In July of 2010, newspapers in Ghana published a "Wanted" poster featuring the face of a quiet-looking man in his sixties with rimless glasses, sideswept hair, and a deeply lined forehead. The image bore a striking resemblance to flyers used by radical anti-abortion groups in the United States to harass abortion providers—posters one U.S. court found to be tantamount to a death threat. The man was James Phillips, a demographer and professor at Columbia University's Mailman School of Public Health. For more than a decade, from 1993 to 2005, Phillips had spent time working on public-health issues in the town of Navrongo, in Ghana's rural, traditionalist Upper East Region near the border of Burkina Faso.
He worked mostly from the U.S., advising health-care workers at the Navrongo Health Research Centre, on behalf of the Population Council, an international research non-governmental organization (NGO). When he first got involved, women in the area—a two-day journey from Accra—had limited access to Ghana's government health services, were having an average of 5.5 children each, and frequently suffered reproductive health problems. One in every five children died before the age of five. Staff at the Navrongo Health Research Centre were studying how different community interventions—from volunteers to traveling nurses, technology to churches—could more effectively bring primary health care, including contraception, to remote areas that government services rarely reached. By 2003, those efforts had resulted in a 70 percent reduction in childhood mortality, and the model—known as Community-Based Health Planning and Services, or CHPS—was being implemented across all of Ghana.
In 2010, Phillips began working on a different project in the Upper East called MOTECH (Mobile Technology for Community Health). With primary funding from the Bill & Melinda Gates Foundation, the government-run initiative involved partnering with local health institutions to use mobile phones to promote better health services for women and children, including distributing an array of 22 basic medications previously approved by the Ghanaian government—among them contraceptives.
Not long after the project launched, Phillips began to clash with one of his managers, a Columbia-educated public-health worker named Mame-Yaa Bosumtwi, over the editing of a newsletter. He had asked her to highlight Ghanaian involvement in MOTECH; she accused him of trying to obscure the project's Western backers. Ultimately, Bosumtwi's contract was not renewed. Taking her complaints to the Ghanaian press, Bosumtwi accused Phillips and MOTECH's funders first of underpaying Ghanaian contractors, then of downplaying the role of American donors in African development. She filed a $50 million lawsuit against Columbia. But when the suit was dismissed, she alleged something far more inflammatory: that Phillips' project in Navrongo had experimented with the birth control drug Depo-Provera on women as a test run for a broader population control campaign; that patients had been abused, and some had died. The "Wanted" poster with Phillips' face was suddenly splashed across the pages of Ghanaian newspapers and nailed to trees around the region. Protesters gathered outside the research center—bused in from universities in Accra, where, students told Centre staff, they had been recruited and paid for making the trip.
Ghanaian health officials decried her claims as libelous; a council of traditional leaders in Navrongo condemned the allegations; and a group of Navrongo women organized a counter-protest. None of it seemed to matter. One newspaper even published Phillips' phone numbers, encouraging readers to call him "and inform that criminal that he is toast." Phillips, members of his staff, even the dean's office at Columbia, began to receive so many death threats—some calls, Phillips recalled, were punctuated by the noise of gunfire—that the university decided to evacuate two members of his team across the Burkina Faso border. (Phillips himself was not in Ghana at the time, and had no idea where the calls might be coming from.) The MOTECH project ground to a halt.
Soon, the "Wanted" posters began showing up in the elevator of Phillips' office building at Columbia—and in other people's email inboxes. Two of his colleagues in Ghana have since filed and won a lawsuit against Bosumtwi and an editor of a Ghanaian paper. As of late last year, Phillips was still receiving mysterious phone messages where the only sound was gunfire.
Although it wasn't clear at the time, the attack on Phillips marked the beginning of a new anti-contraception movement—conceived in the U.S., but unfolding in Africa, where women's frustrations with the dearth of safe, effective family planning options are being co-opted and repurposed by a corner of the Christian right.
Much of this new resistance can be traced to the London Summit on Family Planning, held in July of 2012, which gathered leaders of the international women's health movement. Before a triptych of screens displaying photographs of African and South Asian women as well as a disembodied hand holding a small injectable contraceptive device, Melinda Gates, co-chair of the $40.6 billion Gates Foundation, announced that the foundation was doubling its investment in family planning to a total of more than $1 billion by 2020.
"What we"re doing is an enormous undertaking," Gates said. Her foundation's pledge was part of an ambitious $4.3 billion joint initiative to address a crisis in contraceptive access in the developing world that leads to roughly 80 million unintended pregnancies—resulting in some 111,000 maternal deaths and nearly 29 million unsafe abortions—each year. The goal was to bring high-quality contraceptives to more than 120 million underserved women in the world's poorest countries.
The London summit led to the formation of Family Planning 2020, a coalition of 23 civil society organizations, 23 target countries, 10 donor nations, and seven foundations, all pledging to dramatically improve access to contraceptives by the start of the next decade (the coalition has since grown). Target countries committed to making multiple forms of modern contraceptives more available, while wealthier nations and foundations pledged to increase funding for those efforts. After decades of lackluster support for global family planning initiatives, contraception was back as a cause. An article in the medical journal The Lancet declared it "the rebirth of family planning."
