50 Years of Family Planning for Our Future

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President Dwight D. Eisenhower surely never intended to spark a national debate about birth control. But in 1958, when he appointed General William H. Draper, Jr. to head the Committee to Study the United States Military Assistance Program, he accidentally did just that.

Awareness of global population growth as a pressing issue had already been percolating among demographers and other social scientists for more than a decade. After reaching 1 billion around 1800, global population was about to reach an estimated 3 billion in 1960. Alarmed by projections about future growth and its impacts, advocates began to approach policymakers with proposals for United States-funded family planning programs in the late 1950s. Both Republican and Democratic legislators shied away, however, deeming the topic “too sensitive” for government involvement.

National security concerns finally broke the taboo. Perhaps it’s not surprising, given that the modern concept of development assistance was born in the early days of the Cold War. Helping countries develop, the theory went, would not only benefit their citizens, it would also tie them more closely to the U.S. and limit the influence of the Soviet Union. These new allies would, in turn, help protect the United States and its interests.

This new thinking — that national security was not only about military might and physical protection, but that development assistance could play a key role in creating a safer world — led to the passage of the Mutual Security Act, which was signed into law in 1951 by President Harry S. Truman. The act authorized an ambitious foreign aid program, devoting around $7.5 billion per year to help poor countries with their economic, technical, and military development. The law was meant, said Rep. James P. Richards, Chair of the House Foreign Affairs Committee, “not to fight a war,” but “to prevent a war.”

In the years that followed, the act was renewed, but only after protracted squabbling about the total amount of money to be spent and the relative sizes of the military and non-military aid packages. By 1958, concerns about waste and effectiveness had grown to the point that they could not be ignored. Eisenhower tapped Draper, a retired Army major general, former U.S. ambassador, and early venture capitalist, with evaluating the program and making suggestions for its improvement.

In a letter to Draper after his appointment, Eisenhower wrote, “What is needed from your committee is a forthright evaluation of the extent to which future military assistance can, by strengthening our friends and allies, advance U.S. national security and foreign policy interests… I am especially interested in your committee’s critical appraisal… of the relative emphasis which should be given to military and economic programs, particularly in the less developed areas.”

Eisenhower expected a list of cost-cutting measures. But Draper had a longstanding personal interest in population issues, stemming from his time in U.S.-occupied Japan immediately after World War II. He sought advice from American population and family planning advocates, and included a series of strongly worded pro-family planning recommendations in the final committee report.

The United States, the report said, should be prepared to aid countries in creating plans to address rapid population growth, as well as to increase assistance for local family planning programs — especially those relating to maternal and child welfare. The committee also recommended that the U.S. explicitly include voluntary birth control programs as part of its technical assistance packages, writing, “No realistic discussion of economic development can fail to note that development efforts in many areas of the world are being offset by increasingly rapid population growth.”

One imagines Eisenhower was somewhat nonplussed upon reading that section of the report, which was immediately attacked by American Catholic leaders. The National Catholic Welfare Conference (NCWC), a bishops’ association, released a statement denouncing the report as propaganda.

In a sign of just how unclear the battle lines were and how non-partisan the issue was at the time, Democratic then-Senator and presidential candidate John F. Kennedy issued a press release agreeing with the NCWC statement and opposing American aid for family planning. Three candidates fighting him for the Democratic nomination (Adlai Stevenson, Stuart Symington, and Hubert Humphrey) all took the opportunity to attack him for his stance. Governors, mayors, and other public figures from both sides of the aisle began weighing in, along with other religious groups and organizations such as Planned Parenthood.

Unwilling to force an issue he hadn’t even expected to be raised, Eisenhower finally disavowed the recommendation, telling reporters, “I cannot imagine anything more emphatically a subject that is not a proper political or governmental activity or function or responsibility.” Officially, family planning was off the table.

Draper and other population activists, though, continued to push the issue. Although the Kennedy administration publicly held to the line it had set during the campaign, private conversations with officials indicated some softening. The administration oversaw the passage of the Foreign Assistance Act of 1961, which authorized research on family planning issues. Additionally, the new law removed responsibility for development programs from the military sphere and established the United States Agency for International Development (USAID). The new department, located under the umbrella of the Department of State, cemented foreign aid as a priority of the federal government, independent of its national security implications.

It was only under President Lyndon B. Johnson, however, that family planning programs gained real traction. Public attention to the issue of population growth had increased, and the recent introduction of a reliable oral contraceptive meant there were now more options than ever for avoiding unwanted pregnancies. In his 1965 State of the Union address, Johnson committed to seeking “new ways to use our knowledge to help deal with the explosion in world population and the growing scarcity in world resources.” The first USAID programs focusing explicitly on family planning began that year, with a total of around $10.5 million spent by 1967.

During the same time frame, Senator Ernest Gruening (D-AK), held a series of hearings in Congress dedicated to the issue of population growth. Early in the process, a letter from President Eisenhower was read into the record. The former president expressed his support for the hearings and admitted he had erred by ignoring the issue during his time in office. The letter read in part, “If we now ignore the plight of those unborn generations, which, because of our unreadiness to take corrective action in controlling population growth, will be denied any expectations beyond abject poverty and suffering, then history will rightly condemn us.”

