MIDWAY THROUGH HIS CAREER, Christophe Guilmoto stopped counting babies and started counting boys. A French demographer with a mathematician’s love of numbers and an anthropologist’s obsession with detail, he had attended graduate school in Paris in the 1980s, when babies had been the thing. By the time Guilmoto started his PhD, birth rates had started falling around the world, but the populations of many developing nations were still growing, and it was hard to shake the idea that overpopulation was a grave threat. Like many of his contemporaries he concentrated on studying the drop in fertility, searching for clues to what factors proved decisive in lowering a country’s birth rate. He did his dissertation research in Tamil Nadu, where the birth rate had fallen to European levels even as income levels remained low, and as he graduated and started working as a scholar he returned there many times. By 1998 he headed up the South India Fertility Project, a formal effort to catalogue the successes of Tamil Nadu and surrounding states. But over the course of working in the region, he realised demography’s big story had changed. People in India were not simply having fewer children. They were having fewer girls. Population growth had been slowed, in part, by reducing the number of daughters.
Guilmoto’s first inkling that something was wrong came in 1992, when he interviewed village nurses in Tamil Nadu for a short research project. A wiry Frenchman with wide-set eyes rattling off questions in Tamil, he must have cut an odd profile, but when he explained that he wanted to understand the demographic history of the area, the nurses spoke frankly and openly. Several offered up the detail that villagers occasionally killed their daughters shortly after birth. The news shocked him—as a demographer, he was well aware that humans committed infanticide at various points throughout history, but in most cultures the practice had disappeared by the early 20th century—and he made it his private mission to determine just how pervasive daughter
killing was. Later he visited an orphanage, where he found an aging French volunteer who had lived in India so long that she no longer spoke French. In a mixture of Tamil and English, the woman explained that most of the babies abandoned in the area were female. “Look, in the orphanage we have mostly girls,” she said. “What do you think?”
The encounters left a deep impression on Guilmoto, and he thought of them at the turn of the millennium when Indian census figures showed 111 boys born for every 100 girls. At first glance, the experiences of the village nurses and the orphanage worker helped explain the disparity, and indeed many foreign press reports blamed India’s dearth of girls on infanticide and abandonment. Looking into the matter, however, he realised they were only a small part of the story. Outside of the pocket of rural Tamil Nadu where he happened to have done field research, Indians rarely killed infants. “Everybody talked about infanticide because it carried more emotional weight,” he recalls. “But actually it was hardly in existence.” Tamil Nadu was in fact one of the states where girls had a better prospect of survival, while the sex ratio in the wealthier northwest worked out to 126: 126 boys for every 100 girls. The real cause for the gap, Guilmoto quickly learned, was that pregnant women were taking advantage of a cheap and pervasive sex determination technique—ultrasound—and aborting female foetuses.
The link to technology was alarming, for it meant that India’s skewed sex ratio at birth was an outgrowth of economic progress, not backward traditions. And India was hardly alone in recently developing a sex ratio imbalance. As he expanded his focus from fertility rates to sex ratio at birth, Guilmoto found that several other Asian countries exceeded the biological upper limit of 106 boys born for every 100 girls. In the 1980s, South Korea, Taiwan and parts of Singapore registered sex ratios at birth of above 109. China reported a sex ratio at birth of 117 in 2000. (Figures in both China and India later rose to 118 and 112, respectively.) Humans, Guilmoto realised, were engineering what he calls “rampant demographic masculinisation”—a change with potentially grave effects for future generations. “It was very difficult,” he recalled, “not to see it as a revolution.”
FOR DR PUNEET BEDI, the intensive care unit in Apollo Hospital’s maternity ward is a source of both pride and shame. The unit’s technology is among the best in Delhi—among the best, for that matter, in all India. The technology is one of the reasons he chose to take his gynecology practice here. But as a specialist in high-risk births he works hard so that babies can be born, and the fact that the unit’s technology also contributes to India’s skewed sex ratio at birth gnaws at him. Seven out of 10 babies born in the maternity ward, according to Bedi, are male. He delivers those boys knowing many of them are replacements for aborted girls.
