In Manila, pills, condoms go underground

(First of two parts)

They are not drug dealers or smugglers. They’re not even video pirates. But many non-government organizations (NGOs) in the city of Manila are now feeling as if they were involved in an illicit trade. They do their transactions on the sly, with furtive glances cast here and there to check if someone is watching.

NGOs say that under the administration of Manila Mayor Lito Atienza, they are being forced to provide contraceptive pills and other artificial birth-control materials in the shadows and under the table.

Under Atienza, this congested city of more than 1.5 million has become staunchly pro-life and uncompromisingly against any form of artificial birth control. Pills, condoms and the like are no longer available in any of the Manila’s barangay health centers and city-funded hospitals.

Women’s groups plan to sue Atienza, saying that by depriving Manila’s women a choice of family planning methods, he is violating the Constitution. They are gathering evidence to show that the mayor is infringing on women’s rights.

Meanwhile, NGOs that are still making contraceptives available say there is a creeping yet coordinated effort to stop their efforts. Some groups even say that the city seems determined to drive them away and are worried that their permits to operate will not be renewed once these expire.

Some NGOs have been told that "what they do is abortion, even if they’re just into family planning and contraceptives," says Atty. Carolina Ruiz-Austria, director of Womenlead and one of the legal counsels of the Reproductive Health Advocacy Network (RHAN). "They were told that what they are doing is forbidden in Manila. It’s unnerving."

The National Statistics Office says the country’s population will reach 85.2 million this year. In 2002, over 20 percent of 11.6 million married women had "unmet needs" for family planning. That translates to more than two million women who wanted to space or limit their children, but were unable to get the support they needed.

Chances are their numbers have only grown since. Public health workers and NGOs alike say that President Arroyo’s silence on the issue of population has left women at the mercy of local government officials, who may not always recognize the separation of church and state or appreciate the reproductive rights of women.

For sure, there are officials like Pangasinan Gov. Victor Agbayani, whose province is a role model for population control. But there are also those like Atienza, who has thwarted even the Department of Health (DOH)’s "Ligtas Buntis (Safe Pregnancies)" campaign in his city.

Recently, the Philippine Legislators’ Committee on Population and Development received reports that some towns in Batangas, Camarines Sur, Palawan and Bukidnon are now following Atienza’s lead.

Mrs. Arroyo, who in 2003 admitted to having used birth control pills as a young wife, has no specific program to address the country’s high population growth in the 10-point agenda she issued last year. Through her spokesman, Ignacio Bunye, she said she was leaving the issue to local executives.

Arroyo is an advocate of natural family planning, although she has also said that she doesn’t "impose it." But the lack of a national population control program has left health workers confused — and often forced to follow local officials who are imposing their religious beliefs on their constituents.

Dr. Marie Lorraine Sanchez, Manila’s city health officer, even says quite proudly, "We always put in the natural family planning teachings of our Lord. This is our choice for you, we tell them."

Manila has had negative population growth in recent years, but only because many of its residents have been migrating to less crowded areas. Census records show that in 2000, the city’s population density stood at 41,282 per square kilometer, the second highest in the National Capital Region, and more than three times that of Quezon City, which has the largest number of residents. Manila’s population density was also almost thrice the NCR average.

Not all Manila city health workers share Atienza’s stand, especially those who have been in the service for decades. But the fear of losing their jobs has been enough to silence them into compliance with the mayor’s orders.

Atienza, after all, chairs the ultraconservative Pro-Life Philippines, which was founded in 1975 by Sr. Mary Pilar Verzosa. He insists, "sex must always be related to procreation," and believes that artificial contraception will ultimately lead to legalized abortion.

On Feb. 29, 2000, Atienza issued Executive Order 003, declaring city hall’s "commitment and support to the responsible parenthood movement." It vows to "(uphold) natural family planning... while discouraging the use of artificial methods of contraception like condoms, pills, intrauterine devices, surgical sterilization and others."

The EO does not explicitly ban artificial birth control methods. In reality, however, city hall has slammed the door on the pill and its kin and no longer prepares any budget for such. In previous administrations, city hall had even provided the state-run Jose Fabella Memorial Hospital in Sta. Cruz with artificial contraception materials.

These days, phone calls to Manila’s health centers yield these standard replies: "The mayor has banned all forms of artificial contraception" or "Manila is pro-life." There are religious arguments: "Family planning is not in the bible." There are scare tactics: "(With birth control) there will come a time we will no longer have young people to take care of the aging."

Most health workers even refuse to give out information on how to use the pill. Instead, they warn against the "evils" of artificial family planning methods. Those who are less prone to preaching, however, refer clients seeking ways to plan their families to the health centers of nearby cities or to NGOs.

Population experts and women’s health NGOs themselves say that natural family planning is ideal and that some forms of artificial birth control may have detrimental side effects on some women. Unfortunately, they say, natural family planning, which involves monitoring a woman’s fertility cycle, is not always practical or doable.

Irregular Period

"Often, (the woman’s) period is not regular," says Corazon Raymundo, president of the University of the Philippines Population Institute. "And there are many events or situations that do not allow natural family planning...If the man is an (overseas Filipino worker), how could the woman say they can’t have sex (because it’s not the right time)?"

She adds that since 1968, their studies have shown that couples do not like natural family planning methods.

Raymundo adds, "We should give accurate and sufficient information on the (various) methods because everyone has a different take. No one method is good for everyone for the rest of their lives. They should have freedom of choice and they should be able to make their own decisions."

