[WombanAuset]

CHAPTER 3
FROM NORPLANT TO THE CONTRACEPTIVE VACCINE



Dorothy Roberts *
The New Frontier of Population Control
They told us this and they told us that about the Norplant and I'm going through all these changes and I'm trying to have it removed." Yvonne Thomas, a thirty-year-old Baltimore mother, was describing her experience with Norplant, a new, long-acting contraceptive implanted in her arm at a family-planning clinic. When she began suffering from side effects, Thomas returned to have the device removed. But the clinic staff balked at her request. "Then they tell me that it's not putting me in bed, as if they know how I feel on the inside of my body. . . I feel like because I'm a social service mother that's what's keeping me from getting this Norplant out of me. Because I've known other people that has the Norplant that spent money to have it put in and spent money to have it put out with no problems. . . . That's how they make me feel, like 'you got this Norplant you keep it'."1
Yvonne Thomas is one of thousands of Black women in the United States who have been pressured to try this controversial form of birth control. Like the others, she is a target of a campaign to push the drug on poor Black women in hopes of decreasing their birthrate. Population control policies designed to reduce births of an entire group of people for social ends are usually associated with Third World countries. In the 1990s, legislators and policymakers in the United States seized upon Norplant as a means of domestic population control. Norplant appears destined to be replaced by injectable contraceptives such as the newly approved Depo-Provera or the experimental "contraceptive vaccine" as the method of choice for reducing Black women's fertility. Unlike that of Norplant, which can be removed (albeit by surgical incision), the contraceptive effect of an injection or vaccine cannot be reversed once the agents are shot into a woman's bloodstream. Injections and vaccines are also easier to administer without a woman's full awareness or consent. Negative publicity generated by women's adverse experiences with Norplant as well as class action lawsuits filed against its distributor may make it impossible to convince enough women to use it. Still, the speedy embrace of Norplant as a means of reproductive regulation and the injuries it has already inflicted are sobering omens of the future of birth control in America. In this chapter, I describe how racial politics created this latest threat to reproductive rights and explain why increasing access to new, highly effective contraceptives does not necessarily enhance reproductive freedom.

THE IDEAL CONTRACEPTIVE
Norplant consists of six silicone capsules, each about the size of a matchstick, filled with a synthetic hormone called levonorgestral (the same type of progestin used in some birth control pills). The tubes are implanted in a fan-shaped design just under the skin of a woman's upper arm through a small incision. The minor surgical procedure, which takes ten to fifteen minutes, can usually be performed in a clinic or doctor's office under local anesthesia. Norplant prevents pregnancy for up to five years by gradually releasing a low dose of the hormone into the bloodstream. It works mainly by suppressing ovulation, but also keeps sperm from reaching the egg by thickening the cervical mucus. Originally developed by the Population Council, a nonprofit organization that promotes family planning in the Third World, Norplant is now distributed in the United States by the giant pharmaceutical company Wyeth-Ayerst Laboratories, a division of American Home Products.
When the FDA approved Norplant for marketing in December 1990, it was hailed as the first major birth control breakthrough since the pill. The press release from Wyeth-Ayerst proclaimed the "eagerly awaited medical advance" as "the most innovative contraceptive in thirty years." 2 From this perspective, Norplant is the ideal contraceptive -- long-acting, effective, convenient. Once the tubes are inserted, a woman is protected against pregnancy for five years without any further hassle. There is no need to remember to take it daily, as with the pill. Women do not have to interrupt sex to use it, as with a diaphragm or contraceptive foam. Nor do women need their partner's cooperation, as with condoms. Norplant's failure rate is only 1 percent over the five-year period; in other words, it is 99 percent effective.3 Only sterilization has a better record. In fact, Norplant is so foolproof that it is really a form of temporary sterilization. Yet it has the advantage over sterilization of being reversible once the tubes are removed. At first glance, Norplant seems like the answer to women's prayers. It has already been used by more than 1 million women in the United States and 3 million women worldwide.4

TESTING THE WATERS -- THE INQUIRER EDITORIAL
Norplant's potential to enhance women's reproductive freedom was quickly overshadowed by its potential for reproductive abuse. The new contraceptive was instantly embraced by policymakers, legislators, and social pundits as a way of curbing the birthrate of poor Black women. On December 12, 1990, only two days after the FDA's approval, the Philadelphia Inquirer published a controversial editorial entitled "Poverty and Norplant: Can Contraception Reduce the Underclass?" 5 Deputy editorial-page editor Donald Kimelman began the piece by linking two recent news items: one announced the approval of Norplant, and the other reported the research finding that half of Black children live in poverty. Kimelman went on to propose Norplant as a solution to inner-city poverty, arguing that "the main reason more black children are living in poverty is that people having the most children are the ones least capable of supporting them."6 No one should be compelled to have Norplant implanted, Kimelman conceded. But he endorsed giving women on welfare financial incentives to encourage them to use the contraceptive.
The Norplant editorial sent off shock waves across the country. Black leaders were quick to express their outrage at the editorial's racist and eugenic overtones. Norplant's creator, Dr. Sheldon J. Segal, shot off a letter to the New York Times unequivocally opposing the use of Norplant for any coercive purpose: "It was developed to improve reproductive freedom, not to restrict it." 7 Black reporters and editors at the Inquirer protested the editorial. An emotional meeting brought Black staff members to tears -- was their boss implying that those who grew up in large, poor families should never have been born? 8 The Inquirer's Metro columnist, Steve Lopez, issued a stinging rebuttal the following Sunday. "What we have, basically, is the Inquirer brain trust looking down from its ivory tower and wondering if black people should be paid to stop having so many damn kids," Lopez fumed. "By combining contraception and race, the voice of the Inquirer calls to mind another David. David Duke."9 (Lopez was referring to the editorial-page editor, David Boldt, who okayed the editorial.)

The public outcry moved the Inquirer to print an apology eleven days later. Admitting that the piece was "misguided and wrong-headed," the paper said it now agreed with critics that the incentives it proposed were tantamount to coercion and that other strategies for eliminating poverty should be explored. As further evidence of America's racial cleavage, David Boldt later wrote that he was astonished by the adverse reaction.10 He was unaware of Blacks' fear of genocide and had no idea that readers might be angered by the Norplant proposal. A telephone call from Jesse Jackson, he says, cleared things up.

The Inquirer's apology did not put the idea of Norplant incentives to rest. Far from it. Journalists immediately came to the Inquirer's defense. Within days of the apology, Newsweek offered careful praise of Kimelman's proposal: "However offensive the editorial, Kimelman was clearly on to something. . . . The old answers have mostly failed. After the shouting stops, the problem will remain. It's too important to become taboo."11 The Richmond Times-Dispatch gave an even stronger endorsement, arguing that Norplant "offers society yet another way to curb the expansion of an underclass most of whose members face futures of disorder and deprivation." 12 A year later Matthew Rees, writing for the New Republic, similarly defended Norplant incentives on the ground that "the current threat to children in our inner cities makes it an option that the morally serious can no longer simply dismiss."13 ("Our inner cities" and "the underclass," of course, are another way of referring to the Black urban poor.) Although Rees acknowledged the need to treat poverty's "deeper roots," as well as constitutional objections to interfering with a woman's reproductive decisions, he concluded that "right now, Norplant may be only practical option we've got."

More ominously, people in positions to steer public policy followed the media's lead. David Frankel, director of population sciences at the Rockefeller Foundation, made light of tensions at the Inquirer, writing to the Washington Post, "Despite the infantile reaction of some black staffers. . . . birth control incentives would not be genocide. Such incentives would be a humane inducement to social responsibility.14

Backers of the Norplant scheme were not uniformly white, as reflected by Washington, D.C., mayor Marion Barry's support of mandatory Norplant for women on welfare. "You can have as many babies as you want," Barry stated. "But when you start asking the government to take care of them, the government now ought to have some control over you."15

MARKETING NORPLANT TO POOR WOMEN
The Inquirer episode inaugurated a new wave of birth control politics, with Norplant at the center. What appeared to be an expensive contraceptive marketed to affluent women through private physicians soon became the focus of government programs for poor women. Lawmakers across the country have proposed and implemented schemes not only to make Norplant available to women on welfare but to pressure them to use the device as well.
At a time when legislatures nationwide are slashing social programs for the poor, public aid for Norplant became a popular budget item. Without financial assistance, the cost of Norplant would be prohibitive. The capsules cost $365 and the implantation procedure can run from $150 to $500. Removal costs another $150 to $500, or more if there are complications. The government sprang into action. Every state and the District of Columbia almost immediately made Norplant available to poor women through Medicaid. Tennessee passed a law in 1993 requiring that anyone who receives AFDC or other forms of public assistance be notified in writing about the state's offer of free Norplant. Women in Washington State who receive maternity care assistance also get information about Norplant.

By 1994, states had already spent $34 million on Norplant-related benefits.16 As a result, at least half of the women in the United States who have used Norplant are Medicaid recipients. When Planned Parenthood surveyed its affiliates it discovered that, although only 12 percent of its clients are Medicaid recipients, 95 to 100 percent of women implanted with Norplant at some of its clinics were on Medicaid.17

There were also efforts to provide Norplant to low-income women ineligible for Medicaid. California governor Pete Wilson allocated an extra $5 million to reimburse state-funded clinics for Norplant going to women without Medicaid or Medi-Cal coverage. North Carolina's budget similarly set aside a "Women's Health Service Fund" to pay for Norplant for the uninsured. The Norplant Foundation, a non-profit organization established by Norplant's distributor, Wyeth-Ayerst, devotes $2.8 million a year to donate Norplant kits to low-income women.18

Simply making Norplant more accessible to indigent women was not enough for some lawmakers. Within two years thirteen state legislatures had proposed some twenty measures to implant poor women with Norplant.19 A number of these bills would pressure women on welfare to use the device either by offering them a financial bonus or by requiring implantation as a condition of receiving benefits. In February 1991, only a couple of months after Norplant was approved, Kansas Republican state representative Kerry Patrick introduced legislation that would grant welfare recipients a one-time payment of $500 to use Norplant, followed by a $50 bonus each year the implants remained in place. Patrick touted his plan as having "the potential to save the taxpayers millions of their hard-earned dollars" by reducing the number of children on the welfare rolls.20 He suggested that women needed an extra incentive to get them to take advantage of the state's free supply of Norplant, pointing to a study indicating that only one out of eight women currently used birth control. Republican representative Robert Farr echoed these sentiments when he proposed a similar bill in Connecticut: "It's far cheaper to give you money not to have kids than to give you money if you have kids." 21

In short order, Louisiana state representative and former Ku Klux Klan Grand Wizard David Duke proposed paying women on welfare $100 a year to use the device. Duke's bill was an attempt to fulfill his campaign promise to enact "concrete proposals to reduce the illegitimate birthrate and break the cycle of poverty that truly enslaves and harms the black race."22 The scheme also reflected his earlier support for what he called "Nazism," when he claimed in 1985 that "the real answer to the world's problems" was "promoting the best strains, the best individuals."23 Arizona, Colorado, Ohio, Florida, Tennessee, and Washington have considered similar Norplant bonuses. In addition to these financial incentives, a North Carolina bill would have required that all women who get a state-funded abortion be implanted with Norplant unless it is medically unsafe.

Several states have considered even more coercive means to ensure the infertility of women receiving welfare. In his 1993 State of the State address, Maryland governor William Schaefer suggested that the state should consider making Norplant mandatory for women on welfare. Similarly, bills introduced in Mississippi and South Carolina would require women who already have children to get Norplant inserted as a condition for receiving future benefits. Legislation proposed in other states would deny increases in AFDC payments to women who declined the device.

