Manufacturing Stigma
There is a new gospel for development aid. Its authors are a small group of conservative, mostly Christian NGOs, and their target for proselytizing is the international donor community, some of whom have already converted—and tithed. The gospel and its proponents can be seen creeping into conversations about development aid around the world. Unfortunately, no one seems to be questioning the message or its messengers, or taking a good look at what the outcome will be for women if this gospel is widely accepted as “the Truth.”
The German NGO DSW, together with some faith-based organizations (FBOs), wrote Faith in Action, an example of the new narrative and a document to be used as a springboard for activities and partnerships around the world. Not unlike so many schemes, however, the devil is in the details. In this case, one need only read the annex of this document to understand what some organizations and donors are told they have to be willing to give up in order to work with FBOs. There the reader is told that “family planning is easier to sell to FBOs” because “family planning is associated with married couples,” unlike the connotations of “reproductive health with access for all.” This is a perplexing assertion from DSW, whose executive director explicitly called earlier this year for the UN to guarantee reproductive health and rights for all, a principle that has been soundly endorsed by people of faith for years.
This soft-sell on people’s right to access to healthcare is accompanied by the instruction, “Reproductive health should be defined so as not to include abortion.” Again, DSW, long a staunch supporter of voluntary family planning and comprehensive reproductive healthcare, promises greater faith-based cooperation on contraception for some people while completely selling out on safe abortion, and they are not the only ones who come out the losers. Why did people who should know better decide to start funneling money into the limited programs run by conservative faith-based organizations, thereby trading away the options, access and dignity of the communities who are supposed to be served?
Faith-based organizations are a coveted commodity as partners in international family planning, and understandably so. FBOs can be ideally positioned to deliver messages about family planning, a topic that often has spiritual as well as personal dimensions, in addition to delivering services, because they enjoy a unique trust and respect within the communities they serve. Furthermore, faith-based entities, such as the global Catholic healthcare system, possess medical service provision networks second to none in size and scope.
Some in the global reproductive health community have enlisted the assistance of faith-based organizations to promote family planning in their communities in order to take advantage of the existing global health infrastructure owned and operated by faith-based groups. In some areas, faith-based networks reach more people than government-run systems, especially in remote regions. These two areas would be, for all intents and purposes, impossible for secular organizations to replicate—certainly not without a massive investment of time and financial resources.
With the ascendance of faith-based organizations within the family planning arena arise conflicts that some who champion partnerships with faith-based groups have preferred to simply ignore. For example, even those who encourage partnerships with FBOs on family planning acknowledge that, in many cases, faith-based groups refuse to support the provision of safe abortion care. In fact, faith-based groups have posed contraception-only programs as a way to defeat those who advocate for safe abortion access, and as a method of “reducing the number of abortions” to some unspecified number that would, presumably, be acceptable to these committed antichoice activists.
For example, the New Evangelical Partnership for the Common Good (NEP) sought to convince its supporters to embrace family planning with the following entreaty, which appeared in the Washington Post’s On Faith blog.
Family planning is morally laudable in Christian terms because of its contribution to family well-being, women and children’s health, and the prevention of abortion. Our loving challenge to pro-life Christians: Please do not block family planning efforts, globally or domestically, because of your opposition to groups that provide both contraception and abortion. Instead, consider how a deeply pro-life moral commitment, focusing on the flourishing of all human beings made in God’s image, actually ought to lead to support for family planning.
Christian Connections for International Health (CCIH), a global network with the mission of “promoting international health and wholeness from a Christian perspective” similarly favors stigmatizing abortion in its efforts to secure support for family planning. Under the banner “Family Planning Reduces Abortions. And Faith-Based Groups Can Help,” CCIH has encouraged its supporters to “Know and understand the facts: Abortions are killing women and harming families.” This erroneous assertion is carried over in a consensus statement in Faith to Action referenced above, developed by CCIH together with DSW, which states, “Each year lack of family planning services and education in developing countries results in … 150,000 maternal deaths from abortion and other pregnancy-related causes.” They did not write “unsafe abortion,” mind you, merely “abortion,” although the distinction is critical. Abortion when safe and legal has a remarkably low mortality rate, much lower than pregnancy, and there are far more complications associated with the continuation of a pregnancy than the termination of it.
