Marina, a Guatemalan Indian, went to Aprofam at the suggestion of her sister-in-law. After a ten-minute interview in which no medical questions were asked, Marina was given “the shot” No one told her the pros and cons of using Depo-Provera, other than that it only required her to go to the clinic once every three months. For four years, Marina continued to receive her quarterly shot. During this time, Marina was plagued by headaches, sleepiness and body aches. She did not menstruate once during this entire period. Marina repeatedly questioned the staff about her side effects when she was getting her shot, but was told that the shot was not harmful. Aprofam, she was told, has “the best way and the only way.”
Marina wasn’t the only one in her family ill-treated by Aprofam. Her sister was sterilized by the staff at Aprofam and told that whenever she wanted it, a reversal would be performed free of charge. When she eventually went back, hoping to have the surgery reversed so she could bear more children, she was told it would cost a large amount of money.
Olga went to Aprofam to seek help with planning her family. She was quickly given a shot and told to come back in three months. No medical exam was performed, and no information was requested. Three months later she returned, and again was given a shot, but no medical exam. Olga gradually began to experience serious side effects. including no menstruation, pain in the ovaries, swelling of the abdomen, leg pain. varicose veins, and incapacitating migraines. When she complained to the Aprofam staff of these symptoms, she was put on the pill to regulate her cycle, and then inserted with a Copper-T IUD. The IUD was inserted in a 15-minute procedure during which no medical exam was performed, or questions asked.
A year later, Olga went to a private OB/GYN who discovered a pelvic infection. She was put on antibiotics, for this condition. Olga’s story ends on a positive note: She has recovered from her experience and is now happily pregnant.
In the Countryside
Olga and Marina are two of the 18 women interviewed by a researcher recently sent by PRI to conduct an investigation of reproductive health services in Guatemala. All of these women had been ill-treated by a Guatemalan agency which receives US funds through the United States Agency for International Development (USAID). The Asociacion Probienestar de la Familia, or Aprofam as it is more commonly known, is the Guatemalan affiliate of the International Planned Parenthood Federation. It is a quasi-independent governmental agency in Guatemala, which dispenses population control to the unsuspecting poor.
The sample of women interviewed was large and diverse enough geographically to allow the inference that the real extent of malpractice may be significantly larger than this limited sample. Gynecologists and others knowledgeable of Aprofam’s activities were interviewed at length. Large numbers of women voluntarily stepped forward to be interviewed. They told of Aprofam’s failure to 1] provide minimal medical services, or follow-up care, 2] explain the various family planning options available, including the Billings Method, as they are required to do, or 3] warn of side effects of treatment, then 4] allow the woman to make a free, fully informed choice of all options.
Interviews followed a set format for the sake of comparative value and consistency. Tiahrt Amendment conditions are embodied in the format: When and where was the first contact with Aprofam? What methods were used to draw the woman to the “Ligation Festival”? Were bribes or prizes offered? What threats were made? Was pressure applied to the woman? How did Aprofam personnel conduct themselves? Were they doctors or nurses? How did the woman know the qualifications of the person treating her? Were options explained? Was the woman given a choice of treatment? Were side effects explained? What information was offered on a treatment, such as instructions, written material or packaging to indicate the manner of use and origin? Did Aprofam ask the woman to sign papers? Was the woman harassed by repeated visits from Aprofam? What side effects resulted from treatment? What response was obtained from Aprofam personnel upon being notified of the effects? Did Aprofam accept responsibility’? Does the woman recommend Aprofam? Does the woman know of others who have symptoms from Aprofam treatment?
Interviews produced a remarkably consistent picture of abuse. Most women went to a “Ligation Festival” for first contact. The rest went as walk-ins to Aprofam clinics. Clinics are well marked with Aprofam’s logo. Sometimes administrative personnel issued medical advice. Most often, doctors or nurses gave women a single option without discussion: pills or shots. No proofs of professional qualifications were visible or offered. Thus, women did not always know who they were being treated by.
In the case of tubal ligations, the procedure was assembly-line, without examination or personal history. Operations lasted 10 to 15 minutes. The procedure was laparoscopy by video through the umbilicus to place a small plastic ring over a fold in the fallopian tubes. This is a procedure that takes considerable skill. Women were then sent home, without promise of follow up. Most interviewees developed symptoms immediately: nausea, headaches, weakness, bleeding or discharge, often profuse, abdominal swelling and generalized pain. At least two woman of 15 developed varices. Some simply ceased menstruating. Some were advised the ligation could be removed if they wished to have more children. Several women had 15 year histories with Aprofam during which Aprofarn denied responsibility for any symptoms, placing the blame on the woman and suggesting a change to another form of birth control. These women experienced years of symptoms and treatment without healing. In all cases the women interviewed chose the Billings Method of Natural Family Planning as most beneficial for themselves, their husbands and their family.
