This is an archived USAID document retained on this web site as a matter of public record.
Testimony of Mark Schneider, Assistant Administrator for Latin America and the Caribbean
Before the House International Relations Committee
Subcommittee on International Operations and Human Rights
Washington, D.C., February 25, 1998
U.S. Agency for International Development
Chairman Smith, other members of the subcommittee, thank you for the
opportunity to appear today and discuss recent developments in Peru. We are eager to
work with this Committee in an open and transparent fashion so that we can all
collectively get to the bottom of a very serious issue that demands to be handled
rigorously and impartially. I know we are in full agreement that the human rights of
women must be given the highest priority in Peru, as elsewhere, and that any effort to
abridge those rights runs directly counter to the values and foreign policy of the
United States. We all agree that men and women should be able to voluntarily make
their family planning choices and have access to safe family planning services.
Equally clearly, we must base our judgement of the situation in Peru on a full
accounting of the facts of the matter to be fair to all the parties involved.
I am also glad that the Government of Peru has just this week announced a
number of very important concrete steps that should return their family planning
program to a sound foundation. As of yesterday, we have received the good news
that the Government of Peru will:
-- Discontinue their campaigns in tubal ligations and vasectomies.
-- Make clear to health workers that there are no provider targets for voluntary
surgical contraception or any other method of contraception.
-- Implement a comprehensive monitoring program to ensure compliance with
family planning norms and informed consent procedures.
-- Welcome Ombudsman Office investigations of complaints received and respond
to any additional complaints that are submitted as a result of the public request
for any additional concerns.
-- Implement a 72 hour "waiting period" for people who choose tubal ligation or
vasectomy. This waiting period will occur between the second counseling
session and surgery.
-- Require health facilities to be certified as appropriate for performing surgical
contraception as a means to ensure that no operations are done in makeshift or
substandard facilities.
Again, these are all welcome developments.
Before going into more detail, I think it useful to reiterate the Administration's
policy on the voluntary nature of family planning and look briefly at the larger context
of our overall assistance program to Peru. The United States provides international
family planning assistance to developing nations to help reduce unintended
pregnancies, combat infant and maternal mortality and reduce the spread of deadly
diseases such as AIDS. All of our family planning programs are guided by the
principles of voluntarism and informed choice. We categorically oppose coercion in
any form. The U.S. Agency for International Development's (USAID's) family
planning efforts have helped millions of couples in the developing world achieve their
desire for better cared for and more prosperous families.
USAID family planning programs are built within an internationally accepted
framework that stresses the quality of health care. This quality of care approach to
family planning has six defining features:
-- People can choose from a range of contraceptive methods;
-- Families receive adequate information on all methods available;
-- Health personnel are appropriately trained;
-- Health personnel treat clients with respect;
-- Clients have ongoing access to necessary services; and,
-- These health services should cover other related aspects of reproductive health.
It is clear that the guiding principles of our family planning program are about
giving women and men access to healthy and educated choices about having children
and improving their own lives.
The overall U.S. foreign assistance program to Peru is built around: promoting
democracy and human rights; reducing the entry of illegal drugs into the United
States; protecting human health; and reducing poverty through broad-based economic
growth. These actions contribute to the stability of a trading partner with one of the
fastest growing economies in the region that is becoming increasingly important to the
United States.
Economic improvement has been impressive in Peru, but continuing inequities,
particularly in the poorest urban and rural areas of the country, indicate that much needs to be done to generate productive employment and income to meet the needs of
those in poverty. In 1996, 51.3 percent of Peruvians lived below the poverty line.
Chronic malnutrition of children in rural areas was 40 percent, and infant mortality in
rural areas remained twice as high as in urban areas. Unintended pregnancies among
adolescents are on the rise. Just last week we also saw Peru battered by El Niño and
in the midst of a sizable humanitarian emergency.
Although there has been considerable progress, much remains to be done to
bolster a fragile and uneven democracy in Peru. Improving human rights is an
important part of USAID's effort in Peru. USAID assistance has contributed to
broader citizen participation in decision-making processes of local governments, the
emergence of the Human Rights Ombudsman Office as one of the most respected
Peruvian institutions, and the release of hundreds of individuals from jail who have
been "unjustly" accused or convicted of terrorism. We have also worked to strengthen
the capacity of human rights non-governmental organizations and to try and promote
the capacity of the judiciary system to become more independent.
