The village of Kamanzichana, Tanzania is about a two and a half hour drive from Dar es Salaam by four-wheel vehicle, and virtually unreachable by other means. Jagged hunks of broken pavement lurk unexpectedly along the dusty, pothole-ridden roadway, more like barricades against would-be trespassers than reminders of long-neglected development.
Kamanzichana boasts three hotels. But the existence of a hotel in this context is merely evidence that a resident has an extra room for rent and perhaps a second latrine, as well. The village is miles from electricity, piped water, and telephone service. The unemployment rate is virtually a hundred per cent. And as darkness settles over the town, kerosene lanterns flicker at nearly a dozen “social clubs” that line narrow pathways beaten by years of foot traffic. There one can purchase hot Coca Cola or hot beer, the standard substitutes for clean drinking water.
Kamanzichana is “off the map” as far as the government is concerned. There is no ambulance service, and the nearest health care facility is at tiny dispensary at Kilamahewa, a small settlement several kilometers away, hidden deep in the lush tropical vegetation that covers the country‘s coastal region.
Birth Control Police Rule
And there are no police in Kamanzichana — unless one counts the “birth control police.” These are health workers who go from door to door, introducing themselves as officials of the Ministry of Health, and demanding that women either take contraceptive pills or get injected with Depo Provera, a long-acting anti-fertility agent.
Among the people passing time at one of Kamanzichana’s makeshift bars is 20-year-old Farida, who eagerly joins a conversation about the birth control campaign. Village women are afraid of these people who come to their homes, she says. Their insistence that women participate in the family planning program is taken as a government mandate. And she adds that several women have been made seriously ill by the injections, while others have found themselves unable to bear children long after ceasing to permit the injections to be given.
Farida’s comments are confirmed by Matilda Mkulu, a nurse-midwife at the facility in Kilmahewa, who describes a score of cases in which women sought help for contraceptive-related complications. Some suffered for months with heavy bleeding, while others were found to have dangerously high blood pressure.
And some die…
Some have been even less fortunate. Mkulu tells the story of a Kilamahewa man whose wife went away to find work. During her absence she secretly took the pill — a fact that was discovered when she suffered a stroke and was taken to a hospital where she died.
And one night in November of 1999, a 27-year-old mother of four came to the dispensary with a high fever and painful abdominal infection. When it was learned that a doctor at Kiparang’anda had used surgical instruments to start a miscarriage four days earlier, local people traveled to his clinic and demanded the return of money she had paid for his “services.” They were then able to get transport to Dar es Salaam, but the woman, Rehema Musham, died in the hospital the next morning.
Tanzania through a Microscope
To spend a weekend in Kamanzichana is to see rural Tanzania through a microscope. Development came to a sudden halt in 1986 when international lenders imposed mandatory structural adjustment on the nation. Since then, the country’s infrastructure has crumbled and the promise of economic betterment has all but vanished. The only twentieth century technology on the horizon is modern contraception. And under a population policy mandated by the same financial institutions that ushered in the devastating “austerity” measures, the country has been inundated with it.
This anti-natalist policy, which local people perceive as being that of their own leaders is, in other words, a program of population control engineered by officials in Washington who use their leverage at the World Bank first to demand that borrowing countries agree to set aside development in favor of debt repayment and, once the economy has deteriorated to the point of desperation, to compel borrowing countries to take the lead in running ambitious, western-designed family planning schemes as a show of creditworthiness.
Birth Control Side Effects
One might wonder why birth control measures that are widely used in secular, westernized nations lead to side effects as prevalent and extreme as one finds in Tanzania. A main reason is that women here are normally not screened for pre-existing conditions that would make them medically ineligible for such methods. In the US, for example, a woman’s age, weight, blood pressure and cholesterol levels, lifestyle issues like smoking and alcohol consumption, and even family medical history, are all taken into consideration before prescriptions for such things are written. And even then, women are checked by doctors on follow-up visits to make sure that potential complications are detected before they become serious.
But here, as in most of Africa, women are simply given orders to “take it,” and then to return at a future date for the next injection or packet of pills. It is common for these drugs to be provided to women without any medical examination whatever, either before or after the contraceptives are given.
Unsafe Methods Promoted
But not all birth control methods being promoted in Tanzania are considered sufficiently safe for western women, even under the best of conditions. Two devices that are no longer in general use in the United States — the intrauterine device (alternatively known as the IUD, coil, or loop) and Norplant (which consists of six capsules inserted under the skin of a woman’s arm) — are fairly common in Tanzania. Both were largely abandoned in the US in the wake of massive product liability lawsuits.