The notion of requiring women on welfare to use birth control had circulated decades earlier. In his 1973 book Who Should Have Children? University of Chicago physiologist Dwight J. Ingle advocated selective population control as an alternative to the growing welfare state.24 Ingle proposed that individuals who could not provide their children with a healthy environment or biological inheritance -- including people with genetic defects or low intelligence, welfare recipients, criminals, drug addicts, and alcoholics -- should be encouraged, or forced if necessary, to refrain from childbearing. "By this I mean that millions of people are unqualified for parenthood and should remain childless," Ingle explained in the book's foreword. One of Ingle's proposals was the mandatory insertion of pellets containing an antifertility agent" under the skin of every woman of childbearing age. Women would be required to apply for a license to have the pellet removed; only those who qualified for parenthood would be allowed to become pregnant. William Shockley made a similar proposal in a 1967 letter to the editor of the Palo Alto Times.25 Norplant has the potential to fulfill these eugenicists' fantasies.

WHAT'S RACE GOT TO DO WITH IT?
If these proposals apply to all welfare recipients, what is the relevance of race? Clearly, welfare policy, which concerns how America deals with its poor, is governed by capitalist economics and class politics. Class divisions within the Black community also create differences in Blacks' attitudes toward welfare. Although we should not underestimate this class dimension of programs that regulate welfare mothers, it is crucial to see that race equally determines the programs' features and popularity. Because class distinctions are racialized, race and class are inextricably linked in the development of welfare policy. When Americans debate welfare reform, most have single Black mothers in mind. Some Norplant proponents -- Kimelman and Duke, for example -- have explicitly suggested distributing the contraceptive to Black women. After the commotion over the Inquirer editorial, however, few politicians are likely to link birth control specifically to Black poverty even if that is their intention. But race lurks behind proposals to induce poor women in general to use Norplant. Not only will these incentives disproportionately affect Black women, but they may be covertly targeted at these women as well.
Part of the reason has to do with numbers. Although most families on welfare are not Black, Blacks disproportionately rely on welfare to support their children. Black women are only 6 percent of the population, but they represent a third of AFDC recipients.26 The concentration of Black welfare recipients is even greater in the nation's inner cities, where Norplant has primarily been dispensed. For example, in Baltimore, the site of a government campaign to distribute Norplant,86 percent of women receiving welfare are Black.

it is also true that a larger percentage of Blacks than whites are poor. One-third of all Blacks and half of all Black children live in poverty. Black women are five times more likely to live in poverty, five times more likely to be on welfare, and three times more likely to be unemployed than are white women.27 Welfare programs, then, have a greater direct impact on the status of Black people as a whole. Any policy directed at women on welfare will disproportionately affect Black women because such a large proportion of Black women rely on public assistance. These policies, in turn, affect all Blacks as a group because such a large proportion of Blacks are poor. The second reason has to do with perceptions. Although most people on welfare are not Black, many Americans think they are. The American public associates welfare payments to single mothers with the mythical Black "welfare queen," who deliberately becomes pregnant in order to increase the amount of her monthly check. The welfare queen represents laziness, chicanery, and economic burden all wrapped up in one powerful image. For decades, the media and politicians have shown pictures of Black mothers when they discuss public assistance. Now the link between race and welfare is firmly implanted in Americans' minds.

When conservative activist Clint Bolick called Lani Guinier, President Clinton's repudiated Justice Department nominee, a quota queen," he counted on the public's immediate association of the label with the pejorative "welfare queen."28 The title automatically linked the Black Guinier to negative stereotypes of Black women on welfare, helping to shut off reasoned debate about her views. Similarly, it is commonplace to observe that "welfare" has become a code word for race." People can avoid the charge of racism by directing their vitriol at the welfare system instead of explicitly assailing Black people.

In addition, poor Blacks pose a far greater threat to white Americans than do poor whites. The word "underclass" refers not only to its members' poverty but also to a host of social pathologies such as crime, drug addiction, violence, welfare dependency, and illegitimacy. Although poverty may be relatively race-neutral in people's minds, these other depravities are associated with Black culture. Contemporary welfare rhetoric blames Black single mothers for transmitting a deviant lifestyle to their children, a lifestyle marked not only by persistent welfare dependency but also by moral degeneracy and criminality.

White Americans resent the welfare queen who rips off their tax dollars, but even more they fear the Willie Horton she gives birth to. These images are distinctly Black; they have no white counterparts. As I showed in the Introduction, many whites hold deeply embedded beliefs about the dangers of Black reproduction that infect any scheme to solve social problems through birth control. This panic is exacerbated by the predicted end of white numerical supremacy in the United States within decades.29 Proposals designed to reduce the number of children born to poor parents are an attempt to fend off this threat to white people's welfare, a threat that is specifically Black.

Thus, race and class politics work together to propel coercive birth control policies. The impact of these policies, moreover, crosses the boundaries of race and class. Laws aimed at curbing Black women's fertility restrict poor white women's liberties as well. Programs that apply only to Black women who are poor help to devalue Black people as a whole.

To date, no state legislature has passed a bill offering bonuses for or mandating the use of Norplant. But the numerous proposals for Norplant incentives and the defense of the Inquirer editorial show that the idea is alive and well. Commentators and politicians have tested the waters and found growing support for the use of birth control as a solution to the Black underclass. As the social climate becomes increasingly hostile toward welfare mothers and supportive of drastic cuts in welfare spending, there is a good chance that these proposals could become a reality -- unless people committed to racial equality, economic justice, and reproductive liberty fight back.

PUSHING NORPLANT ON TEENAGERS
Policymakers have also promoted Norplant as the solution to teenage pregnancy. By preventing pregnancy, they argue, Norplant will allow teenage girls to pursue a career and prevent additional children from being born into poverty and dependence on government aid. "A lot of teenagers needed Norplant. I'm about the only girl in my neighborhood who doesn't have kids," a Black teenager testified on a promotional video about Norplant produced at Emory University. "They need to get some [Norplant] so they can have fun and enjoy life while they be young."30Another scene features a conversation between a doctor and another Black girl. "So, what might you tell a young teenage girl?" the doctor asks as he pats the teenager's shoulder. "Get it!" she replies enthusiastically.
The problem of teen pregnancy, too, is intertwined with issues of race and welfare policy. Although most teen mothers are white, the teen birthrate among Blacks is more than double that among whites, and one out of every four Black children is born to a teen mother. Black girls are also more likely to have a child out of wedlock. The gap, however, is rapidly narrowing: the white unwed birthrate has nearly doubled since 1980, while the rate for Black women has risen only 7 percent.31 Many Americans nevertheless see unwed teen pregnancy as a Black cultural trait that is infiltrating white America. In his editorial "The Coming White Underclass," Charles Murray vividly portrays the burgeoning white illegitimacy rate as an impending crisis, destined to cause the same social catastrophes he attributes to Black single motherhood. 32 He observes that the white illegitimacy rate of 22 percent is dangerously close to the point at which "the trendlines on black crime, dropout from the labor force, and illegitamacy all shifted sharply upward." But for now these problems remain concentrated in the Black community, for, Murray reminds us, "an underclass needs a critical mass, and white America has not had one." Not surprisingly, programs distributing Norplant to teens have been implemented in predominantly Black schools.

In addition, one of the key criticisms of teen pregnancy is that young mothers must often resort to welfare to support their children. According to the Congressional Budget Office, half of all teen mothers go on welfare within five years of giving birth. More than two-thirds eventually receive welfare.33 Although teen mothers make up only about 7 percent of welfare recipients, they have been a chief target of attacks on the welfare system. A persistent element in the recent federal welfare reform bill's many incarnations was a provision to cut off AFDC to teenagers. "We are the only society . . . that says to a teenage girl, 'We're going to give you a welfare check if you have a baby,'" explained Robert Moffit of the Heritage Foundation. "If you want to reduce the rate of illegitimacy, you have to stop subsidizing it."34 The link between race and welfare helped to generate support for passing out Norplant to Black teenage girls.

Baltimore was the first city to distribute Norplant aggressively to teenagers. In December 1992, Baltimore's health commissioner, Peter Beilenson, announced a program to encourage the city's inner-city girls to use Norplant at state expense. About 10 percent of girls ages fifteen to seventeen in Baltimore have babies, one of the highest rates in the country, triple the national average.35 The plan called for doctors, hospitals, and clinics to persuade their "high-risk" teenage patients to have the device implanted. School clinics would also offer Norplant to their female students without the need for parental consent.36

Laurence G. Paquin Middle School, a school for pregnant girls and girls who already have babies, became the first Baltimore school to implement a pilot program to provide Norplant in its clinic. All but five of the 350 students at the school are Black. Although other contraceptives are touched on in counseling sessions, the girls are urged to try Norplant. A few other urban high schools, including San Fernando High School in Los Angeles and Crane High School on Chicago's West Side, also include Norplant among the contraceptives distributed from the school clinic. 37

The distribution of Norplant to teenagers has sparked conflict, even within the Black community. Some Black community leaders have denounced its introduction in high schools for its racism. They are angry that Baltimore's Black community was not consulted about a plan directed at its children. Clergy United for the Renewal of East Baltimore (CURE), a group of ministers representing over two hundred churches, opposed the Baltimore program for "push[ing] the issue of social control of an ethnic minority by the majority population whose culture and values may be different." 38 "You know as well as I know that they wouldn't let their twelve-year-old girl get Norplant," the group's leader, Rev. Melvin Tuggle, said of the white officials. "And I know their daughters are just as sexually active as anybody else."39 Members of the Nation of Islam packed the Baltimore City Council hearing on the issue to express their outrage. Cheers rang out as a representative of Louis Farrakhan shouted, "I'm not going to sit and let my sisters and my children be destroyed by Norplant."40 City councilor Carl Stokes, who stormed out of the hearing, charging bias against Norplant opponents, has called the idea of welfare incentives "something I would have thought was unspeakable in America today." 41

But some of Norplant's most vocal promoters are also Black. Baltimore's Black mayor, Kurt Schmoke, and several other city politicians wholeheartedly endorsed the program. The flamboyant principal of the Paquin School, Rosetta Stith, is a Black woman who has traveled the country espousing the benefits of her Norplant program. She has appeared on national television shows such as Nightline and Crossfire, arguing that Norplant gives her students "an opportunity to finish high school and go to college."42 I moderated a program on Norplant at the University of Pennsylvania Law School at which Stith appeared with one of her students, who rose to her feet and upstaged the other panelists with a testimonial about the blessings of Norplant. Ousted surgeon general Joycelyn Elders condemned opponents of Norplant in high schools by likening teenage pregnancy to slavery. "Black people don't want their children born to children," Elders insisted. "They do not want them growing up poor, ignorant slaves. And whoever goes around talking about genocide is someone who likes to see people in slavery."43

There is no question that Norplant works as an effective birth control method for teenagers. The low levels of teen contraceptive use are exacerbated by teens' poor compliance with methods that they do use.44 Contraceptive failure rates are much higher among teenagers than adults because younger women are less conscientious and more fertile than older women.45 Unlike other birth control methods, Norplant eliminates the need for teenagers to remember to use it daily or at the time of intercourse. Nor do girls have to cope with the embarrassment of getting a boyfriend's cooperation or interrupting sex to use it. It is also appealing to girls that the effects of Norplant are reversible once the implants are removed, so they can have children later in life when they may be better prepared to be mothers. In other words, Norplant seems like the ideal contraceptive for sexually active teenagers. This explains why Republican state senator Shirley Winsley of Washington, who sponsored three Norplant related bills, stated, "I can hardly believe a fourteen-year-old mother wouldn't want to have Norplant if it was offered to her." 46

