Reply to comment

Throughout college, I chose all of my courses for one of three reasons: I need to take them for a requirement, the topic looks interesting, or the topic is something that I am already very interested in.  “Politics of Population” fell into the latter category for me. I was already fascinated by population policy within the context of public health, and was excited to further explore the subject by also looking at it from the perspective of environmental concerns and economics.  The class raised many questions that linger every time I deal with issues of reproductive health and justice within work, volunteer, or academic settings.  Is it ever ok to exert pressure on a woman, even if it is in the name of peace or democracy?  Can social justice sometimes be used as a mask to cover much more pernicious motives?  When is it ok for countries from the Global North to dictate policy in the Global South – or is it always a form of neocolonialism?

One of the most interesting projects I undertook was looking at Vietnam’s population policy over time for one of my papers.  It (re)taught me the important lesson that no sources can be trusted without some level of scrutiny.  I found myself looking at old US policy documents, Southern and Northern Vietnam census data, and outside reports – and not knowing who to believe.  It can sometimes seem so easy to pinpoint the “right” side of conflict, that it is easy to forget that even seemingly just sources can have serious inaccuracies.  I took the course at the same time I was writing my thesis, and am glad that I had the extra reminder to remember that all stories can be told from multiple perspectives, and all data can hold bias.  This is especially true with issues of population health, because what it is good for the aggregate (smaller population), can lead to very serious injustices against the individual (forced sterilization or birth control).  I found myself having small spurts of sympathy towards policies that had always repulsed me, such as Ceausescu’s forced birth program, or China’s one child policy, and felt disturbed by my reaction.  But what I think I was realizing is that with something as sensitive as population control and reproductive health – at both the societal and individual level – it is important to remember that questions of right and wrong are not black and white.

For one of my papers I wrote about the US’s involvement with Indonesia’s population control program from the 1960s-1980s, a seemingly benign policy that would help fuel the country’s economic growth.  But, as with many other Peace, Conflict, and Social Justice Studies classes, I had to look at US hegemony from a critical lens.  My paper is below: 

            Family planning programs were a major part of population control initiatives for many national governments throughout the second half of the twentieth century.  Although the rise of family planning programs as an economic development tool was a fascinating public health shift throughout the world, in many places the genesis of family planning programs had even deeper political roots.  Indonesia is one of the countries were population control initiatives were prompted by the United States government and U.S. philanthropic organizations, who often acted as adjuncts of U.S. policy goals, such as the Ford Foundation, Population Council, and Rockefeller Foundation.  Indonesia’s family planning, or keluarga berencana (KB) programs were highly influential in the country’s public health and social transformation, but an analysis into the programs goals shows that they were mainly intended to shape Indonesia’s economic and political development.  The idea of controlling women’s reproduction as a way of reducing fertility rates to replacement levels also shaped the programs themselves, and continue to have an effect on the way family planning and sexual health is understood in Indonesia. 

            What is perhaps most shocking about the trajectory of family planning in Indonesia is the way in which contraception underwent an abrupt shift from taboo and foreign to a part of regular vernacular in only a decade.  From the 1920s to 1940s, while Indonesia was still under Dutch rule, women’s health advocates had tried to get colonial politicians to focus on the country’s problem of high maternal mortality, which many epidemiologists linked to the early start and rapid pace of childbearing.  The Dutch administration, however, balked at the idea of allowing contraception, condemning the idea as being “neo-Malthusian,” and dismissed the idea that uncontrolled fertility contributed to maternal death rates (Hull 2005:3).  Contraception continued to be banned during the Japanese Occupation throughout World War II, and when Indonesia gained independence in 1945, women continued to not have any autonomy over their reproductive health.  Sukarno, Indonesia’s first president, ran a regime based on socialist and nationalist principles, which resulted in very pro-natalist policies.  Sukarno believed that the country’s intense poverty could be fixed through economic planning and the utilization of a large labor force, which required population growth (Holzner 2005:100).  India and China both established family planning programs in 1953, and while other developing countries began to follow their lead, Sukarno refused to do the same.  Interestingly, he did not seem to have a problem with contraception, or even sterilization, as it related to women’s health (unlike some vocal Muslim clerics from the same era) but rather was concerned about the secondary effect of slowing population growth (Holzner 2005).