It was an IUD, improperly inserted, that killed 30-year-old Munira, a married woman with three children who lived in Zanzibar. After the insertion of a “coil” in 1997, Munira became gravely ill and was rushed to the hospital. It was then discovered that the device had punctured the uterus and lodged in the intestines. She was flown by helicopter to Muhimbili Hospital in Dar es Salaam, but too late to save her life. Another woman, 27-year-old Victory, found that her IUD became so deeply embedded that it was impossible to remove without a hysterectomy, something she has not yet opted to have.
Norplant is another choice given to Tanzanian women who are “advised” that they “need” birth control. Norplant is a particularly attractive option to the western population establishment because once implanted surgically it prevents pregnancy for at least five years and, unlike the coil, cannot be removed by a non-professional. In fact, removal has become a major issue both in lawsuits in western countries, where clinics have often found the device extremely difficult to extract, and in less-developed nations, where it has been claimed by human rights groups and the news media that family planning agencies have simply refused to take them out, even in cases where severe side-effects have occurred.
Visit to Morogoro
In Morogoro, a small, picturesque city in the country’s mountainous region, two women describe their experiences with Norplant. Colete, a 32-year-old woman with a husband and four children, received Norplant in 1995. When she wanted it taken out so she could have more children, she learned there would be a fee of 2,500 shillings for the removal, something she was not told at the time of insertion.1
Still more troubling was the fact that clinic workers said that she “should be sterilized” if she had the contraceptive removed. Veronica, age 38, had a similar experience. Like Colete, she was given Norplant in 1995 at the UMATI (Uzazi na Malezi Bora Tanzania) family planning center in Morogoro, an affiliate of the London-based International Planned Parenthood Federation. And she, too, was unaware of the discontinuance fee and the “need” for sterilization until she requested removal. Neither has followed through on the removal option.
Coercion is Rampant
Coercion can take many forms. As local people point out, women giving birth in government hospitals are routinely asked to come to a clinic when the baby is 40 days of age. There they are told that they need “medicine.” The “medicine” — birth control — is prescribed in such a way that a woman is led to assume it is being given for a specific condition that is unique to her. Thus she takes it, not because she wants to stop giving birth, but because she believes it is meant to improve her health.
Maua Rashid, a 31-year-old woman with only a primary school education who lives in Dar es Salaam, gave birth to her first child ten years ago at her mother’s rural home. After returning to the city, she took the baby to nearby Mwananyamala Hospital for a regular checkup. She was surprised to discover that, as a condition for having a doctor see the child, she would be required to attend an “educational” seminar on family planning. Had she refused, she would have had to go to a private facility, something she was unable to afford.
Maua recalls that the family planning counselors used a number of tactics to make women feel guilty if they refused to take contraceptives. She remembers specifically being told that the drugs would “give a chance to the baby to grow,” something she interpreted as meaning it would directly affect the health and development of her son. She dropped out of the program after the contraceptive pills she was taking caused abdominal pain and excessive bleeding, but didn’t become pregnant for another five years, when she had a second son who died three days after birth. She has since been unable to conceive, but wants to have at least four more children.
Stay on Birth Control!
Pressures can be just as relentless on users who wish to discontinue the use of contraceptives. Mwania Karamu, the wife of a policeman in Dar es Salaam, was literally ordered by health workers at the police barracks where she lives to take Depo Provera injections after the birth of her fourth child. After receiving several jabs, she complained about severe and prolonged bleeding and asked permission to stop. She was told that one more dose would eliminate the problem. Instead it made her condition worse, and she concluded that the goal was to prevent births, not to improve women’s health. She has continued to have problems since stopping the injections two years ago, and has not become pregnant despite the fact that she wants to have many children.
Others have been denied health care entirely once they dropped out of family planning programs, Rehema Mwakyusa briefly took Depo Provera after having her second baby at Mwananyamala Hospital. When complications followed, she refused further injections, and attempted to see a doctor about continuing difficulties. She complains that she was repeatedly sent back to the family planning section and believes that once a woman is enrolled in the birth control program, she has to continue or she gives up her right to other services.
