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Winning the Trojan War; what ultra-Catholic third worlders can teach America about contraception.

Blanca Ruth Rodriguez's barrio lives, literally and figuratively, on garbage. Most of the people in her neighborhood, Comuneros, get up at dawn to ride bicycle carts to a nearby garbage dump. They bring heaps of refuse back to their wood and cardboard houses where they pick them over, looking for items to sell or use. Some rooms are piled high with cartons, bags, strips of plastic, and rusted metal; many floors are thick with slime. Today, as it rains, garbage streams flood the shacks.

The nearest health clinic for the 197 families of Comuneros is a bus ride away; patients must bring their own syringes and gloves. No one boils drinking water. Children have constant diarrhea. Yet outside the small store that Blanca Ruth and her father manage is a sign: "Information Post: Family Planning," and the green flag of Profamilia. Amid the bread, eggs, and cigarettes inside is a display of condoms and pills, with brochures explaining how to use them. Another condoms display bears a banner: "Nothing can cure AIDS, but this can prevent it."

"I sell about 25 cycles of pills a month, and God knows how many condoms," says Blanca Ruth, who is 25 and has two children. "But most women here already have their families and preferred to have their tubes tied. Profamilia came to pick them up, took them into the clinic, did the operations, and brought them back the same day."

Next door in a day care center, 15 wet and dirty kids are jammed into a small, smelly room. One baby swings in a hammock, another perches atop a roll of cardboard. I conduct a poll: Most have one or two brothers and sisters. Blanca Ruth beams. "Here, we are planificadas," she says-we use family planning.

Twenty-six years ago, when Dr. Fernando Tamayo, gynecologist to some of Colombia's most prominent women, contemplated establishing a family planning center to serve the poor, few nations in the world seemed less hospitable to such an enterprise. While Colombia had one of the highest birthrates in the world, the Catholic Church was more influential and conservative there than anywhere else on the continent. The left, radical and armed, saw contraception as "imperialist genocide." Most Colombian men, hopelessly machista, thought contraception would encourage their wives to cheat; most Colombian women, more machista still, deferred to their men. Even the medical establishment considered family planning a sin.

Today in Latin America, only Cuba, Uruguay, and Chile have significantly lower birthrates than Colombia. In 1965 women had an average of more than 7 children; today the average is 2.8-%ne of the fastest declines anywhere. The infant mortality rate fell from 80 per thousand live births in 1965 to 27 today. Colombian women now have fewer deaths in childbirth and fewer deaths from abortion (which is still illegal); babies are heavier and healthier, more likely to receive a doctor's attention, and more wanted, since 70 percent of all couples of childbearing age use contraception. These days, Colombian women assume that they can control a part of their lives they used to accept as lo que Dios me mande-whatever God sends me-a development of truly revolutionary implications. Estoy planificada, or "I am planned," has become part of the Colombian vocabulary.

Profamilia, now the second largest private family planning organization in the world after Planned Parenthood Federation of America, is the reason for these public health successes. "It's a model," says Arthur Danart, a population expert at the U.S. Agency for International Development (AID), one of Profamilia's major funders. "It's one of the most successful programs the world has ever seen."

"You can go to the most remote regions of the country, where there is no water and no electricity, and you see Profamilia's little green flag," says Amparo Sanchez, who works at Women's House, a Bogota shelter. Profamilia's pilot clinic in the same city-one of 48 scattered across the country-is the world's largest. By 7:30 a.m., the clean, cheery building is packed with women (and a few men) waiting for counseling, gynecological exams, birth control, pediatric consultations, or legal advice at modest prices. Colorful posters hang on the green and white walls: "A Real Man Doesn't Go Around Sowing Children in the World!"

Colombia still lacks the resources to solve basic social, economic, and ecological problems. But Colombians shudder to imagine the extent of those problems had the country not avoided at least four million unwanted births over the past 25 years, the vast majority in families too poor to care for their children. While conservatives lobby to defeat programs like these around the world, one need only look at India and Bangladesh to see why Profamilia matters. Its success against the odds makes it a lesson for organizers and policymakers not just in the Third World, but everywhere. Contraceptives calling

In 1965, Dr. Fernando Tamayo routinely provided contraceptives to the wives and daughters of presidents and cabinet ministers he saw in his private practice. Yet at the state-run hospital for the poor where he also worked, the circumstances were painfully different. "I saw mothers curse their newborn children-they couldn't afford to take care of them," Tamayo said. "But I wasn't allowed to prescribe contraception at the hospital; it was considered immoral."

