-Caveat Lector- A Look at the Indian Health Service Policy of Sterilization, 1972-1976 by Charles R. England http://www.dickshovel.com/IHSSterPol.html The purpose of this article is to examine the reasons for and results of the investigations prompted by physicians, tribal leaders, and senators concerning allegations that the Indian Health Service (IHS) was indiscriminately sterilizing Indian women across the nation. This topic brings up several questions of morality, ethics, and the law. These questions cannot help but be colored by the culture and values that we are taught. So it is from this perspective that we look at the sterilization policies and philosophies that were at work within the IHS-PHS, Department of Health, Education, and Welfare (HEW) from 1972 to 1976. It was during this period that the greatest number of Indian women were put under the knife for a plethora of medical, social, and monetary reasons. This article consists of six categories which will: explore the federal relationship with American Indian tribes; describe personal accounts from women who were sterilized and their attitudes toward family planning; explicate state and federal policies regarding informed consent and sterilization; examine the contractual relationship between IHS and private practices; consider the U.S. General Accounting Office investigation of IHS sterilization procedures; and examine the meaning behind the statistics of population growth. Finally, it will analyze the historical relevance of this topic to the model of internal colonialism under which the U.S. government operates. The federal trust relationship with American Indian tribes is based on numerous treaty rights and agreements that include medical services and physicians made available to Indians. However, there are very few statements that mention medical services specifically; instead, there is an implicit understanding of the trust responsibility that includes the health of American Indians. As stated in the American Indian Policy Review Commission's report on Indian health: ...the federal responsibility to provide health services to Indians has its roots in the unique moral, historical, and treaty obligations of the federal government, no court has ever ruled on the precise nature of that legal basis nor defined the specific legal rights for Indians created by those obligations (in American Indian Journal, 1977: 22- 23). The implied meaning of health care responsibilities is somewhat vague, but the treaties and agreements were always meant to favor Indians. In 1955, IHS was transferred from the Bureau of Indian Affairs to the Public Health Service (PHS). This move was made with the expectation that the PHS could improve health care for Indians living on reservations. Even after the transfer had taken place, the health needs of Indians were still not adequately met. This was due to the ambiguous nature of the federal government's responsibility to provide health care. In turn, the IHS had no concrete goals or objectives and operated day to day with only a faint clue as to how it should render services. To date, an Indian client will be given services that may well vary each time that patient walks into an IHS facility: ...the specific services available to him will vary from day-to-day and year-to-year, depending on unpublished discretionary decisions made by Indian Health Service officials and commitments and conditions contained in often voluminous appropriation hearings (American Indian Journal, 1977: 23). This quote suggests that the IHS system is ripe for mismanagement of policies, funding, and staff supervision. It will also come as no surprise to find that IHS has been the subject of a number of investigations. One of the people who initiated the government investigation into IHS sterilization policy was Dr. Connie Uri, a Choctaw Indian physician working at the Claremore, Oklahoma IHS facilities. Dr. Uri had noticed in the hospital records that a large amount of sterilization surgeries had been performed. She then conducted her own interviews with the women involved and found that many had received the operation a day or two after childbirth. In the month of July 1974 alone there were 48 sterilizations performed and several hundred had already been conducted in the last two years (Akwesasne Notes, 1974: 22). The hospital records show that both tubal ligation and hysterectomies were used in sterilization. Dr. Uri commented: "In normal medical practice, hysterectomies are rare in women of child bearing age unless there is cancer or other medical problems" (Akwesasne Notes, 1974: 22). Besides the questionable surgery techniques being allowed to take place, there was also the charge of harassment in obtaining consent forms. In an incident of harassment at the