He supports abortion for medical reasons, along with early-term abortion obtained after some deliberation. He performs abortions himself. For sex selection, however, he reserves a contempt bordering on fury. To have his work negated by something as trifling as sex preference—by any preference—feels like a targeted insult. “You can choose whether to be a parent,” he says. “But once you choose to be a parent, you cannot choose whether it’s a boy or girl, black or white, tall or short.”
Bedi says sex-selective abortion has caught on in Delhi precisely because it bears the imprint of a scientific advance. “It’s sanitised,” he says. The fact that sex selection is a medical act, he adds, neatly divides the moral burden between two parties: parents tell themselves their doctor knows best, while doctors point to overwhelming patient demand for the procedure. “There is a complete lack of shame on behalf of the parents and doctors who do it.”
A tall, broad-shouldered man with a disarmingly gentle voice, Bedi has an immaculate British accent that hints at years spent studying at King’s College in London. “I am so emotionally involved in the subject,” he says, his voice wavering, “that it’s difficult for me to be very articulate.” Sex selection, he says, is “probably the single most important issue in the next 50 years that this country and China are going to face. If you’re going to wipe out 20 percent of your population, nature is not going to sit by and watch.” But hospitals have little incentive to do anything about the problem, he adds, because maternity wards bring in substantial business. At Apollo, a deluxe delivery suite outfitted with a bathtub, track lighting, a flat screen television and a large window looking out onto landscaped grounds runs to `9000 a night. Although India outlawed foetal sex determination and sex-selective abortion in 1994, the law is poorly enforced, and as sex selection is an easy procedure in high demand, doctors continue to openly perform it. “Almost a third of Indian gynecologists’ income comes from abortion,” Bedi tells me. “Among those who do female foeticide, 90 percent comes from abortion. Who the hell is going to stop it?” He says he makes less money than many Delhi gynecologists simply because he refuses to abort female foetuses. Some of his patients, he says, are “extremely disappointed when I do ultrasounds. They think it’s just a waste of time and money if you don’t even know whether it’s a boy or a girl.”
Indeed, some of India’s top physicians help patients scan for foetal sex. A notorious case in Delhi is that of Mangala Telang, a Harvard-educated physician who is something like a gynecologist to the stars. Telang’s patients range from wealthy foreigners—both the American and British embassies recommend her to citizens living in Delhi—to Bollywood glitterati. In 2007 a pregnant British reporter of South Asian descent sent undercover by the BBC’s Asian Network caught Telang ordering an ultrasound scan for sex determination and assuring the reporter she could recommend an abortionist if the foetus turned out to be female. (Bedi appears in the segment, commenting dryly: “I’m not surprised at all.”) After the show aired, the health ministry suspended Telang’s licence, but at the time of my visit to Delhi she was practising again. The BBC reporter, moreover, found three other doctors in South Delhi willing to identify the sex of her baby. One didn’t even bother to mention that sex selection was illegal—and then, smelling British money, charged the reporter twice the going rate. “When you confront the medical profession, there is a cowardly refusal to accept blame,” Bedi tells me. “They say, ‘We are doctors; it’s a noble profession.’ This is bullshit.” Later he adds: “When it comes to issues like ethics and morality you can have an opinion, but there is a line which you do not cross. Everybody who does it knows it’s unethical. It’s a mass medical crime.”
To this day, in India and elsewhere, activists often point to tradition as the cause of sex-selective abortion. Instead of challenging Asia’s history of population control or bringing entrenched interest groups like the medical lobby to task, these activists launch awareness campaigns directed at changing prejudices and societal mores. Positive reinforcement is a common theme in such campaigns. Daughters are portrayed as loving, intelligent, capable, fun—everything a parent could want in a child. In India, there is the Save the Daughter Campaign, Shakti—An Initiative to Empower the Girl Child, the 50 Million Missing Campaign. There is even a “motorbike campaign against female foeticide”, which involves politicians touring the country on motor scooters to preach the merits of having girls. Organisations lead focus groups in remote villages. They hire television writers to pen soap operas showing women rejoicing over the birth of daughters. They enlist Bollywood stars to film public service announcements. They sponsor playwrights and hold art contests and develop school curricula. An awareness campaign was the reason well-known Indian designers and models took time out from the shows during Delhi’s 2009 Fashion Week to pose with children plucked off the street. “Through fashion,” one celebrity told Thaindian News, “we want to show that young icons of India are stepping forth to support the unborn girl child.” Even Apollo Hospital runs an awareness campaign staffed by employee volunteers at the hospital’s branch in Punjab. As their coworkers stay back to help well-off urbanites abort girls, the volunteers disperse throughout poor villages to preach the merits of daughters.
