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48–459 CC








FEBRUARY 25, 1998

Printed for the use of the Committee on International Relations

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BENJAMIN A. GILMAN, New York, Chairman
HENRY J. HYDE, Illinois
CASS BALLENGER, North Carolina
EDWARD R. ROYCE, California
JAY KIM, California
TOM CAMPBELL, California
JON FOX, Pennsylvania
LINDSEY GRAHAM, South Carolina
ROY BLUNT, Missouri
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SAM GEJDENSON, Connecticut
TOM LANTOS, California
PAT DANNER, Missouri
BRAD SHERMAN, California
BOB CLEMENT, Tennessee
BILL LUTHER, Minnesota
JIM DAVIS, Florida
RICHARD J. GARON, Chief of Staff
MICHAEL H. VAN DUSEN, Democratic Chief of Staff

Subcommittee on International Operations and Human Rights
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CHRISTOPHER H. SMITH, New Jersey, Chairman
HENRY J. HYDE, Illinois
CASS BALLENGER, North Carolina
LINDSEY O. GRAHAM, South Carolina
TOM LANTOS, California
GROVER JOSEPH REES, Subcommittee Staff Director and Chief Counsel
ROBERT R. KING, Democratic Professional Staff Member


    Mr. Mark Schneider, Assistant Administrator for Latin America and the Caribbean, U.S. Agency for International Development
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    Dr. Hector Hugo Chavez Chucon, President, Regional Medical Federation of Ayachucho, Andahuaylas, and Huancavelica, Peru
    Ms. Victoria Vigo Espinoza
    Ms. Avelina Sanchez Nolberto
Prepared statements:
Hon. Christopher H. Smith, Chairman, Subcommittee on International Operations and Human Rights
Mr. Mark Schneider
Dr. Hector Hugo Chavez Chucon
Ms. Avelina Sanchez Nolberto
Ms. Victoria Vigo Espinoza
Additional material submitted for the record:
Communiqué statement signed and sealed by the Ministry of Health
Report on staff delegation to Peru, February 19, 1998, Grover Joseph Rees
Government of Peru, Ministry of Health, statement of the Reproductive Health Program, February 1998
Inspector General's Report

House of Representatives
Committee on International Relations
Subcommittee on International Operations and Human Rights
Washington, DC.
    The Subcommittee met, pursuant to notice, at 1:20 p.m., in room 2167, Rayburn House Office Building; Honorable Christopher H. Smith [chairman] presiding.
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    Representatives Present: Smith and Burton.
    Staff present: Grover Joseph Rees, staff director.
    Mr. SMITH. At this hearing of the Subcommittee on International Operations and Human Rights we will hear testimony of shocking human rights violations in the country of Peru, a country with whose government and people the United States has a close and friendly relationship. Indeed, I should begin by saying that I myself consider the Foreign Minister of Peru, Eduardo Ferrero, a personal friend. I have had cordial meetings with President Alberto Fujimori both in Lima as well as in Miami, and I have a special feeling for the Peruvian people.
    One of the obligations imposed by friendship, however, is honesty. I hope that today's hearing will help us to know the truth both about the Peruvian population program and about the U.S. role, if any, in this program. To that end, we invited the Peruvian Embassy in Washington to send a witness to this hearing, but our invitation has been declined. The Embassy is invited to submit a written statement which will be made a part of the record.
    [This statement appears in the appendix.]
    Peru is a heavily Roman Catholic country with one of the lowest per capita incomes in the Western Hemisphere. Its population density is also relatively low. Until 1995, the family planning program operated by the Government of Peru was not a particularly high priority among that government's health programs. Sterilization was illegal except when necessary to preserve health.
    In July 1995 President Fujimori announced that family planning would be a major priority for the government. Shortly thereafter, the Congress legalized sterilization as a method of family planning.
    In spring and summer of 1996 government health workers began to conduct sterilization campaigns, often styled ''ligation fairs'' and, to a lesser extent, ''vasectomy fairs'', primarily in areas that were poor and/or rural. Reports began to appear shortly thereafter of sterilizations without consent or without informed consent. These reports came from the Catholic Church, from human rights organizations, from feminist groups, and eventually from the government's own ombudsman.
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    Critics of the government program alleged:
    That sterilizations are performed pursuant to prescribed national and regional goals rather than to patient demand;
    That women, particularly those who are extremely poor and/or illiterate, are often pressured into undergoing tubal ligations;
    That these women are not given adequate information about the risks and disadvantages of the surgery or about the availability of alternative methods of family planning;
    That women are not encouraged to take time to make a considered decision about whether they want an operation that is permanent and likely to be irreversible;
    And that the surgery is often performed in substandard facilities, with resulting medical complications.
    There have also been reports that consent to sterilization has been imposed as a condition of receipt of food in government operated food programs, including programs supported by the United States, and that health workers in some locations have been paid a bonus for each woman they persuade to undergo a sterilization.
    In January I asked my staff director and chief counsel of the Subcommittee, Grover Joseph Rees, to travel to Peru in order to investigate these charges. He met with doctors, human rights workers, government officials, and several of the victims themselves. His report made the following conclusions:
    That the government had announced goals or quotas for the number of people to be sterilized nationwide, in particular regions, and even in particular hospitals.
    That these goals emanated from a very high level in the central government.
    That health officials, doctors, and other health workers would generally feel an obligation to meet these goals and would fear that their contracts would not be renewed if they failed to meet those goals.
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    That other abuses, such as lack of informed consent, pressure to consent, bonuses per woman sterilized, and trading food for consent, were probably not mandated by the central government but were the natural outcome of the mandate that the goals must be met.
    I also asked Mr. Rees to determine the extent, if any, to which U.S. foreign assistance funds might be supporting the abuses in the Peruvian population program. His conclusions were as follows:
    The U.S. family planning program in Peru is the largest in the Western Hemisphere and one of the largest in the world. It is conducted primarily through non-governmental organizations but also consists in some aid to programs of the Government of Peru.
    To its credit, the USAID Office of Population, Health, and Nutrition made efforts to distance itself and its funds from the sterilization campaigns as soon as they became evidence in 1996.
    Unfortunately, these efforts consisted mostly of private meetings and communications with government officials, foreign donors, and a few NGO's. The sterilization campaigns themselves, in contrast, were widely publicized, as was USAID's close and long-time association with the Government of Peru's family planning program. So many Peruvians have the impression that the United States supported the program in its entirety, including the sterilization campaigns.
    Although USAID has made efforts to ensure that its assistance to the Peruvian Government does not support the sterilization campaigns, USAID continues to provide family planning assistance to the government and to NGO's that work closely with the government. In addition to broad support for the Ministry of Health infrastructure that might inadvertently assist the sterilization campaigns, this assistance has included several training courses for doctors in the technical aspects of performing vasectomies and tubal ligations.
    The USAID Food for Peace program in Peru, whose programs are far more extensive than those of the Office of Health, Population, and Nutrition, has been a focus of allegations that poor women were promised food in exchange for their consent to be sterilized. In the face of these allegations, the USAID officials who manage the Food for Peace program failed to make vigorous efforts to ensure that no such abuses could occur. Indeed, Food for Peace operates a large targeted feeding program through an NGO that also conducts family planning programs for the Government of Peru. This NGO conducts its feeding programs in many of the same small rural medical posts in which the sterilization campaigns are conducted. In smaller posts the same government worker may be charged with distributing U.S. food and running the sterilization campaigns.
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    On January 6, 1998, after the sterilization campaigns and associated abuses had been widely publicized, the director of our USAID office in Lima wrote a letter to the Minister of Health stating that ''our desire to collaborate in the area of family planning is based on the free, voluntary and informed choice of contraceptives . . . not in the pursuit of quantitative targets by method for a particular service provider or group of service providers, especially where tubal ligation and vasectomy are concerned.''
    The letter went on to list remedial measures on which ''we need to be able to count . . . as soon as possible'' to ensure that no U.S. food was traded for sterilization and that family planning programs of the Peruvian Government were not conducted pursuant to goals, quotas, or what the government has called ''referential numbers.''
    Mr. Rees' report makes the following recommendations, which I strongly endorse and I hope USAID will discuss today:
    (1) Discontinue all direct monetary assistance to the Government of Peru's family planning programs until it is clear that the sterilization goals and related abuses have stopped and will not resume.
    (2) Discontinue in-kind assistance to the government family planning program unless it is clear that such assistance will not assist or facilitate, either directly or indirectly, the sterilization campaigns or related abuses.
    (3) Discontinue public expressions of support for the government's family planning program, for instance, joint Ministry of Health/USAID billboards encouraging Peruvians to limit their families, that could easily be misconstrued as expressions of support for the sterilization campaigns.
    (4) Dissociate the United States from the sterilization campaigns, goals, quotas, and associated abuses far more publicly than has been done up to now.
    (5) Discontinue the use of words and actions that lend themselves to the accusation that USAID still favors population control over family planning.
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    (6) In choosing non-governmental organizations as grantees or contractors, use only those who will work independently of the government and who have not shown a preference for sterilization over other birth control methods.
    (7) Discontinue the distribution of food through government medical posts or in cooperation with entities closely associated with the sterilization campaign.
    (8) Contract for an independent audit to determine whether any U.S. assistance to the government or NGO's has been used in support of the sterilization campaigns.
    (9) Consult with a broader spectrum of voices within Peru on family planning needs and concerns.
    (10) Finally, notify congressional oversight committees of problems as soon as they appear.
    I am well informed that the USAID Mission in Lima kept its superiors in Washington posted as events unfolded. Yet USAID in Washington did not see fit to inform this Subcommittee or any of the other committees with jurisdiction over foreign assistance programs, although they surely knew we would have been interested.
    This problem is not unique to Peru. When I asked about similar allegations of forced sterilizations in Mexico in 1996, our USAID representative assured us loudly and clearly that this doesn't happen here.
    Mr. Schneider, you might recall I brought that up to you after I returned from that trip.
    It now appears, according to reports described in the State Department 1997 Country Report on Human Rights Practices for Mexico, that she has been mistaken. I hereby make a standing request that the Subcommittee on International Operations and Human Rights, which has the jurisdiction for oversight of these issues, be informed of any reports USAID may have or receive of coercion, lack of informed consent, or other abuses anywhere in the world. I would very much appreciate it if you would do that.