Two women are bedridden from effects of an Aprofam Ligation Festival in a remote village. One woman noted that Aprofam’s administrator put down her age as 33 when she had told them she was 27 [The reason may be to show statistically that Aprofarn sterilizes older women]. Many interviewees were in their mid teens when they visited Aprofam, receiving pills and injections of strong hormonal drugs before they were fully developed.
All alleged that many more women had been victims of similar faulty medical procedures but might not agree to interviews for cultural or personal reasons, such as fear of retaliation. For example, women of certain communities become quite willing to appear on video when they learn that the interview is about, not by, Aprofam. Those chosen for interviews had for the most part histories beginning in the last two years. Most interviewees accepted confidentiality to be interviewed. Two had already gone public and had complained directly to doctors of Aprofam.
The victims were convinced they would receive a full array of medical services whereas in reality Aprofam provides only reproductive health services, under the guise of full medical services. Aprofam claims it will bring happiness to the family. The record shows, however, that it brings suffering and humiliation to those who believe its claims.
In addition, there is reason to believe that Aprofam’s practices violate Guatemalan law. The Constitution of Guatemala of 1983 prohibits abortion, yet Aprofam’s pills and injections are abortifacients, preventing the fertilized ovum from implanting. The same constitution specifies that conception takes place at fertilization, not at implantation. These observations were pointed out during interviews with doctors and lawyers of CODEDENA, a Guatemalan pro-life association for the protection of the unborn [Commission for the Defense of the Right to Birth].
How can this occur in a nation that generally has a very high level of medical practice? A host of factors enter into this picture, the principal one of which is that Aprofam attempts to carry out its mission of reducing population growth through substandard practice of medicine. Good doctors believe that you should “treat the person, not the disease,” Aprofam does neither. It induces healthy women to undergo sterilization and accept contraception, leaving them ill and sometimes pregnant. Then, when confronted with the effects of its malpractice, denies responsibility for them. At Aprofam’s urging, 40 women presented themselves for sterilization at a recent Ligation Festival. In the subsequent months, 21 of them became pregnant. The 21 victims officially complained to the Guatemalan national ombudsman, who concluded that Aprofam compromised the human rights of the complainants.
In Guatemala, Ministry of Health hospitals and clinics in some locales must allocate scarce funds to correct the significant instances of malpractice by Aprofam. Needless to say, the animosity and mistrust directed at Aprofam from among the poor is widespread. The similarities with the infamous Ligation Festivals uncovered by PRI in Peru is eerie. (See “Cutting the Poor” PRI Review, March/April 1998)
Aprofam’s practice of medicine amounts to malpractice because it generally ignores fundamentals available to any doctor whatever the wealth or poverty of his country. There are literally hundreds of malpractice cases. Among the charges are that Aprofam often takes no personal histories, dispenses with physical exams, never discusses side effects of drugs and procedures, gives no proofs of professional qualifications of its doctors and nurses, and allows administrative personnel to dispense medical advice. Follow-up by Aprofam doctors is virtually unknown. Doctors who perform ligations come, operate and leave for the capital the same day. There is no aftercare for these patients, although there are documented cases where it is necessary. There is some question whether Aprofam adequately sterilizes instruments during its Ligation Festivals.
Medical malpractice law in Guatemala has not evolved to the level it has in the United States. The rich, of course, can always obtain justice, but class-action suits are unknown in Guatemala. Direct malpractice suits by individuals are rare. In any event, the poor do not have the knowledge, time or money to bring suit. The only redress is to apply to the Procurador de Derechos Humanos, or national ombudsman, to verify facts presented by plaintiffs. This ombudsman only verifies evidence presented by plaintiffs, without having constitutional power to prosecute. Declarations of this office vindicate plaintiffs who have suffered violations of their human rights and recommend changes or corrective action. Declarations may result in a recommendation of reimbursement for expenses incurred but not awards for damages. For example, some plaintiffs were offered corrective operations by Aprofam as a result of favorable decisions of the ombudsman. The women, however, wanted nothing more to do with Aprofam, and refused.
What Should Be Done?
Specific changes need to be made in the administration of Aprofam in order to bring it into compliance with the Tiahrt Amendment and make it eligible to continue receiving US funds. Until that time, money to Guatemala for population control activities should cease, Specific controls needed include: written records of medical histories and examinations; signed statements by the woman and medical doctor stipulating that counseling was given, which included explanation of the pros and cons of individual methods; presentation of certification by all medical personnel; operations done by medical doctors resident in the community; sterilizations by board-certified gynecologists; signed certification by the woman that she was neither harassed, bribed nor forced to undergo sterilization; and establishment of local oversight boards of medical doctors to insure compliance with the Tiahrt Amendment and national medical practices.
These changes will do little to help the many women already injured by Aprofam, women like Olga and Marina. Or like another poor women who described the quarterly visit for her shot as a “humiliating ordeal” which caused her to develop a painful ulcer. They may, however, prevent other women from having to suffer similar atrocities.