To Bedi, this approach is infuriating. “If people had a son simply because they want a son, girls would have disappeared from this country one thousand years ago,” he says. The campaigns, he says, are an attempt to pawn off modern-day oppression on intransigent cultural mores. He believes it is time for India to start asking hard questions. What if the indiscriminate elimination of girls is the result of subterfuge—of decisions made not by individual parents thinking only of themselves but by those responding to some larger force? And if the Indian and US governments and leading Western organisations played a role in that subterfuge?
IN THE 1950S, demographers who studied global population trends had reliable statistics for the first time, and the prognosis was not good. Projections released by the UN Population Division in 1951 suggested rapid population growth was on the horizon, particularly in the developing world. These projections helped give rise to population control and family planning programmes around the world, many of them paid for with Western money. In India and Tunisia and Taiwan alike, such programmes were founded on an economic promise: staving off overpopulation is good not only for the planet but also for growth. As the agricultural era gave way to the industrial one, a large family was no longer an asset, and by the mid-20th century wealthier countries were ones in which people had fewer children. US President Lyndon B. Johnson made this link explicit in a speech at a 1965 San Francisco event held to mark the 20th anniversary of the United Nations. “Less than five dollars invested in population control,” Johnson said, “is worth a hundred dollars invested in economic growth.”
It was true that unfettered population growth would almost certainly strain developing countries’ resources and deepen poverty. Privately, however, Western donors worried less about poverty than they did about the global balance of power and specifically about what they believed to be one of poverty’s effects: communism. The population control movement arose at the precise moment that Western powers were losing their grip over Asia, Africa and Latin America. Around the world, colonies were gaining independence, with Cold War tensions replacing imperialism. Many early population activists thus belonged to the US business and political elite. Big names included Hugh Moore, the millionaire inventor of the Dixie Cup; John D Rockefeller III, heir to the Rockefeller family fortune; Lewis Strauss, head of the US Atomic Energy Commission; and Will Clayton, former undersecretary of state. Rising birth rates, as this group saw it, would make countries more susceptible to communism at a time when the US urgently needed allies in Asia and Latin America. “We are not primarily interested in the sociological or humanitarian aspects of birth control,” Moore and Clayton once confided to Rockefeller. “We are interested in the use which communists make of hungry people in their drive to conquer the earth.”
As historian Matthew Connelly details in his book Fatal Misconception, the movement coalesced in 1952, when Rockefeller gathered a group of influential Americans at the Conference on Population Problems in Williamsburg, Virginia. When everyone had arrived at the Williamsburg Inn to discuss the possibility of exporting population control to poor growing countries, economist Isador Lubin voiced their collective fears. They mostly centred on Asian countries which, because of their large, young populations, were prime targets for Western organisations, and particularly on China and India. “Almost everybody who spoke this morning talked about India,” Lubin said. “What is there about India that makes this situation so acute? I think unconsciously we are scared, and I think we have a right to be.”
On the heels of the meeting, Rockefeller founded the Population Council. Moore went on to found the Population Crisis Committee. These two organisations, together with the Ford Foundation, the World Bank, the US Agency for International Development (USAID), the International Planned Parenthood Federation (IPPF) and later the United Nations Population Fund (UNFPA), helped sell Asian nations on population control, primarily by spreading the logic that lower birth rates lead to richer people. Between 1965 and 1976, money spent on research and development for contraceptive methods around the world more than doubled. Developing countries received the lion’s share of that money while contributing less than three percent of it. The greatest amount of funding came from the US.
At times, Western donors made the link between wealth and small families disturbingly explicit by making other types of aid contingent on the adoption of population control targets. In 1966 President Johnson signed the Food for Peace Act, which required USAID officers “to exert the maximum leverage and influence” to guarantee that famine-stricken areas accepting food aid also take steps to control their populations. In 1969, World Bank President and former US Secretary of Defence Robert McNamara explained to his advisory council that he didn’t want to fund public health work “unless it was very strictly related to population control, because usually health facilities contributed to the decline of the death rate, and thereby to the population explosion.” According to a history of the World Bank’s population programme, the mood in Washington at the time was that “no organisation concerned with economic development could ignore the implications of accelerating rates of population growth.”