Rarly research confirmed Norplant's effectiveness for teenage girls. A study of 100 adolescent mothers comparing Norplant to the pill, reported in the prestigious New England Journal of Medicine, concluded that the selection of Norplant "is associated with higher rates of continued use and lower rates of new pregnancy than the selection of oral contraceptives."47 It found that only 2 percent of adolescents who used Norplant became pregnant within the first year, compared to 38 percent of adolescents who used the pill.48 In another survey of 280 teens who either delivered a baby or had an abortion at Johns Hopkins Medical Center, nearly half of oral-contraceptive users had discontinued the method a year later, compared to only 16 percent of Norplant users.49 And while 25 percent of the teens who chose a contraceptive other than Norplant experienced an unplanned pregnancy, none of the Norplant users had become pregnant.50 University of Texas researchers similarly concluded that Norplant was "especially suitable for young patients."51

CAN NORPLANT SOLVE THE "PROBLEM" OF TEEN PREGNANCY ?
Does Norplant's effectiveness for birth control mean that it solves the problem of teenage pregnancy? To answer that question requires asking why teenage pregnancy is a problem in the first place. There is no question that there is reason for concern. The United States has the highest teen pregnancy rate in the Western world. Nearly 1 million of the 9 million girls between ages fifteen and nineteen in this country become pregnant each year, with about half giving birth.52 There are an additional 25,000 pregnancies among girls under age fifteen.53
Teenage pregnancy came to be seen as a social crisis only three decades ago. The rate of teen childbirth was actually much higher in the 1950s than in the 1980s, although it started to climb again in 1986. However, very recent data indicate that the adolescent birthrate has even dropped slightly in the 1990s.54 (Declines in recent decades are attributed more to the increased availability of legal abortion than to greater use of contraceptives.) The public's concern about teenagers having babies has depended much more on the politics of sexuality, abortion, family values, and welfare than on the numbers.55 When people refer to the "problem" of teenage pregnancy they may mean one or a combination of several concerns -- teenagers having sex, teenagers getting pregnant, teenagers raising children, teenagers having babies out of wedlock, and teenagers having babies at public expense. Does Norplant solve any of these specific problems?

Teenagers Having Sex
For some people, the problem with teenage pregnancy is that it results from teenagers having sex. Approximately 70 percent of unmarried teenage girls have had sexual intercourse by the age of nineteen; the average age of first intercourse is about sixteen.56 Adolescent sexual activity, in turn, may be a concern for several reasons: some view it as immoral; others, as hazardous to teenagers' physical health owing to the transmission of diseases, including AIDS. Yet others believe that teenagers, especially very young ones, are not emotionally prepared for sexual activity. Most of the babies born to teen mothers are fathered by adult men, some of whom may be immorally and even illegally coercing these girls to have sex with them.57 Older men are primarily responsible for the frightening spread of sexually transmitted diseases (STDs) among adolescent girls. Studies show that as many as one in four girls are victims of sexual abuse, and 75 percent of girls in a national survey who had sex before age fourteen reported having coerced sex. 58
Preventing teenage pregnancy with Norplant is not a solution to the problem viewed this way because it does not guard teenagers from these harms caused by early sexual activity. Indeed, some have argued that the easy availability of Norplant signals tacit approval of teen sex, making the problem worse. For these conservatives, abstinence, not birth control, is the only acceptable answer. There is no hard evidence that Norplant will encourage teenagers to have sex. But Norplant gives no protection against contracting STDs or against coercive sexual experiences. Distributing long-acting contraceptives to young girls unfairly shifts the spotlight away from the adult men who are largely responsible for the problem.

Teenagers Getting Pregnant
For others the problem is not that teenagers are having sexual intercourse, but that sex too often results in unwanted pregnancy. Some 95 percent of all adolescent pregnancies are unintentional. 59 A Johns Hopkins study of 313 sexually active Baltimore girls, for example, found that only 5 percent deliberately set out to have babies.60 The fact that 40 percent of teen pregnancies end in abortion is further proof of the problem. (A third of all abortions performed each year are done on teenage girls.) Yet teenagers wait on average over a year after they begin having sex before seeking any birth control.61 Although teenagers in most Western European countries are as sexually active as those in the United States, their pregnancy rate is far lower.62 Sweden's teen birthrate in 1991, for example, was one-fifth that of the United States. Why is there such a disparity?
One cause appears to be America's ambivalence about teenage sexuality: our culture promotes teen sex on soap operas and music videos while maintaining a puritanical attitude about discussing birth control with teens. The result is the abysmal inadequacy of reproductive health services for teens. Western European governments encourage adolescents' use of birth control by subsidizing contraception education and availability.63 Congress's policies, on the other hand, have been hampered by political compromises such as the Adolescent Family Life Act of 1988 that focuses on "chastity" and "sexual self-discipline" rather than providing adequate contraceptive services. Although nearly all states require some form of sex education in schools, fewer than 10 percent of American students receive comprehensive information covering topics such as sexual behavior and health, abortion, homosexuality, relationships, and condoms.64

Another cause is poverty, the key predictor of adolescent pregnancy. The lower teen pregnancy rates in European countries correspond perfectly with their lower rates of youth poverty.65 Parts of the United States with less poverty also have less of a problem with pregnant teens. Poverty-striken Louisiana, for example, has a teen birthrate ten times higher than affluent Marin County, California. According to one researcher, this link between pregnancy and poverty "demands that we view early childbearing as a symptom of a much larger problem: the status of disadvantaged youth in this country."66 Relying on school programs to reduce early pregnancy, then, is being terribly blind to the problem's complex causes.

Dispensing Norplant at school clinics is a radical departure from the typically reticent policy on teen birth control. Norplant will prevent sexually active teens from becoming pregnant; but, as we will see in the next section, it is not the safest way of accomplishing this goal. Moreover, Norplant simply covers up the underlying reasons why so many teenagers are getting pregnant in the first place. June Perry, the director of a social service center in Milwaukee, reports a new trend among the Black teens she serves: girls who have Norplant let their boyfriends cut it out with a razor blade. "The talk is, 'If you love me you will have my baby,' and the girls say, 'I will endure this pain for you," Perry recounts.67 Without addressing the deeper problems of poverty and marginalization, Norplant's effectiveness is fleeting.

Teenagers Raising Children
The concern about teenage pregnancy often focuses specifically on the harm of "children raising children," based on a concern for the young mother, a concern for the child, or both. One line of reasoning is that motherhood is bad for teenagers, ruining their chances for finishing high school and pursuing a career. As a poster from the Children's Defense Fund advises, "Stick with the crowd that has a bright future -- don't get pregnant." True, teenagers who have babies are more than twice as likely to be poor, but blaming teen pregnancy for poverty reverses cause and effect. While many policymakers argue that this correlation proves that teenage pregnancy leads to poverty, it is fairer to say that poverty makes pregnancy a more rational option for some teenage girls. High rates of youth poverty precede high rates of teen childbearing, not vice versa.68
Many adolescent girls have babies not because they eagerly desire motherhood but because they have little incentive to avoid it. As the director of a Cincinnati parenting program explained, "It's not that teenagers want to be pregnant, it's that they don't want not to enough."69 These teens do not believe that having a baby will ruin their life prospects; and some new, though controversial, evidence indicates that they may be right. Early pregnancy may actually be an adaptive response on the part of some Black teenage girls: it may make sense for many of them to care for infants at the time when they have the fewest employment opportunities, the best health, and the most help from a network of relatives.70 The leading study, which followed Black teen mothers in Baltimore for nearly two decades, founthat early childbearing does not doom women to lifelong destitution.71 A1though they might have achieved more had they postponed child-bearing, most of the mothers studied eventually graduated from high school, found full-time jobs, and got off welfare.

Teen mothers who do not finish school typically drop out before becoming pregnant; having a baby is a response to poor achievement in school and little hope for a decent job. There is no evidence that delaying childbearing with Norplant will markedly improve these adolescents' chances for success. The myth that inner-city teens would be miraculously lifted out of poverty if they would only stop having babies is one of the cruelest hoaxes of our time.

A related view is that teenage pregnancy is bad for children because adolescents make unfit parents. Studies reveal that the children of teen mothers typically experience a number of disadvantages. Babies born to adolescent mothers, for example, generally have a higher risk of prematurity, low birth weight, and death.72 While Norplant would avert these problems, it does not solve the socioeconomic causes of a risky pregnancy and deprived childhood. There is evidence that the difficulties experienced by children of teen mothers stem from poverty and not from early childbearing alone. Poverty and shoddy health care lead to high infant mortality rates among Blacks generally. Indeed, the risk of death is lower for Black infants born to teen mothers than for those born to older mothers. The often tragic consequences of teen parenting could be alleviated if teen mothers had better social support, including prenatal care, adequate nutrition, and assistance with child care. This does not mean that social policy should encourage teenagers to have babies; but it does mean that Norplant will not cure the social problems that have been erroneously attributed to the teen birthrate. Even Rosetta Stith, the Paquin School principal, concedes, "There's not a pill or an implant that's going to solve the teenage pregnancy problem." She adds, "That's going to come when this country decides to be committed to children."73

Teenagers Having Babies Out of Wedlock
What distinguishes contemporary teen mothers from those in past decades is that far fewer today get married or put their babies up for adoption. Teenagers make up less than a third of all single mothers; but two out of three teen mothers are not married, compared with only 15 percent in 1960.74 A whopping 92 percent of Black teen births are out of wedlock.75
This worry about teen pregnancy is based on a value judgment that, for moral, social, or economic reasons, only married couples should have children. Those who hold this view believe that unmarried teens should be prevented from having babies because their singleness (rather than their immaturity) disqualifies them for motherhood. As Florida senator Rick Dantzler stated in support of Norplant incentives, "children born to single-parent families, children reared without 'paternal influence,' are tomorrow's criminals."76

It follows from this theory that teens may have babies as long as they get married. Although marriage to a financially secure man would improve a young mother's economic situation, marrying may also magnify her problems: for pregnant teens, marriage is correlated, with "dropping out of school, having more babies, and ultimately being divorced or separated."77 The typical indigent teen has little economic incentive to marry her child's father, who probably is also unemployed. She is likely to get more financial support and help with child care if she remains with her immediate family. Finding steady work is a better route off welfare than getting married.

Teenagers Having Babies at Public Expense
Condemnation of teen pregnancy is often couched in complaints about its expense to taxpayers. Because unmarried teen mothers are typically poor, they and their children are likely to be supported by welfare. As Charles Murray explained, cutting off welfare benefits to a young single mother will force her to seek support "from her parents, boyfriend, siblings, neighbors, church, or philanthropies. . . .Anywhere, other than the government."78 Murray's observation reveals another value judgment -- that teen mothers' dependency on the government, but not on relatives or private charity, is immoral or unfair. By stopping teens from becoming pregnant in the first place, Norplant prevents the birth of babies who would require government aid. But this justification for Norplant programs fails to scrutinize the underlying judgment that teen mothers do not deserve public assistance as well as the underlying reasons for teen poverty. Moreover, the fear that providing aid to teen mothers will encourage teen child-bearing is unfounded. European countries and Canada, which have higher welfare benefits than the United States, also have lower birthrates.
On every count, Norplant falls short of tackling the social roots of the "problem" of teen pregnancy, however defined. Part of the reason is that the problem of teen pregnancy is really, in many cases, a problem of sexual abuse, of poverty, of racism, and of inadequate resources for teen mothers and their children.