Two years later, in 2014, the Gates Foundation, along with the Children's Investment Fund, announced a deal with Pfizer to make an easy-to-use injectable contraceptive, Sayana Press, available in poor nations for just a dollar a dose (this May Pfizer cut the price to 85 cents). Sayana Press contained a 30 percent lower dose of the contraceptive drug Depo-Provera, packaged within a unique, disposable delivery system—a squeezable bulb and a short, subcutaneous needle—that, like Depo, prevents pregnancy for three months. The product was at once cheap, highly effective, concealable (for women whose partners weren't supportive), and easily administered by either lightly trained health workers or users themselves.
Uganda, which has one of the highest fertility rates in the world, was naturally among the target countries for both the broader campaign and the pilot launch of Sayana Press. The country's demographics painted a stark picture: Nearly 80 percent of the population is under age 30, yet only an estimated 20 percent of adult women used modern methods of family planning. Nearly a quarter of Ugandan girls became pregnant before age 19 and some 6,000 women died from pregnancy complications each year. Though Yoweri Museveni, the country's longtime president, had once called on Ugandans to have as many children as possible, he'd begun moderating his message, hoping Uganda might benefit from the economic boost thought to result from falling birthrates. Uganda signed onto FP2020, vowing to increase family planning spending by almost $2 million per year and reduce Uganda’s "unmet need"—women hoping to avoid pregnancy who don't yet use modern contraception—from 40 percent to 10. From Nigeria to Kenya, countries across sub-Saharan Africa made similarly ambitious commitments.
FP2020 was a massive effort, and the Gates Foundation—and Melinda Gates in particular—quickly became the campaign's public face. Harper's Bazaar dubbed her "The Savior in Seattle." Both the foundation and Gates herself, who is very public about her Catholic faith, were determined to avoid the issue of abortion, seeing birth control as far less controversial. The foundation even registered a URL to support the campaign, No-Controversy.com. Those hopes were dashed almost immediately.
Religious conservatives in the U.S. denounced the campaign, and some called it a "blatant attack on Catholic sexual morality." Human Life International, a hard-line U.S. anti-abortion group that maintains a network of global affiliates, sent its Uganda country director on tour to spread the message that "Western governments and NGOs are using great sums of money and influence to destroy the traditionally life-loving African culture." In 2012, a Catholic Nigerian biomedical specialist, Obianuju Ekeocha, penned an open letter to Gates charging that her campaign would force African women to defy their faith. The letter went viral in anti-abortion circles in the U.S., and Ekeocha, who is based in the United Kingdom, soon formed her own organization, Culture of Life Africa, with assistance and publicity from U.S. groups.
Significant opposition to birth control is common in some African countries. A 2013 Pew Research Center survey found that a majority of respondents in Nigeria and Ghana say contraceptives are morally unacceptable; more than a quarter of respondents in three other African countries agreed.
But the stakes were soon raised with a new argument deployed by Ekeocha and others: that the rollout of Sayana Press was not just immoral, but dangerous.
Sayana Press has regulatory approval in the European Union and dozens of other countries. And even before FP2020, Depo-Provera was already the most widely used contraceptive in many sub-Saharan African countries. Nevertheless, studies had indicated that there were risks. DMPA, the active ingredient in Depo, had been linked with loss of bone density, significant menstrual irregularities, and an increased risk of breast cancer. More troubling, especially for countries with high HIV rates, was some early evidence that DMPA may increase a user's risk of acquiring HIV.
As word of the potential HIV link spread, the shape of the opposition changed. Culture of Life Africa, along with Nigeria's Catholic hierarchy, shifted the focus of its objections to DMPA's alleged dangers, demanding that international donors "Stop Chemical Warfare on Poor Women!" Headlines in Nigeria's Daily Times trumpeted: "Sayana Press, Contraceptive of Life ... or Death?" Zimbabwe's registrar general, Tobaiwa Mudede, began warning women to avoid all modern methods of birth control, both because birth control would give them cancer and because "Western countries are bent on curtailing the population of the darker races of the world." Last summer, Catholic bishops in Nigeria denounced their government for colluding with foreign NGOs to promote "a culture of contraception," and Brian Clowes, a U.S. activist from Human Life International, backed them up with the claim that family planning was just a smoke screen for "rich Western interests whose only desire is to continue to pillage the natural resources of Nigeria, which has been the target of population suppressions since 1974."
Conservatives in countries like Uganda had already cast LGBT rights as a form of Western cultural imperialism, painting laws such as Uganda's "Kill the Gays" bill as an act of nationalist resistance. Now the expansion of family planning was being decried as the "new colonialism" of contraception.
That idea, ironically, has distinctly American roots, going all the way back to the earliest birth control campaigns in the 1920s, which faced accusations of having racist motives.
More recently, in 2009, the anti-abortion group Life Dynamics released a documentary film, Maafa 21: Black Genocide in 21st Century America. Named after a Swahili term for the abduction of Africans into slavery, the film employed ominous music and grainy photographs of plantation slave quarters to condemn Planned Parenthood for leading a racist campaign of population control and eugenics. ("The end of slavery was the beginning of their bondage," reads a title card in a trailer for the film.) The following year, "Abortion is black genocide" billboards began to appear around the country, bearing messages like "Black children are an endangered species" and "The most dangerous place for an African American is in the womb." Around the same time came a wave of proposed state and federal anti-abortion legislation wrapped in anti-discrimination and human rights rhetoric—such as Representative Trent Franks' (R-Arizona) Susan B. Anthony and Frederick Douglass Prenatal Nondiscrimination Act of 2011 (co-sponsored by then-Representative Mike Pence), which would have made it more difficult for women of color to get abortions.