In the area of health, Peru has achieved noteworthy successes in recent years,
and it is fair to say that USAID's large investments in health in Peru, including its
support for family planning, have contributed significantly to those successes. Chief
among the successes over the last five years:
* Infant mortality fell by 22 percent;
* Under-5 mortality fell by 24 percent; and,
* Chronic malnutrition of children under 5 fell 30 percent.
Peru's status as a priority country for USAID in family planning emanates
from the two most important underlying rationales for international assistance in
family planning: reproductive rights and promotion of the health of women and
children. For more than two decades, nations of the world have agreed that
reproductive rights not only include a couples' right to practice family planning, but
also access to contraception and the other services that allow such decisions to be
exercised. Thus, women and men have the right to make decisions freely about the
number and spacing of their children, without intervention by governments or other
entities, at the same time that they have the right to the means to put their decisions
into effect. Information, education and services should be delivered in a way that
provides equal access to women and men of all races, classes, ethnic groups,
education levels and place of residence.
Through both large-scale national household surveys and in-depth qualitative
research with everyday women throughout Peru, the evidence is compelling that most
women desire to space or limit births. USAID supported a massive household survey
in 1996, in which people in some 30,000 households were interviewed through a
random sample. It showed that:
* A full 59.4 percent of married women in Peru want no more children.
* Of the 26 percent of women who want more children, 17.5 percent want
to wait at least two years before their next pregnancy.
* Though women in Peru on average have 3.5 births each, women's
desired family size is 2.5.
* Teen pregnancy is a problem in Peru: 13 percent of young women aged
15-19 are either pregnant or already mothers.
* It is also estimated that some 260,000 abortions occur annually in Peru.
Virtually one of every three pregnancies ends in abortion -- this in a
country where induced abortion is only legal in very restricted cases.
Abortion remains one of the major causes of maternal mortality in Peru.
* Maternal mortality is high in Peru, estimated at 265 deaths per 100,000
live births -- more than 30 times the level in the United States. Unsafe
abortion contributes to this, as does high fertility, adolescent fertility and
short birth intervals. Further, half of births in Peru occur at home.
Regrettably, despite the health successes mentioned above, maternal
mortality has not declined in recent years. Without an active family
planning program in Peru these indicators of human suffering would be
far starker.
The above are national statistics. When one looks at statistics for poor areas in
Peru, the picture is much worse. For example, recent reports of the Ministry of
Health estimate that maternal mortality in some rural regions is 700 per 100,000 live
births. This is why USAID focuses more on meeting the needs of poor populations in
Peru's highland areas and jungle. The goal is to allow the benefits of development to
be distributed more equitably.
Thus it is fairly self-evident that the need for responsible family planning
programs in Peru is considerable and that these programs can have far-reaching effects
in improving the health of women and children. It is my hope that in the discussions generated by the controversy over tubal ligation and vasectomy in Peru, we not lose
sight of the great benefits of family planning programs or of the principles that guide
USAID's efforts in this regard.
Most family planning programs in Peru offer a variety of family planning
services integrated into a comprehensive approach to maternal health. Surveys show
that natural family planning methods are the most common practice in Peru, and
USAID has supported a number of successful programs in natural family planning.
Studies also show that voluntary surgical contraception was the third most utilized
form of contraception in Peru last year. In the United States, and indeed worldwide,
tubal ligation is the most widely practiced family planning method.
Tubal ligations and vasectomies have been a legal method of contraception in
Peru since September 1995. Previously, surgical contraception was allowed only in
cases where a woman's health would be in danger in the event of additional
pregnancies. After legalization, the Peruvian government moved to respond to what
they perceived would be a large pent-up demand for access to tubal ligations and
vasectomies. Unfortunately, either officially or unofficially, the evidence suggests the
Peruvian government adopted a practice of quantitative national targets for surgical
contraception in mid-1996. To help reach these goals, the government of Peru
pursued a strategy of campaigns in which tubal ligation and vasectomy were offered
on a planned date, often in a place where such services were not permanently
available.