Claremore facility, one woman was told by social workers and other hospital personnel that she was a bad mother and they would have to take away her children. They would then place the children in foster homes if she did not agree to the surgery (Akwesasne Notes, 1974: 22). In one study conducted on the Navajo Reservation and sponsored by the PHS, researchers (who may have ignored the reports of such questionable sterilization procedures, or subtly adjusted their language to satisfy their sponsors) reported: >From 1972 to 1978 we observe a 130 per cent increase in the number of induced abortions performed. During this time the ratio of abortions per 1,000 deliveries has increased from approximately 34 to 77 (an increase of 126 per cent) (Temkin-Greener, 1981: 405). While not exactly within the confines of sterilization, the numbers indicate that the family planning program on the Navajo Reservation was definitely acquiring federal funds to carry on such a massive project. The statistics concerning Navajo sterilization are just as interesting: Between 1972 and 1978 the percentage of interval sterilization has more than doubled from 15.1 per cent in 1972 to 30.7 per cent in 1978 (Temkin- Greener, 1981: 406). The report itself is clinical and methodical; however, the researchers did comment slightly about the relationship between patient and physician: Older women who become pregnant may be much less concerned about reducing their childbearing and may do so primarily when they are influenced by health care providers (Temkin-Greener, 1981: 406). There is room for speculation concerning how much influence these providers stressed in light of previously mentioned charges of harassment and deceit. Once the word of sterilization spread through Indian Country, some tribal leaders carried on their own investigation. Marie Sanchez, a tribal judge of the Northern Cheyenne Reservation, interviewed 50 women, 26 of whom reported that they were sterilized. One doctor told several women that they each had several children and it was time they stopped having children; others were told that they could have children after the operation (Dillingham, 1977: 28). The values that American Indians have toward the number of children a woman bears are quite different than that of white America. There are many Indians who feel that population control should not apply to them. They believe the federal government has done enough to limit the number of Indians on this continent, and the idea of limiting the number of children is based on what whites feel is a comfortable amount. Other researchers have found these general feelings to be true in regard to limiting family numbers. One group of researchers gathered data on urban and rural Omaha Indians in Nebraska to determine if either group had different opinions on family planning. The team cited each group's reason for having children as: ...the family economic situation, the ability to care for the children now and later, family happiness, and the feeling that the couple had enough children were valid considerations in a decision to delay or prevent further pregnancies (Liberty, 1976: 63-64). The research team also noted that the: ...freedom for the mother to work, and the belief that a small population is good for the country, were generally not sufficient cause [for birth control] (Liberty, 1976: 64). Dr. Louis Hellman, the Deputy Assistant Secretary for Population Affairs in the PHS, presented statistics confirming that 150,000 low income people were sterilized in the U.S. from federal grants (Akwesasne Notes, 1977: 22). These funds allowed the states to be reimbursed for up to 90 percent of the cost of indigent women. A report from the HEW states: Voluntary sterilization is legal in all states. Although most states have no statute regulating voluntary sterilization, over half authorize the procedure either explicitly by statute, attorney general's opinion, judicial decision or policies of Health and Welfare department or implicitly through consent requirements...(DHEW report, 1978: 89). Because the states themselves are not following any set policies, it would stand to reason that IHS certainly does not either, and that is the evidence which reveals mismanagement of resources and people. The HEW policies and programs regarding sterilization have been in place since 1966. Akwesasne Notes quoted the statistics released by HEW: HEW now funds 90% of the sterilization cost of poor people. Since 1970, female sterilization in the U.S. has increased almost 300%. From 192,000 to 548,000 performed each year" (Akwesasne Notes, 1977: 31). Researchers on the Navajo Reservation observed that the trend toward more female sterilizations had to do with the providers. The providers were responsible for the huge increase of people coming in and "agreeing" to surgery. The team further stated that the pattern of childbearing on the Navajo Reservation was very similar to those in developing countries (Temkin-Greener, 1981: 406). The exact meaning of the statement is unknown; however, there are examples of child bearing patterns that may shed light on their remarks: Between 1963 and 1965 more than 400, 000 Colombian women were sterilized in a program funded by the Rockefeller Foundation. In Bolivia, a U.S. imposed population control program administered by the Peace Corps sterilized Quechua Indian women without their knowledge or consent...