Nevertheless, if Norplant increases control over reproduction, what could possibly be wrong with making it more available to poor Black women and teenagers? The problem with this question is that it assumes that Norplant's efficacy at preventing pregnancy means it promotes women's health and reproductive autonomy. To show why just the opposite is true, I now turn to women's experiences with the new contraceptive. Far from giving poor Black women greater reproductive freedom, it has served as a means for doctors and government officials to dictate their procreative decisions. Once pressured into having Norplant inserted, many have had a tough time getting a doctor to remove it. Meanwhile the tubes remain embedded in their arms, continuing to pump dangerous hormones into their bodies. I once heard a Black health worker aptly describe Norplant as a form of torture.

NORPLANT MAY BE HAZARDOUS TO YOUR HEALTH
Nearly all Norplant users experience at least one of a variety of side effects ranging from annoying inconvenience to potentially serious conditions. The hormone in Norplant can cause the same long list of bodily disruptions as the pill: headaches, depression, nervousness, change in appetite, weight gain, hair loss, nausea, dizziness, acne, breast tenderness, swelling of the ovaries, and ovarian cysts. Norplant has also been linked to rare instances of stroke and heart attack, although a causal connection has not been definitively proven.
Because Norplant does not contain estrogen, it is thought to present less of a risk for heart attack, stroke, and certain cancers than oral contraceptives. But Norplant's continuous release of progestin produces the side effect that is most bothersome to women: it upsets the menstrual cycle. Some women have no period for months at a time; others experience spotting or irregular bleeding; the worst off suffer from prolonged, heavy bleeding that can last for months on end.

Excessive bleeding should not be dismissed as a mere annoyance: it can require costly expenditures for sanitary napkins, it can dramatically interfere with a woman's employment and lifestyle, and it can mask serious gynecological conditions such as ovarian cancer. Anthropologists tell us that menstruation has powerful consequences in many cultures, affecting everything from religious ceremonies to cooking procedures. Some Native American women, for example, have been excluded from certain community functions because of tribal taboos against women's involvement while they are menstruating.79 Other women have lost their jobs when they were absent too many times owing to constant bleeding. One woman complained that Norplant defeated its own purpose by destroying her sex life: "If they want to know why people don't get pregnant, it's because they are bleeding all the time!"80 One in four women in a California study said that their sex life worsened with Norplant.

There are yet other dangers peculiar to Norplant's design. Some women have experienced pain and infection at the site where the tubes were inserted. Some claim that the silicone in Norplant capsules caused debilitating immunological reactions similar to those alleged in the silicone breast implant litigation.81 Two doctors reported in a 1995 issue of Toxicology and Industrial Health the case of a twenty-two-year-old patient who suffered severe complications when the Norplant capsules burst in her arm. Not only did her arm swell to three times its normal size, but she was plagued by persistent headaches, gastrointestinal bleeding, asthma, fatigue, muscle aches, and weakness in her arm.82 The doctors concluded that these ailments were caused by two consequences of the ruptured device -- the excessive release of hormones into her bloodstream and a silicone-induced immunological disease. Norplant inserts that are not removed after five years may cause ectopic pregnancy, which could be fatal owing to massive internal hemorrhaging. The possible adverse effects of the lingering hormone on a fetus are unknown.

These are not isolated cases. The severity and prevalence of Norplant's side effects are reflected in the numbers of women who return to get the implants removed. Almost 20 percent of women in test studies had Norplant extracted within one year, most commonly because of bleeding problems. After three years, over half had it taken out.83

Women suffering from certain illnesses are at extra risk of harm and should be advised not to use the implant at all. Many of these health conditions disproportionately affect Black women -- high blood pressure, heart disease, kidney disease, sickle-cell anemia, and diabetes, for example. Norplant is less effective in women who weigh more than 150 pounds, another concern for Black women, who are more prone to obesity.

Norplant's side effects are especially troubling for poor minority women who rarely see a doctor. Women who do not get regular health care may not know whether or not Norplant is safe for them. There may be delays in treatment of serious side effects or in detection of more dangerous health conditions such as ovarian cancer masked by irregular bleeding.84 Unlike women who use the pill, Norplant users need not return to the doctor for prescription refills. There is no guarantee, then, that poor patients will return two months after the procedure to discuss any side effects or will maintain regular annual checkups, as recommended. Norplant use requires immediate and regular access to high-quality health care -- a privilege most poor Black women do not enjoy.

It is even more likely that physicians will lose track of teenagers once they graduate from the school that dispensed Norplant to them. One study of 136 Baltimore adolescents using Norplant found a high incidence of failure to make routine gynecologic health maintenance visits.85 The same Texas study that concluded that Norplant was "especially suitable" for teens also found that almost a fifth of the patients did not visit a clinic at all in the six months after Norplant insertion, despite their increased risk of cervical dysplasia and STDs.86 Other studies of inner-city patients have found similar follow-up rates of only 25 to 40 percent.87 Rather than making Norplant the perfect teenager contraceptive, teenagers' ignorance and irresponsibility may make Norplant especially dangerous for them.

These are the side effects that women on Norplant have already experienced. But what about Norplant's long-term consequences? Health advocates argue that we do not know enough about the implant's potential for harm because the clinical testing was terribly inadequate. Norplant's developer, the Population Council, points to research collected over fifteen years from 170 clinical trials involving some 55,000 women. Despite the large numbers of women tested, however, there are concerns about the methods the researchers used and the length of time the women were studied.

Most of the testing occurred not in the United States but overseas, in countries such as Brazil, Indonesia, and Egypt. Ethical breaches in administering Norplant to poor, illiterate Third World women place the research findings in question. Researchers in some countries lost track of large numbers of Norplant users (29 percent in Indonesia, for example), jeopardizing both study results and the women's health.88

In addition, there has been no research on whether the increases in cholesterol levels experienced by some Norplant users will lead to higher risk of stroke or cardiovascular disease.89 Nor has research addressed the concern that the long-term administration of the hormone in Norplant may significantly increase women's risk of breast and cervical cancer.90 Norplant's long-term effects on teenagers are even less certain because all of the clinical trials were conducted on women over the age of eighteen. Some women's health organizations, including the National Women's Health Network and Health Action International (a network of one hundred organizations from thirty-six countries), formally opposed FDA approval of Norplant until its long-term safety could be assured through follow-up studies.

The case of testing in Bangladesh raises serious doubts about both the ethics and the reliability of the Norplant research. An investigation conducted by UBINIG, a Bangladeshi monitoring group, discovered alarming problems with the Norplant clinical trial conducted in Bangladesh between 1985 and 1987 on 600 urban slum women. The organization found that procedures followed by the Bangladesh Fertility Research Program, the national family-planning and biomedical research organization, were marred by gross violations of medical ethics, inadequate methodology, and disregard for the health of the female subjects.91

Clinic workers did not give clients a prior medical examination or obtain their informed consent to participate in the testing. Participants were not told about all of Norplant's side effects or that the drug was still in its experimental stage. They did not understand how the device worked or even know its name-nearly everyone referred to the implants as "the five-year needle." Many women were breast-feeding at the time of insertion even though the hormones can travel to a baby through breast milk. The research results were further tainted by giving women monetary incentives for the insertion and then discouraging them from reporting health problems.

Similar methodological errors, ethical lapses, and health complications marked the tryouts in other Third World countries.92 Under pressure from women's groups, the Brazilian government rescinded its authorization for Norplant testing in 1986. Activist Deepa Dhanraj produced a film entitled Something Like a War, which documents abusive testing of Norplant-2, the forerunner of the current version, on thousands of women in India during the 1980s.

Health advocates are also concerned that use of Norplant may increase the risk of STDs. Unlike condoms, Norplant does not provide protection against AIDS and other STDs. Once the implants are in place, women may take fewer precautions against contracting an STD, such as requiring their partner to wear a condom. Studies are already confirming this fear. Although 42 percent of women in a Texas survey used condoms before Norplant, 48 percent of these same women reported that they would rarely or never use them in the future.93 Therefore, the researchers concluded, "almost one-quarter of the implant acceptors in our sample may be at increased risk of contracting an STD."94 Of course, the pill and other birth control methods also provide no protection against STDs. But Norplant may be riskier because its users need not check in with a health care provider who might remind them about the importance of using condoms. It also appears that Norplant users are not receiving the necessary counseling about the importance of continuing protection against STDs. For women and teens at risk for both unwanted pregnancy and STDs, the increased potential for contracting AIDS and other diseases may very well outweigh Norplant's enhanced protection against pregnancy.

Norplant proponents seem to have ignored this calculation. For example, Douglas Besharov, a scholar at the American Enterprise Institute, believes that the scales easily tip in favor of Norplant. Besharov acknowledges criticism that Norplant may lead to a marginal increase in teen sex and to a concomitant increase in STDs, but he is willing to trade off these disadvantages to teenagers for what Norplant has to offer society. "Which is worse: the possibility of a marginal increase in sexual activity," Besharov queries, "or losing the opportunity to reduce abortions and out-of-wedlock births by 10, 20, or even 30 percent? To ask the question is to answer it."95 The peddlers of Norplant curiously minimize the serious health risks from the implants themselves, as well as the increased possibility of disease that comes with them. They also leave out of the equation strategies for improving the availability and effectiveness of less risky birth control methods.

In many cases prescribing Norplant to teenagers is like using a bazooka to kill a gnat. Most young teens engage in sex only sporadically, with sexually active boys reporting no sex at all for an average of six months each year.96 Yet Norplant is only appropriate for women who have sex regularly: it is expensive and intrusive; and it supplies a constant dose of powerful contraceptive hormones. As one commentator pointed out, "A teenage girl cannot simply stop at the drugstore on the way to a date to pick up Norplant." 97 Adolescent girls who have sex a few times a year do not need such drastic pregnancy prevention. The diminished risk of pregnancy for these teens cannot justify Norplant's grave risk to their health. Government officials who press for mass Norplant distribution to teenagers apparently have not bothered to engage in this sort of cost-benefit analysis.

Why the rush to forfeit women's health for the good of society? Perhaps the answer lies in the poverty and race of the women being sacrificed. Let us think about the hypothetical scheme proposed by Isabel Sawhill, an economist at the Urban Institute in Washington, to insert Norplant in the arm of every girl in the country when she reaches puberty. One reason this suggestion sounds so ludicrous is that it would be unthinkable to inflict such a risky device on the daughters of affluent white parents.

THE COMPLICATIONS OF REMOVAL
Removing Norplant can be as dangerous as leaving it in place. The operation required to take out the capsules is more complicated than the insertion procedure, especially if the capsules were implanted improperly in the first place. Because there have initially been far more Norplant insertions than removals, clinicians have not become proficient at the extraction procedure. Some doctors do not even bother to take advantage of the removal training kit Wyeth-Ayerst sends to everyone who orders Norplant, believing the procedure is easier than it really is.98
The results of doctors' inexperience have been horrific. Capsules planted too deep force doctors to dig around to locate them in the woman's arm. The rods have sometimes broken up or migrated to other parts of the body. Thick, fibrous scar tissue called keloids often forms around the capsules, making their removal even more treacherous. In very difficult cases, patients have had to return for multiple incisions. They are sometimes left with debilitating nerve damage. It took over an hour for a doctor to remove the implants from a Massachusetts woman's arm. "[My doctor] said that they were stuck in there," the twenty-six-year-old patient recalled. "She was pulling and yanking them, but they weren't going anywhere."99 Paula Gorman, a day-care provider from Rhode Island, endured a total of six hours of surgery that left noticeable scars on her arm.100 Again, Black women are at extra risk of injury because they have a higher tendency to develop keloid scarring after a surgical incision.101

Norplant's numerous health complications have landed the distributor in massive product-liability litigation. Class action lawsuits consolidating hundreds of cases have been filed in Texas, Illinois, and Florida against Wyeth-Ayerst, claiming health problems connected with Norplant and difficulties in having the implants removed.102 Thousands of similar lawsuits have been brought in other states. Newspaper, radio, and television advertisements by attorneys recruiting plaintiffs are proliferating, and as many as 50,000 women may ultimately file complaints. The litigation is so huge that in 1995 tort lawyers converged in Houston from around the country to share information about the lawsuits and to coordinate strategies.