But Manila’s city government seems to have other ideas, and NGOs there say they have been feeling increasing heat from city hall as a result. Dr. Junice Melgar, executive director of the NGO Likhaan, says some of the member-organizations of RHAN in Manila have received letters from, or have been visited by, city health officials. Others have been "summoned" to city hall.

Ruiz-Austria says that such "summons" lead to a viewing of the anti-abortion film, "The Silent Scream," among other things. The lawyer also says that these sessions constitute "harassment."

She says one NGO recently received a letter where it was "recommended" that the organization’s information kit be "edited" by the Manila Health Department. "It’s tantamount to censorship," she says.

Ruiz-Austria also says that NGO forums on the topic of reproductive health provoke a visit from city hall representatives. She recounts, "They’d come and ask, ‘Do you have a permit? Because this is not encouraged in Manila.’"

Aside from Melgar and Ruiz-Austria, no one from any of the Manila-based NGOs agreed to be interviewed on record for this piece. Melgar says these NGOs want to continue to operate in Manila and do not want to antagonize Atienza. Other NGOs, though, have left Manila for "friendlier" areas, she says.

Melgar says some barangay officials who play host to reproductive-health NGOs are also wary of going against Atienza’s pro-life policy. Still, they recognize that these groups provide their constituents with a needed service now being denied by city hall.

Manila’s four city-funded hospitals also no longer do vasectomies and tubal ligation. Inquiries at these hospitals about such procedures yield replies like, "Pro-life si Mayor"; "Bawal sa amin"; "Ayaw ni Mayor"; "Basta, mag-anak nang mag-anak ang gusto niya." ("The mayor is pro-life"; "We’re not allowed"; "The mayor doesn’t like that"; and "He wants everyone to just keep on having children.")

Cristina Ignacio, a nurse at Fabella Memorial’s Comprehensive Family Planning Department (CFP), recalls that a woman once came to Fabella asking for a tubal ligation to be performed on her. The woman has had several caesarian operations and had in fact just given birth a month earlier; her wound was just beginning to heal. The Fabella doctors had to turn down her request.

The procedure should have been carried out when she was opened up for birthing, but she had delivered in one of Manila’s city hospitals. Personnel at Fabella could only counsel her on alternative contraception methods before they sent her home. Recalls Ignacio: "She was pitiful. She’s recorded in our minds."

Dr. Enrique Samonte, officer-in-charge of Manila’s Safe Motherhood Office and devotee of the Holy Face of Jesus, confirms sterilization procedures are no longer practiced in city-funded hospitals.

"It was included in the EO that the different hospitals funded by the city government should only promote natural family planning and should not do ligation and vasectomy," says Samonte, whose office has a poster of a weeping Christ holding an aborted fetus and with materials used in artificial contraception scattered at his feet.

A scrutiny of Atienza’s EO, however, reveals that the city hospitals were merely instructed to "promote and offer as integral part of their functions counseling facilities for natural family planning and responsible parenthood."

Sanchez, for her part, says that Manila-funded hospitals bar sterilization not on the orders of the mayor, but because of the hospital managements’ belief in the policy. She also denies there is an effort to curb the activities of health workers who support artificial contraception, saying that the mayor is "democratic."

The Normal Way

Atienza himself says he is not forcing Manilans to follow his thinking. Yet he confirms that health centers do not provide information about the use of artificial birth control. He says that is the job of NGOs.

Atienza credits his parents for his policy on population control. He says he learned about sex "the normal way," at home, with his family. He says his father sat him down and taught him about contraception, but advised him to postpone sex until after he was married. Asked if he was able to comply, he says, "I can’t say I obeyed him 100 percent, but I remember the lesson." He passed on that lesson to his children, he says.

Atienza and his wife had five children in quick succession, but their sixth and last child came years later. He says that was because his wife "took the pill without my knowledge and I tell you, she became a devil, a demon," blaming what he thinks was hormonal imbalance brought on by the pill.

Atienza believes that a population boom will pave the way for prosperity, and birth rates will drop as a by-product of wealth. In any case, he says he would prefer not to intervene in population growth, saying he has not read a religious teaching that said man should meddle with the plan of the Divine Master.

Apparently, though, he has no problems with local governments messing up national reproductive-health campaigns. Earlier this year, the Manila city government effectively blocked the "Ligtas Buntis" campaign from being conducted there. The nationwide campaign was meant to inform couples on health, fertility, and contraception.

Because it was going to be done house to house, NGOs were hopeful that women who could not go to government hospitals or private clinics would finally be able to get information about artificial birth control and maybe even be given contraceptives.

But that never happened, with talks bogging down quickly when the subject of family planning came up. According to Samonte, the city and the DOH failed to agree on even the reading materials for the campaign, and that the DOH ultimately "backed out."

Atienza, however, may have a more difficult time getting rid of RHAN. The incensed network of some 30 groups dispensing reproductive-health services and materials across the country is gearing up for a big fight. Since last year, it has been gathering witnesses and evidence to bolster its planned cases against Atienza, who they say should reverse his population policies.

Lawyer Ruiz-Austria says some women she has interviewed were elated to find out that "artificial contraception is legal and it is the ban that is illegal." She points out Atienza’s EO 003 was worded without expressly prohibiting artificial contraception because it is illegal to do so. The EO itself, she says, is without legal basis.

"We have a strong case against him because his local executives are interpreting it as a ban," says Ruiz-Austria. She adds, "The constitution guarantees the right of spouses to family planning and this is part of health care. It is the mandate of local governments."

To be continued