Norplant and AIDS: The Family Planning and Standard Control Connection
HOW IS IT POSSIBLE THAT IN THE AGE OF AIDS a tribal woman in Thailand's northern region, where that nation's raging epidemic is at its worst, can have Norplant surgically embedded in her arm without also being given condoms and instruction about how to protect herself from HIV infection and other STDs? Sadly, this case of contraception divorced from STD prevention is not unique. For example, in the early 1990s Tanzania's national family planning program, with advice and support from the US Agency for International Development (USAID) and the UN Fund for Population Activities (UNFPA), emphasized long-term contraceptives rather than condoms (Brooke Grundfest Schoepf, personal communication).
Thailand has been hailed as a "success story" in population control; in just under three decades the nation's fertility has been more than halved to among the lowest levels in the world. Since the government's push to reduce birth rates began in the 1960s, family planning services have been primarily viewed as a matter of maternal health and implemented through natal clinics and midwives, thereby largely ignoring men as well as unmarried and infertile women. Official STD control, on the other hand, has historically been linked to prostitution, with women seen as vectors of disease transmission. To the Ministry of Public Health's bureaucratic divisions for family planning and for STD control yet another separate division for AIDS has recently been added, as if AIDS were not itself an STD.
Whereas in nearby Indonesia Norplant, is administered by "family planning personnel, accompanied by soldiers" (p. 99),1 in Thailand coercion takes a more subtle form, hidden in the limited and/or hierarchical "choices" presented to family planning clients. The Planned Parenthood Association of Thailand targets the tribal minorities of the nation's northern periphery for Norplant (Patricia V. Symonds, personal communication). WorldAIDS (6 November 1994, p. 8) reports that in the family planning unit of one of the largest public hospitals in the capital, Bangkok, "AIDS prevention is only mentioned at the final group counselling when the providers discuss the last choice of contraception-the condom"-and that "some family planners are unwilling to recommend condom use at all."
How is the promotion of Norplant connected with AIDS? Since women who use long-term contraception have no need for condoms to prevent pregnancy, condoms use must be motivated solely by the aim to prevent HIV infection and other STDs. But women are not likely to receive STD prevention information from family planning programs that do not consider STD control to be within their purview. Moreover, the link found in Thailand and elsewhere between STD control and prostitution discourages the practice of STD prevention outside the context of the commercial sex industry, yet having an STD increases the efficacy of HIV transmission 5-20 times. Thus the lack of connection between family planning and STD control may be seen as linked in multiple and complex ways to the spread of HIV. In addition, the surgical procedure to insert Norplant itself poses the threat of HIV transmission if not practiced in aseptic conditions. "Reuse of disposable syringes and use of unsterilized instruments" have already been documented for Indonesia (p. 99) and may also occur elsewhere. Frequent bleeding, a "common side effect" of Norplant (p. 118), may increase a woman's vulnerability to AIDS because intercourse during menstrual bleeding has been identified as a possible risk factor for HIV infection. Finally, those who promote Norplant have not taken into consideration the fact that as the AIDS pandemic intensifies, doctors and nurses will become increasingly unwilling to perform surgical interventions for fear of encountering HIV-infected blood. In the future will medical personnel be willing to remove the Norplant they implant in women today?
The Cairo document calls for an inclusive concept of women's reproductive health, encompassing family planning, the prevention and treatment of STDs, and reproductive cum sexual health. Yet the tribal woman in northern Thailand who was given Norplant but no condoms testifies to the persistence of the ideological and institutional separation of family planning and STD control, a separation found not only in Thailand but elsewhere, including the US. While the May version of the Draft Platform for Action for the UN Fourth World Conference on Women, to be held in Beijing, China, this September, focuses on both sexual and reproductive health and endorses "accessible, available, and affordable high quality primary health care services including [sexual and reproductive health care as well as family planning information and services]" (Strategic objective C.1.107(e), brackets in the original), it falls short of explicitly calling for the integration of family planning and STD control. Without that connection AIDS prevention in Thailand and around the globe is crippled.
1. This and other page references are to Population Policies Reconsidered: Health, Empowerment, and Rights (Gita Sen, Adrienne Germain, and Lincoln Chen, eds., Harvard Series on Population and International Health, 1994).
Cornelia Ann Kammerer, an anthropologist who has done fieldwork among the Akha tribal minority in Thailand, is a Resident Scholar in Brandeis University's Women's Studies Program.