Refugee Women and Population Control

Controversy is mounting over a reproductive health field manual for emergency settings jointly produced by the UN High Commission for Refugees (UNHCR) and the UN Fund for Population Activities (UNFPA).1 In Great Britain two major NGOs, Save the Children and OXFAM, have removed their names from the manual because of concerns over lack of attention to quality of care in the provision of contraceptive and abortion services. Health workers from a number of other NGOs have voiced similar concerns.2

Although the manual includes many useful reproductive health interventions, parts of it display a dangerous population control bias, in particular a cavalier attitude toward contraceptive safety. The manual explicitly states, for example, that the benefits of contraceptive methods “largely outweigh any side effects” (p.48). It recommends use of Norplant and IUDs once a camp situation is stabilized and if service providers who can remove them exist in the country of origin should the refugees return home.

The health risks of these methods alone make their use unwise in a vulnerable population, and caveats notwithstanding, it is all too easy to imagine women will be given them who do not have access to removal once they leave the camp. Displaced populations, especially in situations of conflict, are unlikely to return home to well-functioning and accessible health services with staff trained in implant and IUD removal. These are hard enough to come by in normal conditions.

NGO critics believe the manual has been intentionally hijacked by US population interests. The job of the UNHCR’s Reproductive Health Officer, Kate Burns, is funded by the US Agency for International Development (USAID). In a recent article in The Observer (London), Burns portrayed birth rates in the camps as “enormously high.”3 Prior to the drafting of the manual, the Women’s Commission for Refugee Women and Children produced an influential report funded by the Andrew Mellon Foundation, which echoed this view and set the stage for population interventions. It begins with this statement:

For a variety of reasons, women in refugee settings are having extraordinarily high numbers of children. Camp life often creates conditions that unintentionally result in completed fertility rates of near-record levels.4

In fact, there is no systematic research to substantiate this claim. Even the report admits as much and is forced to generalize on the basis of data for only a few countries, anecdotal evidence and dubious “on-the-spot calculations.” Moreover, in situations of famine and food shortages, a not infrequent occurrence in emergency settings, there are typically high child mortality rates and low fertility rates. Clearly, demographic patterns are likely to be highly context-specific and bear thorough investigation rather than alarmist inference.

The report argues that family planning agencies may welcome the chance to extend their programs into refugee settings:

In fact, many family planning program planners in developing countries might find the provision of services to a ‘captive’ refugee population in a well defined geographic area supplied with most of the basic services needed for survival to be a comparatively modest challenge, after facing the logistical, technical and financial problems associated with delivering family planning services in far-flung and isolated rural areas of the world with no existing health infrastructure (p. 17).

This idea of refugees as ‘captive populations’ is particularly worrying, as is the assumption that camps are well-equipped with basic services.

NGO critics are also concerned about the manual’s recommendations for the provision of manual vacuum aspirators to treat the complications of miscarriage and unsafe abortion. They do not oppose the provision of abortion services, but question whether these procedures can be safely performed in the context of limited health facilities in emergency settings. They are particularly worried about the risk of spreading HIV and the complications of sepsis, hemorrhage and uterine perforation. Instead they recommend transport of refugee women to district hospitals for abortion and related procedures. Margaret Fyfe, an aid worker who served as a British government observer during deliberations over the manual, told The Observer:

In the past we’ve rarely done surgical interventions in camps but always referred refugees to the nearest local hospital. Refugee camps are particularly dangerous places. Supervision is critical. Expatriates may leave suddenly if fighting intensifies or funding ceases. These minimally trained workers are then left totally unsupervised and this is where the true danger starts creeping in.

As a result of these concerns, Oxfam and Save the Children in the UK have been pressing for minimum safety standards to be included in the manual. Until recently they have met with resistance, but in the wake of the Observer article, there is hope that UNHCR may be willing to negotiate. Similar controversy surrounds World Health Organization guidelines for reproductive health during conflict and displacement.5

Unfortunately, the anti-abortion movement has also become a player, attacking the UN agencies involved for supporting abortion.6 The fear is that once again women’s health may become a political football tossed between population control interests on the one hand and anti-abortion forces on the other.

There are many positive recommendations in the UNHCR/UNFPA manual and WHO guidelines-few would argue that there is not a need for appropriate reproductive health interventions in refugee settings. Condom distribution is a case in point. But the situation needs to be closely monitored in order to ensure that the interventions:

1) do not become a vehicle for population control;
2) and occur in cooperation with, and not at the expense of, other aspects of primary care.

And we need to ask the larger question of why refugee women themselves have been so little consulted about their needs—why is there such a lack of informed research?7

1 UNHCR/UNFPA, Reproductive Health in Refugee Settings: An Inter-Agency Field Manual, 1995.
2 Statement by health workers from Oxfam (UK/Ireland), Concern (Worldwide), CAFOD, Trocaire, Tear Fund, Save the Children (UK), MERLIN, GOAL, Children Aid Direct — still to be ratified by the agencies.
3 Melanie Phillips, “The UN says it wants safe birth control for refugees — but risks killing the very women it aims to help,” The Observer, 5 April 1998, p. 10.
4 Deirdre Wulf, Refugee Women and Reproductive Health Care: Reassessing Priorities, Women’s Commission for Refugee Women and Children c/o International Rescue Committee, New York, June 1994, p. 3.
5 World Health Organization, Reproductive Health Services During Conflict and Displacement: Guide for Program Managers, draft, 1997.
6 Statement of Representative Christopher H. Smith, Chairman, Subcommittee on International Operations and Human Rights, United States House of Representatives.
7 A related issue is how refugees are being portrayed as destroyers of local environments in policy circles, including UNHCR, despite lack of systematic evidence and analysis.