The plaintiffs allege that Wyeth-Ayerst designed Norplant negligently, actively promoted the device without adequately warning women about its potentially dangerous consequences, and sold this hazardous product to doctors who were not properly trained at inserting and removing it. Actions filed in Missouri and New Mexico also claim that the company profits by marketing Norplant specifically to minority and low-income women who are unable to "control discontinuation of the product."103 Besides asking for millions of dollars in damages, the plaintiffs also want an injunction to prevent the company from continuing to sell Norplant to untrained doctors. Wyeth-Ayerst reports that the wave of lawsuits has already caused daily sales to tumble from 800 to 60. New York Times reporter Gina Kolata wonders in the title of a recent article, "Will the Lawyers Kill Off Norplant?"104 On February 24, 1997, however, a federal judge in Texas ruled against the plaintiffs in five cases, finding that Wyeth-Ayerst had adequately notified doctors about Norplant's potential side effects. The fate of the other lawsuits, and of Norplant's wide-scale distribution, remains uncertain.

To the extent that Norplant should be made available, the medical profession must ensure better information about its short-term and long-term effects on women and adolescents. Health experts should also figure out ways to minimize the risk of STDs through use of condoms and to ensure access to regular gynecologic checkups and counseling. But if we could accomplish all this, I question whether any additional benefits of Norplant would outweigh its potential hazard to women's health and reproductive autonomy. Of course, nearly all contraceptives carry some degree of health risk, as do pregnancy and childbirth. The fact that Norplant has side effects is not enough to prevent women who are aware of these potential problems from willingly using it. But health risks are cause to prohibit or restrict distribution of a product that has not been adequately tested, that has not been fully explained to users, and that is being foisted on certain groups to achieve social objectives.

NORPLANT'S COERCIVE DESIGN
Norplant's health risks are only the tip of the iceberg. Its hazard for poor Black women is compounded by the coercion that has marked its distribution to this group. The relative permanence and accessibility of Norplant has proven to be a double-edged sword. The very features that enhance Norplant's convenience for women also allow for its coercive deployment. Unlike every other method of birth control except the IUD, a woman cannot simply stop using it when she wants to. As Judy Norsigian of the National Women's Health Network puts it, "It's a contraceptive that's controlled by the provider, not the woman."105 Because its use, once it is implanted, does not depend on a woman's compliance and is easy to monitor, it works well as a means for regulating women's reproduction.
Women's inability to remove the inserts without medical assistance facilitates abuse in several ways. It currently gives doctors and other health care workers the opportunity to impose their own judgments upon poor minority patients by refusing' to remove the device. If in the future the government offers incentives for Norplant or mandates its use, officials will be able to ensure that the implants remain in place. Even aside from these deliberate abuses, Norplant is designed to deprive women of control over their reproductive health. By relieving women of the day-to-day management of birth control, it places poor women at the mercy of a health care system that remains insensitive to their needs.

A study of young, low-income women in South Carolina who requested early removal discovered some disturbing aspects of the counseling they received. A majority reported that the information they had been given "emphasized the positive aspects and minimized the possibility of adverse side effects," giving them the false impression that side effects were uncommon and less severe than they later experienced.106 Others who were offered Norplant in the hospital after giving birth felt that medical staff took advantage of the situation to pressure them into consenting to use it. As one woman explained,

I really did not want it but after I had my baby, they came in my room and asked me to look at the educational movie. . . . They put mine in the day I had my little girl. . . . [T]hey just kept hassling me.
Another echoed this experience:
They were telling me, "What you gonna do for birth control? Are you gonna get a Norplant? It's good. . . . Medicaid will pay for that to go in, you know." I had a week to figure out what I was gonna do. . . so I just jumped on that.107
Judith Scully, an attorney and gynecological health care worker at a Chicago clinic, confirms that young Black women are being steered toward long-acting contraceptives. "Doctors are saying, 'I've got the answer for you,' and then telling them to choose between Norplant and Depo-Provera," Scully told me.108 Women who are not given other contraceptive options may believe that Norplant is the only appropriate method of birth control available to them.
TRYING TO GET NORPLANT OUT
Being able to get Norplant removed quickly and easily is critical to a user's control over reproductive decisionmaking. Yet poor and low-income women often find themselves in a predicament when they seek to have the capsules extracted. Their experience with Norplant is a telling example of how a woman's social circumstances affect her reproductive "choices." A woman whose insertion procedure was covered by Medicaid or private insurance may be uninsured at the time she decides to have the tubes removed. A woman who had the money to pay for implantation may be too broke to afford extraction. Some women have complained that they learned of the cost of removal -- from $150 to $500 -- only after returning to a physician to have the implants taken out.
The scarcity of doctors willing and able to remove Norplant poses another set of problems. The doctors in the clinic who inserted the device may not be trained at removing it. A small clinic may not have enough doctors on staff to perform time-consuming, complicated removal procedures. Many centers have a long backlog of patients in line for Norplant extractions. These obstacles force women with limited resources to search around for another doctor who can perform the operation. A new doctor may be hard to find, however, for the threat of legal liability makes some practitioners wary of removing Norplant improperly inserted by someone else.

Imagine the panic of bleeding for weeks on end, witnessing your hair fall out, or gaining fifty extra pounds only to be turned away from every clinic you approach to remove the source of your affliction. An indication of users' desperation: an Ohio woman trapped in this bind tried to slice the implants out herself with a razor blade, but was not able to cut deep enough.109 A teenager on Medicaid in Chicago who used a sharpened pencil to dig out the capsules only succeeded in pushing them deeper into her arm.110 Is it an exaggeration to call this experience a form of torture?

The suffering visited on these Norplant users is not just an accident of their own financial problems. State funding structures and health professionals' private biases have worked together to pressure poor women to keep the device in place.

Some state legislatures impose Medicaid reimbursement requirements with the deliberate aim of making it difficult for recipients to have the implants removed. These states implant Norplant for free, but will cover the cost of early removal only in cases of documented medical necessity." This means that poor women must scrape together the funds themselves, even if they are suffering from side effects or decide that they want to have a child. Those who cannot find the money must wait out the five years until the state will pay for the procedure. Many private insurance companies mimic this policy, and doctors in states that do pay for removal have misinformed their patients about Medicaid coverage.

A physician's directive issued by the state of Oklahoma discloses the government's purpose of coercing poor women to keep the implants in place for as long as possible:

It is not the intent of the Department to cover removal of the Norplant system prior to the expiration of five years unless there is documented medical necessity. Payment is not intended to be made for the removal of the contraceptive for the convenience of the patient, minor menstrual irregularities, or for the purpose of conception.111
By enticing poor women to use Norplant with the offer of free implantation and then refusing to pay for removal, the state has achieved the same end as more controversial financial bonuses.
There are reports that poor women routinely have trouble getting doctors to remove Norplant. Investigators from the International Reproductive Rights Research Action Group tracked thirty-eight poor Black women in Soperton, a rural community in Georgia, who had been implanted with the device. Some claimed that doctors refused outright to remove the Norplant despite their complaints of side effects.112 One woman was told that since Medicaid did not pay for the cost of removal, she would have to cover the cost herself, as well as reimburse Medicaid for the cost of the insertion procedure. "If you didn't know where Soperton was, you'd think it was a Third World country," a researcher for the National Black Women's Health Project observed.113

The case of a Native American woman in South Dakota is reminiscent of the forced sterilization practices of the 1970s. When she requested that her doctor remove the implants after she had gained sixty-five pounds, she was told the operation would be contingent upon her consenting to a tubal ligation.114 The Department of Human Services in Tippah County, Mississippi, tried to force Rose Sexton, a poor twenty-year-old white woman, to keep Norplant in her arm against her will and against the wishes of her husband and mother. The agency argued that Rose, who as a minor had already given up three children for adoption, was unable to care for children due to her limited intellectual ability. When Rose went to the public clinic to have the device removed because of the side effects, the Department of Human Services petitioned the juvenile court for an order restraining her from taking the implants out. A lawyer from North Mississippi Rural Legal Services eventually persuaded the agency to drop the motion.115

The South Carolina study mentioned above discovered similar obstacles. A majority of participants recalled that the medical staff reacted with reluctance to their request to remove the implants.116 Doctors and nurses expressed skepticism about patients' experience of side effects and urged the women to "wait it out." As one woman reported:

I was still having heavy bleeding . . . and they said, well, it takes a little while, so I went for a year . . . It didn't get no better. I mean, who wants to go 19 days' worth of bleeding? They don't jump to take it out but they sure do want to put it in.117
The women generally felt that their difficulty getting the implants removed stemmed from their doctors' belief that young unmarried women on Medicaid should not be having children. The doctors were enforcing their conclusion that Norplant was good for their patients, regardless of their patients' thoughts on the matter. Some women suspected that they had been used as guinea pigs to test the drug's safety; they believed doctors were reluctant to extract the rods precisely because they wanted to observe the side effects their patients were experiencing. There is some basis for their suspicions: Blacks have been the unwitting subjects of cruel medical experimentation for centuries, most notably the Tuskegee syphilis experiment that lasted from 1932 to 1972.118
Publicly funded programs are also under financial pressure to dissuade clients from removing Norplant before its five-year expiration. A clinic that has just invested $500 in the insertion procedure will be reluctant to spend another $500 of its budget for early removal. Clinic workers in Los Angeles, for example, admit that women who come into have Norplant removed are encouraged to try it a little longer for just this reason. "We don't want her to have it [out] after spending that money," explains Pam Garcia of Planned Parenthood of Pasadena.119 Although Garcia says Planned Parenthood will remove the device if the patient insists, it is clear that financial concerns compete with attention to their patients' wishes.

The Los Angeles Regional Family Planning Council recognizes that Norplant counseling is especially susceptible to workers' biases. Its counselors receive a training notebook that requires them to write down their honest reactions to statements such as "All drug-abusing women should have Norplant" and "All sexually active teens should have Norplant."120 The council hopes that pushing counselors to recognize their biases ahead of time will prevent abuse of patients' rights. But what about the counselor who thinks that his or her biases are well-founded? This training technique is unlikely to deter a healthcare worker who firmly believes that all women on welfare should use Norplant from imposing this view on poor minority clients.

Whatever the precise reason, Black women around the country report a sense that health care workers do not respect their personal decision to remove the contraceptive. We would expect clinic staff to help patients understand the physiological aspects of their symptoms and to allay any unwarranted fears about Norplant's consequences for their health. But many workers are going beyond informing their patients and attempting to manipulate their decisions about using Norplant. They have already decided what "choice" they want poor Black women to make -- keep Norplant in at all costs.