Some of his wealthy patients told Tamayo that their cooks and maids were desperate to have IUDs or diaphragms, and Tamayo began to stay after hours to help them. In September 1965 he hired another doctor, and the pair set aside two days each week to provide inexpensive contraception to poor patients. By the next year, they had formed a nonprofit corporation to train other doctors, received a grant from the International Planned Parenthood Federation (IPPF), and were seeing more than 800 patients a month.

Colombia did not react warmly to Tamayo's efforts. Although he had political friends eager to assure that their wives' gynecologist wouldn't lose his license, Tamayo was nearly kicked out of the medical association. And while the government was worried that population growth would hamstring Colombia's development, it was unwilling to take on the political and financial challenge of promoting contraception. Although the political left, suspicious of Profamilia's funding from such gringo sources as U.S. AID, was hostile, the government's major worry was the Catholic Church: not the parish priests and nuns (many of whom were openly enthusiastic), but los perfumados-the perfumed ones-in the singularly conservative Colombian hierarchy. Yet among the poor and middle classes, there was an indisputable need for contraception, Catholicism or no. As more women entered the workforce and families gravitated to the cities, children were no longer an economic asset, but a liability.

Tamayo carefully positioned himself to navigate Colombia's political shoals. In the first years, he assembled a governing board of prominent business, political, and medical leaders-a board that might establish contraception as a legitimate public good and sustain the support of foreign funders. "It was the golden age," Tamayo said. "The IPPF and AID had plenty of money, and there were only a few serious organizations that could use it." His was one of them. And before long, the Colombian government decided it was happy to have a private organization do the work.

From the beginning, Tamayo and his staff realized that the women who needed access to contraception most were those who were the least informed. He decided to advertise Profamilia's services on the radio, the one medium that reaches all Colombians. His counterparts in other countries were outraged. Lindsay Stewart of the IPPF recalled a 1969 meeting of IPPF's Latin American affiliates: "One director was banging his shoe on the table like Khrushchev, yelling about Profamilia's radio ads: We can't sell family planning like Coca-Cola!' . . . Now, of course, everyone does it."

Following up on the radio appeals, Profamilia instructors appeared in factories, union halls, and schools, using everything from filmstrips to puppet shows to promote contraception. Doctors traveled in vans to remote villages to perform sterilizations. (After a medical brigade was arrested at an army outpost and held for two days, the practice changed; now vans pick up women who want the operation and take them to a clinic.) Most important, however, Profamilia made birth control widely available by selling condoms and pills wholesale to thousands of small stores and pharmacies. Instructors-Avon ladies of contraception-knocked on doors in every community.

"They almost lynched me at an IPPF meeting in 1972," remembered Tamayo. "How could I give out pills without a complete medical exam? I kept repeating that it's much riskier to have children than to take the pill, that half a million women die each year in the world due to complications from pregnancy. Now that we have low-dose pills, almost everyone in Latin America is doing exactly what we do."

Among the initial skeptics, however, were Colombian women themselves. "Women realized that they couldn't feed more children," remembered Mercedes Martinez, an instructor who worked in the rural province of Cundinamarca. "But they'd say, 'My husband doesn't let me plan. He thinks I'll prostitute myself.' I'd explain that you can take pills or have an IUD inserted without your husband finding out."

And then there was religion. "They'd say, 'God sends children, and we shouldn't interfere,'" Martinez said. "I'd say: 'God also sends scientific methods so we can plan our families.'" One by one, city by city, Profamilia began to convince.

The work of persuasion is by nature delicate, and Profamilia's zeal may have at times carried it over the line. Women's House's Amparo Sanchez said that in the early seventies, Profamilia worked with the government in a program to provide milk and other nourishment to new mothers-as long as they used contraception. "That was hitting women at their most vulnerable moment," Sanchez said. But over the years, Profamilia's tactics-and sheer ubiquity-have made it a respected and fundamental part of Colombian life. In 1986, when Pope John Paul II-well known for his opposition to contraception-visited Colombia, he did not once in 27 speeches mention family planning. This time, Profamilia was the powerful institution to be appeased.

When Profamilia questioned the conventional wisdom-say, "Catholics don't want contraceptives"-it often ended up creating a new one. It was the first organization in Latin America to sell contraceptives over the counter, the first to use paramedics for such procedures as inserting IUDs, the first to offer voluntary vasectomies and tubal ligations, and the first to depend on local volunteers like Blanca Ruth.