(Akwesasne Notes, 1977: 31). In 1967 the American Public Health Association and the American College of Obstetricians and Gynecologists conducted a study and found that 54 percent of the teaching hospitals nation-wide "...made sterilization a requirement for winning approval for an abortion" (Weisbord, 1975: 155). The following statement further illustrates the paternalistic and authoritative attitude that many physicians have toward women: Persons in the lower educational classes rely more on such operations [hysterectomies]; they have been least likely to control their fertility in other ways, and doctors may finally suggest this method (Westoff, 1971: 56). For years surgeons have used a "Rule of 120" to determine judgments about sterilization. This judgment concerning fertility is a means by which a woman qualifies for sterilization: ...fertility multiplied by age should equal 120 or more to qualify a woman as a candidate for contraceptive sterilization. A 25 year old woman with three children would not be eligible, whereas a 30 year old woman with four children would be. (Arnold, 1978: 11). Attitudes such as these cross the lines when dealing with either private or government employees. Contract Care entails formal agreements with private vendors. It is used when IHS cannot equip its staff or facilities for emergency or specialty care, or an overload of patients. It is also used when alternate resources are available (DHEW, 1978: 2). Most of the circumstances are dictated by the small IHS facilities and specialized services that are usually found in larger facilities. Contract physicians associated with IHS are reimbursed for each sterilization (Miller, 1978: 424). The reimbursements that the physicians receive are from federal funds, but are not federally accountable: Thirty percent of the sterilizations were performed at 'contract' facilities. IHS officials in the Albuquerque and Aberdeen areas said they do not monitor.cgi the consent procedures in contract care, nor are doctors required to follow federal regulations (Akwesasne Notes, 1977: 4). Normally, anybody that receives funding from the government must also follow federal regulations. IHS, however, shows a lack of concern and accountability with the patients they treat and the money they handle. Complaints continued throughout the country of these unethical sterilization practices, but little was done until the matter was brought to the attention of Senator James Abourezk (D.SD), and affirmative steps were taken. Abourezk commissioned the General Accounting Office (GAO) to investigate the affair and to determine if the complaints of Indian women that they were undergoing sterilization as a means of birth control, all without consent, were true (Dillingham, 1977: 27). The problem with the investigation was that it was initially limited to four area IHS hospitals„later twelve„so that the total number of women sterilized remains unknown (Dillingham, 1977: 27-28). The GAO investigators came up with 3,400 women, but others speculate that at least that many were sterilized each year from 1972-76. When the GAO report came out, the U.S. Information Agency issued its own report denying the allegations. The report claimed that all women who underwent the surgery had given their consent (Akwesasne Notes, 1977: 4). This is where the charges that informed consent was not given were challenged. The GAO confined its investigation to IHS records, and did not probe case histories, nor observe patient-doctor relationships or interview women who had been sterilized (Jarvis, 1977: 30). What the GAO conducted was not an investigation; instead, it played the political game of "looking into allegations," and who would blame them otherwise„with less than a million voters who rarely participated in elections. The Indian people, in this unfortunate case, were "humored" with the GAO investigation. In 1974, to set up safeguards, Congress defined the term "voluntary sterilization" to mean "...