NORPLANT INCENTIVES: ACCESS OR EXCESS?
Government aid to purchase Norplant and proposals for financial incentives to use it raise another set of concerns. Do these programs benefit poor and low-income women by making an expensive contraceptive available to them or do they coerce these women into using this form of birth control? Because Most of the Norplant proposals are offers to provide a bonus rather than threats to take away aid, their proponents argue that they do not coerce poor women to use the implant. Indeed, Norplant incentives are promoted as a way of expanding the reproductive options of women on welfare.
There is evidence that public funding of Norplant does influence women's decision to use this particular contraceptive. A study of Black inner-city patients at a Planned Parenthood clinic in Baltimore sought to find out how women who select Norplant differ from women who choose the pill. The researchers discovered that the strongest predictor of that decision was the method of payment: "Ninety-five percent of women who selected the implant were Medicaid recipients, compared with only 32 percent of those who selected the pill."121 The Alan Guttmacher Institute similarly found that patients at family-planning clinics who received Medicaid were twelve times more likely to get the implant than clinic patients who were ineligible for Medicaid.122

This evidence could easily suggest that, by paying for Norplant, the government benefitted these patients by enabling them to pick their contraceptive of choice. Without government assistance, few of these poor and low-income patients would be able to afford the $550 the clinic charged for the implant kit, insertion fee, counseling, and follow-up visits. The same patients studied could have chosen Medicaid reimbursement for the pill if they wanted to.

Dr. David Grimes, former chairman of the National Medical Committee of Planned Parenthood, dismisses charges of coercion by pointing out, "If we put at the disposal of poor people the same contraceptive that is available to persons who are more affluent, that is a social equalizer."123 Planned Parenthood views even financial incentives to use Norplant as an enhancement of reproductive choice. As Tina Proctor of the Aurora, Colorado, branch argued, "Our agency believes that if a woman chooses to accept extra welfare payments for using Norplant, it's a choice that the woman makes and if she can get something extra for using birth control, that's positive."124 Kansas representative Kerry Patrick similarly defended his Norplant incentive bill on 60 Minutes as increasing poor women's freedoms: "Why not try a program with an incentive? Why not give the welfare woman a choice? Why not empower her to make a decision as to whether or not she should use Norplant?"125 To take another example, reproductive rights advocates do not see government funding of abortion services as pernicious government encouragement of abortion; rather, a major part of the pro-choice agenda is to push for passage of abortion-funding legislation at the state and federal levels.

A Voluntary "Choice"?
True, no one has suggested passing a law that mandates that certain women have Norplant embedded in their arms. As Samuel Parrish, head of adolescent medicine at the Medical College of Pennsylvania, points out, I don't know of a single clinic in town that would say, 'Your mom wants you on this, so therefore, hold still.'"126 The Constitution would not tolerate hauling women and girls into clinics to be forcibly injected with Norplant. But lesser forms of pressure can make a decision unacceptably involuntary. A woman who has no money to feed her children faces greater pressure to accept a financial bonus to use Norplant than does an affluent woman. We can easily recognize that the poor woman's decision is less voluntary and that the government's financial enticement wields a strong influence over her judgment.
Indeed, Congress recognized as much when it passed the Family Planning Services and Population Research Act in 1970 that prohibits programs receiving federal funds from coercing women to undergo an abortion or sterilization procedure "by threatening . . .the loss of . . . any benefit."127 The American Medical Association opposes Norplant incentives on the ground that government benefits should never be "made contingent on the acceptance of a health risk."128

These offers not only place pressure on poor women to forfeit their ability to have children and to overlook the potential danger Norplant poses to their health; they also place on these women a pressure to use the contraceptive that wealthier women (and most white women) do not experience. Even if we would not call a financial benefit "coercive," we can still recognize that the government is exploiting poor women's economic desperation to get them to make a decision they otherwise would not make.129 We still must decide, however, whether or not the poor woman's decision to use Norplant is sufficiently voluntary to be her "choice."

The central question in cases of government incentives is whether the form of pressure the state uses is acceptable. This is true about consent to any deal. A person's consent does not necessarily enhance her autonomy since she may agree to a transaction out of suission to a more powerful authority or to adverse circumstances outside her control. Has a woman "consented" to sex, for example, if she agreed only after the man threatened to hit her? What if he threatened to fire her or leave her? Legal determinations about whether a decision was freely made are never simply conclusions about what the actors did. They are value-laden judgments about what should be considered choice.130 This determination, in turn, depends on whether we think consent resulted from an acceptable inducement. We might decide that threatening to end a relationship is an acceptable inducement to engage in sex while threatening to smash someone's face is not.

Moreover, a woman's freedom to choose among reproductive options does not mean she has reproductive freedom. We should also be concerned about the quality of options available to her. It is possible that all of the alternatives decrease her control over her reproductive health. As a German health activist put it, "more choice has no meaning in itself, what is important is the question: more choice of what?"131 It makes a mockery of the concept of reproductive liberty to say that telling young Black women to pick between Depo-Provera and Norplant, for example, increases their "choice."

The issue, then, is more complicated than asking whether providing Norplant expands poor women's choices. We must question whether the government's inducements are acceptable within an understanding of why reproductive choice is important in the first place. Does the government's distribution of Norplant enhance Black women's control over their reproductive health?

Norplant is promoted on the assumption that poor Black women are incapable of taking responsibility for their own sexuality and re-production. As conservative Richard Neuhaus bluntly observed in National Review, often underlying whites' promotion of Norplant for teens is "the unsavory assumption that inner-city black kids are little more than rutting animals incapable of the discipline we expect from our own kind -- an assumption accurately described as racist."132 Norplant is a way of giving that function over to government programs for a period of five years at a time.

Moreover, the government pushes this birth control method on all women receiving public assistance regardless of its suitability for each woman -- it disregards whether Norplant would cause intolerable or dangerous side effects, whether she has access to removal, and whether she wishes to have a child. Certainly bribing women to implant a potentially harmful device they cannot remove on their own is not what reproductive liberty is about. These programs use contraception as a means of social control over individual misbehavior rather than as a means of women's control over their own reproduction. Norplant may be an infallible way of preventing pregnancy, but it is a miserable means of promoting reproductive autonomy.

Does the End Justify the Means?
Others contend that criticism of Norplant has undermined the contraceptive's potential for good. A report issued by the Hastings Center, an ethics think-tank, argues that focusing on the coercive potential of long-acting contraceptives like Norplant ignores the equally important risk that women will be improperly influenced not to use them. Thus, the authors conclude, "In these instances it can be appropriate and responsible to use different techniques to influence a woman to consider long-term contraceptive use, even if she is not immediately inclined to do so."133 Unlike the previous argument that sees acceptance of Norplant incentives as entirely voluntary, this position holds that incentives may be ethical even if they exert some degree of pressure.
The state has more reason to influence teenagers' sexuality and reproduction than that of adults, for example. Teenagers have less right to make autonomous decisions because they are not always mature enough to judge what is in their own best interest. The state is allowed to override teenagers' wishes in many contexts --marriage, alcohol consumption, voting, to name a few. Directed counseling maybe required to counteract the negative influences of peer pressure, poor judgment, and misinformation bombarding teens. In addition is the strong argument that delaying pregnancy benefits most teenagers rather than devalues them. Norplant incentives directed to adolescent girls attempt to put off motherhood, not deny it altogether.

Proponents of Norplant bonuses also point out that the government often attempts to influence citizens' behavior through financial incentives. It offers income tax deductions to wealthy people, for example, to get them to make charitable contributions. Why are incentive programs that prod poor women into acting in socially responsible ways any different?

This argument correctly raises the possibility that we might want the government to influence people to act in the public interest. A basic premise of this book is that the single-minded focus on individual liberty as the full meaning of reproductive freedom disregards the social context in which we make procreative decisions. We cannot determine whether Norplant incentives are coercive, for example, without looking at the social constraints facing poor women offered monetary bonuses. But recognizing that there may be countervailing reasons to encourage Norplant use does not end the inquiry; it brings us to scrutinize the reasons why certain teenagers and women are encouraged to use long-acting contraceptives.

Do these Norplant policies address the state's legitimate concerns? George Will asks, "What is more dangerous to the flourishing of black America, Norplant for teenagers or a growing number of black adolescents headed for a life of poverty because they were born into poverty to a single mother whose life chances were blighted by a pregnancy at age 15?"134 His question implies that Norplant incentives are acceptable, even if coercive, because they will reverse the course of "black adolescents headed for a life of poverty." This line of reasoning is based on the faulty premise that Black people's poverty is caused by their reproduction -- the belief that, as the Inquirer editorial asserted, Black poverty persists because "the people having the most children are the ones least capable of supporting them."

Blaming the birthrate for poverty ignores the structural reasons for people being poor. The public funding of Norplant at a time of drastic cuts in welfare spending is particularly significant. This willingness to pay for poor women's birth control but not for their basic needs is strong evidence that the government is more interested in population reduction than in furthering poor women's welfare. Perhaps this is the greatest danger of Norplant incentives: they reinforce the belief that the solution to Black poverty is to curb Black reproduction.

I find the very terms of the Norplant debate offensive. The fighting over Norplant assumes that Black women's reproduction is a proper arena for social regulation. The only question asked is what are the appropriate means to regulate it -- mandates or bonuses, for example. While politicians squabble over the most effective means to reduce Black fertility, the notion of Black women's control over their own reproduction escapes discussion. Why have government programs that distribute Norplant been promoted so heavily in the Black community? Why is Norplant dispensed at Black inner-city high schools and not white suburban ones? The coercive nature of the device itself, as well as the incentives used to promote it, treats Black women's bodies as objects of social supervision.

NORPLANT AND INTERNATIONAL POPULATION CONTROL
The history of Norplant's introduction underscores this point. Norplant was originally developed by the Population Council, working through its international research branch, as a tool of population control In Third World countries. Its research was financed by nearly $15 million in U.S. foreign aid. The scientists designed the contraceptive specifically for distribution to poor, uneducated women of color. Norplant is ideal for this aim: it is more socially acceptable than sterilization, the method used for decades to reduce Third World birthrates, yet its effectiveness does not depend on the continuing cooperation of women thought to be too ignorant or backward to use other contraceptive methods.
Indonesia, the country with the fourth largest population in the World, was one of the first sites of Norplant use. Under pressure to decrease population growth, the Indonesian government dispenses two-thirds of the world's supply of the contraceptive.135 This high rate of Norplant implantation comes at the expense of citizens' rights. In the city of Bogor, only government employees who use Norplant or sterilization for birth control receive their paychecks on time.136 Some jobs, such as work on Indonesia's tea plantations, require proof of Norplant use. Teams of government agents and military personnel scour villages in so-called safaris recruiting women to have the device implanted.137 In order to meet strict quotas, the safaris seldom ensure that women give fully informed consent to the procedure. Women even report being threatened at gunpoint. A USAID program located in Peru in the late 1980s used a less blatant tactic: it offered clients a choice between only Norplant and sterilization.138

Additionally, there is every indication that the Indonesian government intends for women to retain the implants, regardless of the consequences for their health. A 1990 Population Council report found that Indonesian doctors trained to insert the device were completely unprepared to remove the inserts after the expiration of five years.139 Even apart from the flagrant government abuses, it is unconscionable to market Norplant to women in areas that lack the basic health systems necessary for even minimally safe use of the device. Yet Indonesia is held up by U.S. foreign aid officials as a birth control success story.