            Around this same time, the United States started agitating for population control programs in the country, and began to provide funding for Indonesian researchers and doctors to come to the United States and learn about family planning techniques.  Sukarno’s continued resistance to these family planning initiatives was therefore not solely about being against population control, but also a reluctance to accept policy advice from foreigners, particularly the United States.  Throughout the 1950s, the United States Agency for International Development (USAID) sponsored dozens of Indonesian fellows to come to the Margaret Sanger Research Bureau in New York City, and the Ford Foundation provided additional funds for Indonesian academics and intellectuals to study about reproductive health in the U.S. (Hull 2005:7-9).  Although the pioneers of the American birth control movement were arguably concerned about women’s health, safety, and autonomy, the impetus behind the United States providing this funding was because they saw it as an important part of their Cold War jockeying (Hull 2007:236).  Followers of Malthus saw increasing population sizes as being a threat to economic development, and felt that instituting family planning programs could help reduce poverty levels, and thus stave off communist uprisings.

            Sukarno’s power did not last long however, and in 1965, his regime fell following a coup d'état by then military general Suharto, largely orchestrated by the CIA, who were very concerned about Indonesia’s growing communist party, the P.K.I.  In the year that followed, CIA-backed political massacres occurred across the country, and millions of communists were killed, with many more put into prison camps or simply “disappearing” (Wines 1990).  Following this intensely violent period, Suharto marked a deep change from his successor, and sought to build ties with the international community, including strengthening Indonesia’s relationship with the United States.  He soon found himself under increasing pressure from U.S. technocrats and donors to sign the UN-sponsored “World Leaders’ Declaration on Population” in December, 1967.  Although  there is little evidence that Suharto independently considered population control to be a pressing policy initiative, he was eager to ensure international funding and investment in Indonesia, and declared in 1967 that family planning would receive the “aid, support and protection of the Government” (Utomo et al 2006:73).

            Shortly thereafter, an arrangement was made with Merck & Co., a U.S.-based pharmaceutical company, to import the raw materials needed to manufacture contraceptive pills in Indonesia.  By 1968, the central government’s Family Planning Institute (Lembaga Keluarga Berencana Nasional – LKBN) was established, and began to implement a program to provide contraceptives to the most populated islands in Indonesia.  USAID and the World Bank provided the majority of the funding for LKBN, and within a year had helped the Indonesian Ministry of Health set up 215 clinics across Java and Bali (Sciortino 1998:33).  The initiation of the Institute was also largely influenced by the Ford Foundation, who had first arrived in Indonesia in the 1950s with the desire to fight communism and anti-Americanism through higher education initiatives and other programs, and build a “modernizing elite” with American world views (O’Connor and Griffiths 2005:185).  As Hull, explains, Ford Foundation advisors, as well as other U.S. organizations such as the Population Council “played a catalytic role” in developing LKBN, not only because of their direct monetary support, but also through organizing family planning conferences, conducting research on the feasibility of instituting a family planning program in a poor, Muslim country, and giving policy advice (2005:18-19). 

            In 1970, LKBN was replaced by the “Coordinating Agency for Population and Family Planning” (Badan Kependudukan dan Keluarga Berencana Nasional – BKKBN), and the emphasis on “coordinating” in the title was seen by many women’s health and other community-based organizations as being highly ironic.  Since the beginning of the Indonesian government’s foray into providing family planning services, women’s advocates had been asking for the opportunity to coordinate with the Ministry of Health, to insure that women’s reproductive health concerns were being addressed, but were met with resistance (Sciortino 1998:35). Moreover, under the New Order (the term given to Suharto’s regime), all government workers and civil servants were expected to fit certain ideological and political standards and align themselves with Suharto’s Golkar party.  As Adioetomo explains, even within the BKKBN, “anyone suspected of leftist tendencies was likely to be expelled from the bureaucracy, and could be arrested” (2005:124).  The people who did remain in BKKBN, particularly those at the highest rungs of the organization, were not only loyal to Golkar but also had ties to the U.S. government.  In fact, the head of BKKBN, Suwardjono Surjaningrat, who was appointed at the organization’s establishment in 1970, had been one of the doctors given a grant by USAID to study at the Margaret Sanger Institute in the early 1960s (Hull 2005:35). 