Faith-based groups claiming to support some aspects of reproductive health while “protecting” women and families from other parts of it have contributed to the stigma around abortion. It begs the question: whose interests do they really serve? In a world in which nearly half of all abortions are unsafe, nearly all unsafe abortions occur in developing countries and an estimated 47,000 women die each year due to unsafe abortion, for many women and their families the price of stigmatization is quite high. Women living in remote areas, as well as poor women in all settings, are likely to have only one option for medical care, if any at all. In many cases, the single medical provider in their area is operated by a faith-based group that refuses to provide safe abortion care—even when medically indicated to save a woman’s life. If for financial or health reasons a woman is unable to travel to a willing provider, she will almost certainly be unable to obtain the care she needs. She, and her family, face a highly uncertain future.
In an article for the Bill and Melinda Gates Foundation’s “Impatient Optimists” blog, columnist David J. Olson, a board member of CCIH, quoted Ray Martin, executive director of the organization, who said, “Many faith-based organizations, like CCIH, are finding ways to promote family planning that show respect for religious beliefs and sensitivities.” Dropping safe abortion from the agenda is key to this approach, he claims, yet some groups agree that simply excluding abortion is not sufficient. According to a summary of responses from “International Family Planning: Christian Actions and Attitudes,” a 2008 CCIH survey solely of its own 92 members, “the most common concern was about abortion—that ‘family planning’ or ‘reproductive health’ might imply promotion of abortion, or provision of contraceptive methods that acted as abortifacients.” Not only abortion, then, but also modern methods of contraception, must be disassociated from “family planning” in order to secure the buy-in of CCIH members—although the findings are being used as if they are more representative of people of faith than merely of that group’s organizational membership.
If reluctance to embrace contraception as part of family planning sounds illogical, that’s because it is. Nevertheless, this is exactly the situation faced by women who seek modern, highly effective methods of contraception from Catholic-affiliated healthcare providers everywhere in the world. FBO funding for the provision of reproductive healthcare goes disproportionately to Catholic-affiliated healthcare entities—entities that refuse to provide and, in some cases, to even refer for modern methods of contraception, not to mention abortion. To suggest, as some have, that funding can go to other FBOs that can offset the effect on women’s health of the Catholic-affiliated healthcare systems—especially in the developing world—is disingenuous at best, and, at worst, dishonest. Some FBOs assert that providing information about some “traditional” and less-effective methods of contraception, like Natural Family Planning, is somehow sufficient, but it amounts to a further disservice to the women who rely on these programs. Why should poor women who have no alternative to the FBO nearby have to use a traditional method of family planning? If given the choice between modern contraception and a traditional method, how many more privileged women would choose a traditional method? All women, whether rich or poor, religious or not, regardless of where they live, deserve access to the full range of contraceptive options, as well as the right to choose what is best for themselves and their families.
The uncritical embrace of faith-based organizations by the global health community may sound familiar because it is an echo from a very recent chapter in history. In 2003, former president George W. Bush launched the President’s Emergency Provision for AIDS Relief (PEPFAR). This initiative, which set out to provide treatment to millions of people living with HIV & AIDS while preventing millions of infections, notably included non-evidence-based funding provisions that resulted in billions of dollars granted to faith-based organizations. As outlined in the Catholics for Choice report, “Seeing Is Believing,” the first generation of PEPFAR required that one-third of all funds for prevention efforts be used for abstinence-only programs. The program also had a practice of privileging startup conservative evangelical nonprofits that were deemed to possess the correct ideology, but often had little or no experience in development or HIV & AIDS work.
How little faith they seem to have in religious people’s support of their neighbors’ rights to health and justice.
That PEPFAR was driving funding to organizations implementing non-evidence-based programs eventually became apparent. For example, Uganda abandoned its highly successful pre-PEPFAR approach for preventing HIV, which emphasized condoms (among other strategies), in favor of faith-based organizations promoting abstinence and monogamy. Condoms became, in the words of President Yoweri Museveni, “a means of last resort.” The Center for Public Integrity describes what came next by citing a statement from the director general of the Uganda AIDS Commission, who said that after Uganda’s youth programs began concentrating on abstinence in 2003, the rate of new HIV infections almost doubled. As Canon Gideon Byamugisha, a religious leader and AIDS activist in Uganda, told the New York Times, “If you have an environment that stigmatizes them, then don’t expect people to use condoms.” Much like DSW’s attempts to deal with FBOs, the Ugandan government may have seen faith-based organizations as valuable new allies, but HIV-prevention efforts suffered from these partners’ very specific idea of what “reproductive health services” means.
Sadly, it’s not just governments or development agencies that find themselves in the business of placating conservative FBOs at the expense of public health. The Guttmacher Institute, usually a reliable source for information and analysis on matters of sexual and reproductive health, seems to be viewing the impact of faith-based organizations on women’s health and rights through rose-colored glasses.
In fall 2013, an article funded by the UN Foundation that appeared in Guttmacher Policy Review sang the praises of faith-based organizations working on family planning in the developing world. CCIH, a UN Foundation grantee and an organization that claims abortion kills women, is lauded as “unequivocally … supporting family planning….” Except that’s not really an accurate characterization. CCIH is quite equivocal on family planning: it demonizes abortion, is not keen on supporting contraception for unmarried people, and rejects modern, effective contraceptive methods that some people claim, without any evidence, cause abortion.
After mischaracterizing Catholics as “staunchly opposed to all modern methods of family planning,” the report holds out the Institute on Reproductive Health (IRH) at Georgetown University as a model of USAID-funded faith-based collaboration, in this instance in Rwanda. The tiny problem with this collaboration is that IRH promotes only fertility awareness methods, offering women “Cycle Beads” to try to avoid pregnancy. As a result, Rwandan women reliant on IRH have no practical way to access modern, highly effective forms of contraception.
If an organization were providing only long-acting reversible contraception in areas when poor, less-educated women had no reliable recourse to another provider, someone might raise the question about whether this limited offering was coercive. The situation in Rwanda that IRH has created, and USAID has funded, is not really all that different, yet the Guttmacher publication did not criticize Georgetown’s approach, nor the fact that US taxpayers footed the bill.
After whitewashing the inadequate and inaccurate family planning education and services delivered by faith-based organizations, the report wraps up with a call to policymakers to “catch up with the fact that a large swath of [FBOs] actively supports a robust US family planning program overseas.” If the “robust US family planning program[s]” the author refers to are those highlighted in the Guttmacher article, one might argue that women would be better served if policymakers kept their distance.
Perhaps one of the biggest disservices done by the Faith to Action document from DSW, CCIH and other partners is the way it depicts all people of faith as skittish about comprehensive reproductive healthcare. A section on consensus statements warns that it is important not to solicit signatories who are “too liberal” because “others might have doubts about following.” The authors advise that the statement itself shouldn’t ask for too much support of reproductive health or family planning because “too strong language can scare people away.” How little faith they seem to have in religious people’s support of their neighbors’ rights to health and justice.
But donors, policymakers and advocates need not water down scientifically sound, evidence-based approaches to either the provision of reproductive health services (yes, including abortion) nor HIV prevention strategies in order to secure the support of religious people. There are religious people everywhere who support increased access to the full range of reproductive health services and to evidence-based approaches to stemming the HIV & AIDS pandemic. Teachings within every major faith support both of these ideas. For example, Catholicism teaches that we must be guided by the certain judgment of our conscience in all things. If a woman’s conscience guides her to use contraception, or to terminate a pregnancy, who are we to judge? In Catholicism, the answer is clear: it is not anyone’s place to judge the dictates of another’s conscience, nor should anyone attempt to impose his or her conscience onto others.
The global health community would be wise to consider the tough questions implicit in pandering to FBOs—or any organizations—that do not support family planning without qualifiers. Organizations that stigmatize abortion and contraception show little faith in the decision-making ability of the people they are pledged to serve. There is no reason that donors and advocates need to follow their lead, and indeed, so many reasons why we shouldn’t.