The Norplant experience in Bangladesh offers another example of abuse. Before its clinical trials were under way, the Bangladesh Fertility Research Program (BFRP) promoted Norplant as particularly suitable for our semi-literate population" because it does not require day-to-day use.140 "The effectivity question is mentioned and is specially targetted towards . . . the poorer section of the population," the BFRP explained, "so that population control can be ensured." From the beginning, the objective of Norplant research in Bangladesh was to create the conditions for mass promotion," not to test its safety for Bangladeshi women.141

In a 1987 article, BFRP's director, Dr. Halida Hanum Akhter, further praised the advantages of the implants:

It has been found by researchers that contraceptive pills containing progestin and more commonly used other reversible methods necessitate continuous motivational involvement by the user. In a country like Bangladesh this fact is more true than in the developed world. It is, therefore, necessary to introduce methods in Bangladesh which can continue to be effective for long periods without continuous motivation by Family Planning Workers. Norplant is perhaps the most effective method which is likely to prove successful here.
Part of Norplant's "success" in Bangladesh was due to women's difficulty in getting the implants removed. A researcher there found that only 25 percent of women who wanted Norplant removed were successful at getting doctors to take it out on their first request.142 On average, it took three requests to persuade a doctor to extract the implants, with women waiting seven weeks for the operation. Some were told that it was medically impossible to remove the device before the five-year duration expired. One distraught woman reported that she could not get anyone to listen to her until she lied by saying her two children had drowned in the river and her husband wanted another child.143
These views on Norplant reflect a widespread attitude among population control advocates: to them, the "effectiveness" of a contraceptive means its ability to guarantee widespread birth control, period. This preoccupation with reducing fertility allows little concern for either the safety of the device or women's ability to control its operation. Unlike the concept of reproductive freedom that focuses on women's liberty and equality, population control centers on decreasing births of an entire group with the objective of changing economic, political, or ecological conditions.144

A host of private foundations, consulting firms, academic centers, and government agencies have combined their efforts in a powerful political establishment that promotes family planning in the Third World. The Population Council, the developer of Norplant, is one of the major players in this arena. For several decades, these Western population control agencies have shipped birth control programs overseas based on the philosophy that overpopulation is the primary cause of poverty and instability in developing countries. Flowing from this premise is the belief that native women must be persuaded or forced to have fewer children, with efficacy in preventing pregnancy taking precedence over their health and autonomy.145 Given this history abroad, it is not surprising that, once transplanted to the United States, Norplant has been used for similarly coercive ends.

The Population Council's contribution to repressive family-planning agendas raises doubts about its professed commitment to informed consent and freedom of choice. According to Betsy Hartmann, director of the Population and Development Program at Hampshire College, "the Council has actively promoted the mass introduction of easily abusable contraceptive technologies into already abusive population control programs."146 The council defends its research by calling for safeguards to ensure women's voluntary acceptance of new types of birth control. Recall, for example, Dr. Sheldon Segal's letter to the New York Times objecting to the coercive use of Norplant. But why does the council insist on developing long-acting technologies that are inherently susceptible to abuse, rather than safer, user-controlled methods? In fact, the council's liberal veneer lends legitimacy to population control programs whose abuses would otherwise be more glaring.147

Moreover, the Population Council's origins are closely linked to the American eugenics movement. Frederick Osborn, one of America's key eugenics strategists and a long-time officer of the American Eugenics Society, helped John D. Rockefeller III establish the Population Council in 1952. As the council's first president and a member of its board of trustees, Osborn promoted his eugenic philosophy through the organization's birth control research. On March 5, 1969, Osborn wrote to Rockefeller, "The best hope of improving genetic qualities of the race lies in the universal extension of effective and easy means of birth control."148 Osborn believed that this work could be accomplished more effectively "in the name of the Population Council than in the name of eugenics" and described the council's development of new birth control techniques as "the most important practical eugenic measure ever taken."

The development of Norplant, then, is tightly linked both to the eugenics movement in America and to population control efforts abroad. No doubt Wyeth-Ayerst's decision to market Norplant in the United States was based on estimates of a growing demand for long-term contraceptives in this country. But contrary to the hype accompanying its U.S. introduction, Norplant was not created to increase the choices of liberated American women. It was designed to limit the reproductive control of Third World women to better accomplish the aim of population policy -- producing fewer people in developing countries.

LESSONS FROM THIRD WORLD INCENTIVE PROGRAMS
Employing incentives to induce sterilization or contraceptive use is a familiar aspect of international population control policy. Incentive programs have been implemented in Third World countries for decades, causing controversy within both overseas communities and the international population establishment. Women in Bangladesh receive food aid only if they show a card confirming that they have been sterilized. Sterilization gets Korean couples a priority for business and housing loans and medical care for their children.149 The much criticized one-baby policy in China is also enforced through a system of government benefits. The most common system makes a one-time payment to "acceptors" who agree to use birth control, to "motivators" who persuade others to use birth control, or to doctors who provide the birth control. Supporters of incentives argue that these programs help to educate people about contraceptives and to overcome cultural resistance to using them.
By paying a fee for each sterilization performed or IUD inserted, however, incentive schemes have permitted unscrupulous villagers to use women's bodies for profit. "Once the procedure is finished, so is the patient," writes Dr. Zafrullah Chowdhury of the People's Health Center in Bangladesh. "No one cares about them post-operatively, they have complications, if further problems arise later. They have served their usefulness."150 One of the most appalling examples of profiteering was the "IUD factory" in Pakistan, where doctors, motivators, and women collaborated to have IUDs repeatedly inserted, removed, and reinserted for multiple bonuses.

Hartmann points out as well that incentive advocates sidestep the fundamental question of why people need to be pushed into having fewer children in the first place. "Isn't it because of the very absence of the most powerful incentive of all: the economic and social security of having fair access to the fruits of development?" she asks.151 Incentive programs have tried to substitute mass sterilization for the equitable distribution of wealth in Third World countries, sacrificing the health and dignity of poor women of color in the process. Feminists in these countries argue that family-planning programs must be motivated instead by the aim of giving women the social power needed to control their own reproduction.

The Inquirer's infamous editorial tried to distance Norplant incentives from these deplorable programs overseas. "This is not Indira Gandhi offering portable radios to women who agree to be sterilized," Kimelman maintained. Presumably what distinguishes the acceptable U.S. proposals from the intolerable Indian program is that Norplant is only temporary while sterilization is permanent.

But the problem with Third World sterilization programs has as much to do with the government's objective as with the precise method of birth control. The coercion involved in paying poor women to implant Norplant in their bodies and then refusing to pay for its removal -- even when they are suffering from medical side effects - is also deplorable. It is often easier to recognize atrocities when they are committed by foreign governments. Like their Third World counter-parts, however, this domestic policy violates women's bodily integrity as well as their reproductive self-determination. We can only grasp the full weight of Norplant schemes in the United States when we situate them within the massive worldwide effort to reduce dark-skinned populations.

THE NEW FRONTIER:INJECTABLE AND IMMUNOLOGICAL CONTRACEPTIVES
There are already signs that policymakers determined to curtail Black birthrates will soon discard Norplant as the contraceptive of choice. Negative publicity arising from the class action lawsuits, as well as word of mouth concerning Norplant's side effects and removal problems, has dampened interest in the device in targeted communities. Some attribute Norplant's fall from grace to allegations about Black genocide.
Clinics across the country have seen a dramatic decline in Norplant use. The Johns Hopkins family-planning center in Baltimore reported doing less than twenty Norplant inserts in three months in 1995. "That's what we used to do in the course of a couple weeks," its director commented.152 Planned Parenthood clinics in Washington, D.C., have stopped supplying the implants altogether because of their patients' reluctance to use them.153 A Detroit gynecologist says he has removed three-fourths of the capsules he had inserted and does not expect to implant any more.154 And while thirty-six out of fifty girls offered Norplant at the Paquin School complied in the program's first semester, the number who agreed to use it dropped to four the following semester.155

Medicaid records confirm that in twelve large states the number of removals skyrocketed after a couple of years, as the number of insertions plummeted.156 Taxpayers will soon become fed up with the cost of removing the device; Ohio alone spent $1.9 million for Norplant extractions by July 1994. Without more draconian methods, the effort to pressure poor Black women to use Norplant en masse appears destined for failure.

The leading candidate for Norplant's immediate replacement is the injectable contraceptive Depo-Provera. Depo-Provera, the trade name for medroxyprogesterone acetate, is manufactured by the Upjohn Company and used by 15 million women in over ninety countries. Depo-Provera also delivers progestin into the bloodstream, making it the contraceptive most similar to Norplant. Depo-Provera, however, shoots an intense concentration of the hormone into the system, rather than releasing it gradually as does Norplant. Its effect lasts from three to six months. Many women on Depo-Provera suffer from the same side effects caused by Norplant and other hormonal contraceptives, including heavy bleeding, although most have no periods at all after a year. Upjohn is also studying long-term users' risk of bone loss and osteoporosis. The FDA banned the marketing of Depo-Provera as a contraceptive until recently, based on studies showing that beagles formerly used in contraception testing developed breast cancer when given high doses of the drug.

Depo-Provera has some advantages over Norplant: at a cost of $45 every three months, it is more affordable than Norplant's exorbitant lump-sum expense. Depo-Provera can be used in secret, whereas Norplant leaves telltale ridges where the implants are embedded. In addition, some Third World women are more receptive to an injectable contraceptive owing to their association of shots with inoculations against disease. The hormone shot also avoids the problems Norplant users have experienced with insertion and removal procedures. On the other hand, Depo-Provera gives women suffering from side effects no recourse until the drug wears off. Am injection is also closer to temporary sterilization because its effects are irreversible once the hormones are shot into a woman's bloodstream.

The FDA approved Depo-Provera for use in the United States only in 1992, after decades of heated debate about the drug. Depo-Provera's distribution here has renewed interest in injectable contraceptives. Some clinics report that most of their patients prefer Depo-Provera to Norplant.157 While Norplant has received the most attention, the Maryland contraceptive program initiated in 1993 also offered Depo-Provera to low-income women. Over 360 women received injections in the program's first three months.158 State legislative proposals to distribute long-acting contraceptives are beginning to include funding for Depo-Provera, along with Norplant. In 1994, Indiana approved a $175,000 contract with Upjohn that allows the state to offer Depo-Provera free at family-planning clinics, more than the amount allocated for Norplant.159

Depo-Provera has an alarming track record for abuse both in the United States and in developing countries. American doctors, who had access to the drug as a cancer therapy even before its approval for contraceptive use, regularly administered it to Southern Black and Native American women for birth control.160 A 1978 FDA audit of a Depo-Provera trial at Emory University in Atlanta discovered reckless disregard for the health of the 4,700 Black subjects. The drug has been administered to women in Third World countries such as Thailand, Mexico, and India without adequate patient counseling or medical supervision. The South African government under apartheid pressured Black women to use Depo-Provera by distributing free injections at factories and farms, sometimes threatening women with the loss of their jobs if they did not consent.161 In France, 20 percent of immigrants from sub-Saharan Africa on contraceptives use the drug, compared to only 4 percent of French-born women.162

This history suggests that lawmakers will soon seize upon Depo-Provera to replace or supplement Norplant in programs designed to discourage women on welfare from having children. Doctors are already offering a choice between Norplant and Depo-Provera to young Black women who walk into their clinics.