The Gruening hearings, along with the publication of works like Paul Ehrlich’s The Population Bomb and the founding of organizations like ZPG, brought the issue of global population growth to the forefront. The United Nations Fund for Population Activities (now the United Nations Population Fund, although the acronym remains UNFPA), founded in 1969, received bipartisan support from the U.S. Congress. Indeed, in 1969, the $4 million U.S. contribution to UNFPA accounted for roughly 80 percent of the agency’s budget. United States bilateral investments in international family planning grew steadily throughout the 1960s and early 1970s as well, reaching $100 million per year in 1974.

Domestic family planning programs also flourished. Although there is evidence that some maternal and child health programs had been quietly using federal funds for family planning efforts as far back as 1942, the amounts were small, as these expenditures were not officially allowed — although neither were they technically prohibited. Part of President Johnson’s War on Poverty, the first officially sanctioned programs began in 1964, under the Economic Opportunity Act.

On March 1, 1966, Johnson, in requesting a substantial funding increase for 1967, told Congress the programs were necessary “to foster the integrity of the family, and the opportunity for each child.” He continued, “It is essential that all families have access to information and services that will allow freedom to choose the number and spacing of their children within the dictates of individual conscience.”

A change in administration only accelerated the growth of family planning programs, both international and domestic. In July of 1969, President Richard Nixon called for the creation of the Commission on Population Growth and the American Future, which would examine the potential impacts of population growth — both in the United States and around the world — and suggest ways the United States might respond. At the same time, he called for a dramatic expansion of birth control access for American women, stating, “It is my view that no American woman should be denied access to family planning assistance because of her economic condition. I believe, therefore, that we should establish as a national goal the provision of adequate family planning services within the next five years to all those who want them but cannot afford them. This we have the capacity to do.”

Only a little over a year later, he signed the Title X family planning program into law, dedicating $6 million to the program in 1971. The bill passed the Senate unanimously, and passed the House by a vote of 298 to 32. Nixon noted the extraordinary bipartisan support for the program in his signing statement.

The 1973 Roe v. Wade Supreme Court decision heralded the first real signs of pushback for the reproductive rights movement. Numerous advocates of contraception — including Nixon — had already distanced themselves from support for expanded access to legal abortion. Opposition to federal funding for the procedure led to the passage of the 1973 Helms Amendment to the Foreign Assistance Act, which has been interpreted as a blanket prohibition of the use of U.S. funding for abortion “as a method of family planning.” The Hyde Amendment, passed in 1976, similarly prohibits federal funding of abortion through domestic programs, although it does specifically contain an exception for pregnancies that threaten the life of the woman. In 1993, a new version of the amendment expanded the list of exceptions to Hyde to include pregnancies resulting from rape or incest. Helms, however, continues to be interpreted as prohibiting funding for abortion in all circumstances.

Since the 1980s, the rise of the Religious Right as a political force, along with the growing polarization of America’s political parties, have radically altered the landscape for America’s population and family planning programs. Hostility toward government programs generally and the consistent (and calculated) conflation of family planning with abortion have created a toxic environment.

Beginning in 1980, family planning programs were automatically on the chopping block for many Republican politicians. The Reagan administration pushed through cuts to the Title X budget for the first time in the program’s history. Defenders of international family planning were able to stave off similar attacks, including a 1983 effort to zero out the program. When attempts to directly defund the program failed, the administration tried another tack. During the International Conference on Population in Mexico City in 1984, the Reagan administration announced new policies targeting international family planning: the Mexico City Policy, which soon became known as the Global Gag Rule, and an anti-UNFPA policy later packaged as an appropriations rider known as the Kemp-Kasten Amendment.

The Global Gag Rule states that no foreign non-governmental organization may receive U.S. funds if it performs abortions, offers counseling or referral for abortion, or engages in any political advocacy around the issue of abortion, even if it does so with its own, non-U.S. funds. It remained in place throughout the Ronald Reagan and George H. W. Bush administrations, was rescinded by President Clinton, reinstated by George W. Bush, and removed again under President Obama.

Upon assuming the presidency in 2017, Donald Trump moved immediately not only to reinstate the Global Gag Rule, but to expand it. Although the policy had previously applied only to family planning funds, Trump’s version applies to global health funding more broadly. Programs to combat HIV/AIDS, tuberculosis, malaria, and even childhood malnutrition have seen their funding eliminated.

The Kemp-Kasten provision, included in the foreign operations appropriations bill every year since 1985, states that no U.S. funds are to go to any organization that, in the determination of the president, “supports or participates in… coercive abortion or involuntary sterilization.” Although ostensibly intended as a blanket protection not targeting any particular program, in reality, the Kemp-Kasten provision has never been invoked except to deny funding to UNFPA. Republican presidents since Reagan have uniformly determined that UNFPA’s work in China renders it ineligible for U.S. funding, despite the fact that UNFPA does not perform or promote abortion anywhere in the world and has been a leading critic of China’s human rights abuses in this area.

