IN DEPTH AT americas.org OCTOBER 1999

Mexico Still Forces IUDs on Chiapas Mayans

By Jonathan Kirsch
Ejido Jalisco, Mexico

Late in the evening, Dora arrives at our one-room clinic in this Chiapas highland town after a six-hour walk from her village. “My belly hurts,” she says in the broken Spanish of a Tzeltal Mayan. She looks to be in her mid-20s but doesn’t know her exact age.

“Have you been treated for worms?” I ask. After six months volunteering here and three previous medical trips to Chiapas, Mexico’s southernmost and poorest state, I’ve come to know all about intestinal parasites, from the common Giardia to the 25-foot Ascaris. Most children in the area get anti-parasite medicine every three months, but it does little good when they have to sleep on the floor with siblings and when there’s no soap for washing hands.

“Have you had diarrhea?” asks my co-worker, Dr. Sergio Meneses, who came here from Mexico City for a “social service” year required of all Mexicans who earn a professional degree.

Dora doesn’t divulge much about her pain, but her answers seem to rule out worms. We continue talking with her by candlelight. The clinic, a nongovernmental facility, has lacked electricity since a government worker visited two weeks ago to “readjust the wires.” It’s now the only building in town without lights.

Dora eventually lets on that the pain began eight months ago and that it has accompanied heavy menstrual bleeding. The rest of the story quickly falls into place: She is one of thousands of Mexican indigenous women who, without their consent, were inserted with an intra-uterine device (IUD), a T-shaped apparatus of plastic and metal that prevents fertilized eggs from implanting in the womb.

The IUDs are part of a federal “health” program to reduce the population. In Chiapas, the program complements a low-intensity war the government has waged since 1994, when the indigenous Zapatista rebels emerged.

The International Covenant on Civil and Political Rights, signed by Mexico in 1981, bans involuntary medical treatment. Yet it’s routine for Mexican medical personnel to place an IUD, or even perform sterilization, without the woman’s consent and even without her knowledge.

QUOTAS

Here in the heavily indigenous Chiapas highlands, health care access is severely limited. The area has only one doctor per 19,000 people, according to a report by the state’s Education, Culture and Health department. The figure for Chiapas as a whole is one doctor per 1,500 people and, for the entire country, one per 750. The disparity was among reasons behind the Zapatista National Liberation Army (EZLN) revolt.

The federal government has responded to the revolt with a military occupation. Today some 70,000 soldiers, about two-thirds of the Mexican army, are operating in or near the highlands. Though military-backed massacres have occurred, the usual tactics are less intense: constant patrols through otherwise-quiet villages, petty attacks on crops and livestock, unfair distribution of water, electricity and health care services, and so on.

Another front of the low-intensity war is coercive population control. Here the main weapon is the federal Program for Education, Health and Food (PROGRESA), which functions like the U.S. Medicaid program, reimbursing hospitals and other health-care facilities that serve extremely poor people. PROGRESA reimbursements hinge on, among other conditions, whether the facilities meet quotas for IUDs and sterilizations. The program does not closely monitor whether patients give consent for the procedures.

In Chiapas, where most poor people are Mayan, many hospitals and clinics provide PROGRESA-funded pregnancy care only in exchange for permitting IUD placement. Often medical staffers get paid according to how many IUD insertions and sterilizations they carry out. The women, as a result, are often pressured to give consent. Often during cesarean sections, they are sterilized without their knowledge.

In 1997, when the Boston-based Physicians for Human Rights visited government hospitals in Chiapas, IUD and sterilization consent forms were completely absent. The government hospital in the highland city of Comitán, according to a 1999 PHR report, sterilizes 30 percent of women who give birth there.

These population control tactics have drawn negative attention from nongovernmental organizations such as PHR and the New York–based Center for Reproductive Law and Policy and even from major media. The Dallas Morning News reported on the issue in 1995.

Yet the Chiapas war continues. A Mexican physician in a government hospital here describes a technique for obtaining IUD consent: ask the women when they’re in the pushing stage of childbirth. The physician says government hospitals award and punish medical staffers according to how many IUDs they place.

WAITING

Dora had her first two children in San Carlos Hospital, a nongovernmental facility in the highland city of Altamirano.

The hospital, opened in 1967, provides culturally competent care for Mayans, with a full-time staff of interpreters that speak Tzeltal, Tzotzil, Tojolabal, Chol and Mam. Because San Carlos doesn’t receive government funds, even poor patients have to pay something. So the hospital houses their visiting family members across the street and allows them to pay off bills by working in the hospital.

But serving highland indigenous people comes at a steep price. San Carlos frequently loses incoming medical equipment and supplies at military checkpoints. In 1995, for example, soldiers confiscated a Brazilian-donated X-ray machine, demanding a tax exceeding the cost of purchasing a new one.

The nuns who run San Carlos endure constant bullying. In 1994, government-backed paramilitary men and the Altamirano mayor threatened to burn down the hospital for treating Zapatista rebels. The government also bars foreigners from volunteering in the facility.

Repression isn’t the only strategy. In 1995, just down the street from San Carlos, the federal government erected the Social Security Medical Institute (IMSS) and began offering free services such as prenatal care (but without cultural efforts such as language interpretation). Many Chiapas medical professionals say the plan, unsuccessful to date, is to put the nonprofit San Carlos out of business.

Dora appreciated the care at San Carlos, but her finances eroded after the army arrived in her village in 1995 and set up blockades to halt trade between area towns. Unable to pay even the small amount charged by San Carlos, she went to the IMSS for her third pregnancy.

Shortly before giving birth in the government hospital’s delivery room a year ago, Dora was asked whether she wanted a cesarean section and sterilization. She had never heard of these procedures, and refused both for fear of surgery. Next she was asked to agree to an IUD, but she refused again, she says. The question alone was inappropriate, as an IUD is not supposed to be placed within a month of giving birth, so it sits properly in the uterus.

After delivering her healthy boy, Dora briefly fainted.

The mysterious abdominal pain and bleeding started four months later. Dora went back to the IMSS, where a nurse took an X ray and asked when the IUD had been placed. Shocked, Dora asked for the device to be removed, but was told she would have to wait four weeks.

That was eight months ago. Since then, Dora says, she hasn’t had time for the seven-hour walk back to the hospital. And she didn’t want to raise a fuss, fearing that the IMSS would cut off medical care to her family. So she tried to endure, hoping the complications would go away.

Here at the Ejido Jalisco clinic, we tell her with regret that we can’t remove the IUD safely without electricity because we need to sterilize instruments and shine a bright light to see what we’re doing. Dora will have to wait a little longer to have her IUD removed.

FORUM: Women Need IUD Option