Now population control research is heading on a radical course. "Contraceptive vaccines" promise to regulate fertility by manipulating the body's immune responses. They work by stimulating the immune system to shut down some body functions necessary for pregnancy, analogous to the way vaccines given to infants cause the body to fight childhood diseases such as smallpox, mumps, and measles.163 Different vaccines attack the development of reproductive hormones, eggs, sperm, or the early embryo. Of course, pregnancy is not a disease, says health activist Judith Richter, who wants to reject the term "vaccine" in favor of "immunocontraceptive."164 Under investigation for two decades, the best-studied immunological approach uses antibodies to a hormone called human chorionic gonadotrophin (hCG) that is essential for the implantation and development of the embryo.165 The effect of the anti-hCG vaccine would last six to twelve months. It has already undergone clinical testing for safety on women in India and Australia.

Researchers are also developing an oral contraceptive vaccine that will prevent pregnancy for years in a single dose. The possibility of using recombinant DNA technology in a vaccine has unfurled yet another range of research in this field. One project seeks to create a vaccine from genetically altered salmonella bacteria that would be marketed as a powder. But the complexity of immunological research makes it hard to predict when an antifertility vaccine will actually hit the market. It is difficult to identify antigens that will produce an immune response as well as to develop and test safe delivery systems.

Nevertheless, the population control establishment is devoting a huge effort to this investigation. It is estimated that 10 percent of worldwide spending on contraceptive research is currently devoted to developing immunizations.166 Banking on the venture's eventual success, billionaire Ross Perot has invested $2.8 million in a Texas biotechnology company called Zonagen, Inc., which is developing an antipregriancy vaccine.167 The fledgling company has teamed with Germany's Schering AG, the world's largest manufacturer of oral contraceptives, which has agreed to finance clinical testing of the vaccine. Immunological contraceptives pose a novel, and more alarming, set of risks than existing methods. Their antibodies may trigger dangerous immune responses, such as allergies and autoimmune disorders. They may also exacerbate existing infectious diseases and immune disturbances, perhaps hastening the onset of AIDS. In addition, the risks to a developing fetus, if pregnancy occurs despite the vaccination, are unknown. Like Depo-Provera's, a vaccine's effects are irreversible. While a Norplant user may be able to get the inserts removed from her arm, women who are vaccinated will have no choice but to wait several months-or years-for the immune response to wear off.

Activists fear that vaccines are even more susceptible to government abuse than is Norplant because women can be inoculated without their consent or even their knowledge. An especially unscrupulous or incompetent program could add the contraceptive antibody to another vaccine and administer the combination without the patient's awareness. Rumors have already circulated in Tanzania, Indonesia, the Philippines, and other countries that a laced tetanus vaccine given to schoolgirls causes abortions and sterility. Whether these rumors are true or not, they have decreased participation in immunization programs. The development of immunological contraceptives has begun to poison Third World women's acceptance of vaccines -- an acceptance that, ironically helped to market contraceptive injections.

Because vaccines can be delivered in pills, food, or liquids, the potential for abuse on a mass scale is chilling. Already, biologists have proposed slipping antisperm antigens into bait as a way of reducing burgeoning wildlife populations. The scheme's potential for human population control was not lost upon a New York Times journalist:

Biologists say that new vaccines under development . . . will provide a humane method for drastically reducing populations of rabbits in Australia, rats in Indonesia, white-tailed deer in the United States, and other rapidly multiplying species that threaten the environment. . . . Genetically engineered vaccines are being developed in several countries for controlling populations of animal pests. Since the vaccines work by immunizing a female against the male's sperm, the same principle should be effective as a contraceptive in humans. . . . [T]he method could make contraception far more accessible to residents of poor countries. 168
In a 1969 Science article, the Population Council's then president, Bernard Berelson, seriously considered a similar proposal of mass use of a "fertility control agent" that would be available in five to fifteen years and "would be included in the water supply in the urban areas."169 Berelson seemed more worried about the plan's "administrative feasibility" than ethical concerns, asking, "How are fertility control agents' or 'sterilants' to be administered on an involuntary mass basis in the absence of a central water supply or a food-processing system?"
Harmed by contraceptive research in the past, women around the world are protesting the development of antifertility vaccines. 170 1n 1987, Brazilian feminists, who had run the Norplant trials out of the country a year earlier, put a stop to the Population Council's proposed testing of the anti-hCG vaccine. Ten thousand citizens, including three hundred scientists, signed a petition opposing the immunological research in Brazil. Am international lobby against contraceptive vaccines, coordinated by the Women's Global Network for Reproductive Rights, began organizing in 1993.

By 1995, a coalition of over four hundred organizations from thirty-nine countries was demanding an immediate halt to the research. Their petition, "Call for a Stop to Research on Antifertility 'Vaccines' (Immunological Contraceptives)," declared that this technology had an unprecedented potential for abuse and that the health risks inherent in manipulating the immune system for contraceptive purposes outweighed any possible advantage to women. It also called for a radical reorientation of contraceptive research "to enable people -- particularly women -- to exert greater control over their fertility without sacrificing their integrity, health, and well being."171 Most of the institutions conducting this research responded to the petition, arguing that providing new contraceptive methods only increases women's choice, that abuse could be prevented through proper monitoring, and that predicting the worst creates "a fortress mentality and a paranoid society."172 People who question the direction of medical research are often accused of being antiscience. It is assumed that developing novel reproductive technologies necessarily constitutes progress, that technological innovation necessarily betters humankind. But it is not true that every new form of birth control will ultimately benefit women just because it is more effective at preventing pregnancy. Indeed, Norplant's' brief history on the American market demonstrates that long-acting contraceptives that are not user-controlled and not adequately tested pose grave dangers to women's health and liberty. Why should these concerns not steer the course of medical research? The developers of the contraceptive vaccine have not justified creating a birth control method likely to increase abuse that we know already exists.




. . .




Despite all the commotion over the Inquirer editorial, lawmakers managed to install programs that distributed a powerful contraceptive highly susceptible to abuse to thousands of poor Black women. This is only the first step. As the climate grows increasingly hostile toward welfare mothers, especially those who are Black, we can expect increasing coercive measures to pass. The population control researchers are poised to supply the technologies needed to meet policymakers' objectives -- technologies that sacrifice women's health and autonomy for the sake of "effective" birth control. Underlying these measures are the twin assumptions that the problem of Black poverty can be cured by lowering Black birthrates and that Black women's bodies are an appropriate site for this social experiment. Once again the notion of Black women's reproductive liberty has dropped out of the picture.


Notes
Skin Deep (September 1994), a documentary produced by Deb Ellis and Alexandra Halkin.
Lynn Smith and Nina J. Easton, "The Dilemma of Desire," Los Angeles Times Magazine, Sept. 26, 1993, p. 24.
American Medical Association Board of Trustees Report, "Requirements or Incentives by Government for the Use of Long-Acting Contraceptives," Journal of the American Medical Association 267 (April 1, 1992), p. 1818.
Albert G. Thomas, Jr., and Stephanie M. LeMelle, "The Norplant System: Where Are We in 1995?" Journal of Family Practice 40 (1995), p. 125.
Donald Kimelman, "Poverty and Norplant: Can Contraception Reduce the Under-class?" Philadelphia Inquirer, Dec. 12, 1990, p. A 18.
Ibid.
Sheldon J. Segal, "Norplant Developed for All Women, Not Just the Well-to-Do," New York Times, Dec. 29, 1990, p. Al8.
David R. Boldt, 'A 'Racist Pig' Offers Some Final Thoughts on Norplant," Philadelphia Inquirer, Dec. 30, 1990, p. F7.
Steve Lopez, "A Difference of Opinion," Philadelphia Inquirer,, Nov. 16, 1990, P. B1.
Boldt, "A 'Racist Pig' Offers Some Final Thoughts on Norplant," p. F7.
Jonathan Alter, "One Well-Read Editorial," Newsweek, Dec. 31, 1990, pp. 85, 86.
"Journalistic Thought Police," Richmond Times-Dispatch, Dec. 27, 1990, p. A12.
Matthew Rees, "Shot in the Arm: The Use and Abuse of Norplant; Involuntary Contraception and Public Policy," New Republic, Dec. 9, 1991, p. 16.
David Frankel, Letter to the Editor, Washington Post, Dec. 29, 1990, p. A18.
Quoted in Sally Quinn, "Childhood's End," Washington Post, Nov. 27,1994, p.C1
Deborah L. Shelton, "Complications of Birth; Norplant Contraceptive," American Medical News 38 (Feb. 20, 1995), p. 15.
Planned Parenthood Federation of America, Survey of Planned Parenthood Affiliates on Provision of Norplant (December 1992).
Smith and Easton, "Dilemma of Desire."
Ibid.
Rees, Shot in the Arm," p. 16.
Quoted in Alan Harper, "Racism Suggested in Payments to Poor for Norplant Implants," New York Beacon, March 4, 1994 (available on Ethnic News Watch, Softline Information, Inc.).
Quoted in William H. Tucker, The Science and Politics of Racial Research (Urbana: University of Illinois Press, 1994), p. 294.
Quoted in Craig Flourney, "Duke Says He's Proud of Years as Klan Chief," Dallas Morning News, June 17,1992, pp. Al, Al6.
Dwight J. Ingle, Who Should Have Children? An Environmental and Genetic Approach (Indianapolis and New York: Bobbs-Merrill, 1973).
Tucker, Science and Politics of Racial Research, p. 193.
Staff of House Committee on Ways and Means, House of Representatives, Overview of Entitlement Programs 1994 Green Book, 103d Cong., 2d sess., 1994, pp. 402, 444; Teresa L. Amott, "Black Women and AFDC: Making Entitlements Out of Necessity," in Linda Cyorclon, ed., Women, the State, and Welfare (Madison: University of Wisconsin Press: 1990), p.280.
Nadia Zolokar, The Economic Status of Black Women (Washington, D.C.: U.S. Commission on Civil Rights, 1990), p. 1.
Clint Bolick, "Clinton's Quota Queens" Wall Street Journal, April 30, 1993, p. Al2.
William Henry, "Beyond the Melting Pot," Time, April 9, 1990, pp. 28-31.
Smith and Easton, "Dilemma of Desire," p. 24.
Department of Health and Human Services, Annual Health Profile Release, Public Health Report 11O (Sept.-Oct. 1995), p. 645.
Charles Murray, "The Coming White Underclass," Wall Street Journal, Oct. 29,1993, p. A14.
Congressional Budget Office, Sources of Support for Adolescent Mothers (Washington, D.C., 1990), p. 52.
Quoted in Jean Hopfensperger, "The Great Welfare Debate: Overhaul Proposals Are the Next Item on the GOP Agenda," Minneapolis Star Tribune, Feb. 11, 1995, p. 7A.
"For High School Girls, Norplant Debate Hits Home," New York Times, March 7, 1993, p. A28.
Esther Oxford, "What They Learn at Laurence Paquin School," The Independent,Oct. 28, 1993, p. 25.
Tracey Kaplan and John Johnson, "Birth Control Implants at Valley School Defended," Los Angeles Times, March 26, 1993, p. Al; Colin McMahon and Carol Jouzaitis, "Taboos Leave Many Teens Unprotected," Chicago Tribune, May 24, 1994, p. N1.
Clergy United for the Renewal of East Baltimore, Information on and Concern about Norplant in the Black Community (January 1993). See also Laura M. Litvan, "Norplant Program Assailed; Poor Black Girls Seen as Targets," Washington Times, Dec.4,1992, p. Bl. When the all-Black DuSable High School in one of Chicago's poorest neighborhoods recently started a family-planning program in its clinic, 13 ministers from local churches filed a lawsuit to shut it down. They charged that the clinic was a "calculated axis pernicious effort to destroy the very fabric of family life among black

(Message over 64k, truncated.)