Some of the strategies they came up with bordered on demeaning. In 1967 Disney produced a movie for the Population Council called Family Planning that was translated into 24 languages. The film depicted Donald Duck as the responsible father of a small family, wealthy and surrounded by modern appliances. Without family planning, viewers were told, “the children will be sickly and unhappy, with little hope for the future”. But in the end it was the influx of Western money that did the trick, especially in Asia, where beginning in the 1950s countries implemented comprehensive population control programmes. In South Korea, which following the Korean War remained under American influence, the ruling military regime embraced family planning as an integral part of its economic development strategy, writing birth targets into its five-year economic plans. Extensive population control measures were also adopted in Taiwan, which like Korea received a steady flow of US aid. Singapore first moved ahead on family planning while a British colony; later the authoritarian leader Lee Kuan Yew withheld tax and housing benefits from couples who had three or more children, and deemed fourth and fifth children “antisocial acts”. And India, the country that economist Isador Lubin had declared “makes this situation so acute”, became the site of ambitious, often draconian experiments directed at getting couples to stick to two children, again funded by Western money. For a period, Delhi was overrun with American population advisers, and for years afterward the Indian government continued to operate within “a paradigm where the entire problem was population”, public health activist Sabu George told me. “Everything was oriented toward fertility. That was a national obsession.”
AT THE TIME that Bedi was in medical school, in the 1970s, he was vaguely aware that population control had become a critical priority for the Indian government. Under Prime Minister Indira Gandhi, 59 percent of the Indian Health Ministry budget went toward family planning, and even as a student he could sense that level of investment. “Between the 1950s and the 1980s,” he recalls, “all public health meant was family planning. There was nothing else done. There wasn’t malaria or tuberculosis. You would go to a hospital and all you’d see were advertisements for birth control, IUDs and sterilisations.” But he did not yet fully understand the reasons behind this push. Nor could he know that in the West, India represented the holy grail of population control.
Following the 1952 Conference on Population Problems in Williamsburg, Western activists had seized on the idea that if a family planning approach worked in India, with its mushrooming, impoverished population, it might work anywhere in the world. One group of Harvard researchers charged with examining birth control use among Indian villagers went so far as to call the country “the cauldron in which mankind will be tested”. As Western advisers flooded into Delhi in the 1960s, they backed major surveys, paid for training India’s first demographers and wooed doctors over to their cause. Medical schools became an important source of potential recruits.
In 1975 the All India Institute of Medical Sciences (AIIMS), the country’s most prestigious medical school, unveiled India’s first amniocentesis tests at its government teaching hospital. AIIMS officially introduced the test to identify foetal abnormalities. But almost from the start doctors used it to pinpoint foetal sex. Before long, other government hospitals were offering the test as well.
In contrast to today’s India, where a woman seeking a sex-selective abortion may have to shuttle among multiple physicians, hinting at what she wants, the early procedures were performed openly at government-funded institutions. Doctors helpfully identified foetal sex. Then if a woman learned she was carrying a girl and wanted to abort, the doctors helped with that as well. In some cases, physicians may have even encouraged women to abort female foetuses; population control was deemed so urgent that they sometimes encouraged women to abort healthy foetuses in other situations.
In their remarkable openness about the tests, it wasn’t simply that the physicians neglected to consider the ethics of sex selection in the face of widespread patient demand. No: not only did the doctors believe sex selection acceptable, they believed that by culling female foetuses they were making the world a better place. Shortly after the amniocentesis tests began, several AIIMS doctors published a paper in the journal Indian Pediatrics explaining the project as an experimental trial with potential to be introduced on a larger scale. Indian couples clearly desired sex selection, wrote Dr IC Verma and colleagues. And that interest, if tapped more widely, could be a boon for India—and the world:
In India cultural and economic factors make the parents desire a son, and in many instances the couple keeps on reproducing just to have a son. Prenatal determination of sex would put an end to this unnecessary fecundity. There is of course the tendency to abort the foetus if it is female. This may not be acceptable to persons in the West, but in our patients this plan of action was followed in seven of eight patients who had the test carried out primarily for the determination of sex of the foetus. The parents elected for abortion without any undue anxiety.