[the] requirement that the individual have at his disposal the information necessary to make his decision and the mental competence to appreciate the significance of that investigation" (DHEW report, 1978: 8). The GAO investigators were able to show that there was a lack of clear statement to notify the patients of a federal court requirement "...that individuals seeking sterilization be orally informed at the outset that no federal benefits can be withdrawn because of failure to accept sterilization" (Dillingham, 1977: 27). A U.S. District Court for the District of Columbia had ruled in 1974 that the HEW had to abide by these laws (DHEW report, 1978: 8). Coercive sterilization, on the other hand, can be defined by one or more of the following: caused by outright deceit; offering sterilization as a means to escape further obligation to an institution, such as an asylum; threats to person; sterilization of minors, or mentally or physically disabled persons; failing to explain procedure in a language that the patient understands (Trombley, 1988: 1). As the newly appointed director of Claremore IHS stated: Even if many of these operations were done at the request of the patient, it is all too obvious that there is little or no attention given to proper counseling as to the serious implications of such a decision" (Akwesasne, 1974: 22). Coercive sterilization can be defined by examples of testimony, but the burden of proof is on the patient that has her signature on the bottom of the page. The sterilization of minors is another problem which the GAO investigators could have, but did not pursue. There are special consent forms for cases where women under 21 are to be sterilized, but IHS did not use such forms. Thirty six women under 21 were sterilized without proper consent between 1973-76 (Akwesasne, 1977: 4). Congress passed laws in 1975 making it punishable by fines and/or penalties for "...any officer or employee of the United States," or others using federal funds who "...[coerces} or endeavors to coerce any person to undergo an abortion or sterilization" (DHEW report, 1978: 9). The fact that the U.S. has no prior law concerning the punishment of coercive sterilization underlines the seemingly reckless abandon that physicians had in sterilizing Indian women. The conclusion of the GAO investigation reported that IHS consent procedures lacked the basic elements of informed consent, particularly informing a patient orally of the advantages and disadvantages of sterilization. Furthermore, the consent form had only a summary of the oral presentation, and finally the form was lacking the information usually located at the top of the page notifying the patient that no federal benefits would be taken away if they did not accept sterilization (Wagner, 1977: 75). The GAO notified IHS that it needed better consent procedures. Some IHS Area Directors, like John Davis at Claremore, were pressured by local Indians and by Indian physicians and staff to suspend certain nurses and to move the hospital administrator to another post. Otherwise, there was little else done by government officials (Akwesasne Notes, 1974: 22). Individual women victimized by the procedure were not interviewed in the investigations, and were infuriated by the GAO results. Some of the women took the matter to court, but soon found out that IHS officials covered their trails very well: "Doctors have taken care to obtain some kind of consent documents which can be reproduced in a courtroom..." (Larson, 1977: 63). Further, "...the written consent form is the only piece of evidence that documents the transaction between doctor and patient which gave rise to the patient consenting to the recommended treatment" (Doudera, 1981: 103). Outraged Indian people accused IHS of making genocide a part of its policy. IHS officials responded that the word "genocide" was unwarranted.: ...officials also point out that the report does not prove forced sterilization, that the consent documents are on file and in absence of reliable national statistics on sterilization rates, it is impossible to tell whether Indians are being sterilized at a higher rate than anybody else (Larson, 1977: 63). For IHS, being charged with genocide was a serious accusation. IHS was intended to somehow alleviate the terrible health conditions in Indian communities. However, the accusation was not far off base. As Thomas Littlewood stated in his book on the politics of population control: Non-white Americans are not unaware of how the American Indian came to be called the vanishing American...This country's starkest example of genocide in practice" (Littlewood, 1977: 82). The 3,406 women that appeared so often in government reports were those taken from only four health service areas: Aberdeen, SD, Albuquerque, NM, Oklahoma City, OK, and Phoenix, AZ. All four service units were found to be "...generally not in compliance with government regulations requiring informed consent" (Dillingham, 