As soon as USAID became aware of the government of Peru's move toward
quantitative targets for sterilization and campaign strategy, U.S. officials
communicated strong concerns about the potential for distortions to the government.
The agency also quickly segregated USAID family planning support from the
campaign strategy. USAID implementing agencies were told not to support the
campaigns in any way, and Ministry of Health officials, including the Minister of
Health, were informed that USAID support could not be used in this strategy. USAID
refused to permit our programs to support the target/campaign strategy in any way.
USAID disagreement with the strategy at the earliest moment was not based on
awareness of any particular abuses at that time, but rather because of USAID's
knowledge of worldwide experience in family planning programming, as well as
USAID conceptualization of family planning within a quality of care framework.
Experience has shown that targets and campaigns are often counterproductive.
USAID's philosophical opposition resides in the belief that the vertical imposition of
targets in family planning opens the door to many types of distortions in what should
be a sacred relationship between the health provider and the client. Worldwide experience has shown this statement to be particularly the case where tubal ligation
and vasectomy are concerned.
As a matter of policy, USAID does not support performance-based quota
systems in family planning programs. While targets connected with provider
performance do not necessarily lead to the use of "pressure tactics", they, at a
minimum, increase the vulnerability for abuses. Moreover, for ethical, political and
programmatic reasons, such drastic steps are unwarranted and counterproductive.
USAID programs seek to satisfy unmet demand for family planning which, with few
exceptions, still outpaces the ability of public and private sector programs to provide
these services.
Over the past 18 months, USAID has not relented in its opposition to setting
targets for vasectomies and tubal ligations, and over 80 contacts with government
officials, including the Minister of Health and a top advisor of the President, have
taken place on this subject between July 1996 and December 1997. USAID has also
mobilized public debate on this issue in Peru through its support for the Human Rights
Ombudsman, which has looked into reports of abuses, through our support and
cooperation with women's groups, and through statements at public events with a
variety of health care practitioners, concerned citizens and non-governmental
organizations.
While the campaigns continued, USAID gathered information continuously,
through official and unofficial sources and ongoing monitoring in the field by USAID
staff and specialized consultants. In November, we wrote to the Minister of Women's
Development expressing our concerns about these programs. In early January the
USAID mission director sent a letter to the Minister of Health requesting a response
concerning the allegations, as well as programmatic changes. But let me stress again,
no U.S. family planning funds or those of U.S. contractors have been used to support
the campaigns. The Staff Director of this subcommittee has agreed with that finding.
In the last few months, there have been reports in the press that the right to
fully informed consent may have been violated and that tubal ligations and vasectomies
have not always been safely performed. It has also been alleged that some health
workers may have conditioned provision of food or medical care on acceptance of
sterilizations. These reports reached the press in December and January. The Staff
Director of the House Subcommittee on International Operations and Human Rights,
went to Peru to investigate the reports the week of January 19-25 and, together with a
USAID representative, visited alleged victims of the abuses.
USAID urged Peru to: 1) discontinue tubal ligation and vasectomy campaigns;
2) disavow any policy of setting provider targets for voluntary surgical contraception;
and 3) implement a comprehensive monitoring program to ensure compliance with
family planning norms and informed consent procedures, including conducting a
nationwide family planning user satisfaction survey.
We believe these are significant measures, and we are pleased that the
Government of Peru itself determined to take these and the other steps I detailed at the
beginning of my testimony.
It is also important to clear up some possible misperceptions that may exist as a
result of the trip report of the Subcommittee's Staff Director. The author states he
traveled to Peru "to investigate allegations of mass sterilizations of poor women
without informed consent and other abuses in the population/family planing program
of the Government of Peru." While the report contains a series of recommendations,
it does not substantiate claims of mass sterilizations of poor women without informed
consent.
Despite a call through various media in Peru for society at large to submit
complaints of abuses, the Defensoría del Pueblo to date has validated cases from not
more than 9 individuals who have suffered reproductive rights abuses. Though clearly
not even one abuse is acceptable, the allegation that abuses have been "massive" has
not been substantiated at this time. The possibility exists that further cases may arrive
at the Defensoría and be validated, but present evidence does not support the
contention of massive abuses.