Funding levels have seen similar attacks. After hitting their high-water mark in fiscal year 1995, international family planning funding declined throughout the George W. Bush administration, before recovering somewhat during the Obama years. The Trump administration took a page out of the Reagan playbook, calling for the elimination of the program in its first budget proposal. Title X has been under similar threat.

It remains to be seen where U.S. family planning programs are headed in the future. With high levels of unintended pregnancy — especially among young and low-income women — still occurring in the United States, and with 214 million women with unmet need for family planning in the developing world, it’s clear the programs are still desperately needed. What’s less clear is whether the United States will, going forward, be there to answer the call.

“Magic Pill” Empowered Women, But Violated Rights of Vulnerable Groups During Development

It’s no exaggeration to say the modern world wouldn’t exist without “the Pill.” Although condoms, cervical caps, and even an early form of the IUD were all in use in the first half of the twentieth century — along with withdrawal and periodic abstinence (the “rhythm method”) — it was the introduction of the first oral contraceptive that made the notion of “birth control” more than aspirational for many women.

The birth control pill was a great step forward in contraceptive technology, allowing millions of women the kind of control over their bodies never before seen in human history. But there’s a dark irony to that triumph: It was achieved, in large part, through the exploitation of women’s bodies, particularly the bodies of disabled women and women of color.

Margaret Sanger, Planned Parenthood founder, was already in her seventies when she met Dr. Gregory Pincus in 1951 at a dinner party in New York. She’d already been dreaming of a “magic pill” to prevent pregnancy for nearly 40 years, and the former Harvard professor was exactly the kind of scientist she believed could make it happen. He had a longstanding interest in reproductive endocrinology and a marked disdain for anyone who was squeamish about pushing ethical or scientific boundaries.

Philanthropist (and MIT graduate) Katharine McCormick had supported Sanger’s work for years — even funding her attempts in the 1920s to smuggle contraband diaphragms into the United States. McCormick wholeheartedly supported the goal of inventing a birth control pill and stepped up to bankroll the majority of the project, eventually spending over $2 million — more than $20 million in today’s dollars.

Pincus recruited John Rock, a Catholic physician who was already experimenting with the use of hormones as a means of treating infertility, to join the project, and the two men got to work. Pincus began his experiments on mentally ill patients at Massachusetts’s Worcester State Hospital. Claiming he was testing the drugs’ “calming effects,” he gave patients early versions of the pill, then cut into their uteruses to examine their ovulatory patterns.

Eventually, Pincus and Rock moved their experiments to Puerto Rico, where laws concerning birth control and patient protections and disclosures were looser and they knew they could find a larger pool of test subjects. They began in 1955 with twenty female medical students in San Juan, who were told to participate in the trial or risk being expelled from the university. In addition to dealing with the side effects of the heavy doses of hormones (progestin and estrogen) they were taking, the women were required to record their temperatures and provide a vaginal smear each day. Every month, they had to submit to a painful and invasive exam in which their cervices were dilated so that tissue from their uterine lining could be collected. Several underwent surgeries in which their abdomens were opened so researchers could observe their ovaries in real time. Eventually, more than half quit the study — including some who left medical school altogether.

But Rock and Pincus got the data they wanted. They formulated a prototype pill, and then began recruiting local women as test subjects. Many of the women who took the drug did so willingly, desperate for a reliable way to avoid pregnancy. Still, a significant number dropped out, reporting terrible side effects. Rock and Pincus ignored this, with Pincus telling The New York Times in an interview many years later that the side effects ‘[w]ere largely psychogenic,” happening “because women expect[ed] them.”

In 1957, the FDA approved the first version of the pill, Enovid, for “menstrual regularity,” printing a warning on the side of the bottle that the drug was likely to prevent pregnancy — a wink and a nudge for doctors in states where birth control was still illegal. Finally, in 1960, Enovid was explicitly approved as a contraceptive. The dosage (5mg of norethynodrel and 0.075mg of mestranol) was many times higher than what is actually needed to prevent pregnancy.

All modern forms of hormonal birth control have their genesis in the work done by Gregory Pincus and John Rock. The dosages are lower and the delivery mechanisms are more varied, but the basic concept and function remain the same. And millions of women all over the world have benefitted. The problematic nature of its development, however, cannot be overlooked.

Pincus and Rock (and Sanger and McCormick) were products of their time and culture. Much of what is, to modern eyes, horrifically unethical and clearly racist was, at the time, business as usual.

As those of us fighting for reproductive justice know, the echoes of that time still linger. We cannot change the past, but we can do better going forward. We can ensure that family planning services are voluntary and that patients have complete information about potential side effects. We can offer consumers every type of approved contraceptive method so they can find the one that works best for them. And we can honor the contributions of historic trailblazers while recognizing that they weren’t perfect, or even always altruistic in their motivations.

Family planning is undeniably one of the most important inventions of the past hundred years. Its development was carried out in ways that would be totally unacceptable today, but its impact has been immeasurably positive and wide ranging.

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