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    I would like to now ask our first witness for today's hearing, Mark Schneider, the Assistant Administrator for Latin America and the Caribbean for the U.S. Agency for International Development, as well as a board member of the Inter-American Foundation, if he would present his testimony to us at this time.

    Mr. SCHNEIDER. Thank you, Mr. Chairman. Let me just say before I begin that I want to take this opportunity to say that I have read the statements of some of the women who will follow me to testify today. I just want to say that one can only express sorrow and frustration; sorrow at the fact that those events occurred with respect to those women, and frustration in not having been able to stop them from happening. It's unacceptable and it cannot be excused. I think that we all have to redouble our efforts to ensure that it doesn't happen again even if the instances are one, two, or a handful.
    I want to thank you for the opportunity to appear today. I know that we are in agreement that the human rights of women must be given the highest priority in Peru, that any effort to abridge those rights runs directly counter to the values and foreign policy of the United States.
    The Government of Peru has just announced this week, as I mentioned previous to the session, a number of very important concrete steps that should return their family planning program to a sound foundation. Those copies have now been given to the Committee.
    As of yesterday, we received the following news that the Government of Peru will:
    First, discontinue campaigns in tubal ligations and vasectomies.
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    Second, make clear to health workers that there are no provider targets for tubal ligations and vasectomies or any other specific family planning method, nor any targets of any kind at the regional or local levels. The only goal will be to ensure that women have the information and counseling to achieve their individual desires with respect to spacing and number of children.
    Third, they have announced that they will implement a comprehensive monitoring program to ensure compliance with family planning norms and informed consent procedures.
    Fourth, they welcome the ombudsman office's investigations of complaints, the nine complaints that have been received and commented upon by the ombudsman, and the opportunity to respond to any additional complaints.
    Fifth, they will implement a 72-hour waiting period for people who choose tubal ligation or vasectomy. This must come after two separate counseling sessions.
    Sixth, when judicial evidence of malpractice or uninformed consent is verified and a special judge has been named for this purpose, the Minister of Health has requested that compensation be provided to the women involved.
    Finally, they will require that health facilities be certified in order to make sure that no operations are done in makeshift or substandard facilities.
    We obviously believe that these are all welcome developments, and I think it perhaps is useful to reiterate the Administration's policy with respect to the voluntary nature of family planning. All of our family planning programs are guided by the principles of voluntarism and informed choice. We categorically oppose coercion in any form.
    The evidence is compelling that there is and continues to be a real unmet need for family planning services in Peru. As a poor beneficiary noted, we had a lot of children because before we didn't know how to keep from having them.
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    Responsible family planning programs have a strong track record in improving the health of women and children. It is my hope that in the discussions generated by the controversy over surgical contraception in Peru that we not lose sight of the benefits of family planning programs or of the principles that do guide USAID's efforts.
    If I could give some history, Mr. Chairman. Tubal ligations and vasectomies have been a legal method of contraception in Peru only since September 1995. Previously surgical contraception was allowed only in cases where a woman's health would be in danger from an additional pregnancy. After legalization, the Peruvian Government moved to respond to what it perceived would be a pent-up demand for access to tubal ligation and vasectomies.
    I should add that around the region, when one looks at the full range of methods of family planning that are used, tubal ligations and vasectomies constitute among the modern forms of family planning one of the higher percentages, approximately akin to the use of natural family planning methods in many of the countries.
    To help meet this demand, unfortunately, the Government of Peru pursued a strategy of campaigns in which tubal ligation and vasectomy were offered on a planned date, often in a place where such services were not permanently available.
    As soon as USAID became aware of the Government of Peru's move toward a campaign strategy, U.S. officials, as your staff recognized in the report, communicated to the government strong concerns about the potential for distortions and abuse. The agency also quickly segregated USAID family planning support from the campaign strategy. USAID implementing agencies were told not to support the campaigns in any way, and Ministry of Health officials, including the Minister of Health, were informed that USAID support could not—I repeat, could not—be used in this strategy.
    Again, let me reiterate. The USAID disagreement with the strategy was not based on awareness of any particular abuses at that time, but rather, because of our worldwide experience in family planning as well as our conceptualization of family planning within a quality of care framework, experience has shown that targets and campaigns in this area are counterproductive and fraught with risk. As a matter of policy, USAID does not support performance-based quota systems in family planning programs.
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    While targets connected with provider performance do not necessarily lead to the use of pressure tactics, they at a minimum increase the vulnerability to abuse.
    Moreover, for ethical, political and programmatic reasons, such drastic steps are unwarranted and wrong. They should not occur, and we will not support them.
    Over the past 18 months USAID has not relented in its opposition to setting targets for vasectomies and tubal ligations. More than 80 contacts with government officials, including the Minister of Health and a top advisor to the President, have taken place on this subject between July 1996 and December 1997, when the campaigns were first indicated.
    USAID has also contributed, we believe, to responsible public debate and inquiry on this issue in Peru through our support for the human rights ombudsman, whose office has looked into the reports of abuse, through our support of and cooperation with women's groups, women's rights organizations, and through our statements at public events with a variety of health workers, practitioners and others.
    In November of last year USAID sent a letter to the Minister of Women's Advancement and Human Development reiterating USAID's opposition to campaigns and to targets for surgical contraception or any other specific method, and indicating again USAID's opposition and its avoidance of any support for those activities.
    In early January of this year, Mr. Chairman, as you noted, the USAID Mission director sent a second letter, this time to the Minister of Health, requesting a response concerning the allegations which had then appeared in the Peruvian press during November and December. At that point the letter was prepared and was sent on January 6, requesting response with respect to those allegations as well as again reiterating our view of the need for programmatic changes.
    Let me stress, to the best of my knowledge no U.S. family planning funds or those of U.S. contractors have been used to support the campaign. In his trip report the Subcommittee staff director himself concluded that since shortly after the onset of the campaigns USAID has made efforts to distance itself from those campaigns. We appreciate and acknowledge the objectivity he exercised in reaching this conclusion.
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    In the last few months, as I stated, there were reports in the press that in some cases the right to fully informed consent may have been violated and that tubal ligation and vasectomies have not always been safely performed. It also has been alleged that some health workers may have conditioned provision of food or medical care on acceptance of sterilizations. USAID urged Peru again in that letter to discontinue the tubal ligation and vasectomy campaigns, to disavow any policy of setting provider targets for voluntary surgical contraception, and finally, to implement a comprehensive monitoring program to ensure compliance with family planning norms and informed consent.
    We believe these are significant measures and we are pleased that the Government of Peru, as I indicated in this statement and in the statement that we just received from the Government of Peru, has determined to take these steps.
    Let me add as well that the Ministry has reiterated that it is against the law for any coercion or donation of goods or services, food or otherwise, in exchange for the acceptance of any contraceptive method.
    If I could, Mr. Chairman, let me move to the staff director's report which was shared with USAID. It contains a series of recommendations, several of which mirror the concerns expressed in the letter from our Mission director to the Minister of Health. A significant number of those recommendations are reflected in the Ministry's actions this week.
    I should add as well that they reflect the recommendations that the Peruvian ombudsman's office made following its review of complaints of abuse. It issued a call through various media in Peru to the society at large seeking complaints. To date that office has received complaints from a reported nine individuals who have alleged that they suffered reproductive rights abuses. Though clearly not even one abuse is acceptable, the allegation of mass abuse without informed consent has not been substantiated.
    I would also like to briefly discuss, as you requested, the role of USAID food aid in Peru. USAID's Food for Peace Title II program in Peru benefited approximately 2.3 million poor Peruvians in 1997. We are absolutely convinced that that program has been a critical element in the 30-percent reduction in child malnutrition in Peru over the last 5 or 6 years.
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    The Subcommittee staff directors's report refers to recent allegations linking food assistance to sterilization. Two allegations, one in the report and one that we saw in the press with respect to United States provided food, were investigated immediately through onsite interviews with the women and their family members along with local non-governmental organizations and health promoters.
    There are no known cases, no evidence that we are aware of, and no evidence in these two cases, no substantiation—and I can go into detail in the cases at some point, Mr. Chairman, of any U.S.-funded food assistance being used to coerce sterilizations.
    The Subcommittee apparently has been provided material with respect to these two cases, but again, let me add that we will investigate any allegations which are made in this regard and take appropriate action. We concur with your deep concern, Mr. Chairman, and we will investigate any allegations that allege U.S. food aid in any involvement.
    In concluding this testimony, let me make a few final points.
    We obviously are pleased that the Government of Peru has announced the key changes it has informed us of this week in its family planning program and policy. These steps will help ensure informed choice. We obviously regret that these steps were not taken earlier, as we and others had urged. Nevertheless, this is an important development, and we will continue to keep you and your staff apprised of progress toward implementing these improvements.
    The course of our future action will depend in part upon the continuing response of the Peruvian Government to this situation. We will continue monitoring the implementation of the steps that we have been informed of. And it's essential, we believe, that the Government of Peru continue to listen to the voices of its own people, in this case the ombudsman's office, women's groups, health worker providers, the National Medical Association, and the Ministry of Health's own evaluation of its program.
    We look forward to working closely with you and your staff in the future to support America's international family planning programs.
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    I thank you for the opportunity to appear today.
    Mr. SMITH. Thank you very much, Mr. Schneider. I appreciate your testimony.
    [The prepared statement of Mark Schneider appears in the appendix.]
    Perhaps like you, I just got this statement from the Government of Peru. In looking at it very quickly—we will analyze it very carefully, I can assure you—there seems to be a minimizing or an attempt to minimize the extent of the problem. Perhaps all governments go through that when they try to spin and try to suggest that it's not as bad as you think it is.
    I notice in one of the changes that will be made, it says there will be no provider targets for tubal ligation or any other family planning method. What about national targets? It says regional and provider, but what about national?
    Mr. SCHNEIDER. My understanding is that there will be no provider targets in terms of goals at the national level either.
    Mr. SMITH. At any level? They left that out. It was local or regional.
    Mr. SCHNEIDER. I think when it says there will be no provider targets. Period. The indication was that that was at the national level. In other words, my understanding is that there are no goals to reach.
    Mr. SMITH. I would ask that you try to get them to be very clear on that.
    Mr. SCHNEIDER. Let me just say, Mr. Chairman, that I am perfectly prepared to say that we are prepared, after a period of time, to inform the Committee fully as to the implementation of these steps. We will advise our contracting agencies to report to us if there is any reappearance of the campaigns or if there, in fact, appear to be goals set.
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    We do support the ombudsman's office and the women's rights organizations, and we will ask them specifically on this matter, as to whether or not they have found anything that contradicts this.
    Mr. SMITH. In my opening comments I asked that an independent audit determine whether any U.S. assistance to the government or NGO's has been used in the sterilization campaigns. Can you agree to that?
    Mr. SCHNEIDER. As I stated, what we have done is from the beginning we have segregated these programs. We would be happy to supply you with the information that demonstrates that.
    I should add that the general support that we provide is generally going through non-governmental organizations to the largest extent. We will continue to monitor and we will continue to inform the Committee, and as I stated with respect to this, we will inform the Committee of these activities.
    We do have a series of continuing reports of activities and the use of funds, and we will continue to monitor that. We are confident from the examination of these reports that these funds were not used for the campaigns.
    Mr. SMITH. One of USAID's projects in Peru is called Project 2000. It is a program in which several NGO's, including a population control organization known as Pathfinder International, assists the government in developing a wide variety of health care systems and services. How sure are we that none of this assistance has benefited the government sterilization campaigns?
    Mr. SCHNEIDER. My understanding is that that project relates to a range of health services, not merely the family planning program. The focus of it does include maternal and perinatal health, but we have been monitoring the program. They would be violating their agreement with us; essentially they would be violating their contract with us.
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    Mr. SMITH. Has there been any independent audit of that?
    One of the concerns that many of us have—I have it—goes back to when we first became aware of coercion in the People's Republic of China that the groups that most aggressively defended that program were many of the NGO's, some of those that to this day continue to receive large donations from the U.S. taxpayer, and chief among them is the U.N. Population Fund, which to this day continues to say it's a totally voluntary program.
    That is not even a question anymore. It was a question, and I lived through it, throughout the 1980's when I offered amendment after amendment and had people at USAID tell me that I was missing the mark by a wide mile. Some agreed but many of them disagreed, and especially the NGO community and UNFPA, very aggressively.
    So there is a past to denials and assertions of non-complicity that I'm concerned about, especially when the whole trend in the NGO community is toward integration of health and other humanitarian services. They could become tainted wittingly or unwittingly, like in the food distribution centers and things of that kind.
    Please respond.
    Mr. SCHNEIDER. I understand your concern, Mr. Chairman. What I would like to be able to do is to put together the financial reports that we have on the use of the grant funds. I'm fully prepared to make those available. If after that you believe that there is an additional need, we will discuss it. But I am confident that there has not been any misuse of funds.
    As I say, we do have continuing internal audits; we do have the review by our own Inspector General of the use of grant funds. I am confident that they have not been misused. We will be happy to provide that for you.

    [I am providing a copy of the Inspector General's September 1996 report, the most detailed audit of food aid undertaken up to that date. I shopuld also state that the report found no diversion of food aid nor any misuse of funds resulting from monetization of food aid by the cooperating NGO's. The recommendation in the report, all of which were improvements on an already well-run program, were implemented promptly by the Mission in Lima.
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    [The report appears in the appendix.]
    Mr. SMITH. Every grant is not inspected. There is a certain amount of trust that is implied, especially if there is a track record of having provided grants to that group. So spot checks may or may not discover something. Now that we have a very real and compelling problem on our hands, that's why I asked if an independent audit is something that you could agree to. Could you say yes or no to that?
    As I think we have demonstrated, we are trying to be as absolutely honest and transparent as humanly possible. I don't want to bring up the PRC again, but having lived through that and having seen chicanery and distortion that I still can't believe, the jury is out. When the government says ''there are eight cases.'' Well, there are eight cases maybe that he knows of and looked into. I'll never forget when I started making trips down to Central America finding how small many of the human rights contingents were that were looking into massive violations from the FMLN or any of those other groups. There are just too few people looking at this.
    As my chief counsel advises me, the ombudsman had one investigator. How aggressive were they? How wedded to the program potentially were they? Any conflicts of interest? He says they were good, but that's one person.
    Mr. SCHNEIDER. They are totally independent, and I think they are respected throughout Peru. The international human rights community would also say that the ombudsman represents an independent view.
    Mr. SMITH. But understaffed, certainly. We need to know and have confidence that our tax dollar, wittingly or unwittingly—and I think it would be unwittingly—is not being used to promote this kind of violation of women's rights.
    Mr. SCHNEIDER. Mr. Chairman, as I say, we will put together those reports for you. If after that you still feel there is a need for a further audit, then we will provide it.
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    Mr. SMITH. I appreciate that commitment.
    Could you describe what USAID did to segregate its aid from the sterilization campaigns, what technical steps were involved in the segregation process? For example, were certain kinds of aid that we had been giving before July 1996 immediately discontinued? Did we require new reports of the government and/or the NGO community that worked closely with the government?
    Mr. SCHNEIDER. As I stated, we informed the government that no funds would be provided to them for the campaign; we informed the government that none of our other resources could be used for the campaign; we segregated the program from the campaign at the start and informed our NGO's as well of the same prohibitions.
    Mr. SMITH. Would you provide for the record more information on the technical details on how that was done?
    Mr. SCHNEIDER. Sure.
    Mr. SMITH. That would be helpful.
    [The information is being prepared by the USAID Mission in Lima, and will be found in the Committee files as soon as it arrives.]
    Mr. SMITH. One of the requests in my opening statement was to discontinue the distribution of food through government medical posts which are closely associated with the sterilization campaign. Is that something that USAID can support?
    Mr. SCHNEIDER. I think one has to review what the food programs are aimed at and how they function.
    Mr. SMITH. Nutrition.
    Mr. SCHNEIDER. Let me explain. There are five different cooperating agencies. Four of them provide the food directly in sites other than those that are health clinics. The fifth was an organization which has previously been cooperating in the food distribution program, and it was the one that demonstrated that it could provide programs in the poorest areas of the country where the highest vulnerability children were.
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    In the context of dealing with the problem of malnutrition, or extreme malnourished children, the view was that it is essential to have them linked to the health clinics where the families also could obtain information about clean water, how to prevent diarrheal disease, assuring that the children were immunized at the same time.
    Essentially what happens is the children go into the programs for between 6 months and year. They are severely malnourished; there are a series of criteria. In that process it's a combination of the food plus the health services that result in their being able to achieve a more adequate nutritional level.
    The program you are referring to, there are some 2,300 of those sites. Only 200 of them are the ones directly run by a Ministry of Health official who is also responsible for the family planning services.
    Mr. SMITH. How do you respond to the report that we have—we did submit this. It was part of Joseph Rees' staff report—that Dr. Jon Matta, President Fujimori's health advisor, defended the practice of going house to house to persuade women to undergo sterilization because, to quote the doctor, ''if the Ministry of Health did not do the campaign house to house, people would not come.'' Asked whether there was a need for health workers to go back to the houses time and time again, Dr. Jon Matta replied, ''with a long discussion of a hypothetical male patient with a hernia, a man might not want to get the hernia operation for any number of reasons, but'', Jon Matta said, ''it was a doctor's responsibility to convince the patient into doing what was best and having the operation. It's exactly the same with the ligation,'' he said. ''Women in Peru are having too many children.''
    Poverty is one thing, but if there is an overwhelming health component, perhaps an argument could be made. But when there is an ongoing process to convince someone that children should not be born to that woman, and when you have the very substantial allegation of quotas and people getting bonuses for numbers of ligations performed, it paints a picture of a not so subtle pressure campaign. We've heard of these things, and I have met at least one doctor in Mexico where this allegation has been made, and a number of patients who were sterilized against their will. In this case it's a matter of pressure.
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    How do you respond to that kind of statement, the mindset of this Presidential health advisor?
    Mr. SCHNEIDER. That's the reason that we opposed the campaigns and that's the reason that we segregated our program; that's the reason that no U.S. funds are used to support it. Precisely.
    Mr. SMITH. If in the macro with the sterilization campaigns they are doing, what's to prevent it in the micro, if it just becomes parceled out so that in the implementation the mindset is still there, and there is no changing of stripes?
    Just like nobody in this room believes, I don't think that Saddam Hussein has changed his stripes on a whole host of issues. If this is the mindset going into this, why if the campaigns are discontinued won't it just be done in a more piecemeal fashion?
    Mr. SCHNEIDER. I think what we have seen is recommendations from the ombudsman's group in Peru, the health providers in Peru, recommending that these changes be made for many of the reasons that you are describing along with our recommendations and along with your recommendations. As a result of that, the Ministry of Health has agreed to make the changes that we have heard about, which in fact end the campaigns.
    I believe that it's clear that in all instances health services, family planning or otherwise, should respond to the spontaneous and informed demand of the individuals not recruited for these kinds of services.
    There is one thing that you said at the initial part of your comments with respect to the food program, and I just want to be clear. There are about 400,000 children who receive food through this program. I believe it's 150,000 families. There have been only two alleged instances on problems, and we investigated them specifically.
    Even before last year, last April, as part of the internal review of our programs, we asked that they begin to undertake a review of family satisfaction with the program, including what kinds of information they received with respect to family planning and their satisfaction.
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    This is one of the areas where there is a slight inaccuracy in the Subcommittee report. It was not a precondition for the 1998 program, but it was a fact to be accomplished during the 1998 program. It is under way now. In the preliminary part of that—this is what I wanted to get to—they analyzed 55,000 cases in terms of saying has there been any change during this period in terms of the use of family planning methods, and the answer is no.
    They are now going to go back and interview and undertake interviews with the people who receive services in terms of, did you get adequate information with respect to family planning services? Were you pressured in any way? They are going to attempt to determine that user satisfaction during this time period.
    By the way, that was before any allegations were made.
    Mr. SMITH. With respect to the Food for Peace food distribution programs, why has USAID dramatically cut the role of CARITAS, the Catholic relief agency, and increased the role of PRISMA, the NGO that ran its food distribution programs through the government over the last 4 years?
    Mr. SCHNEIDER. It's very simple really. There was an effort made worldwide to increase our focus on the most food-insecure communities and the most malnourished. In the initial proposal from CARITAS they had 44 dioceses that they had proposed to cover. Eleven of those are on the coast where the levels of food insecurity were relatively low. Compared to the other areas of the country, those areas were not the highest problems, and therefore we requested that those 11 areas not be included. We funded fully the 33 that met the criteria of being in the areas of highest food insecurity and higher problems of malnutrition.
    The program that you mentioned had a higher concentration in those communities of food insecurity, and that is why they received additional funding. That was basically it.
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    Mr. SMITH. The new monitoring and supervision system that the Government of Peru in its statement asserts that it will implement, have you gotten any word from them what that might look like so it's not people who potentially have a conflict of interest?
    Mr. SCHNEIDER. I have, and will try in general terms to describe it. My understanding is they are putting together internally a combination of doctors and lawyers both inside and outside the ministry. It's a committee made up of OB-GYN, medical association, physicians college, the main medical school in Peru, and representatives of the Ministry of Health that will be reviewing all of these allegations. They are undertaking their own monitoring system of these new changes that they have put into effect.
    I believe as well, which I think is very important for us because of the reason I stated earlier, that they are going to use the ombudsman's office as well as women's organizations to report on the implementation.
    Mr. SMITH. One of the other action items speaks of compensation for those individuals or families where there is legal evidence of malpractice. Have you gotten any additional elaboration on what that means? What kind of effort will be undertaken to find these women? Very often it's a lack of knowledge that there is some way of redress that will prevent people from coming forward.
    Mr. SCHNEIDER. Two things. The ombudsman's office does have—I forget the number—district office, regional offices around the country in terms of human rights concerns. My understanding is that they do have nationwide target areas that they can reach with their announcements that they are available for complaints to be made.
    The other is that the human rights organizations, particularly the women's rights organizations, will be made aware of this. I can assure you that the women's rights organizations in Peru are very active. We support them. Manuela Ramos is one of those. I have no doubt that they will be seeking out women who feel that they have in some way had their reproductive rights violated to bring their cases.
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    I think it's important that in this process that apparently there has already been an ad hoc judge named to look into this for this purpose. Once they are verified, they would go for compensation.
    I am also informed that the ombudsman's office itself has a women's rights office.
    Mr. SMITH. Is that something USAID would consider as part of your publicity campaign, to inform women that if it was something less than voluntary or informed consent——
    Mr. SCHNEIDER. Absolutely. We would inform our own cooperating agency.
    Mr. SMITH. What about the larger public relations effort?
    Mr. SCHNEIDER. To the degree that we do public relations in this area, absolutely. We generally would do outreach and dissemination through the groups which are located all over the country. The groups are the ones that are out there.
    Let me say this. What we will do is we will work on development of a statement for all these groups to put out through their programs and through their local organizations.
    Mr. SMITH. I'd like to yield to the staff director and general counsel, Joseph Rees.
    Mr. REES. Mr Schneider, someone in another congressional office was kind enough to give us this morning something that is called the USAID Peru Population Assistance Fact Sheet, which apparently was faxed around to other congressional offices yesterday—not to our office, but to other offices—which makes some rather stronger statements than you do about the report that I issued. Frankly, it's a crummy way to do business, but I do feel that we need to get on the record some of the things that are said in this ''fact sheet'' and get your reaction to them.
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    Mr. SCHNEIDER. I'd like to receive a copy of the fact sheet myself. Apparently there is some confusion. Perhaps you could make a copy available to me.
    Mr. REES. It has a USAID fax logo on it.
    Mr. SCHNEIDER. Or else send it to me.
    Mr. REES. Perhaps it's a clever forgery, but it does seem to mirror your testimony. It makes some rather stronger statements than you make in your testimony. It's not the first time this has happened.
    Mr. SCHNEIDER. I'll be happy to respond once I see it. We'll send you a written response.
    Mr. REES. Some of the things here are also in your testimony, and I'd like to ask you about them.
    Mr. SCHNEIDER. Sure.
    Mr. REES. The general pattern that is kind of disturbing—I did spend only a week in Peru. It was therefore necessary to rely primarily on secondary sources. You can only visit so many people who claim that things actually happened to them. We visited with feminist organizations, with church representatives, the human rights coordinator, the ombudsman. As is clear from the report, the impression that I emerged with was that this was not a small problem; this was a big problem.
    Although it is not possible to quantify the number of women out of those 110,000 who did not have fully informed consent, I don't think it's a fair characterization of the ombudsman's position that only nine people didn't have fully informed consent. The coordinator of human rights, which is a respected, independent——
    Mr. SCHNEIDER. Who we helped finance.
    Mr. REES. Right. I want to quote here from their report. In May of 1977 they reported in a petition to the U.N. Economic and Social Council, ''The national population policies have on many occasions resulted in the imposition of methods of sterilization.''
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    The impression I had from a meeting at which Ms. Brems from USAID was also present with some representatives of feminist groups—it was an informal meeting; I didn't put any of their names in the record—was that this is a pattern. This is not something that just happened a few times. I really thought we were agreed on that when I was down in Peru, that this was a big problem. Yet if I only read this fact sheet, I would think that this Subcommittee was making much ado about nothing, that there were nine cases that we know about and there might be a couple of others lying around there. That's disturbing.
    There is a traditional lawyer story, that the good lawyer can make three arguments simultaneously: my dog didn't bite your client; your client provoked my dog; and I don't have a dog. That seems to be what you are doing here. You are saying we dissociated ourselves from these campaigns, and they weren't so bad anyway.
    Mr. SCHNEIDER. I think that's wrong. They were bad. We argued from the beginning that they should be stopped, because inevitably what they do is they open the door to abuse. Whether that is one or nine, by opening the door to abuse we said that we would not provide any support, and we did not provide any support.
    We also said that when those kinds of abuses occur that we believe the government should, and thankfully in this instance they did, announce that they would stop those campaigns, because they are wrong, and we think that they failed to provide for women's rights, and we think that they inevitably tend to result in the possibility for inadequate health care for the women, particularly when they take place in places that are not the traditional places where appropriate medical treatment can be given.
    Let me also just add, however, there is a difference between—this perhaps relates to your concern—saying that the overall policy of campaigns and setting goals we believe in general is wrong and saying that it has produced widespread violations. That, we do not believe has taken place. Let me just give you some of the reasons.
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    Mr. REES. So you disagree with the Coordinadorn.
    Mr. SCHNEIDER. The difference is what is——
    Mr. REES. They said many occasions.
    Mr. SCHNEIDER. To me nine is many.
    Mr. REES. You think they only meant nine?
    Mr. SCHNEIDER. All I'm saying is that there has not been substantiated a mass lack of informed consent. What we said is that the policy and program created that possibility and we should not participate in it, and we should investigate and press the government to change the policy, and that's what we did, and we should continue to do so.
    Mr. REES. An anonymous source identified as a U.S. Embassy official told a Peruvian newspaper in the last few days that the abuses in the Peruvian program were just isolated cases. You just said nine is many. How many cases would they have to come up with that they validated, that is, people who came forward, despite whatever they may perceive as the risk to themselves, people whose cases were thoroughly investigated, and yes, this is a definite yes? How many do they have to come up with before you would be prepared to tell our Embassy officials to stop calling up and saying that they are isolated cases?
    Mr. SCHNEIDER. I don't think that it's going to produce any particular number. All I can tell you is that I believe that we did what we should, which is to say stop the policy, change the policy; it can produce abuses; those abuses are not acceptable, whatever the number is.
    Now that the government has changed the policy, it's our responsibility to monitor it, to see that it's implemented, and to ensure that there is no repeat if we are going to continue to cooperate in the future.
    Let me just add here. There is something which I think is important in one of the recommendations you suggested, that we stop support for family planning.
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    Mr. REES. That was going to be my next question. That recommendation is not in the report. Where do you see that recommendation in my report?
    Mr. SCHNEIDER. I believe that was in one of the questions.
    Mr. REES. Direct monetary assistance to the government program. Money, unlike in-kind assistance, can be used for anything that the people want to use it for.
    Mr. SCHNEIDER. Currently, my understanding is that we virtually do not provide direct monetary support. There is a very small amount of money that goes to the Government of Peru, and it is basically for training in a particular area of informed consent.
    My concern was that I believe in the earlier questions there was a view that we should not provide support, and I wanted to make it clear that we believe that we should continue to provide family planning support in Peru, because we do think that it results in saving women's lives, and we do believe it helps ensure the reduction of infant mortality rates.
    Mr. REES. Just so we can be clear on what we agree on and don't agree on, and since I don't know how many people you faxed this fact sheet to, the ''Fact Sheet,'' as it calls itself says that ''despite the impossibility of a thorough investigation into allegations, the report suggests''—that's my report—''recommendations that would have far-reaching ramifications such as discontinuing U.S. support for technical assistance and contraceptives for the entire national family program.''
    Then you go on to defend a number of particular kinds of assistance which the report does not attack. Here's what the report actually does recommend. The report recommends that USAID stop training government doctors on how to perform sterilizations. It recommends that we discontinue direct monetary assistance to the government family planning program—you're correct, I think there is only a little—until the sterilization campaigns are discontinued and other abuses corrected.
    With respect to contraceptives and other in-kind assistance, it suggests only that USAID evaluate such assistance in light of the possibility that it could directly or indirectly benefit the sterilization campaigns or give rise to a perception of continued U.S. support for the campaigns.
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    It doesn't say that you need to cut those off. It discusses that question at some length, and that's just not what the recommendation is.
    Mr. SCHNEIDER. I'm pleased to hear that, because I think that would be a mistake.
    Mr. REES. You could have known it already.
    Mr. SCHNEIDER. The problem is there was an assumption if you answer that in the negative, that therefore you should cut off all the family planning programs, and we clearly now agree that that would not be the wise thing to do.
    There is also, it seems to me, one question. The fact sheet that you are referring to, I did not fax those to anyone. If I had, I would have made sure that you received it first.
    Mr. REES. I was using ''you'' in the plural.
    Mr. SMITH. I think you may have indicated this earlier. Will you let us know who sent this around? It would be nice to know since it had some things that raised questions.
    Mr. SCHNEIDER. I agree.
    Mr. SMITH. It is important, and I said this in my opening statement, in terms of keeping us abreast of anything that you hear of in your shop regarding these things happening. We would have loved to have known this a year and a half ago. We were out of the loop per se in terms of USAID notification.
    Mr. SCHNEIDER. Let me be clear. We had no reports of allegations of abuse a year and a half ago. The first time that those reports were received was in November and December. That's when we sent the letter and briefed the staff.
    Mr. REES. When I was in Peru I saw newspaper articles from early 1997. The Coordinadorn's report was from May 1997. If the possibility of problems was important enough to segregate our assistance in July 1996, then why not say to Chairman Smith—who you have got to know is concerned about this and who has asked you about similar issues in the past—hey, look, you'll be happy with us. Frankly, we probably would have recommended even more dramatic steps. It's just a little awkward to read these things in the newspapers a year and a half later.
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    Mr. SCHNEIDER. If I could, Mr. Chairman, what I would like to do is to suggest that whenever there are actions that result in a policy or program change that we undertake such as this that we do inform the Committee. I think that's fair.
    Mr. SMITH. If I could just ask that it be expanded when you hear of allegations that are judged at least to be credible. Even in a collaborative way we can then speak hopefully with one voice to an offending country that this is absolutely outside the norm of acceptable human rights behavior; it is to be condemned by everyone regardless of their position on any of these issues.
    Mr. SCHNEIDER. I understand.
    Mr. REES. As the Chairman mentioned, we were in Mexico in June 1996. Not about this issue. We were meeting with a group of human rights advocates, broad-based, not people with any special interest in family planning. Congressman Smith asked, ''By the way, is there any problem with coercive population control here?''
    Before the question could be translated into Spanish, the USAID person who was there, who we had not actually invited to the meeting, said, ''No, that doesn't happen here.''
    Then the question was translated into Spanish, and I think five of the six people nodded their heads and said, ''Oh yes.'' And several of them knew of particular cases and knew of doctors who had been put under pressure.
    Nevertheless, on a subsequent visit that I made to look further, USAID took the position that this wasn't happening. And I should say that that was in contrast to Peru, where I thought they were much more engaged. But now in the human rights report, the country report that came out just last month, it really suggests that there are some very serious allegations in Mexico. We have requested a full briefing on that. Will we be able to get it very soon? And if you have any thoughts on what is happening in Mexico, it would be good to get them on the record.
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    Mr. SCHNEIDER. Two things. First, yes, we would be pleased to brief you on it.
    Second, the human rights report, the paragraphs that you saw in the 1997 report also were in the 1996 report. There was no change, according to the State Department. I looked at that, and they informed me that they simply put in the same paragraphs that were there in 1996.
    With respect to the specific cases, if you recall, I indicated last year that we would undertake a review of those cases and attempt to investigate the allegations. There has been subsequent action since the letter that I sent to the Chairman. It took some time to go through a process where the women were prepared to have their names given to someone who would then undertake to investigate the allegations.
    Finally, we did contact PROVIDA, and they arranged with the women to contact the Mexican Human Rights Commission, which is similar to the U.S. Civil Rights Commission in the sense of autonomous operating.
    My understanding is that they have begun the investigation. They have opened files in those cases, and in fact we received yesterday information from the Mexican authorities that the commission will be preparing its response shortly. Presumably that will be either verification or not of the allegation and recommendations with respect to those cases.
    Mr. REES. Just one more question about Peru. The one case where there was a woman who alleged that she was promised food through PANFAR in exchange for sterilization, the investigation seems to have been done by the NGO, by PRISMA, the organization that was accused of the violation. Is that the regular way to do things? Wouldn't it be better to send somebody else?
    You are often dealing with somebody who is in a position or perceived position of authority in the community, and a very poor, perhaps uneducated woman. Are we really sure that what they tell or what the NGO says they told them is the ultimate fact of the situation?
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    Mr. SCHNEIDER. No. I agree with that. The initial information, however, was with respect to the records of when the child had entered the program, what were the conditions, in terms of attempting to look at the allegation. It was on that basis that the information was sought from PRISMA and from the Food for Peace office which undertook the investigation. The allegation was not verified.
    We will provide you with the details in both cases, both the case that you mentioned——
    Mr. REES. I think I got it. It was in your fact sheet.
    Mr. SMITH. Will the gentleman yield?
    Mr. REES. Sure.
    Mr. SMITH. Part of the concern that we have is the whole area of independence. I'll never forget a number of meetings that I had, especially one in New York, with Dr. Sadik in 1989 when I was one of George Bush's two congressional representatives to the United Nations. So I spent quite a lot of time up there. I asked for a meeting and got a meeting with her and asked her all about the coercion in China. She said there were reports done; there were investigations undertaken under the auspices of UNFPA; and they found it to be totally voluntary.
    I said, well, please let me see the reports. I had an USAID person sitting right there. He was nodding his head. Let's see the reports.
    I never got the reports. Apparently there were no reports. If there was an investigation, it was internal or never reduced to writing.
    The independence factor of who is investigating. That's why even with our own process here on the Hill, as you know so well, there always needs to be the GAO, and there always needs to be this oversight to ensure an absolutely pristine investigation, or as much as you could possibly get. So the independence of this report, as you just mentioned, is drawn into question.
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    Mr. SCHNEIDER. If I could, we had as of June 1996 one of the most intensive worldwide Inspector General's reviews of the food program in Peru, looking at questions with respect of did it get to its beneficiaries, et cetera. Those results were extremely positive with respect to the food program.
    I guess the answer is that we do have independent reviews. When these kinds of allegations occur, we also immediately try and get the information that would permit us to make a judgment of whether there is a basis for further investigation.
    I think it's fair to say that when these cases arise that we shouldn't be satisfied with simply the same organization that has the information undertaking an investigation, that we should have a third party, and I am fully prepared to ask in this case the human rights organizations in Peru to look at these cases as well.
    The fastest way for us to try to find the information when these allegations occur is obviously to ask the people with the data when did that person enter the program, when did she and the child leave the program, what was the situation.
    We will make that information available to you, and I'll be happy to ask the independent human rights organizations to review this.
    Mr. REES. Thank you. Just one more thing on the ombudsman. I did meet with Rocio Villanueva who was the investigator who worked on this. I don't remember if Ms. Brems was in that meeting or not. I don't think she was. She is obviously very determined. She made it clear that she doesn't have any problems with family planning; there is no axe to grind there. I didn't know until I read this piece of paper today that there were only nine cases. I did read the report of the Defensoria.
    It was clear from our interview with her, which came out before the report, that she didn't think there were only nine cases. In fact, I think there is a direct quote which I did not attribute to any particular person, but I said one investigator said. And that was who it was.
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    She said she had found a lot of women who were satisfied with their ligations, who were happy, but that even in those cases she did not think they had been fully advised of all the risks and the disadvantages of the operation. And from person after person, including many, many people who don't have any axe to grind against family planning in general, there was a general impression that if you consider it an abuse that a woman has this operation without being fully informed of the advantages and the disadvantages and the other methods, this was not isolated; this was systemic.
    Mr. SCHNEIDER. It's clearly a violation of civil rights; it's clearly a violation of what we consider to be an adequate family planning program; it's clearly what we consider to be something that results in our saying that these campaigns should be stopped, and they were stopped.
    In this particular instance, let me just add that I have no question that there are instances such as those we have heard that the ombudsman has discovered where full informed consent was not provided. That's why we made the statements that we did.
    I think as you know, we have asked that an independent, if you will, study of user satisfaction be undertaken nationwide, similar to what is already under way with the food program in terms of the participants that I mentioned earlier.
    Mr. REES. But which you didn't require the food program to begin until January 1998, right?
    Mr. SCHNEIDER. No, because there had been no allegations of any kind. As part of the normal program management we said we think you need to do this, and the first step was to review 55,000 women and to look at the data, and they are doing that currently. We will be quite prepared to provide you with the results from that study and the one on user satisfaction in terms of family planning services.
    Mr. REES. The only point made in the report is that you should have asked them to do it shortly after April 1997 instead of in January 1998. We might have found out things in time to deal with some of these problems.
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    Mr. SCHNEIDER. On the one hand you have very in-depth study by the Inspector General of the overall program. For 3 months they had inspectors in the country looking at the Food for Peace program, and they found it to be one of the best programs that they saw, and that it did reach the needy beneficiaries, and the statistics show reduced malnutrition among children by 30 percent. It was working.
    That was followed by continuing regular monitoring of the program itself. As a result, in that process we asked this additional information to be made available during the course of 1998, and there had been no allegations at the time that we requested that. Had there been, we obviously would have said immediately do it. That's why we have gone back and said accelerate that, complete it faster.
    Mr. REES. When was that Inspector General's report, by the way?
    Mr. SCHNEIDER. It was completed, I believe, in June 1996.
    Mr. REES. So that was when you were still operating primarily through CARITAS or CARITAS was your largest grantee at the time.
    Mr. SCHNEIDER. No. There were five, I think.
    Mr. SMITH. We have a vote on the floor on the Witness Protection and Interstate Relocation Act. I am going to ask very briefly three final questions.
    First of all, are you aware of any other country where any pressure or inadequate informed consent is an issue in the family planning program?
    Mr. SCHNEIDER. No. Let me be clear about one thing. In the case of Mexico, for example, we have continued to follow that up. I traveled to Mexico along with Sally Shelton, and we attempted to continue to follow up the questions that you raise.
    It's a question that we believe needs to be asked continually in order to be sure that programs are run in accord with the policy that I've stated, which is voluntary, fully informed consent, that the program provides those family planning services that women desire.
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    Mr. SMITH. All of us are always concerned about the other major issue of population control and meeting numbers; the belief, which I think is myth, that somehow the world can't sustain certain numbers of people.
    President Fujimori, as you know, announced his family planning program in July 1995. A couple of questions. Do you know what was behind his newfound population priority?
    I had met with him before that and sensed zero concern about those issues in terms of launching that.
    Were the U.S. Government or any of our personnel encouraging him to move into this whole area of family planning/population control?
    In Peru or in any other country does the IMF or the World Bank encourage, either orally or in writing, either directly or indirectly, that a country establish a family planning or population control program?
    Mr. SCHNEIDER. Family planning programs are viewed to be an integral part of maternal child health programs. I would say that most world health organizations would argue strongly that family planning services need to be provided in order to permit women to be able to space the births, if that's what they want.
    Mr. SMITH. The question is not about the rationale. With the IMF or the World Bank, is it in any way a part of their negotiation with a country?
    Mr. SCHNEIDER. I can't tell you in terms of negotiation. I will tell you, however, that integrated family health programs, maternal/child care programs, I know that World Bank, World Health Organization all believe that family planning should be a part of——
    Mr. SMITH. I know what the rationale is and what their assertion is. The question is——
    Mr. SCHNEIDER. Do they support it?
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    Mr. SMITH. No. These are people who have substantial lending capabilities, the IMF and the World Bank, and obviously can exercise considerable clout over a nation that is in dire economic straits. A reallocation or a restructuring, for example like Peru, of its loans, and in comes a basket of issues of which population/family planning is one of them. That can easily be perceived, orally or written, directly or indirectly, as a pressure on a government to get with the program or else run the risk of losing or not being as favorably received by that institution. I want to know if it's part of the mix.
    Mr. SCHNEIDER. It clearly would be.
    Mr. SMITH. With IMF as well?
    Mr. SCHNEIDER. I don't know with IMF. If, for example, you want to reduce maternal mortality and the World Bank has a program to do it, they would undoubtedly say there should be some family planning services available to women in that process. Particularly in Peru, because Peru unfortunately has the third highest, I believe, maternal mortality rate in Latin America. As you know, Mr. Chairman, one of the tragedies is that it's listed the third, but probably even a higher cause of maternity mortality in Peru are illegal abortions because they don't have access to family planning services.
    Mr. SMITH. As you know, Mr. Schneider, there is a great controversy as to what is acceptable, what is not. There are those who feel natural family planning is the only way to go; some who feel that abortifacient disguised as family planning and contraception is something that is part of the overall mix, but the bottom line question that I need to know, and I want it for informational purposes, and I always get a stall; I never get a clear answer. Do these institutions require a population stabilization of any kind as part of a sustainable development as in any way a condition for a loan or some economic support that they are looking for? If the answer is yes, OK. If it's no, OK.
    Mr. SCHNEIDER. I don't believe so in the way that you just phrased the question.
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    Mr. SMITH. That's why I said directly or indirectly. That's why it's important to get to the heart of it. Is it something that is part of a package and ''you'll be looked at favorably if you meet this criteria''?
    Mr. SCHNEIDER. You said something which I want to also be clear. USAID, and I believe all of those organizations, when I say family planning services, I included natural family planning services.
    Mr. SMITH. As we know U.S. law, and I think USAID would disagree with our changing the law, says only those organizations that provide the full array. So there are many who would provide, for example, natural family planning or maybe natural and condoms, but don't believe that abortifacient should be part of that mix. They're excluded from that provision of U.S. Government aid.
    Mr. SCHNEIDER. What I want to get back to is your original question. Do I believe that the bank, et cetera, includes a maternal mortality program? When I say, yes, I'm sure they would, it would include natural family planning as a choice.
    Mr. SMITH. The question is, why is that a criteria for a loan for a country like Peru, that needs, or it did some years ago, restructuring of its loans?
    Mr. SCHNEIDER. When I say a loan, I can't tell you for sure in terms of a loan in agriculture, but I can say that if it's a health loan that is aimed at improving maternal health and reducing infant mortality, I would be very surprised if it did not include a full array.
    Mr. SMITH. Could you get back to us with a more detailed answer? I know you are attempting one. And also as it relates to an economic loan, as a restructuring of debt, which these countries are riddled with.
    Mr. SCHNEIDER. I don't believe so, but I will be happy to.
    [The answer below was supplied following the hearing.]
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    The IMF conditions its assistance on macroeconomic reforms. I am not aware of an instance where the IMF has required any condition related to family planning. Likewise, the Treasury Department has informed me that the World Bank has no policy that requires family planning programs as a condition for its lending, even within the health sector.

    Mr. SMITH. It seemed there was some suspicion that after a visit by some U.S. officials and then some of these announcements one could only guess that all of a sudden Fujimori was enamored of population control, which again, having seen him face to face, wasn't even on his radar screen.
    Mr. SCHNEIDER. I will say that earlier in the 1990's President Fujimori was clearly focused on issues of terrorism and hyperinflation and getting the economy under control. I did see him in 1996 or 1997, and at that point his focus had shifted to poverty as his focus of concern. But we will get back to you with respect to the questions as to what we are able to find out with respect to——
    Mr. SMITH. I appreciate that. Mr. Schneider, you have been very gracious with your time. Regrettably there is a second vote. I missed one already. I'd better make this one. It's the final passage.
    Let me just say for the record we did get a copy of that fax. It went to seven very, very ''pro choice'' members. No pro lifers got that fax. That again hurts this idea of being completely up front and open when some of those talking points were criticisms. I'll lay it all on the table every day of the week with you folks. I hope you would do the same with me.
    We are temporarily in recess.
    Mr. SMITH. The Subcommittee will continue its hearing. I apologize for the break. There are some additional votes coming up right afterwards, but we will try to keep the hearing going to hear this very, very important testimony.
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    I would like to present our next panel, beginning with Dr. Hector Chavez Chuchon, who is a physician and the president of a regional medical federation in Peru; Avelina Sanchez Nolberto and Victoria Espinoza are women from Peru who sadly and tragically underwent tubal ligations at medical facilities of the Government of Peru under very, very bad circumstances.
    Let me just say on behalf of the Subcommittee this record will be very widely disseminated to Members. I know when they hear of your story, they will be moved, as I was when I first heard of it. Now we will hear in greater amplification what has happened and what is going on in Peru. I do thank you for your willingness and courage to come to the United States, to come to the Congress and bear witness to a very harsh reality and a truth that some would like to see put under the table. So I do thank you for your willingness to do so.
    Doctor, if you could begin.
STATEMENT OF DR. HECTOR HUGO CHAVEZ CHUCHON, PRESIDENT, REGIONAL MEDICAL FEDERATION OF AYACUCHO, ANDAHUAYLAS, AND HUANCAVELICA, PERU     Dr. CHUCHON. Thank you very much. I thank you very much for hearing us. My name is Hector Hugo Chavez Chuchon. I am the president of the regional medical federation of Ayacucho, Andahuaylas, and Huancavelica in the Republic of Peru. I must say this is the poorest region in our country, in Peru.
    Right now I want to say very clearly that I don't belong to any particular political group, and I hope that the Peruvian Government has the best possible success in its work for the Peruvian people, but I have the moral obligation to come forward to give the moral position when things are being badly done.
    I'd like to describe what has happened since the start of the tubal ligation and vasectomy sterilization campaign. In my region there are about 200 doctors. Some of the doctors in my region have come forward to complain about the inhumane and massive and expanding sterilization campaign, one that imposes quotas on medical personnel. As proof I have this document.
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    Mr. SMITH. Without objection, the full document will be made a part of the record both in Spanish and in English.
    [The communiqué appears in the appendix.]
    Dr. CHUCHON. I am going to read only a part of that document. It's a communiqué. This is a communiqué to all the health personnel in the region of Huancavelica.
    There will be no payment for the bringing of patients for the AQV, which is the sterilizations that are done through obligation.
    At the indication from our executive directorship of health the persons in the basic health program, the persons on the list, have to bring in two patients per month for sterilization.
    The personnel termed focalizado have to bring in three persons for the AQV, the sterilization, per month.
    The personnel labeled as clas have to bring in three people per month for sterilization.
    I have concluded the places where these sterilizations are done are generally deficient and the personnel doing the sterilizations are usually not sufficiently trained for the operations.
    The Ministry of Health denies that there are campaigns or quotas, referring to sterilizations, and absolves itself of its responsibility but doing this without taking into account among other things that the doctors work underneath their own orders. The doctors who are contracted work underneath a very subtle pressure, because employment conditions are very unstable and there are very few social benefits, and they can easily lose their work position.
    I would like the Members of Congress and the people of the United States to understand that my country is a very large one, and we are not yet at 25 million inhabitants. So this in no way calls for a brutal campaign of population control and much less one that features sterilization.
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    The facts show us that prosperous countries like Japan have a higher density of population. Even though geographically it's a much smaller country and they lack the natural resources of my country, they still live prosperously. So it's clear that the most important thing are human resources which can generate wealth and well being. Therefore, I would say that for those who really want to help my country, it would be better to invest in education and job creation the millions of dollars that go in population control programs.
    Thank you very much.
    Mr. SMITH. Thank you very much, doctor.
    [The prepared statement of Dr. Chuchon appears in the appendix.]
    I would like to ask Ms. Espinoza if she would proceed.
    Mrs. ESPINOZA. Good afternoon. My name is Victoria Esperanza Vigo Espinoza. I am 34 years old. It's very important to say that before they did the tubal ligation it was very difficult for me to have children because I had hormonal problems. I took pills to regulate my menstrual cycle and to become fertile so that I could become pregnant.
    On the 23rd of April 1996, I went to my private consultant, to the clinic, because I had had small spotting of blood. I didn't give it too much importance. I was about 32 to 33 weeks pregnant, and because I was not insured, I preferred to go to the hospital, and the doctor gave me a transfer to the hospital. I didn't have any family members with me, but just a friend.
    An obstetrical nurse admitted me into the hospital, and she told me to wait for the intern who would be coming down. I told the intern my situation, that I had a great deal of pain, a great deal of pain.
    At that moment the obstetrical nurse, the intern asked me, ''How many children do you have?'' I told her this is the third. And she asked me, ''Are you going to receive a ligation?'' I didn't even answer because I wasn't interested in it, and I was feeling great pain. And they prepared to operate on me.
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    The intern then asked me if I had any family members present, and I told him no. And he said, ''Sign this release for the operation.'' I didn't read it. I was in a huge amount of pain. And they did a caesarean on me.
    In the afternoon of the next day I got up to go see my child, and they told me that my child had died. The next day the intern came in with the doctor, and I said that I wanted to go home. He asked me why. The intern said, ''She is very sad because of her child's death.'' And the doctor tried to calm me down and said, ''Maybe you'll have another child.'' And I heard the intern tell him, ''No, she's ligated.''
    The next day an obstetrical nurse came in to take my blood pressure and check on me and asked me if I was still depressed. I said, ''Mostly because they had done a ligation on me.'' But in my chart there was not indicated a ligation. So she went to go find the intern and asked him if it was true, and he said, ''Yes, it's true. They did a ligation on you.''
    Later on that afternoon the intern came up and said, ''Forgive me for what has happened.''
    On the third day I left. I felt very sad and very defeated, because I wanted to have this child and other children. And I had to go do psychological, psychiatric treatments. Somehow I still have faith that one day I'll have more children.
    It's very rare for a case like mine to come to light. Thanks to God I heard what they were saying to each other. I do know my rights, and I'm educated. I know how to defend myself. It was very difficult for me to make a formal complaint, and it is much more difficult for the women in the countryside who don't know their rights, who don't know how to do it, to lodge their complaints.
    And that's all.
    [The prepared statement of Victoria Esperanza Vigo Espinoza appears in the appendix.]
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    Mr. SMITH. Ms. Espinoza, thank you very much for your courage. We heard earlier about the new Peruvian policy that would allow some right of redress. My hope is that it will be a very aggressive attempt to discover and ascertain who has been abused by the government's family planning program to date and not just a cursory effort, but an all-out effort to find the victims, and second, to provide every means available to enable those who have been abused to make their case effectively so that the burden of proof isn't so high and the bar isn't so high that recompense is not forthcoming. An example has to be made.
    As you pointed out, Ms. Espinoza, you knew your rights; you were abused by the system, by an individual doctor. There are not nine as the ombudsman probably thinks, but there are probably many, many, many more. I can assure you we will do everything we can from our Subcommittee's point of view to make sure that the victims are identified.
    Mr. Rees and I have talked about this, but I hope to undertake a trip sometime in the very near future to Peru, and now with the government's apparent commitment—I say apparent, because we've gotten words before from governments. I'm going to make sure the deeds match the words. Part of my agenda will be, in addition to addressing this issue in its totality, to make sure the victims like yourself are identified, are given a chance to come forward, and to receive that recompense so that it never happens again in Peru.
    So thank you very much for your very compelling testimony.
    Let me ask Ms. Nolberto if she would now proceed.
    Mrs. NOLBERTO. Good day, Congressman Smith. My name is Avelina Sanchez Nolberto. I live in Ayacucho. I had a tubal ligation. The ligation that was done on me was done through trickery.
    I had complications after the tubal ligation, and I've been an invalid since. I can't work to maintain, to help raise my children. Before the tubal ligation I was healthy and I was able to maintain my children. I've had to have four operations to help repair what the tubal ligation did, and I'm still in delicate health.
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    I've suffered quite a bit from all the different operations and the damage that was done to me. There have been major sacrifices for my husband and children as well as feeling kind of abandoned.
    I want to denounce this, but I'm very poor and I don't know how to speak. Thank you very much.
    [The prepared statement of Avelina Sanchez Nolberto appears in the appendix.]
    Mr. SMITH. Thank you very much for your testimony.
    Dr. Chuchon, Mr. Schneider when he was here made reference to the few validated cases of women who were sterilized without informed consent. Do you believe that these cases are isolated? Is it the exception, or is it more the rule that there are many more cases that simply are not known or have not come forward?
    In like manner, you talked about the physicians and the subtle pressures. You've come forward, probably at great risk to yourself in terms of your career. Are there others who might be willing as this scandal becomes more apparent to come forward to give testimony and bear witness to the abuse of women through coerced or pressured sterilization and a lack of informed consent?
    Dr. CHUCHON. In the first case, I would like to say the Ministry of Health has accepted that there were people who died from ligations for the AQV, the sterilizations. They talked about three cases that were confirmed. But there are also complications from these procedures. In my work and being in contact with the people, there are not a few people who come in and lament and have all kinds of problems with what had happened to them. I would say it's a considerable number.
    Responding to the question about pressure, unfortunately in my country, in the working sector it's very hard to get names, especially in health. What does exist are contracts. These contracts come for services that aren't personalized. It's a modality where there really isn't stability in terms of employment or social benefits. So it's logical to see the subtle pressure that exists on people who work in the medical field.
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    When people come in with complications that were ''voluntary'' the Ministry of Health would say the program is good, it's the doctor that's bad, that made a mistake, and they would try to shirk their responsibilities. This has created a lot of concern among the doctors, and they have gone to the medical federation to protest. The National Medical Federation has put out formal protests in the newspapers of the country, saying that the infrastructure was deficient and that the personnel doing these procedures were not well trained.
    You asked if other people would be willing to come forward. I wouldn't know what to say in answer to that question, because really there is fear.
    Mr. SMITH. Do you fear for your own career, having been willing to speak out?
    Dr. CHUCHON. I don't know if the fear is founded or unfounded, but I definitely feel the obligation for my country to defend it, and that is why I decided to take the honor to come here before yourself, because I think this is too much. That's why I say this country which is so powerful and always helps us should invest especially in education and infrastructure and in job creation.
    I want to repeat that my country is very large. It's the 16th country in size in the world, and we are a very rich country, and I would like help in education and in general cultural development and job creation.
    Mr. SMITH. Is it possible that some of the women who come in, especially for childbirth, are perhaps sterilized without their knowledge as well as without their informed consent and as a consequent never get pregnant again but do not know that they have had a tubal ligation?
    Dr. CHUCHON. It's very hard to affirm or deny such things. These are situations that are basically known on the inside. So it would be hard to affirm or negate. But there are rumors of this and people not being in agreement.
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    Mr. SMITH. With regard to the Peruvian Government statement that these mass sterilization campaigns are to be no more, do you have any concern that rather than being an overt mass sterilization campaign that it will just go more underground but the same mindset that drove the initial campaign will now be employed on a more individualistic type basis, a smaller basis?
    Dr. CHUCHON. First of all, I'm very pleased to hear that news, and I hope it's really true. As you know, my country is very large and I'm just in one spot, in the heart of the Andes, and I couldn't know what is going on in the whole country.
    In any case, I certainly hope there will be respect for the human person and that full information will be given with the advantages and disadvantages, and I would hope that in all these programs of family planning those that really do the planning would be the families, and not offer them just artificial methods, but also natural methods, as the World Health Organization said, that have 98.5 percent effectiveness. But people are not being given this option of using natural methods of family planning, and what has happened is they have actually gone against natural methods, saying that they were obsolete, et cetera. So I think there is a lack of freedom there.
    Mr. SMITH. Mr. Schneider earlier had indicated that natural family planning was provided. Is it your testimony that it is not, or if it is, it is cast in a disparaging light?
    Dr. CHUCHON. No. I would say that the information comes from a different point of view. It's really coming from a point of view that favors artificial methods of family planning. Speaking particularly about my region of Ayacucho where there doesn't exist—in the whole region of Ayacucho there is not a single institution that promotes natural family planning. We think that it's very enriching that it's much better in all cases, because it brings out good values, and it contributes to the uniting of families; it doesn't cost anything and it doesn't do any damage at all.
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    Mr. REES. Doctor, in your English translation of your testimony that was provided to the Subcommittee you say, ''I would like to have the people of the United States understand what their government is doing in Peru.'' In light of Mr. Schneider's testimony that we had separated the U.S. program from the sterilization campaigns, why do you say that it's the U.S. Government that is doing this?
    Dr. CHUCHON. We know by information from literature that the rich countries in general apply pressure on the poorer countries for their own objectives. When I was referring to the United States, I don't think a large part of the population of the United States is in agreement with this, and that's why I allowed myself to say this prayer. It's a good plea, a humane one, that asks for the well-being of many people. I would hope that all this money would not go to family planning, that it would go for support to all the different necessities that they have, especially after all the damage that has been done by the El Nino phenomenon.
    Mr. REES. I think our Chairman, who will be back in a few minutes, would agree with you that sometimes there is an imbalance, that we spend more money in some countries on population programs and less on other health programs, other development programs that we ought to, but I am trying to get on the record here whether there is any U.S. connection with the sterilization campaigns themselves. Our own government representatives have assured us that they distanced themselves from those campaigns, that they did not participate in them. I just wanted to make sure that you don't disagree with that. If you do, please tell us.
    Dr. CHUCHON. I think that there might be links.
    Mr. REES. But you're not sure?
    Dr. CHUCHON. No, I don't have proof of it.
    Mr. REES. Congressman Burton has a question.
    Mr. BURTON. I only have one question. I just ran into Chairman Chris Smith in the hall. I was appalled when he told me that these two ladies were forced to have themselves sterilized. Is that correct?
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    Mrs. ESPINOZA. Yes.
    Mr. BURTON. This was a government demand?
    Mrs. ESPINOZA. I don't know. I can't say. The person who was responsible was the doctor.
    Mr. BURTON. Is this government policy down there?
    Mrs. ESPINOZA. I only know my own personal case. I don't know what the politics of the government are, but I can talk for my own personal case.
    Mr. BURTON. What did the doctor say?
    Mrs. ESPINOZA. The doctor accepted his responsibility that he had done it, and then we went before the judge. But when I read my own case, then the doctor then denied that it was his responsibility.
    Mr. BURTON. When the doctor did the sterilization on you, did he tell you he was going to do it, and did he say why he was doing it?
    Mrs. ESPINOZA. No.
    Mr. BURTON. He didn't tell you anything?
    Mrs. ESPINOZA. No. No one asked me anything. He didn't ask me. The obstetrical intern at the entrance asked me if I wanted a tubal ligation, in the emergency room.
    Mr. BURTON. Were you in the process of giving birth to a child?
    Mrs. ESPINOZA. I was 32 to 33 weeks into my pregnancy and I was coming in in great pain into the emergency room.
    Mr. BURTON. Maybe you can answer this question. When I talked to Chris, he said that this was a governmental policy, and it hasn't been made clear to me that this is a policy of the government.
    Mr. REES. I think what the testimony reflects so far, including the USAID testimony that came earlier, is that there was a government policy to set certain goals, certain numbers of people in the country who would be sterilized, and that the government did not specifically say you should sterilize people without their consent.
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    Mr. BURTON. But there is a policy?
    Mr. REES. There is a policy to encourage sterilization.
    Mr. BURTON. To cut down population growth?
    Mr. REES. I'm not sure the government gives that reason.
    Mr. BURTON. They're just for a sterilization program?
    Mr. REES. They would say that in many cases it's the best thing for the woman, for the family.
    Mr. BURTON. Well, that's a subjective judgment by government and one that I don't think the good Lord would tolerate.
    I would like to know more about this. I'm a Member of the full International Relations Committee. Any information you could give me. I think we ought to have a full hearing of the full Committee on this, especially when we are talking about any kind of assistance to Peru. Our assistance in Peru or in Latin America ought to be based upon human rights, and this is a violation of people's human rights. I'd certainly like to have more information.
    Mr. REES. We will get you the full information as soon as possible.
    Mr. BURTON. Thank you very much for letting me ask these questions.
    Mr. REES. Thank you.
    Dr. Chuchon, I had one more question for you along the lines of the questions the chairman was asking. With respect to the question of informed consent, of whether women were sterilized without being fully advised of the risks and disadvantages of the procedure and of the availability of other methods, in your personal experience was this something that just happened every once in a while, or was this systemic? Was this typical that the government workers would encourage women to be sterilized without really telling them everything they needed to know? Or was it just isolated?
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    Dr. CHUCHON. I would say it's more of a generalized situation, generalized cases. With respect to information, the information comes from a source that is compromised. There are certain types of stimulations, like this document, which has at the end of the year——
    Mr. REES. Incentives, right?
    Dr. CHUCHON. Incentives. That they will give prizes to the establishments that have the lowest cost and the greatest benefits to the population for the AQV, the sterilization; for the best organized campaign; and the greatest work to bring people in without cost; the effective participation of the head of the health center and the personnel in the campaigns; the best results in bringing people in at the level of the health post; and then personal certificates for members of the campaign.
    Mr. REES. So there is no special award for the person who gives the best informed consent?
    Dr. CHUCHON. No.
    Mr. REES. I know this comunicado has been published in the newspaper in Lima. Has the government maintained that this document is a forgery, or do they acknowledge it, or has there been any reaction at all?
    Dr. CHUCHON. What the government has said is that this was an initiative of the subregional director for Huancavelica, and we would see this as another case of not accepting their responsibilities.
    Mr. REES. Does the government maintain that this is inconsistent with the government's general policy?
    Dr. CHUCHON. You will easily understand that this type of document is not something that most people can get. In the health establishments these type of documents are secured. Many doctors are very uncomfortable and feel badly about this type of thing. So they did this to get it to us, but they asked to remain anonymous. As president of the federation, it's my responsibility to show this document, and so we show this in Peru.
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    Mr. REES. I have some questions for Senora Espinoza. Some of these are technical questions, and I know that some of them may hurt you to answer, but I hope you understand we have to be as complete as possible in the record.
    What was the date of your sterilization, approximately?
    Mrs. ESPINOZA. The way it happened was an indirect way through the surgical nurse.
    Mr. REES. When did it happen?
    Mrs. ESPINOZA. The 23rd of April, at night.
    Mr. REES. Which year?
    Mrs. ESPINOZA. 1996.
    Mr. REES. So if someone at that meeting with you said it was 1995, they probably heard wrong, right?
    Mrs. ESPINOZA. That's right, no.
    Mr. REES. And this happened in a government hospital?
    Mrs. ESPINOZA. In the regional hospital, at the Social Security hospital.
    Mr. REES. That's a government hospital, right?
    Mrs. ESPINOZA. Yes.
    Mr. REES. Was this before or after the beginning of the sterilization campaigns?
    Mrs. ESPINOZA. The sterilization campaigns had already started, and in my house, they came to visit. During the campaign they had come to my house looking for people that would be candidates for sterilization, in the same way that they do other campaigns, for malaria and other things.
    Mr. REES. You were not sterilized as a direct result of these campaigns?
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    Mrs. ESPINOZA. I couldn't say that it was done directly through the sterilization campaign because I didn't know everything about it. The campaigns started in 1995.
    Mr. REES. I'll just state for the record that there are elements in Senora Espinoza's story that suggest that there might have been a preference in the government hospital for sterilization whether or not it was actually done during one of the campaigns.
    Mr. MEANEY. She said she didn't understand.
    Mr. REES. She doesn't need to answer. That has been a point of contention.
    Do you know if your baby passed away during the operation or later, or during the caesarean or later?
    Mrs. ESPINOZA. He died 18 hours after birth, when I was still in the intensive care area.
    Mr. REES. When I met with an official of the Ministry of Health he told me that there were two justifications for your sterilization—he had your records right there with him, and he told me that there were two justifications, and one of them was this idea, apparently mistaken, that you had already had at least two caesareans. The other was that you had cancer, that it was discovered during the caesarean that you had a malignant growth. Did you hear that, and what is your reaction to it?
    Mrs. ESPINOZA. Yes, I was reading that. My first child, who is 16 years old, was born normally and not through caesarean. I have the history of my child. My second child is 4 years old, and that was at 42 weeks that they did the first caesarean.
    Mr. REES. What about the cancer? Did you hear about cancer?
    Mrs. ESPINOZA. I went in for an examination and they said I was fine. Some people said I was crazy.
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    Mr. REES. But other than that you were fine.
    Mr. REES. One of the things that happens when we have a controversial hearing is that we get a lot of interesting faxes. In addition to the fax that I discussed earlier with Mr. Schneider of USAID, I received anonymously, with no mark for who sent it, a fax in Spanish. I want to read it to you. It talks about me for a little while, and then it says—I am translating into English:
    ''I induced Senora Espinoza, I guess when I was in Peru, to make statements against the family planning program with a promise, fooling her into thinking that if she did that somebody would pay for an operation to reverse the sterilization.''
    I guess I would like to put this in the record. I don't know where it came from, but I would like to put it in the record, and ask you if there is any truth to that.
    Mrs. ESPINOZA. No, not at all.
    Mr. REES. When you and I met, was I the first person you had ever told this story to?
    Mrs. ESPINOZA. Yes. My case wasn't made public, and I did it after 7 months of fighting to have a reparation of the tubal ligation and going to the judges, and after having fought so much, I didn't have the money to go for a more powerful attorney to look into it. The students from the university came and studied it. They came to my house. They were studying journalism and law. To study this as a case that had been on the record. They asked to have my testimony as a help for their studies, but I never made anything public, and it was not a public scandal at all.
    Mr. REES. I may be wrong about this, but I thought that when you talked to me—we had a videotaped interview—I thought you had already given an interview to a newspaper, or maybe even television.
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    Mrs. ESPINOZA. No. The first time that I spoke publicly was with the defender of the people, and she then took it to a show called Panorama and then made it public.
    Mr. REES. By the time we talked, that was later, right? I talked to you after you talked to the Defensoria.
    Mrs. ESPINOZA. Yes.
    Mr. REES. So I wouldn't have been able to trick you into making these statements if you had already made them to somebody else, right?
    Mrs. ESPINOZA. No.
    Mr. REES. Do either of you, Senora Espinoza, Senora Nolberto, know of other cases in your personal experience of women who have been sterilized without being fully informed of the risks and the disadvantages of that operation or of the availability of other methods?
    Mr. MEANY. Mrs. Espinoza says that she doesn't know of any cases except for those that came out in the media and in the press, and she's only really known her own case.
    Mrs. Nolberto says she doesn't know of other cases, just her own that happened.
    Mrs. NOLBERTO. The people that came in, they deceived me, but I don't know of other people. A person came and took me from my house, although I didn't want to go. They said it was for my good, that it was free. And they said to take advantage of it, and that you're still young and that you might be able to have more children. So they wanted me to go. I thought they were going to do something good for me.
    Then I gave my story. They wanted to get my medical history. I was scared that they were going to do some harm to me, and I didn't have any money to pay for the medical history. They said don't worry, we'll pay for that. So they took the medical history, and then they took blood, and then they took me to the operation room to do the tubal ligation. Then they made me fall asleep.
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    When they woke me up I was hurting quite a bit, and my stomach swelled up. They said that I would be going home the same afternoon. This and no more.
    Mr. REES. Thank you.
    Mr. SMITH. Thank you, Mr. Rees.
    I want to conclude by thanking the very distinguished and courageous individuals from Peru who have come forward. We will be following this very closely from the Subcommittee. We will be following how you might be treated or perhaps mistreated in the future.
    One of the things that I have learned from 18 years of human rights work, and I am the chairman of the Helsinki Commission as well, dealing with Eastern and Central Europe and Russia, is that you always protect your whistleblowers. In the European context, they are often called Helsinki monitors. Whatever their name, they are people who come forward with credible evidence regarding human rights abuse.
    It seems very clear that Peru has a major problem. Maybe this statement from the Ministry of Health is a step in the right direction. Kofi Annan just returned with a statement from Saddam Hussein that certainly is not being all that well received, given its ambiguities. But we will be looking for the deeds.
    The Indian Government not so long ago brought gross dishonor on itself because of its forced sterilization campaign. Mrs. Gandhi felt the brunt of that.
    The People's Republic of China since at least 1979, although its coercion preceded that, in a coordinated, U.N.-sponsored way continues to bring gross dishonor to itself because of its forced abortion and forced sterilization and its use of quotas, timetables, and making children illegal if they exceed the one-child limit. An absolutely foreign, alien, and I think grotesque notion that somehow the government can confer legality on a child because he or she fits into a population/family planning program; if you have two, the second child is illegal.
    We see this in other places like Vietnam, where there is a two-child per couple policy.
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    I just say this because I frankly am sick and tired of governments abusing their people. When the NGO's stand arm in arm with the oppressors, they become part of the oppression. We need to speak out very clearly on this.
    When Rajiv Gandhi did this years ago in India there was a loud outcry about the coercive population control. To think that it is in our own hemisphere is doubly troubling. The reports out of Mexico and now this very substantial report out of Peru we are going to be watching. I hope to undertake a trip myself along with my staff director and other interested Members in the very near future.
    The pressure is just beginning to build. We will be watching to see how the government reaches out to the victims, and hopefully USAID, our own government's response will be above and beyond what one might expect to make sure the victims are reached and adequately compensated as this paper from the Peruvians is outlining.
    This hearing was very informative, but it is just the beginning. I do again want to thank you for your bravery in coming forward.
    Without objection, I will make the report written by Mr. Rees as a result of his trip there a part of the record.
    [The report appears in the appendix.]
    Mr. SMITH. Again, I want to thank you very, very sincerely for your testimony and your willingness to bear witness to these atrocities.
    This hearing is adjourned.
    [Whereupon at 4:10 p.m. the hearing was adjourned.]


    Insert "The Official Committee record contains additional material here."
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