            BKKBN began its mission of providing family planning services on only Java and Bali, the country’s two most overpopulated regions, with no programs for Indonesia’s other 8,000 inhabited islands.  This move was justified by the fact that the program was entirely focused on population control, and thus had to give priority in areas where fertility levels had to be decreased most immediately (Surjaningrat et al 1980).  As Hull argues, such a decision “would have been ludicrous if made concerning a program designed to provide contraception for purposes of women’s welfare and reproductive health…the focus on population control had completely overshadowed any health-based arguments, and there was little opposition to the division of the country for family planning” (Hull 2005:27-28).  It is impossible to argue that this direction was entirely due to maneuvering by U.S. government agencies and organizations, but it is clear that the focus on population control for political purposes was an imported concept.  Many Indonesian academics had begun to read books such as Paul Erlich’s Population Bomb, which was published in 1968, but the economics profession understood the utility of family planning in terms of resource conflicts and economic development, not avoiding communist sentiment (Hull 2005:15).

            Although BKKBN initially began as a government bureau that mainly operated clinics and provided community education on the benefits of family planning, they soon began to more aggressively encourage women of childbearing age to use contraception or undergo sterilization surgery. As Prata writes

In collaboration with a group of young experts working for USAID, BKKBN developed a series of projects that turned the network of clinics from passive providers into very active and target-oriented outreach operations.  There are many claims for the invention         of the strategy used by the BKKBN.  Some see it as a Western-designed approach to enlist villages in a grander struggle, something akin to the way the US military undertook village-development programs in Vietnam as part of the effort to “win hearts and minds” (Prata 2006:22).

The tactics used included sending “family planning fieldworkers” to bring both information and actual contraceptives door-to-door, to women’s homes (Molyneaux 2000:63).  These fieldworkers also set up village contraception-distribution posts throughout villages, and organized “drives,” where they would try to identify all couples who had not yet joined the program, and press them to come in large groups to have IUDs inserted (Molyneaux 2000:66) The huge success in these tactics was largely due to the central government giving prizes and other recognition to the locales that got the most women to start using contraception.  The BKKBN was hierarchical, with field workers at the lowest rung, who reported to fieldworker supervisors responsible for subdistricts, who reported to BKKBN district heads, who in turn reported to provincial chiefs, who were directly subordinate to the central headquarters.  Because there were positive incentives for workers throughout hierarchy, fieldworkers were under tremendous pressure to recruit.  Throughout Bali and Java, BKKBN workers began to talk about recruiting “akseptors,” or women who joined the program, indicating how deeply entrenched USAID terminology was at all levels of the BKKBN (Hull 2005:29-31).

            Eventually, the programs expanded to Sumatra, Sulawesi, and West Nusa Tenggara, and began to popularize the slogan “Two Is Enough,” referring to the suggested limit of having only two children per couple.  Local governments continued to be given strong incentives to ensure the success of the program, and were frequently told that their promotions, or even their jobs, depended on convincing enough women to start using contraceptives (Holzner 2005).  The United States continued to play an active role in BKKBN activities, and particularly helped to fund research to assess the true impact of BKKBN programs.  Large surveys were sponsored by USAID, and the US also provided technical assistance for Indonesia’s first census, which was taken in 1971 (Utomo 2005: 115).  The Ford Foundation also felt that “Indonesia would need strong academic organizations to oversee the impact of such a huge social experiment,” and began the Population Research Training Program, which funded Indonesian academics who wanted to pursue population research and training (Shiffman 2004).

            In fact, by the late 1970s, BKKBN’s access to foreign assistance became a cause of widespread concern, both among other government agencies, who were jealous of the bureau’s relative wealth, and among Indonesian NGOs and private donors who were upset about the nature and direction of Indonesia’s family planning programs (Utomo et al 2006).  Many critics argued that BKKBN’s programs were not truly voluntary, and that the fact that family planning was framed as a “campaign” took away from the real reproductive health concerns of the women enrolled.  One of the most dramatic indications of this was during a highly publicized fight outside the Jakarta USAID mission, involving an embassy driver whose wife had an IUD inserted without her knowledge or consent (Hull 2005:36).  Other public health experts were upset that the BKKBN had no confidentiality rules, and even put symbols on all houses in certain villages to indicate what kind of contraception women were using.  Finally, there were concerns about the safety of inserting IUDs or providing sterilization operations in mobile clinics (which were often tents), and the high rate of infection amongst women who were provided family planning services (Utomo et al 2006). 

