It’s highly important that USAID follow the law so U.S. taxpayer money does not fuel human right abuses and targeted population control abroad. That doesn’t seem to be happening right now.

A group of women lay on the hospital floor, like beggars on the side of the streets, two unconscious and fighting for their life after a botched sterilization procedure. A doctor had chipped one of the women’s bladders as he rushed to snip his target.

He performed more than 30 sterilization procedures in just two hours. That’s four minutes per woman. This scene unfolded at the government-run Patliputra Medical College hospital last year in Jharkhand, India, according to Elle magazine.

“I don’t understand what has happened,” said Gopal angrily. He is the husband of Gudia, one of the victims of the botched sterilization procedure. Gopal’s question makes one wonder about informed consent for family planning, which has long been neglected. Most family planning globally is carried out with either direct or indirect support from U.S. taxpayers through the agency USAID.

Was the family fully informed about the risks and side effects of the procedure? Did they receive proper counselling, or were they lured and rushed into the program? Did they receive instructions about post-operative care? Were the doctors given targets to be achieved, and compensation for each procedure?

These are just some of the questions that scream for our attention. The answer tells whether these family planning programs violate the Tiahrt Amendment—the statutory requirement pertaining to U.S. tax dollars spent on global contraception programs like this sterilization camp.

“Botched sterilizations are not unusual,” according to health activist Devika Biswas. She is right. According to a 2013 U.S. State Department report, three women die from botched sterilization procedures every week in India. A 2015 report by Population Research Institute exposes USAID’s direct involvement in incentivized population control programs under the “Maternal and Reproductive Health” rubric for decades.

Pressure on Indian states from USAID and the government of India make it likely to happen again unless USAID is forced to revise its funding policy to eliminate these abuses.

Is India Violating the Tiahrt Amendment?

The Tiahrt Amendment enacted in the 1999 Foreign Appropriations Act is a statutory requirement that ensures “choice, voluntarism and informed consent” in USAID funding for global family planning programs. The key requirements of the Tiahrt Amendments as described by USAID include:

Service providers cannot use of targets/quotas for the FP acceptors or use quantitative estimates or indicators for budgeting and planning purposes No incentives, bribe, financial reward or payment of any type for accepting family planning and no incentives involved for the service providers or referral agents in achieving targets or quotas Rights and benefits not be withheld from persons who decide not to become acceptors Acceptors get comprehensible information either through counseling, brochures, packet inserts or posters on the risks and side effects of the family planning method of their choice.

USAID cannot bypass these requirements under the pretense of providing only technical assistance and claiming that they’re not directly involved in funding the camps or any target-based contraception programs. As the USAID website says, “Tiahrt applies when any kind of development assistance is provided for FP service delivery projects (such as improving the project’s management capability and not just service delivery support), regardless of whether the assistance is in the form of cash, technical assistance, commodities, or training.” The guidelines further clarify: “The requirements of the Tiahrt amendment must be implemented effectively in bilateral family planning activities with foreign governments.”

Yet Devika Biswas, the health activist in India instrumental in the landmark Supreme Court case that ordered the shutdown of sterilization camps, says, “Sterilization procedures are conducted on women without prior medical exam and there have been instances where half way through the surgery they find out that the woman was pregnant. All these rules about medical assessment and informed consent is not ensured because it demands more time spent on each woman and the government is not ready to do it. “

Americans Spend a Lot to Sterilize India

India is one of the largest USAID recipients, receiving an average of $100 million each year. The money India receives for contraception is relatively higher than the total it receives for basic health. It’s highly critical for the USAID administration to ensure statutory compliance so that U.S. taxpayer money does not fuel human right abuses and targeted population control abroad.

Around 4 million sterilizations and 6 million IUD insertions were performed in India in 2017. Close to 200 million IUD insertions and 200 million sterilizations were performed in the country in just six years (2010-2016). USAID disbursements for the corresponding period add up to $100 million. This is money dedicated exclusively for contraception and does not include funds for other population policies and maternal health.