USAID knew of no reports of sterilizations without consent in 1996 nor, for
that matter, in much of 1997. Further, several of the allegations that have been
characterized recently in the media as forced sterilization have turned out, upon closer
scrutiny, to be cases of poor quality of services that led to preventable mortality and
morbidity, which are certainly regrettable in their own right, though quite different
from involuntary sterilization.
I would also like to briefly discuss the role of U.S. food aid in Peru, since
there has been some question as to whether any of these resources were unknowingly
diverted for use in the campaigns. USAID's Food for Peace Title II program in Peru
provides approximately 94,000 metric tons of food annually, valued at over $50
million. This program benefited approximately 2.3 million poor Peruvians in 1997,
providing short and long-term solutions to the conditions of poverty that afflict
approximately 50 percent of the overall population.
The program is implemented by five non-governmental organizations -- the
Adventist Development and Relief Agency, CARE, CARITAS, PRISMA, and
TechnoServe. In 1997, over 400,000 children benefited from nutrition activities.
Since food has been shown to have more impact on reducing child malnutrition when
used in combination with other health and nutrition interventions, these nutrition
activities also put emphasis on monitoring the weight gain and overall health of
participating children, recommending they be fully immunized, and requiring
attendance by their mothers at a series of information/training sessions covering pre-natal care, breast feeding and weaning techniques, diarrheal and respiratory diseases,
and family planning.
PANFAR (Food and Nutrition Program for High Risk Families), which is
implemented by PRISMA in cooperation with the Ministry of Health, is the only Title
II-supported program to be the subject of allegations that food distribution is
conditioned on consent to surgical contraception. Again, it is important to stress that
we have heard of only two such allegations. Each of these cases were quickly
investigated and no abuses were found. Because the program is extensive --
benefiting over 150,000 families in 2,360 population centers in the poorest areas of
Peru -- PANFAR has a very thorough monitoring system. The system includes
participation in every PANFAR community by both PRISMA and Ministry of Health
officials to ensure that all precepts of the program are adhered to. These precepts
include the prohibition of offering food assistance either as an inducement to enter
PANFAR or to adopt any method of family planning.
The Subcommittee Staff Director's report refers to one case allegedly linking
Title II food assistance under the PANFAR Program to coerced sterilizations. In
addition, an article in the local newspaper El Comercio dated January 26, 1998,
alleges another case linking PANFAR to coerced sterilization. However, neither of
these cases appears to be validated by further investigation. The Subcommittee has
been provided with material relevant to these cases. We will investigate any other
cases, beyond these alleged incidents, if they come to our attention.
Any allegations of misuse of food assistance are investigated immediately. In
the case of PANFAR, past cases of intended or actual misuse of food have been dealt
with swiftly and fairly, including discontinuation of food resources until allegations
have been investigated, and removal, and in one case jailing, of Ministry of Health
officials for improperly using food assistance in a case of financial abuses. Recent
allegations linking food assistance to coerced sterilizations have been investigated
immediately through on-site interviews with the women and their family members,
local non-governmental organizations and health promoters. There are no known cases, or no evidence that we are aware of, linking U.S.-funded food assistance to
coerced sterilizations.
In concluding this testimony, I would like to add several final points. We are
pleased that the Government of Peru has decided to take the steps it has informed us
of this week. This is an important development, and we will keep you and your staff
apprised of progress toward meeting this commitment. The course of our future action
will depend, in part, upon the continuing response of the Peruvian government to this
situation. I am optimistic that the Government of Peru appears to be willing to listen
to the voices of its own people -- the Ombudsman's Office, women's groups, health
care providers, the national medical association and the Ministry of Health's own
evaluation of its program -- and come out with a clear enunciation of support for the
voluntary nature of family planning programs.
We look forward to working closely with you and your staff in the future to
support America's international family planning programs, and I thank you for the
opportunity to appear today.
This is an archived USAID document retained on this web site as a matter of public record.
 |
Last Updated on: July 18, 2001
|
:
:
:
:
:
:
:
:
:
:
