How abortion changed the world

From a sketchy underground doctor to the American fight against communism, a look at the unlikely forces that helped spread global family planning.

Published April 10, 2009 10:25AM (EDT)

In the 1950s, before he became notorious, Harvey Karman was a psychology student at UCLA, attending on the GI bill. Writing a paper on the emotional impact of abortion led him into the abortion underground, where he helped a number of desperate coeds find ways to terminate their pregnancies. "It seemed like every guy who got a girlfriend pregnant, everyone who had remotely heard about me, said, 'This guy knows about abortion,'" he told Ms. magazine in 1975. Often he'd help young women make their way to Mexico to end their pregnancies. Some of them came through the procedures fine, but some came home sick or injured, and Karman would take them to the school's medical center for treatment. Frustrated with this system, he eventually started performing abortions himself.

Much of Karman's early history is hazy, but one horrific incident stands out. In 1955, one of the women who sought Karman's help died of an infection, and he was charged with both murder and abortion. A court rejected his insistence that he was a mere middleman between the woman and a doctor, finding that he himself had tried to induce a miscarriage using a speculum and a nutcracker. Nevertheless, he was convicted only of the lesser charge, and after serving two years in prison, he emerged unfazed to resume the work that had become, for him, a kind of crusade.

A man of the nascent counterculture, Karman dabbled in experimental films and worked with juvenile delinquents and at Head Start, but abortion remained his consuming passion. A sympathetic doctor told him that if he could induce just a small bit of bleeding in a pregnant girl, she could be admitted to the hospital and her abortion could be completed legally, a technique he adopted. In fact, all around the world, in countries where abortion is restricted, that's often how it's done. According to Malcolm Potts, an Oxford-educated doctor who is one of the world's leading authorities on abortion, the "extralegal person is usually trying to produce uterine bleeding that will take the woman to the public hospital where she will be cleaned up."

However standard, this system struck Karman as crazy, and he started trying to devise something better. Karman "was a very dexterous person," said Potts, who later became his friend. "He used to make model airplanes when he was young. I once locked myself out of my car, and I'd never seen anybody break into a car as quickly as Harvey did. And he's pretty good at breaking into the uterus." As Potts recalled, Karman read the medical literature about abortion in Eastern Europe, where it had been legal since the 1950s. He wanted a method that was as painless as possible, allowing a woman to get up and walk away as soon as it was over. So he started experimenting in his kitchen. Karman cut the end off a large, plastic, handheld syringe, attached some polyethylene tubing to it, and soon came up with the prototype for the manual vacuum aspiration (MVA) syringe, a simple, hand-operated device that today is used all over the developing world. "It's probably done many millions of abortions since then," Potts said.

Starting in the 1960s, Karman used his invention to perform illegal abortions out of a rented room next to a dentist's office in Los Angeles. Charismatic and swaggering, he was remembered by some in the nascent abortion rights movement as a hero, by some as a huckster. He added a Ph.D. to his name, though his degree came from a dubious Swiss diploma mill. Without a doubt, there were abundant reasons to be suspicious of him, but he was no mercenary backroom butcher, and many recall him as more interested in spreading word of his discovery than in profiting from it, giving free demonstrations to interested doctors and health care workers. "I was most impressed ... because of the safety for the women and because [the technique] made it possible to bring the price way down. And Harvey never charged a cent for his visits," one San Diego Planned Parenthood official told Ms.

In 1972, the device came to the attention of Reimert Ravenholt, the head of population affairs at the U.S. Agency for International Development. Ravenholt, a roguish figure gleefully dismissive of political sensitivities, had already decided that poor countries sorely needed abortion equipment that could be run without electricity. USAID was primarily focused on spreading contraception, but government officials knew that birth control was always going to fail for a certain percentage of people, especially in places where access was sporadic and use inconsistent. As a then classified 1974 government report on overpopulation would conclude, "[I]ncreasing numbers of women in the developing world have been resorting to abortion, usually under unsafe and often illegal conditions ... [A]bortion, legal and illegal, now has become the most widespread fertility control method in use in the world today." To Ravenholt it seemed obvious that no comprehensive American program to bring family planning to the world could ignore abortion. Besides, after Roe v. Wade was decided at the beginning of 1973, the issue seemed to be settled. Abortion was legal in America. Why shouldn't American aid reflect that?

Reimert had USAID contract with the Battelle Corporation to reengineer Karman's innovation for mass production. It was a modified 50 cc syringe topped with a thin plastic tube, or cannula. When the plunger was pulled, a thumb-operated valve retained the vacuum. The abortionist would insert the cannula through the cervix, then gradually release the valve to suction out the uterus. "This was a very efficient way of terminating early pregnancies," said Ravenholt.

If there was a risk in putting an illegal abortionist to work, albeit indirectly, for the U.S. government, it seems not to have occurred to Ravenholt. "I knew what we needed, and Harvey had done something along that line, so what the hell?" he said. Through the U.S. government's General Services Administration, he ordered a thousand "menstrual regulation kits" that included a syringe, a dozen cannula, a speculum and a plastic basin, and he supplied them to doctors all over the world. The feedback was positive, so he ordered ten thousand more. His staffers would bring suitcases full of them when they went on trips abroad. The technology has since been introduced in over one hundred countries.

It's hard to believe now, after years in which the United States has exported its antiabortion movement all over the globe, that the American government was once responsible for bringing safe abortion to great swaths of the developing world. Hard to believe, too, that support for distributing contraceptives to remote corners of the planet was once a solidly bipartisan undertaking. As George H. W. Bush wrote in 1973, "Success in the population field, under United Nations leadership, may, in turn, determine whether we can resolve successfully the other great questions of peace, prosperity, and individual rights that face the world." (As a congressman, Bush earned the nickname "Rubbers" for his enthusiastic interest in family planning.)

Today abortion is broadly legal in the vast majority of the developed world and in Asian countries, including China and India; more than 60 percent of people live in countries with liberal abortion laws. Another 14 percent or so live in nations like Colombia and Ghana that allow abortion under certain circumstances. But in many poor countries, including large parts of Africa and Latin America and parts of Asia and the Middle East, abortion is either banned entirely or allowed only to save a woman's life.

Twenty-six percent of the world's women and men live under such laws, which are largely the relics of colonial constitutions promulgated by European countries that have since abandoned such restrictions for themselves.

Given that so many abortion bans are artifacts of colonialism, it is particularly ironic when the contemporary global antiabortion movement accuses reproductive rights activists of neoimperialism. Yet it's also true that realpolitik-driven fears of swelling third world population, more than humanitarianism, drove early efforts by the United States to bring family planning to poor countries. America's international commitment to birth control was intended to fight communism, not to liberate women. If it did the latter, that was at best a bonus. Eventually, the national security rationale would give way to a focus on women's rights, leaving birth control programs far more politically vulnerable to right-wing attacks, since nothing but women's lives was at stake.

The vicissitudes of the United States' policies on birth control and abortion have always had at least as much impact abroad as they do domestically. Americans don't pay much attention to what goes on beyond their borders, giving those working on issues of sexual health abroad a freer hand than at home, whether that means blanketing neighborhoods in other countries with packets of pills or channeling money to abstinence-promoting, condom-excoriating missionaries. American officials have introduced safe abortion into foreign countries, and they've interfered to make abortion more perilous. The United States pushed to create the United Nations Population Fund, the world's premier agency promoting reproductive health, in 1969. Decades later, the United States government tried to destroy it.

By then it was in some ways too late: The family planning infrastructure that America did so much to build had taken on a life and a legitimacy of its own. At the same time, the forces of cultural globalization -- undermining sexual taboos and celebrating individual rights above community attachments -- continue to be associated with Americanization. Thus a country like Nicaragua can pass abortion legislation that mirrors the position of the party then in power in the United States and still spin it as a blow against Northern imperialism.

The global spread of family planning has vastly changed the world. Even as the planet's population increased nearly fourfold in the twentieth century, from 1.6 billion to 6.1 billion people, fertility rates have declined sharply in most countries, and smaller families have become the norm. "In the 1950s, women in less developed regions had an average of six children," wrote UN demographer Joseph Chamie. "[T]oday's average is closer to three. By mid-century, the global fertility average is anticipated to be close to replacement levels of around two children per couple." There are many reasons women are having fewer children, but many studies show that a substantial part of the decrease is due to increased access to contraception, now used by more than half the couples in the world.

In some countries effective family planning programs have been a great boon to development. Falling birthrates, which for a time increase the percentage of working adults to dependent children in a society, create a window where a greater share of the population is productive. Demographers call this the "demographic dividend," and it can be a major spur to development. Harvard economists David Bloom, David Canning, and Jaypee Sevilla have argued that the demographic dividend created by East Asia's postwar embrace of family planning "was essential to East Asia's extraordinary economic achievements, accounting for as much as one-third of its 'economic miracle.'" (The Philippines, conversely, is the only big East Asian country to eschew family planning, and the only one whose economy never took off.)

Perhaps most important, the global family planning movement has -- often inadvertently, and in the face of great internal resistance -- given rise to a new vision of universal women's rights that has changed both international law and individual lives. At the 1994 International Conference on Population and Development in Cairo, more than 180 countries adopted a program of action proclaiming, "Advancing gender equality and equity and the empowerment of women, and the elimination of all kinds of violence against women, and ensuring women's ability to control their own fertility, are cornerstones of population and development-related programs. ... The full and equal participation of women in civil, cultural, economic, political and social life, at the national, regional and international levels, and the eradication of all forms of discrimination on grounds of sex, are priority objectives of the international community."

This was a remarkable statement (and to some social conservatives an appalling one). Like most UN declarations it remains more a goal than a reality. Given the persistence of sexual oppression and even terror in much of the world, the half a million women who die due to pregnancy complications each year, the millions more who have their genitals cut in the name of purity, and the plague of illegal abortion that fills hospital wards from Nicaragua to Nigeria, the Cairo program of action can today seem like empty verbiage. But just as peacekeeping remains a crucial endeavor despite the endurance of war, and human rights law matters despite constant violations, the global commitment to reproductive rights represents an important attempt to unite humankind against an ageless scourge: the wholesale devaluation of women.

There have been setbacks and backlashes, some caused by right-wing forces in the United States, others by related movements in countries such as Nicaragua. In all likelihood there will be more, since fundamentalism and feminism are both spurred by the upheavals of globalization. Still, slowly, in frustrating fits and starts, a relatively new international ideal of women's rights as human rights is altering laws and societies in subtle but systematic ways, forcing changes to discriminatory inheritance laws and patterns of education, draconian abortion bans, child marriages, and other sources of female misery. The attempt to liberate half the world's people from the intertwined tyrannies of culture and biology is one of the least heralded but most ambitious global initiatives in history.

By Michelle Goldberg

Michelle Goldberg is a frequent contributor to Salon and the author of "Kingdom Coming: The Rise of Christian Nationalism" (WW Norton).

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