And on the southern outskirts of the city, a woman who introduces herself as “Mrs. Issa” reveals what happened when she had a loop inserted after her fourth birth. She says she experienced no particular medical problems with the device, but asked that it be taken out so she could have more children. Her request was denied on the grounds that she gave no acceptable reason for removal. Indeed, a full year went by before she succeeded in having the device extracted. And over the next several months, she became pregnant twice, only to suffer painful miscarriages both times. It was not until 1999 that she successfully gave birth. At that time, she learned that her fallopian tubes had become enlarged, a condition which the doctor attributed to the loop.
The Cost of “Free” Services
Many Tanzanian women are dismayed by the fact that they are “persuaded” to avail themselves of free family planning services, only to find out later that they end up paying huge sums of money to treat lingering problems brought about by the contraceptives. Jesca, now 40, is an example. After being told at Mwananyamala Hospital to begin the contraceptive routine 40 days after the birth of her last child, she took the pill. But in a short time, she noticed an irregular heartbeat and went to a private facility for advice. According to Jesca, the first thing the doctor asked was whether she used the pill. She was diagnosed as having dangerously high blood pressure, and was told to immediately abandon the contraceptive. Since then she has been on medication for her blood pressure which she gets at a private pharmacy for 2,000 shillings per month. Because she cannot always afford the Cost, she occasionally skips the medicine until the symptoms recur. The birth control pills, she says bitterly, were always free.
And in some instances, the loss has been even greater. A widower in the Mbagala district of Dar es Salaam, insisting on anonymity to avoid embarrassment to his in-laws, reveals in detail the agony his wife endured after starting Depo Provera injections. She was hospitalized twice, for three weeks each time, because of high blood pressure and other conditions which a Kenyan teaching physician describes as “multiple glandular failure” brought on by the drug. The man gives a less-scientific portrayal of his wife’s illness: she was “totally helpless.” In the end, the woman was so sick she could not even recognize family members. She died at home on 13 February 1997, leaving her husband alone to care for their seven children. The youngest, a son born in 1993, died less than a month later.
Midwives Called on to Help
In rural areas, it is often local midwives who find themselves called on to deal with contraceptive side effects. Ukonga village, just west of Dar es Salaam, is modern in comparison to Kamanzichana. Electricity and telephone services are available, though few residents can afford either. Here, in place of the mud huts so common in Kamanzichana, stand sturdy brick houses with tin roofs. But both towns are targeted for nearly identical population control measures.
On a hot November afternoon in Ukonga, eight traditional birth attendants have gathered at the home of Mrs. Hadija Abdallah to talk about a contraceptive distribution project in the area. Field workers make house calls in an attempt to persuade residents to try various birth control methods, the women explain, and they are paid monthly according to the number of users they recruit. One woman points out that these “community-based distributors,” as aid agencies call them, are trained in marketing, not health care.
And the consequences have been terrible. Several women speak of a 40-year-old woman with children and even grandchildren who agreed to get injections. She bled heavily for months before finally going, in desperation, to nearby Kisarawe Hospital. There she was admitted for surgery, but died. They also mention a woman, age 26, who underwent a hysterectomy after her experience with an unknown birth control method and another who became partially blind. Loss of vision is one of several reported complications associated with the abortifacient Norplant.
The midwives complain that they have recently come under pressure to assist with the promotion of birth control, but have refused. Asked if they would be surprised to know that a foreign government was behind the push for birth-prevention, they women say they would not. Such people have “no good intention,” one volunteers.
Tanzania’s Future is at Stake!
Tanzania was one of the last developing nations to give in to pressures from aid-donors and lenders to embrace a population policy. In 1988, when it became apparent that the country’s leaders had no political way out, the late President Julius Nyerere called a meeting of Islamic and Catholic leaders at Dodoma. There, in effect, he turned the fight over to the people. And his initiative continues to bear fruit in the ongoing cooperation between members of the two faiths that represent the vast majority of the nation’s people.
Tanzania, ironically, is a rich country populated by poor people. Its territory holds a wealth of minerals and its fertile land could feed hundreds of millions. But it is hindered by an extraordinary low population density — just 33 people per square kilometer. In order to have the capacity to exploit its own raw materials, Tanzania urgently needs a huge labor force. And religious leaders are aware that the birth control campaign does more than violate religious beliefs. They understand that the future of their people is at stake.
This article originally appeared in Impact International, February 2000. Reprinted with permission.
1 This is the equivalent of about a week’s salary, but, as most rural Tanzanians have little in the way of discretionary income, it represents a significant amount of money.