1977: 27). Senator Abourezk himself stated that: "Given the small American Indian population, the 3,400 Indian sterilization figure would be compared to sterilizing 452,000 non-Indian women [out of 55,000 Indian women of childbearing age]" (Wagner, 1977: 75). However, the Senator failed to realize that the figure represented only four service areas. The estimate of total sterilizations was actually around 3,000 per year for four years. As late as 1979 in the 96th Congress, there was a statement from a national council of churches that condemned the policy of non-medical sterilization and asked for a full investigation into HEW to find all responsible people guilty of this act, and the extent to which IHS had incorporated this policy (96th Cong., Hearing, 1979: 65). One can see that the charge of genocide was not just a romantic cry out to the liberals and bleeding hearts. There is justification. From the United Nations Convention on the Prevention and Punishment of the Crime of Genocide emerged a list of acts that constitute genocide. Article II states: In the present Convention, genocide means any of the following acts committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious group, such as...imposing measures intended to prevent births within the group... (Whalen, 1989: 169). It is interesting to point out that these measures were adopted by the United Nations Center for Human Rights in 1948, but were not adopted by the United States until 1988. >From an anthropological perspective, Steve Polgar comments on population policies, international and national: ...it helps those who want to reduce foreign aid, since exporting propaganda techniques for 'zero population growth' or consulting on how to 'weaken' the family is much cheaper than providing significant development assistance or establishing fairer prices for imported products (Polgar, 1972: 208). The problems of IHS have always stemmed from a lack of clear and precise objectives and goals. IHS will continue to have problems if it cannot act responsibly: "Changing administration of Indian Health... will never solve these problems until Congress...defines the legal scope of the Indian Health program and then determines the appropriation on the basis of this definition" (American Indian Journal, 1977: 23). However, not even Congress can solve the problems without the input and cooperation of Indian people. Selected Bibliography "American Indian Policy Review Commission's Report on Indian Health." American Indian Journal ofthe Institute for the Development of Indian Law. Feb., 1977; Arnold, Charles B. "Public Health Aspects of Contraceptive Sterilization." in Behavioral-Social Aspects of Contraceptive Sterilization [Sidney Newman, ed.]. Lexington Books, 1978; Dillingham, Brint. "American Indian Women and IHS Sterilization Practices." American Indian Journal... Jan. 1977; Doudera, A. Edward. "Informed Consent: How Much Should the Patient Know?' Rights and Responsibilities in Modern Medicine [Marc D. Basson,ed.]. Alan R. Liss, Inc., 1981; Jarvis, Gayle Mark. "The Theft of Life." Akwesasne Notes, Autumn 1977; "Killing Our Future: Sterilization and Experiments." Akwesasne Notes, Spring 1977; Larson, Janet Karstan. "And Then There Were None: Is Federal Policy Endangering the American Indian Species?" Christian Century, Jan. 26, 1977; Liberty, Margot. "Rural and Urban Omaha Indian Fertility." Human Biology, Feb. 1976; Littlewood, Thomas B. The Politics of Population Control. University of Notre Dame Press, 1977; Miller, Mark. "Native American Peoples on the Trail of Tears Once More." America, Dec. 1978; Polgar, Steven. "Population History and Population Politics from an Anthropological Perspective." Current Anthropology, Apr. 1972; Rabeau, Erwin S. & Angel Reaud: "Evaluation of PHS Program: Providing Family Planning Services for American Indians." American Journal of Public Health Aug. 1969; "Sterilization of Young Native Women Alleged at Indian Hospital. Akwesasne Notes , Jul. 1974; Temkin-Greener, Helen. "Surgical Fertility Regulation Among Women on the Navajo Indian Reservation." American Journal of Public Health, Apr. 1981; Trombley, Stephen. The Right to Reproduce: A History of Coercive Sterilization. Weidenfeld & Nicolson, 1988; U.S. Dept. of HEW. Family Planning, Contraception, Voluntary Sterilization and Abortion. GPO, 1978; U.S. Dept. of HEW. Indian Heath Trends and Services [report]. GPO, 1978.; Wagner, Bill. "Lo the Poor and Sterilized Indian." America, Jan. 29, 1977; Weisbord, Robert C. Genocide? Birth Control and the Black American. Greenwood Press, 1975; Westoff, Leslie A. & Charles F. From Now to Zero. Little, Brown & Co., 1971; Whalen, Lucille. Human Rights: a Reference Handbook. ABC-Cilo, Inc., 1989.) 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