Peruvian women a wide-range of family planning choices, including sterilization, PRI’s investigation found that the government sterilization campaigns were single-minded. None of the women sterilized in the campaigns that we interviewed (as opposed to those sterilized, for example, in hospitals] reported being offered any options other than sterilization. Most were adamant on that point because, like Celia Durand, they were unsure if they wanted to be sterilized at all and would have welcomed a chance to take another option. Several women, particularly those who had already begun in other government family planning programs like those using Depo-Provera (which must be injected every three months), told of being instructed to have the sterilization procedure because their current program was being curtailed. Later, when asked directly about why women were pulled off Depo-Provera and pressured to accept sterilization, Dr. Eduardo Yong Motta, former Minister of Health and now President Fujimori’s health advisor, replied that “Depo costs too much,” and that the Ministry had a problem with a method which a “woman might forget” or decide that she no longer wanted.
5. Medical histories not taken and post-operative care inadequate.
None of the women sterilized in the campaigns that PRI interviewed reported having had any medical history taken prior to undergoing the sterilization procedure. This means that no one sat down with the women before the surgery to find out if any were experiencing medical conditions that might, in another circumstance, delay surgery. This is particularly important in light of the fact that the medical team was assembled and brought into a local area especially for the campaign. Familiar medical staff sterilized none of the women interviewed and thus, in some cases, no one was able to stop surgeries from proceeding in incidents where women were pregnant, menopausal or suffering from possibly complicating conditions. Post-operative care, particularly in cases leading to serious complications and even death, was sorely lacking. It was not uncommon for a woman to be rapidly sterilized in an unhygienic theatre in an afternoon and then sent home, feverish or still in pain, a few hours later.
Despite being a signatory to the 1994 Program of Action on Population and Development, which explicitly disapproved of the use of quotas in family planning and population programs, the government of Peru has reacted with denials and obfuscation to complaints of abuse in its sterilization program. Marino Costa Bauer, Peru’s Minister of Health, appeared before the Peruvian Congress to answer legislators concerns about the sterilization abuses. He denied that any such program, quotas or other concerns even existed. If women have died due to sterilizations, the government maintained, the fault lay with peer doctors and badly performed operations (an allegation that the Peruvian Medical College swiftly denounced).
The government’s reaction stands in sharp contrast to the still-strengthening consensus among many different elements of Peruvian society, which agree both that a sterilization program exists and that it has both abused and killed women. Among the organizations which have denounced the campaign and its abuses have been the feminist groups Manuela Ramos and Flora Tristan, the Peruvian bishops conference, the Public Defender’s office (a sort of national ombudsman), doctors, groups which work with Peru’s poor and even USAID.
But the government’s position has remained intransigent. Even though a USAID representative testified before the House Committee on International Relations’ Subcommittee on International Operations and Human Rights that the government had promised the Agency an end to the campaigns, spokesmen with the Ministry of Health were quick to “clarify” the government’s position. The campaigns would continue, the government said, although modified a bit from the way they had been conducted in the past.
Much of the government’s position seems to arise from a deep-seated paternalisrn on the part of its leading officers. When confronted with the numbers and variety of Peruvian groups which oppose the government’s sterilization campaign, for example, Eduardo Yong Motta refuted each of the complaints that Peruvian groups had made. Peru’s human rights groups, he said, were blowing the problem out of proportion, as were the feminist groups. Doctors, he maintained, knew what was best for their patients and for most Peruvian women it was better to be sterilized. “Peruvian women have too many children,” he said.4
Where from here?
In many ways Peru now stands at a crossroads. Resource rich, and with a long awaited measure of political stability, the country should expect to soon be a South American leader. But the government’s sterilization campaign, and the reaction to its detection, reveals a society still deeply split along racial, cultural and class lines. The only way forward for the nation as a whole would seem to entail a move toward evermore transparency and honesty on the part of President Fujimori and his officials. Nothing less will rebuild the trust in that part of Peruvian society whose trust the government needs the most if any long term development is to take place.
1 Bermudez “Sterilization without consent,” Catholic World Report, March 1998.
2 Miller, “The Disassembly lines,” Population Research Institute Review, July/ August1997.
4 David Morrison, interview with Doctor Eduardo Yong Motta, Presidential Health Advisor, Presidential Palace, Lima, 29 January 1998.