            Singarimbun argues that the target system encouraged by USAID technical advisors and adopted by BKKBN actually weakened the program’s ability to effectively provide a public service.  He explains that because family planning workers received such strong incentives and sanctions, the medical and needs of women became less important than the bureaucratic goals laid out in Jakarta (Singarimbun 1997).  In fact, in the 1980s, many BKKBN workers began using the phrase “ABS” (Asal Bapak Senang, or Keeping the Boss Happy), to describe the program’s goals.  Achieving these objectives was often done by involving the military, to help make sure that women “accepted” the proposed method of contraception.  Moreover, because the programs were so large scale (20,000 women were being treated daily), with such tight targets, there was not even the time available to truly give every women being treated sufficient attention (Singarimbun 1997). 

            In the early 1980s, a report put out by the USAID-funded Futures Group, began to have a strong influence on “the integration of a target orientation in service delivery and the promotion of voluntary sterilization as a preferred method of contraception” (Bertrand et al 1996:79).  Previously, oral contraceptives had been a major focus of BKKBN programs – largely due to the partnership the Indonesian government had with Merck – but after the report came out, BKKBN’s policies shifted as well.  The organization created the acronym MKET, which stood “for Selected Effective Contraception Methods,” and included IUDs, implants, and sterilization.  Interestingly, one area where the U.S. was able to have very little influence was in getting men to agree to undergo sterilization procedures, even though it was a contraceptive method highly lauded by the USAID-funded study.  Women, however, were highly “encouraged” to switch to MKET forms of contraception, especially the injectable contraceptive Depo-Provera.  While only four percent of women used Depo Provera in 1981, by 1987, this had grown to 37 percent of women, for a of 1.8 million new injection users (Adioetomo 2005:140).

            Throughout the 1980s, USAID and the World Bank continued to concentrated on reducing the rate of population growth, but organizations like the Ford Foundation and the Population Council started to express concerns that focusing so narrowly on population control, without addressing larger social welfare issues, was problematic.  By the late 1980s, the Ford Foundation had already shifted its focus to maternal health, infectious disease, and malnutrition, arguing that families with healthy children would be less inclined to continue reproducing (Hull 2005:42.  Eventually, BKKBN itself began to focus on “family welfare” as part of its mission, and slowly adopted programs exclusively centered on child and maternal health.  By the 1990s, BKKBN had developed “integrated health posts,” which were village clinics that, in addition to providing contraception, also gave vaccines, additional food to malnourished children, and regular health checkups (Hull 2005:43-44).  Suharto’s regime also began to distance himself from the goals of USAID, and in 1994, the director of BKKBN was quoted in a major Jakarta newspaper as saying that “Western concepts of individual rights for women, such as the right to their own bodies, or to decide on children, are inapplicable in Indonesia where the wider family makes the decisions” (Hull 2005:54).  Suharto eventually fell from power in 1998, and as part of the country’s democratization process all government agencies decentralized, giving autonomy to all of the country’s regional governments to operate as they please.  Today, therefore, while BKKBN still exists across the country, there is no unified mission, and each province runs their family planning programming very differently (Kurniawan et al 2010). 

            Nonetheless, the BKKBN that operated as a project of USAID and U.S.-based philanthropic organizations continues to have a major effect on how family planning, contraception, and reproductive health is understood in the country.  Because there was such a strong campaign to define contraception in terms of limiting population growth for the sake of the economy, it has been difficult for the country to stem its growing HIV/AIDS epidemic.  Around the same time that BKKBN most intensely advocated IUDs and birth control pills in the 1970s, condom use fell to only 8 percent.  By the mid-1980s, and until today, condom usage fell to only one percent (Hull 2005:32).  Ironically, the same organizations who helped to instill the message that family planning has no relation to health, are now some of the biggest donors for HIV/AIDS prevention and treatment efforts in Indonesia.  In the 1990s, the Ford Foundation created the “National Epidemiology Network” to research HIV education and prevention methods, and USAID is one of the main sources of funding for HIV counseling, testing, and treatment centers in Indonesia (Hull 2005:42-45). 