While the doctors defended their actions with cultural relativism—“This may not be acceptable to persons in the West”—their logic was a variation on Malthusianism, which India inherited from Europe. Verma and his colleagues aborted female foetuses in the name of population control.
Western money had backed the creation of an extensive network of community family planning advisers in India, and as amniocentesis spread from AIIMS to other government hospitals in Delhi, these advisers encouraged women to go in for the test, which the hospitals provided, like other services, free of cost. Finally in the late 1970s, when sex-selective abortions showed no sign of abating, Indian feminists organised. India had a fledgling but vibrant culture of activism, and the noise women’s groups made marked the first anti-sex selection campaign in the world. In late 1978, the health minister responded to the protests by barring government hospitals from performing sex determination.
By then, however, the hospitals had already done substantial damage. At AIIMS alone, doctors had aborted an estimated 1,000 female foetuses. Verma and his colleagues had also presented their research at a national conference, arguing before paediatricians from around India that sex selection was an effective and ethical method of population control. For physicians from rural areas who sat in on that session, sex-selective abortion must have seemed a breakthrough in family planning, coming as it did from researchers at India’s top medical school. How many returned home to put it into practice is impossible to tell. In Delhi, meanwhile, the ban had the paradoxical effect of increasing the number of places a woman could go to abort a girl. For with government hospitals out of the market, private clinics stepped in. By the early 1980s amniocentesis would be so commonly used for sex identification that Indians began popularly referring to it simply as the “sex test”. Still, it was a relatively invasive procedure that carried a risk of miscarriage, and it lacked mass appeal.
Feminist outcry over the amniocentesis trials focused on the fact that Indian government money had been used to fund sex-selective abortions. Though privately Indians speculated about a link to the Western foundation money that had been flowing in to Delhi for population control, no one succeeded in proving any connection. “I believe it was both the Population Council and International Planned Parenthood Federation—but mainly the Ford Foundation,” Bedi speculated years later, when asked which organisations might have backed the trials. But, he added, “everyone is very tight-lipped about it.” By the late 1970s most Western advisers had left, and the details of their activities in India remained opaque, sealed away in dusty boxes in office storage rooms or in closed archives on American benefactors’ estates. Recently, however, IPPF and the Rockefeller Foundation opened up their early files, revealing reams of documents that are impressive in their detail. The intricacies of the organisations’ work in India finally became clear. In the story told by those documents, the AIIMS experiments trace back to the West.
THE STORY BEGINS in the mid-1960s, when Sheldon Segal, head of the Population Council’s biomedical division, headed to Delhi for an overseas post. India was already overrun with foreign population workers, but Segal was no middling figure within the population control movement. He had been hired by John D Rockefeller III in 1956, after graduating from the University of Iowa with a doctorate in embryology and biochemistry, as assistant medical director of the Population Council, a position from which he oversaw the council’s research laboratories. Shortly before his departure to India, Rockefeller promoted Segal to director of that same division. As one of the more senior members of the council, then, with coveted access to Rockefeller and other power brokers and an assignment in a country that had come to represent everything for the population control movement, Segal was poised to make decisions affecting tens of millions of lives. The Ford Foundation underwrote the cost of posting him to Delhi.
Over his two years in India, Segal performed several roles. One of the most important was to serve as personal adviser to Lieutenant Colonel BL Raina, the former Army Medical Corps officer who had become India’s director of family planning. Before Segal arrived, Raina had been responsible for both population control and maternal and child health. That soon changed. Segal sat on a three-person World Bank committee that scrapped Raina’s job description—the World Bank wielded so much power in India that it could effectively determine the duties of Indian government cabinet members—and recommended that the colonel give up the maternal health focus and make population issues his “unconditional first priority”.
By the 1960s, the US government, the United Nations, the Ford Foundation and the World Bank together accounted for most of the $1.5 billion India received in annual aid. Of these, the World Bank—which, recall, made loans for food and public health projects conditional on population control—had special influence. India was its biggest debtor. Anxiety among Western advisers that no strings attached aid was a bad idea was particularly acute when it came to India. At the 1952 Williamsburg meeting, Rockefeller Foundation representative Warren Weaver had cautioned that India was in danger of becoming “nigger rich”. He had explained: “A man who finds out that he has a little income... just stops working four days or a week, and he just sits there. I do not think that is what we want to bring to India.”