Like many Profamilia volunteers, Blanca Ruth and her father distribute birth control from their store. Once a month, Mercedes Martinez stops in to collect records, answer questions, and replenish the stock. "A lot of girls, even 13 and 14, want information but don't want to go downtown to visit a doctor, so they come to me," Blanca Ruth says. "They're shy! People die of embarrassment talking about sex-I tell them it's just normal. I get them to sign up for pap smears. I answer their questions, and they buy condoms and pills and antiparasite medicine. We even have some men who decided to have vasectomies.... They don't want to work hard enough to feed more mouths."

When Profamilia has a new film-AIDS and parasites are recent topics-someone from Profamilia leaves Blanca Ruth a message at the factory across the street. "Then I go from house to house, telling everyone about the movie," she says. The shack that serves as a cultural hall is always packed.

Profamilia's reliance on local volunteers like Blanca Ruth is not only a smart way to promote contraception and create local women leaders; it's also a management necessity. Funds from international donors are drying up, redirected to Africa and places in Latin America where the need is greater. Now Profamilia raises more than half of its $9 million budget from contraceptive sales and clinic fees in Colombia, using the money to run an increasingly diversified operation.

Today, eight new Profamilia clinics serve only men: A vasectomy costs $5 for those who can't pay more. In high schools there are lectures and counseling sessions about contraception, pregnancy, and AIDS. Legal offices provide lawyers in domestic violence and child support cases. HIV-infected men speak about AIDS in gay bars, and lawyers have gone to brothels to talk about legal rights and AIDS. (Maria Isabel Plata, who founded Profamilia's legal clinic, recalled, "The prostitutes didn't even get up from their beds.") There is even an infertility clinic in Medellin that is noted for performing South America's first in vitro fertilization.

Profamilia's innovations often come from people in the field. The clinics for men were the idea of a director in Cali who noticed that men disliked waiting for an appointment in a clinic full of women. But management's trust in its staff has another, less tangible benefit: It contributes to the organization's crusade spirit-its mistica. "Not everyone can do this," said instructor Mercedes Martinez. "It's a calling." From the door guards who expound on the virtues of contraception to top management, Profamilia's staff shares Martinez's mistica.

While Profamilia's democratic management style is peculiarly gringo, Colombians, as the world has had occasion to note, have a knack for business. Administration costs are below IPPF's average, and expensive new technology is avoided. "If I had just one recommendation for new organizations in this field," said Tamayo, "it's 'run it like a business.' "

"The organization is very self-critical," said Timothy Williams, project analyst at IPPF. "They make managers pay attention to what's going on in the field." Every month, instructors visit distribution posts and talk to clients and volunteers. Hard research supplements the shoe leather. ("The only thing in Colombia anyone has reliable statistics on is sex," said Amparo Sanchez.) For instance, when Profamilia's surveys found that contraception was pervasive enough to obviate door-to-door visits, it dropped the practice. But when research shows that a community's contraceptive use is dropping without those visits, the Avon ladies reappear. Play mistica for me

One test of Profamilia's staying power will be what happens after the 69-year-old Tamayo retires. But the organization's success should offer hope to fellow Latins, Africans, Asians-and Americans. Government and private-sector family planning officials from the Third World, Australia, and Europe have already come to Colombia, studying everything from Profamilia's advertising campaigns to its warehouse management. Yet while they go back inspired and informed, they are not always ready for action.

Why not? Even when the public will is strong, not every country enjoys the harmonic convergence of need, funding, and leadership that made Profamilia happen. Money is short, governments are suspicious, and politics often intervenes. "I just spent four years in east and southern Africa," one family planning expert told me. "There was precious little going on except in Kenya, Zimbabwe, and Botswana. People in Ecuador and Peru are wonderful, courageous, but they are not organized." The key, family planning experts agree, is indigenous, mistica-driven leadership like Profamilia's-with its Fernando Tamayo and a thousand Blanca Ruths.

Blanca Ruth takes me to visit Amelia, a garbage picker in Comuneros with just two upper teeth and an improbable wool beret. Amelia had seven children but only four lived. Now, at 57, she shares a house with two of them, their spouses, and four grandchildren. They never miss a Profamilia film.

Amelia gives me a tour of her house. The beds are in rooms as small as train berths, heaped with filthy sheets. There is one bed for Amelia, one for each couple, one for the four children. A center room serves as bathroom and kitchen. Amelia apologizes for the mess. "I have chickens, cats, and dogs in there," she says. "The dog is about to have puppies."

What?" Blanca Ruth recoils in mock horror. "You don't have her planificada?" The two women break up laughing. Tina Rosenberg is a visiting-fellow at the Overseas Development Council. Her book on violence in Latin America, Children of Cain, is forthcoming from Morrow.
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Author:Rosenberg, Tina
Publication:Washington Monthly
Date:Jul 1, 1991
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