            Although public health and family planning goals and pressing concerns in Indonesia are today very different than they were half a century ago, it is still important to understand their trajectory.  The involvement of the United States, both directly and indirectly, made a major impact throughout the Suharto regime, and continues to have reverberating effects.  By providing funds for doctors and scholars to study in the U.S., giving policy advice, directly funding government agencies, and undertaking research projects, USAID and organizations like the Ford Foundation, the Population Council, and the Rockefeller Foundation all framed contraceptive services as being a way to reduce population levels, increase economic development, and in turn stave of communism.  The effectiveness and morality of these goals are debatable, but what is clear is that contraception was not widely understood as a public health issue in Indonesia until the 1990s.  Even today, with growing HIV/AIDS and Hepatitis B and C crises, it is difficult to change perceptions about family planning.  It is unfair to cast all US public and private foreign donors as harmful or problematic, but the legacy of family planning initiatives in Indonesia stand as a stark reminder of the unintended consequences of using aid as a way of furthering U.S. policy initiatives. 

Works Cited

Adioetomo, Sri Moertiningsih. “Women’s Lives: Fifter Years of Change and Continuity." In Hull, Terence H., ed., People, Population, and Policy in Indonesia. Singapore: Institute of Southeast Asian Studies, 2005. 71-125.

Bertrand, Jane T., Robert J. Magnani, and Naomi Rutenberg. "Evaluating Family Planning Programs." Knowledge For Health. archive.k4health.org/system/files/Evaluating%20Family%20Planning%20Programs%20with%20Adaptations%20for%20Reproductive%20Health.pdf (accessed May 8, 2012).

Holzner, Brigitte. "Two Is Enough: Family Planning in Indonesia under the New Order 1968-1998." SOJOURN: Journal of Social Issues in Southeast Asia 21, no. 1 (2005).

Hull, Terence H. "Formative Years of Family Planning in Indonesia." In Robinson, Warren C., and John A. Ross, ed., The Global Family Planning Revolution: Three Decades of Population Policies and Programs. Washington, D.C.: World Bank, 2007. 235-257.

Hull, Terence H. "From Family Planning to Reproductive Health Care." In Hull, Terence H., ed., People, Population, and Policy in Indonesia. Singapore: Institute of Southeast Asian Studies, 2005. 1-69.

Kurniawan, Ukik Kusuma, Hadi Pratomo, and Adang Bachtiar. "Performance in The Indonesian Family Planning in The Era of Decentralization." Kesmas: The National Journal of Public Health 5, no. 1 (2010). http://indonesia.digitaljournals.org/index.php/KESMAS/article/view/127 (accessed May 9, 2012).

Molyneaux, John W. "The Impact of Targeted Family Planning Programs in Indonesia." Population and Development Review 26 (2000): 61-85.

O'Conner, Brendan, and Martin Griffiths. The Rise of Anti-Americanism. New York: Routledge, 2005.

Prata, Ndola. "Assistance to International Family Planning Programs." U.C. Davis Journal of International Law & Policy 13 (2006): 18-35.

Sciortino, Rosalia. "The Challenge of Addressing Gender in Reproductive Health Programmes: Examples from Indonesia." Reproductive Health Matters 6, no. 11 (1998): 33-44.

Shiffman, Jeremy . "Political Management in the Indonesian Family Planning Program." International Family Planning Perspectives 30, no. 1 (2004). http://www.guttmacher.org/pubs/journals/3002704.html (accessed May 8, 2012).

Singarimbun , Masri. "Population Studies." International Institute for Asian Studies. http://www.iias.nl/iiasn/16/general/gen4.html (accessed May 8, 2012).

Surjaningrat, Suwardjono, R. Henry Pardoko, Peter Patta Sumbung, and M. Soedarmadi. "Indonesia." Studies in Family Planning 11, no. 11 (1980): 320-324.

Utomo, Iwu Dwisetyani, Syahmida S. Arsyad, and Eddy Nurul Hasmi. "Village Family Planning Volunteers in Indonesia: Their Role in the Family Planning Programme." Reproductive Health Matters 14, no. 27 (2006): 72-82.

Utomo, Iwu Dwisetyani. “Reshaping Populations." In Hull, Terence H., ed., People, Population, and Policy in Indonesia. Singapore: Institute of Southeast Asian Studies, 2005. 126-169.

Wines, Michael. "C.I.A. Tie Asserted in Indonesia Purge." The New York Times. http://www.nytimes.com/1990/07/12/world/cia-tie-asserted-in-indonesia-purge.html?pagewanted=all&src=pm (accessed May 8, 2012).