And many in the Indian elite did not want that, either. With support from wealthy Indians, Western organisations unveiled measures aimed at the lower classes, bankrolling sterilisation campaigns that paid men in famine-stricken areas to undergo vasectomies. It didn’t hurt that the West courted the elite by funding university departments and doling out research grants. But AIIMS was the biggest target: by maintaining a presence at the institution that trained India’s leading physicians and many of its public health officials, Western advisers ensured their access to both doctors and policymakers.
The Rockefeller Foundation first posted an employee at AIIMS in 1958 as an adviser to the institute’s director, and the foundation maintained a presence there throughout the 1960s. The Ford Foundation began backing the institution in 1962, giving it the lion’s share of a $1.7 million grant for research in reproductive medicine at Indian universities. Segal was the first adviser from the Population Council, and his primary assignment in Delhi was to found the department of reproductive physiology at AIIMS. Along with the administrative drudgework that came with setting up a department, Segal worked closely with medical students and doctors to get them up to speed on established Western techniques. It was in this role that he taught a group of AIIMS students how to determine sex in humans.
In the late 1960s Segal returned to New York, where he continued to rise through the ranks of the population control movement. Back in India, the links he had helped establish between East and West grew stronger, and Western money and expertise flowed into the new department of reproductive physiology at AIIMS. In 1969, the year Segal took the podium at a national US conference to advocate sex selection as a means of population control, the Ford Foundation allocated $63,563 for “research in reproductive biology” at AIIMS. Even more money came from the Rockefeller Foundation, which between 1950 and 1973 gave AIIMS $1.5 million that paid for everything from new buildings to fellowships for the institute’s doctors. The bulk of that funding came between 1962 and 1974.
Then things got dark. Following Indira Gandhi’s declaration of emergency in June 1975, health officials in her administration saw an opportunity to force drastic measures on Indians who had previously resisted birth control—and Sanjay Gandhi wasted little time in announcing a massive effort to sterilise poor men. Widespread sterilisation was an idea that had been introduced to India by Western advisers, but Sanjay Gandhi ratcheted it up to an unprecedented scale. By the time democratic rule was restored, 6.2 million Indian men had been sterilised in just one year—15 times the number of people sterilised by the Nazis.
Western experts later distanced themselves from the excesses of the Emergency, but records from the time show that many advisers supported, if not cheered, India’s fling with despotism. A World Bank official in Delhi at the time the Emergency began returned to Washington to urge that the bank increase its support for India’s family planning programme. The Indian government asked for $26 million from the bank, explaining it would use a portion of the money to build sterilisation camps in remote areas. The committee that considered the proposal turned it down—not because committee members were alarmed at the human rights violations being perpetuated with World Bank money, but because $26 million was, as one employee wrote to a colleague in the bank’s population division at the time, “disappointingly conservative”. Money came instead from UNFPA, which in 1974 had issued its largest grant yet to India, and the Swedish International Development Authority, which in 1976 contributed $60 million toward family planning in India. And World Bank money continued to flow into India. Between 1972 and 1980 the bank doled out $66 million in loans to the country for the express purpose of population control.
A few months after the committee considered India’s proposal, World Bank President Robert McNamara flew to India to make the bank’s support for the Emergency explicit. Arriving in Delhi as men were being forcibly rounded up for vasectomies, he met with Health and Family Planning Minister Karan Singh, who admitted the sterilisation campaign had entailed a few abuses. Still, McNamara was apparently unfazed, writing in a summary of his trip: “At long last, India is moving to effectively address its population problem.” When the archives of Western population control organisations were finally opened, the scholars who sifted through them might be forgiven for overlooking the role the organisations played in bringing sex-selective abortion to India. At a time when the president of the World Bank endorsed the forced sterilisation of millions of men, a few thousand voluntary abortions must have seemed like nothing.
(Adapted from Unnatural Selection: Choosing Boys Over Girls, and the Consequences of a World Full of Men by Mara Hvistendahl, available this month from PublicAffairs Books © 2011.)