Women have died and still die in these sterilization camps. It’s highly questionable that Tiahrt was upheld considering the huge numbers of IUD insertions and sterilizations presented by the government of India as “achievements” in their family planning program.

Population Control and Ethnic Minorities

The idea of target-based population control programming masked as voluntary family planning is not far-fetched. Lately, public discussions and repugnant statements from politicians about eugenic population control have resurged in the country.

Late last year Giriraj Singh, the union minister of the right-wing ruling political party, said, “I am in favor of a law for population control.” In an earlier comments, Singh said things like, “The Hindu population is witnessing a sharp decline and the population explosion of divisive forces is dreadful.” His statements are likely to instill panic and division among religious groups.

Several ministers in the government, especially those affiliated with the right-wing Hindu nationalist organization called Rashtriya Swayamsevak Sangh, known as RSS, have used the rhetoric of population control and a two-child policy.

The Push for a Two-Child Policy

Around 125 ministers of Parliament have signed a writ petition calling for a nationwide two-child policy. A writ petition is a formal call for action from the government on any issue. It is the precursor of a bill.

Elected representatives and government employees who do not abide by two-child norm are punished and have been forced to resign from their positions. Eleven Indian states already have such policies in place. Schools deny admission to children if a family has more than two. Propaganda and policies such as these can lead to gross exploitation of women, especially poor people.

The eugenic motivations of this population-control campaign are further underscored by India’s overall demographics. The need for a two-child policy is entirely questionable given how 24 Indian states of the total 29 have reached a total fertility rate of 2.1 and below, which is already below replacement level.

Public discourse of incentivized population control raises alarms among citizens, especially after China’s state-sponsored population control efforts. One wonders whether India is another China in the making.

“I was shocked to learn that certain MPs are now holding up China’s one-child policy as an example that India should follow,” says Steven Mosher, president of the Population Research Institute in Virginia. “Those in India that are pushing for the country to adopt a two-child policy on the Chinese model are embarking on an extremely dangerous path. I know first-hand how draconian population control policies like China’s play out on the ground. Population control policies like China’s now two-child policy always lead to coercion and abuse. India’s will too, if it is not stopped now.”

If that is the case, India’s future social problems may be much bigger than a petty population dispute between Hindus and Muslims, including the collapse of the workforce, a slow or stagnating economy, unsustainable government finances, and the inability of the government to sustain social support and infrastructure.

Other Laws May Have Been Violated, Too

The Tiahrt Amendment is not the only tool to ensure USAID is properly vetting family planning programs funded by U.S. taxpayers. Other laws and regulations for USAID contraception programs also come into play. The DeConcini Amendment (1985) guarantees choice of broad range of family planning methods and services, for example, and the Silijander Amendment (1981) prohibits the use of funds to lobby for or against abortion. Notably, many USAID implementing partners in India, including Jhpiego, IPAS, Path, and IPPF, all lobby for liberalizing abortion.

The data on contraceptive usage raises questions about the family planning methods offered to people through such programs. Why is a permanent and unpopular method of family planning like sterilization so prevalent in India as opposed to other methods? Were women simply lined up to be snipped? Was it easier to get poor, uneducated women to accept sterilization to avoid followup visits and additional work, as is required for the other birth control methods more widely used in more developed countries?

USAID’s bureaucratic labyrinth makes it hard to ensure accountability, even with this anecdotal evidence of abuses. The legal offices of USAID no doubt have artful explanations for using U.S. taxpayer money on India’s population control programs.

But it is evident beyond the slightest doubt that the spirit of Tiahrt and similar congressional safeguards are being ignored by USAID and the implementing partners. It is also beyond doubt that U.S. taxpayers don’t want their money spent on deceitful programs that sponsor eugenic projects, which are contrary to the fundamental rights and values of the American people. It is therefore urgent to re-evaluate USAID’s contraception programs, especially its work in India, for possible violations of U.S. law and values.