Few of those advancing these arguments—that black women are dupes of "Klan Parenthood"; that anti-abortion activists are the true heirs to the civil rights movement—had a record of concern about black people's well-being. Among the co-sponsors of Franks' bill was a defender of the Confederate flag.
Still, the arguments touched on painful histories with lasting scars. Health researchers say the legacy of the nefarious Tuskegee Study—which left hundreds of black men with untreated syphilis so the U.S. Public Health Service could study the disease's progression—was particularly damaging. According to a 2016 federal study, the experiment made many African Americans so suspicious of the health system that, eight years after the Tuskegee Study was disclosed in 1972, black men's life expectancy had dropped by almost one-and-a-half years, as mistrust of medical institutions "hampered public health education efforts in the black community."
At the height of the billboard campaigns, Reverend Clenard Childress, founder of the website BlackGenocide.org, told me, "In the African-American community, if you shout conspiracy, they'll listen, because of the history they've had."
In the midst of this controversy, in 2011, a U.S. women's rights group called the Rebecca Project for Human Rights published a report, "Non-Consensual Research in Africa: The Outsourcing of Tuskegee," outlining what it claimed were a series of unethical medical experiments undertaken by U.S. researchers in Africa. The report compiled stories documented by the press or well-respected non-profits, such as charges that HIV-positive women in Namibia and South Africa had been coerced into sterilization by local health-care entities that received funding from USAID, or that some women who enrolled in a drug trial in Uganda designed to prevent mother-to-child transmission of HIV had received placebos. But the real focus, it would become clear, was Columbia's James Phillips.
"In the Navrongo Experiment," the report argued, "researchers allegedly injected thousands of impoverished and illiterate Ghanaian women with a Pfizer contraceptive, Depo-Provera, and administered other unidentified oral contraceptives during human research experiments to reduce population and modify health care."
The report was released at the 2011 Congressional Black Caucus Annual Legislative Conference. It called for congressional hearings on victims of unethical medical research; legislation regulating U.S. research in Africa; travel bans on African researchers and health officials who appeared to collude in non-consensual experiments; and a United Nations tribunal to prosecute suspect researchers for crimes against humanity. Those accused of conducting contraceptive research, the author later suggested, should be charged with attempted genocide.
At the time, the Rebecca Project was a small but respected Washington, D.C.-based non-profit with a budget of less than $1 million. Founded in 2003 by two women, Malika Saada Saar and Imani Walker, the group had worked on a range of relatively uncontroversial issues, including girls' education, the rights of incarcerated mothers, and access to treatment for substance abuse.
But things started to change in 2010, when one employee, chief financial officer and policy director Kwame Fosu, the Italian-born son of Ghanaian diplomats, began writing "The Outsourcing of Tuskegee." Fosu, who'd graduated from law school at Georgetown University and had worked as a legislative fellow for Representative Charles Rangel (D-New York), had never written a report for the organization before. It turned out that Fosu, who has gone by other names at times, was far from a disinterested researcher on this subject. Although his report didn't mention it, Fosu's former partner—and the mother of his child—was Mame-Yaa Bosumtwi, the former MOTECH employee who sued when Phillips chose not to renew her contract.
Former employees of the Rebecca Project said they'd been unaware of this history when Fosu began his research. But once he released the report, co-founder Saada Saar asked him to retract the sections on Phillips. When Fosu refused, he claimed she tried to have him fired (Saada Saar declined to comment for this story). The dispute split the organization, and Saada Saar left, taking with her several colleagues and all of the funding.
Fosu doubled down. In 2013, he released a new report, "Depo-Provera: Deadly Reproductive Violence Against Women," which used his claims against Phillips as a springboard to denounce what he charged was a massive conspiracy involving international organizations, including the Gates Foundation, USAID, the United Nations Population Fund, and Pfizer, to push a dangerous contraceptive on poor black women.
If the first report was provocative, and heavily dependent on unnamed sources, the second veered into florid paranoia.
"Against a backdrop of the pure innocence of beautiful smiling females," wrote Fosu, "esteemed philanthropist Melinda Gates announces her four billion dollar contraceptive strategy featuring Depo-Provera as the optimum choice for women of color. These beautiful females, oblivious that they are being insidiously exploited as diversionary cynical props to mask Gates' egregious intent, are in an unprecedented Depo-Provera campaign with serious racist implications to prevent their very births." The report characterized most global family planning campaigns as genocide, African women as "modern day slaves for human medical experimentation," and black women working within the reproductive rights field "a 'Depo Proveran' Trojan Horse" driven by internalized racism.
The report sparked a second schism at the Rebecca Project. Imani Walker, the remaining founder, disowned Fosu's work and, according to an email she sent supporters, fired him for "breach of fiduciary duty and unethical conduct." Fosu was prepared. Along with several sympathetic board members, he enacted a quiet, digital coup. Walker (who did not respond to multiple interview requests) was locked out of the organization's website and email system. A messy internal fight ensued. Walker filed a restraining order against Fosu. Fosu announced that Walker had been fired by the organization's "ethics board"—a board that Walker, in an email to supporters, said didn't exist. And a lawsuit over the organization's remaining assets wound its way through court. Fosu sent a barrage of confusing emails to a long list of foundation and government officials. Ultimately, a judge barred Fosu from entering the organization's shuttered offices or coming within 50 feet of Walker. The Rebecca Project was, for all intents and purposes, dead.
But Fosu was just getting started. In November of 2013, the office of Representative Chris Smith (R-New Jersey), one of the most stalwart abortion opponents in Congress, announced that the House Foreign Affairs Subcommittee on global health, which he chairs, would hold hearings on unethical medical testing in Africa—including, a Smith staffer wrote, "the misuse of Depo-Provera."
If there was ever a congressman primed to hear Fosu's message, it was Smith. A devout Catholic and longtime co-chair of the Bipartisan Congressional Pro-Life Caucus, Smith exerts powerful influence in his party. In the first few days of the Trump administration, he sponsored a bill to make permanent the Hyde Amendment, which bans the use of federal funds to pay for poor women's abortions, and is currently renewed annually. (The bill passed the House in January, on the eve of the March for Life, and as of this writing a companion bill is awaiting a vote in the Senate Finance Committee.) In the fall of 2016, Smith was named an early member of Donald Trump's "pro-life advisory council," alongside other abortion-as-black-genocide advocates like Representative Trent Franks; Alveda King, Martin Luther King Jr.'s vehemently anti-abortion niece; and Austin Ruse, president of the Center for Family & Human Rights, or C-Fam.
Time and again, over his 36 years in Congress, Smith has sought to use his office to limit the globalization of reproductive rights, lobbying heads of state and parliamentarians across Latin America and Africa to fight abortion. In 2000, during an address to the Vatican, he characterized family planning as "population control," a weapon against the family tantamount to a nuclear bomb; a brutal Western attempt to "thin the human herd" by volunteering "others—mostly Africans, Asians, and Latinos—to do the dying." In 2014, when Culture of Life Africa, on behalf of the Catholic Bishops' Conference of Nigeria, organized the International Family and Pro-Life Conference, Smith traveled to Abuja, Nigeria, to be the event's "special guest speaker."
By then Fosu was settled in as policy director of a reconstituted Rebecca Project—the Rebecca Project for Justice—which suddenly had a new set of allies, a close-knit group of conservative Catholic non-profits, including two organizations spun off from Human Life International: C-Fam, a right-wing U.N. lobby group that's been designated as a hate group by the Southern Poverty Law Center for its anti-LGBT vitriol, and the Population Research Institute, an anti-contraception group focused on fighting family planning efforts abroad. This network of groups has held little sway in the United States, but has nonetheless succeeded in spreading U.S.-style culture-war tactics around the globe, setting up scores of crisis pregnancy centers in Latin America, launching affiliate groups there and in Africa, and mobilizing a conservative bloc at the U.N.
The board of the new Rebecca Project included anti-abortion star Alveda King and Mark Bold, the executive director of the traditionalist Christian Law Institute, who's made a career advocating for U.S. victims of forced or coercive sterilization. Elaine Riddick, who sued the State of North Carolina for forcibly sterilizing her when she was a 14-year-old girl in the 1960s, was named executive director.
But it was Fosu who seemed to hold the reins of this "women's" organization, and he put a laser-like focus on Depo-Provera. He retained a flamboyant Florida personal-injury attorney, Willie Gary, to work with him to file class-action lawsuits on behalf of women harmed by Depo. In a surreal biographical video on his website set to "Eye of the Tiger," Gary brags about the hundreds of millions of dollars he's won in corporate settlements—among them a suit against Bill Gates' Microsoft, which Gary accused of harboring a "plantation mentality" toward black employees.
As the two men began visiting members of Congress, distributing Fosu's reports and asking for their support in defunding organizations distributing Depo, Fosu presented himself as a bold truth-teller, slinging stones at Melinda Gates and the other giants of family planning. Pitching his campaign in African papers, Fosu described their fight as "a battle of good versus evil, evocative of the immortalized biblical story, 'David and Goliath.'" But the roles seemed reversed: Here was a calculating David, and a well-intentioned but blundering Goliath, marching onto a cultural battlefield pocked by inconclusive science and the unfinished business of the women’s rights movement.
On the shores of Lake Victoria, in the small Ugandan fishing village of Mamba, Namatovu Scovia, a 38-year-old mother of seven, held a square slip of paper bearing the number 63 in one hand and her nursing seven-month-old in the other. She was waiting in line for the area's first "family planning day" at a clinic sponsored by Marie Stopes International—a non-profit that runs hundreds of reproductive health-care centers around the world. For weeks, the organization had been advertising the free services that would be offered—everything from condoms to tubal ligations—via a roving truck with a speaker on its roof. Namatovu was Catholic, but believed that religion had nothing to do with family planning; she and her husband wanted at least one more child, but not yet. And in the last year, droughts had meant failure for many of their crops, and not enough money for school fees. Their four oldest children were taking turns attending school each semester.
"We feel oppressed and marginalized," Namatovu told me via a translator last summer. "We give birth to so many children, so closely spaced, that you end up miserable, because your children are unable to live a decent life, and there’s not much you can do about it."
The same week, in Kampala, on a tiny triangle of land in the slum of Bwaise, flanked by steep banks that cut down to a shallow, garbage-choked creek, 24-year-old Babra Ainebyona told me she was deeply skeptical about contraception. As volunteers from Marie Stopes spread the word about a free birth-control clinic happening on the other side of the slum, Ainebyona watched with suspicion from the hut where she was selling heavy stems of bananas. She'd had "the family planning shot" before, she said, and the side effects had been intolerable, including a period that lasted for three months. The clinic where she'd gotten the shot, she said, never warned her about that, and so when people later told her that family planning caused birth defects, she believed them. "Now I hate it," she said, "and will never use it again."
Health-care workers in Uganda talk frequently about the challenges of dispelling what they call "family planning myths," misconceptions that lead from the familiar to the outlandish: that birth control leads to cancer, fibroids, or death; that IUDs and hormonal implants can become dislodged and swim through the bloodstream to the heart; that birth control pills might pile up, undigested, in the internal organs; that family planning leads to babies born with no eyes, no ears, maybe even animal parts.
Some of the fears are rooted in old sensitivities around population control. In the 1980s, recalled one clinic official in Kayunga, when a destabilized Uganda, still reeling from a decade of dictatorship, was the recipient of international food aid, people had told her not to eat the yellow corn that came in sacks marked usaid. They feared that the grain—different in color than pale Ugandan corn—must have birth control additives, since "everyone knew" the Americans "don't want us to have children."
The new wave of fear-peddling by U.S. anti-contraception groups in Africa has fanned the flames. "It has totally undermined the government program to raise consciousness," said Jackson Chekweko, executive director of Reproductive Health Uganda, an affiliate of the International Planned Parenthood Federation. "We're in a country where literacy is low, so people may be shaped."
But, Chekweko added, some of the issues raised by these groups are legitimate concerns in Uganda: that women may not be told about the side effects of the contraceptive methods they're being prescribed; that they may not have money to see trained health workers if complications arise.
Also problematic, says Chekweko, is a lack of options. In many areas of Uganda, the family planning push has effectively become a "single method campaign," he said. Family Planning 2020 was designed to offer a robust mix of different contraceptives. And yet, at the local level in Uganda, many women only have one option: Depo-Provera.
This is, in large part, due to financial constraints. Last summer, at the midway point in the FP2020 campaign, the initiative was facing a funding crisis. Many governments among the 69 target countries had failed to meet their family planning budget commitments, and donors were shifting their giving to the refugee crisis instead. In Uganda, despite the government's 2012 commitment, the only increase in family planning spending had come from a World Bank grant that had since expired.
Without that financial support, according to a 2016 report issued by Uganda's Ministry of Health, most government health facilities had run out of nearly every contraceptive commodity except Depo-Provera; there were no IUDs or pills left in many clinics. A Ugandan health official denied that this indicated a shortage; most of the country's family planning budget for contraceptives had been intentionally spent on Depo, he said, because it was clearly Ugandan women's preferred method.
But that's a chicken-and-egg proposition. A rapid assessment of government facilities across the country by the NGO HEPS-Uganda found that many had lacked birth control pills for at least 10 months. Often, explained the group's executive director, Denis Kibira, rural clinics lacked even condoms, let alone trained providers who can insert and remove long-acting options like implants and IUDs. The result was that women settled for what they could get.
"Most women 'prefer' Depo-Provera," he said, "because that's the most available."
Independent, internationally funded clinics in Uganda like those run by Marie Stopes tend to offer a much wider array of methods, allowing patients to choose everything from condoms to IUDs (they also provide free IUD or implant removal at any time). But the lack of choices for women who can't or don't access those facilities has had unintended consequences—among them, lending purchase to the right-wing narrative about callous Western organizations pushing bad drugs on African women. A 2011 health survey by the Ugandan government found that 43 percent of Ugandan women who use family planning stop within a year, usually because of concerns about side effects—a finding echoed in a 2016 Guttmacher Institute report, which suggested that 19 to 26 percent of the "unmet need" for contraception globally is due to fear of side effects. If the only option available is one many women find unbearable, they may come to reject contraception outright.
Concerns about contraceptive safety largely originated with the advent of the pill. A decade after it first became available, feminist Barbara Seaman's critical book, The Doctors' Case Against the Pill, recounted stories of women who'd suffered serious side effects, including blood clots and pulmonary embolisms. Seaman demanded that women be told about all of the pill's possible side effects so they could evaluate the downsides and decide for themselves. Her book sparked congressional hearings where radical feminists showed up, shouting at an all-male panel of senators that women were being treated as guinea pigs. Despite pushback from drug company reps, the Food and Drug Administration sided with the activists, choosing to require that an information sheet, detailing potential health risks, be included with every packet of pills.
Outside the U.S., family planning first arrived in many developing nations under the banner of population control. Fears that rampant population growth would destroy the environment and cause massive civil unrest led to systematic abuses that landed overwhelmingly on women of color—the sterilization of some 35 percent of Puerto Rican women of childbearing age by 1968, following a law modeled on U.S. eugenics policy; the conditioning of '60s and '70s-era U.S. food aid to India on that country’s birth control policies, prompting India to pay incentives to women who were sterilized or received IUDs and to men who had vasectomies.
Starting in 1974, widespread problems with an IUD called the Dalkon Shield (initially marketed as a safer alternative to the pill) sparked one of the largest mass tort litigations in U.S. history, as hundreds of thousands of women claimed the contraceptive had resulted in pelvic inflammatory disease, miscarriage, sterility, or death. The device, marketed by the A.H. Robins Company, was recalled in the U.S., but continued to be offered overseas for several more years, mostly in developing nations. Then came Norplant, a hormonal implant created by Wyeth-Ayerst Laboratories (later bought by Pfizer), which, beginning in 1994, faced over 70 class-action lawsuits among women who claimed they hadn't been warned about side effects like excessive bleeding, depression, headaches, and nausea. Norplant was quietly pulled from U.S. markets in 2002, but remained on shelves abroad until 2008.
Because of safety concerns, Depo-Provera wasn't approved in the U.S. until 1992. By that time, it had already been used by tens of millions of women worldwide. It had a stunning effectiveness rate—nearly 100 percent—but also a history of complaints. Women reported excessive bleeding, followed by missed periods; weight gain; depression; decreased libido; and, for some period of time after discontinuing the drug, fertility problems. Some studies of DMPA found an increase in breast cancer risk similar to that associated with the pill, and one 2012 study found that DMPA use doubled that risk. Other studies noted a loss of bone density in some users severe enough that the FDA warned women not to take Depo for more than two years. Notably, Depo use in the U.S. appeared to be concentrated among vulnerable groups: One 2005 study found that 84 percent of Depo users were black, 74 percent low-income, and 33 percent under 19 years of age.
The data was troubling to Loretta Ross, who became one of the first African-American plaintiffs against the manufacturers of the Dalkon Shield after the IUD left her sterile in 1976. A founder of the reproductive justice group SisterSong, Ross had worked with numerous women's-health organizations since the 1980s, including one, the Committee for Women, Population, and the Environment, that released its own warning about Depo.
"Most of us who are critiquing Depo are not expecting any contraceptive to be 100 percent safe," Ross said. "There is no such thing." But she wanted what the feminists of the '70s wanted: full disclosure, allowing women the opportunity for fully informed consent. Having that conversation has not been easy, Ross said. During the years following Depo's U.S. debut, the lines of a culture war were drawn over reproductive rights and family planning, even as the Christian right softened its approach from the violent rhetoric and attacks of the 1990s to appeals on behalf of women's health and safety. So when problems with the drug began to emerge, some groups on the reproductive-rights side were unsure how to respond. "To the extent that we call attention to it," Ross said, "we're feeding the other side bullets."
E. Tyler Crone, a founder of the HIV and gender-equality group the Athena Network, points out that Depo is an old contraceptive, with lousy side effects—one she'd never encourage her own daughter to take. In an ideal world, there would be more and better contraceptive options for all women, Crone said. "Yet we live in an environment where very fundamental issues—about women's autonomy, ability to control their fertility, to have sex with pleasure, and have babies when they want to—when all of that is so contested and challenged in every corner that it makes it really difficult to open up and talk about hard questions honestly."
There is no escaping the hard questions surrounding Depo-Provera—especially one question that has proved to be particularly vexing. Since the late 1990s, dozens of studies have been focused on whether DMPA increases women's risk of contracting HIV. There are theoretical reasons why this could be. Early studies on macaque monkeys found that progestin, the hormone in Depo, thinned the vaginal epithelium, making it easier for the virus to get through. More recent research has suggested an immunological effect—the drug suppressing natural immune responses in vaginal cells—could be in play. The studies so far have been relatively inconclusive. Of 25 studies performed to date, 11 showed a statistically significant possibility of risk, while others showed no effect at all. But an outlier study appeared in The Lancet Infectious Diseases in 2011. Led by University of Washington epidemiologist Renee Heffron, it found that DMPA might double the risk of infection.
All of the studies looked at the standard DMPA dose, and not the lower DMPA dose options. And every one of the studies used only observational data—watching what happens over time to women who are already taking different types of contraception, rather than using structured control groups. This means that the higher HIV risk found in some studies could simply be an indication that women who choose long-acting injectable contraceptives have other lifestyle factors—having more sex, using condoms less—that put them at higher risk.
"There's always this question of whether it's about the injectable contraceptive or the woman's behavior," Heffron said. "And we can't answer that well."
Despite these caveats, Heffron's study "rocked the global health community," recalled Chelsea Polis, a former government epidemiologist who has studied the intersection of HIV and contraception for years. The World Health Organization responded in 2012 with a suggestion that, due to the "inconclusive nature" of the evidence on increased HIV risk, health-care providers should advise women to always use condoms as well. It seemed nonsensical, since family planning experts have found that many women are drawn to Depo specifically because it can be taken without the knowledge of a sexual partner, unlike condoms. A subsequent WHO guidance document issued in 2014 advised public-health advocates and clinicians to inform women that DMPA "may or may not" increase their HIV risk, which only sowed confusion: What were women to do with that information?
In 2013, Polis and a colleague, Kathryn Curtis, published a systematic review of all the studies to date on the relationship between HIV acquisition and hormonal contraceptives, narrowing them down to the most rigorous ones available—those which, like Heffron's, had attempted to control for variables like condom use, among other factors. The studies concerned a number of contraceptive methods, but DMPA was of primary concern, with some, but not all, observational data "pointing to a potential causal association between DMPA use and HIV acquisition." (When the systematic review was later updated to include studies published after 2012, the evidence suggesting a potential causal link grew.)
But even if some risk exists, that doesn't necessarily mean that Depo shouldn't be promoted in localities with moderate HIV prevalence. Public-health experts agree that any such decision would involve a delicate cost-benefit analysis: weighing the public-health risk of HIV acquisition against a potential spike in maternal mortality, should access to one of the only contraceptive methods currently available to many African women be diminished.
In 2012, Polis co-authored a separate modeling study that posed scenarios in which DMPA increased HIV acquisition risk by zero, 20, or 100 percent and estimated both the potential decreases in HIV-related deaths, and the potential increases in unintended pregnancies and resultant maternal mortality, if the use of DMPA were reduced. The data painted a different picture from country to country, suggesting that, unless DMPA were proven to more than double HIV risk in women, reducing its use would not likely result in an overall public-health benefit in most places. The exceptions were a handful of countries in Southern Africa, and South Africa in particular, where some estimates show that HIV prevalence is so high—19.2 percent of adults between 15 and 49—that 5,000 women and teenagers acquire HIV every week.
"In South Africa," said Polis, "it seems that it would be a very appropriate policy response at this point to put a heck of a lot of effort into making sure that women have access to other contraceptive options.” In fact, that's exactly what South Africa has done. While the country has some of the highest rates of DMPA use in the world, the government has begun promoting hormonal implants, which don't seem to pose the same potential risk.
"We should all be sleeplessly trying to ramp up access to as many different methods as exist so that all women have the ability to choose the method that best fits their lifestyle and values and health profile," Polis said. Nevertheless, her subtle finding that, "'Do no harm' means different things in different contexts"—that different countries call for different policy solutions—made her a target. After she and Curtis submitted their paper to The Lancet Infectious Diseases and it was sent out for peer review, one reviewer responded with unusual hostility, making unfounded accusations that the authors had selectively ignored evidence, lied to African women, and put them at risk of HIV acquisition. The reviewer, they would come to suspect, was David Gisselquist, an unaffiliated HIV/AIDS researcher who believes that HIV isn't spread primarily through sex but by unsafe medical injections—a position widely viewed as AIDS denialism. Gisselquist was also a board member of the reformed Rebecca Project, and just as Kwame Fosu released his second report in 2013, a leaked version of Polis and Curtis' paper, complete with markings sent only to peer reviewers, appeared on the Rebecca Project's website. Fosu painted Heffron as a heroic truth-teller and Polis as a careerist bought off by Gates to suppress evidence, even though Polis and Heffron are close colleagues who have co-authored work in the past, and both are widely respected in their field.
I met Kwame Fosu in the lobby of One UN New York, a swank Millennium hotel kitty-corner from the U.N. headquarters, in the spring of 2015. A tall man with dreads, wearing a dark suit, Fosu took us to the 30th floor, outside the guests-only Skyline Club. Lacking a keycard, Fosu knocked, explaining to the waiter who answered that we'd be meeting a regular customer, a U.N. delegate Fosu had come with before. The waiter looked skeptical, but afraid to offend, and Fosu stepped over the threshold before he could say no.
In the year and a half since the Rebecca Project takeover, Fosu had been in town a lot, promoting his reports. Sometimes he was shut down, as in the case of a 2015 Georgetown talk, which was canceled after women's groups worked behind the scenes to challenge his claims. Other times he was welcomed, as at 2014's Left Forum, where Fosu urged New York progressives to fight "the DDT of contraceptives" as fellow "people of the left." He claimed he was working with university students in Ghana, Nigeria, and Uganda to stage protests outside clinics distributing Depo, promising a replay of the demonstrations outside the Navrongo clinic in 2010.
"It's going to be serious conflict and great social media," he said. "We'll block entrances—we'll do exactly what the civil rights movement did."
But as the months wore on, and both his promised protests and Smith's congressional hearing failed to materialize, Fosu settled on a new strategy. He'd begun working with C-Fam, which had recently acquired U.N. lobbying credentials, and he started inviting African delegates to briefings at which he called up the websites for the FDA and the European Medical Association to demonstrate that the contraceptives most widely used in Africa were rarely used in the West.
His efforts were beginning to have an impact. In March of 2015, the U.N.'s Commission on the Status of Women held its 59th annual meeting, and credentialed civil-society groups reported hearing echoes of Fosu's messaging from African delegates: that they supported family planning in general, but opposed methods that increased the risk of disease. At the meeting's end, the African Group delivered an unprecedented statement: "We are concerned by the spread and use of harmful contraceptives for African women and would welcome contraceptives to African families that are not detrimental to women's health and are of a better quality and are not perpetuating cancer and HIV and AIDS diseases."
The next month, at the U.N. Commission on Population and Development's annual meeting, global-health advocates again noticed Fosu's presence, along with Marie Smith (Chris Smith's wife, who leads an international anti-abortion organization and serves as a U.N. observer for the Holy See) and members of C-Fam and such anti-abortion groups as the U.K.'s Society for the Protection of Unborn Children (which had been active in the International Family and Pro-Life Conference in Nigeria). Together, the small coalition of anti-contraception activists distributed Fosu's cleaned-up policy brief to each African delegate they met, and invited them to individual sessions with Fosu. At the end of the meeting, global-health advocates were stunned when, for the first time in the Commission's 48 years, the delegates could not reach consensus on an outcome document, stymied by challenges to basic reproductive- and sexual-health language that had been in place ever since the pivotal 1994 U.N. Conference on Population and Development in Cairo. Much of the opposition came from the African Group and other developing countries, which, Marie Smith's organization boasted, had become "frustrated at the profusion of references to population control, adolescent sexual activity, abortion, and comprehensive sexuality education."
Fosu had long insisted that his campaign was about protecting African women, not an attempt to open up new fronts in the culture wars. The day we met, he told me he'd carefully trained his African student protesters to avoid mentioning abortion, and vehemently refuted the notion that his partners at C-Fam had an ideological or religious agenda. But by the summer of 2015, Fosu seemed to have dropped the pretense, as the Rebecca Project embraced a series of anti-abortion "sting" videos purporting to show Planned Parenthood engaged in selling fetal tissue.
Nearly two hours into our conversation, after Fosu's friend failed to appear, the waiter who'd let us in timidly approached our table with a pen and paper in hand, asking for the room number of the delegate Fosu had said we were meeting.
Fosu waved him off. "We're about to leave." But the waiter pressed further: This was a private room, only for guests; he needed the room number.
"Oh, Taj? He doesn't stay here," Fosu replied, offering no further explanation.
"No outsiders," said the waiter.
Fosu heaved a dramatic sigh. "No problem," he said. And it wasn't. No matter under what false pretenses he'd gotten in the door, he'd finished what he'd come to do.
There is new hope that the questions surrounding a possible connection between DMPA and HIV may soon be settled. In late 2015, a randomized controlled trial—the gold standard of scientific research—began in sub-Saharan Africa. The Evidence for Contraceptive Options and HIV Outcomes, or ECHO, trials constitute a four-year study of nearly 8,000 women across Zambia, Kenya, South Africa, and Swaziland. Trial participants were randomly assigned to one of three long-acting, highly effective contraceptives—DMPA, the implant Jadelle, and a hormonal copper IUD—and tracked to compare both pregnancy prevention and HIV acquisition.
The trial methodology was almost two years in the making, and it took almost as long to raise the necessary funds. In 2014, as reproductive-health groups pressed global donors to commit to the $60-to-$80 million cost, Heidi Jones of the City University of New York's Graduate School of Public Health argued against it, saying that it was time to "let go of unanswerable questions" about DMPA and focus instead on creating a better range of options for African women. ECHO investigator Helen Rees, executive director of South Africa's Wits Reproductive Health & HIV Institute, insisted that, after 25 years of inconclusive findings, African women needed a definitive answer.
"The academic bartering that juxtaposes the risk of maternal mortality against the HIV risk for African women is unlikely to stop unless more definitive data are generated," she wrote in the journal Contraception. "Their question needs to be addressed."
The question has only become more urgent. Last August, a new study by Chelsea Polis, which appeared in the journal AIDS, found more evidence supporting a causal link between DMPA use and HIV risk. A press release suggested that the WHO consider revising its clinical guidelines for DMPA, even before the ECHO trials conclude (results are expected in 2019). After convening a technical consultation meeting in December to review the new evidence, the WHO issued amplified warnings for women using DMPA in areas with high HIV risk.
Then, just this past April, the U.S. Department of State cut all funding for the U.N. Population Fund on the false grounds—already disproven by a previous Department of State investigation—that it supported coercive abortions and sterilizations in China. And there are other signs of a sea change in Washington on family planning. At this year's Commission on the Status of Women meeting at the U.N. in March, C-Fam was no longer present as an outsider organization, but as a member of the official U.S. delegation to the U.N., appointed—along with a staffer from the Heritage Foundation—by Trump's new Department of State. A week later, at the Commission on Population and Development—as several participants noticed Kwame Fosu telling African delegates he was working on behalf of African women—delegates from Africa joined with U.S. conservatives to help block the acceptance of an outcome document, after clashes over whether the term "sexual and reproductive health" includes modern contraception and abortion. (One advocate attending on behalf of a major family planning organization said that the reproductive health and rights coalition "had never seen so much opposition" at a U.N. event, nor one so organized and emboldened.)
Whatever ECHO's findings reveal, larger issues linger. Foremost among them, said Lillian Mworeko, executive director for the International Community of Women Living with HIV Eastern Africa, is the lack of contraceptive choices in Africa. She was frustrated that African women don't get enough information to make educated decisions; that documented side effects are sometimes dismissed as myths; that the sexual and reproductive health needs of these women were approached with a sense of triage.
The real solution, she suggested, is not a calculation weighing how many women will die from either HIV/AIDS or childbirth, but rather an expanded vision of what real reproductive justice could look like in Africa. "What we want is comprehensive access to sexual and reproductive health and rights, which of course includes access to family planning, but also a much broader range of issues. I must know my rights. I must understand my sexuality. I must know what I need, and what's available."
"We've been used, pitied, and made to choose between maternal mortality and HIV infections—as if these are not about the same person," she said. "Take away our Depo and we'll die; give us birth control pills and our husbands will beat us." But just as there is no single narrative that can account for African women's feelings about contraception, there is no single solution to their family planning needs. Amid what is at once an ideological battle and a health crisis for millions, Mworeko said, one thing has been sorely missing: the desires of the African women themselves. Somehow their voices have been sidelined in a global debate over their own lives.