At no point in my medical education – nearly a decade of university, three degrees and countless hours spent on the wards – did anyone mention how the legacies of colonialism and racism affect my decisions as a doctor.
Shortly after completing my master’s (at arguably one of the world’s best public health schools, the London School of Hygiene and Tropical Medicine), I became disillusioned with how healthcare is taught and discussed. I’d spent a year studying sexual and reproductive health, particularly that of countries in the Global South, and I felt that there were gaping holes in many of our discussions.
It was the same feeling that I had felt in my undergraduate medical education. I would sit in lectures and listen to senior doctors disparagingly make sweeping generalisations about why some Black people were at risk of high blood pressure and how these patients often did not take their medication. We never discussed the tension between majority white, middle-class doctors and racially marginalised patients. We never discussed how our health institutions had been shaped by imperialism.
“Only a few bodies have ever historically mattered: usually those of white, male, able-bodied and heterosexual people.”
Nobody challenged these narratives. No one was given the space to do so. The system was heavily weighted in favour of a few. Medicine and healthcare is taught the way it is practised. Only a few bodies have ever historically mattered: usually those of white, male, able-bodied and heterosexual people.
While the contraceptive pill brought liberation to many white women living in the West, this would not have been possible without scientific trials on poor, working-class women in Puerto Rico. Many previous efforts to create a hormonal pill for ‘birth control’ had largely failed, partly due to conservative views that it would lead to sexual promiscuity and a lack of willing test subjects. Yet, as concerns about the changing demographic within the US grew and interest in eugenics mounted, scientists saw birth control as a unique opportunity.
A recent study found that women who take hormonal contraception have a 25% higher lifetime risk of breast cancer.
Margaret Sanger (1879–1966), founder of Planned Parenthood – now one of the largest reproductive health and rights organisations in the US – is often credited as the driving force behind the pill trials.
Sanger gained considerable influence with more conservative members of the political establishment as they began to see the long-term benefits of birth control and had financial backing from philanthropists, which allowed her work to progress. She was able to enlist the help of Harvard scientists Gregory Pincus and John Rock and received financial backing from Katharine McCormick, also a biologist and one of the earliest women to graduate from the Massachusetts Institute of Technology (MIT), to conduct trials on the hormonal contraceptive pill.
The US territory of Puerto Rico, which in many ways functions like a colony, was selected as a trial location due to a combination of hostility surrounding birth control in the US as well as concerns about a surging population and poverty in Puerto Rico. The first trial took place in Rio Piedras, an area where the government was trying hard to regenerate and where women were eager to find work and raise their living standards. Since the 1930s, there had already been in place widespread sterilisation programmes and contraception clinics, partly funded by the US government.
Approximately two hundred women were enrolled in the Rio Piedras trial, unaware of the potential risks of the pill or that they were part of an experiment, most thinking that the contraceptive was safe to use. It was estimated that a fifth of the study participants suffered side effects, some even dying as a result. The connection between the contraceptive pill and serious side effects for some patients, like bloods clots and strokes, had not yet been made. During the trial, much higher doses of hormones were given than the dose that was eventually licensed in the final Enovid medication. The trial subjects were likely deliberately chosen due to their unfortunate circumstances. Many of these women were keen to access birth control, having already had multiple children and living in poverty. But they did not realise the risk. Ultimately, poor Puerto Rican women gave their lives so that countless others could access safe contraception. Today, at least 150 million people use the oral contraceptive pill.
Don't their preferences matter?
Sanger’s approach to reproductive rights changed decisively as she became influenced by eugenicists.
In her earlier years, she was much more committed to reproductive choice for all, writing in her pamphlet ‘Family Limitation’ in 1914 that forcing motherhood on a woman was ‘the most complete denial of a woman’s right to life and liberty’. Yet, over the years, perhaps due to financial and political pressure, her commitment to reproductive choice waned and became contingent on a woman being an upstanding and worthy member of society, increasingly asking both British and American eugenicists to advocate for her birth control measures.
Later in life, Sanger began to dissociate herself from the wider eugenics movement, but she did endorse the Supreme Court’s 1927 decision in the Buck v. Bell case, which saw the state able to sterilise those they deemed to be ‘unfit’ parents.
For several years, criticisms of Sanger’s reputation have been ongoing. In 2016, Time magazine published an article claiming that her reputation was being twisted for political point scoring by popular Black conservatives, like Herman Cain and Ben Carson, who had commented that Sanger’s sole interest in family planning was to limit the Black population and “kill Black babies.”
Although it is unlikely that Sanger set out to deliberately limit the Black population, ignoring the darker parts of her work continues to fuel suspicion around the organisation she founded and the true purpose of family planning measures. Even global rap star Kanye West weighed in, tweeting a link in 2020 to a New York Post article on the legacy of Margaret Sanger, and commenting that “over 22,500,000 black babies have been aborted over the past 50 years.” West was regurgitating a long-established myth, often parroted by both Black conservatives and Black nationalists, that abortion services were introduced into Black communities to reduce their numbers. It is impossible to understand the opinions towards both contraception and abortion held by some Black people without a deeper discussion on how, historically, birth control has been weaponised.
It's estimated that 78% of men would take contraception, but they fear the potential side effects.
As a sexual health doctor, I know how liberating contraception can be for many, allowing reproductive autonomy in a world which often pressures women to become mothers above all else. But it has also been an oppressive tool, used to subjugate marginalised groups and to advance eugenicist ideas.
While the racist legacy of contraception is often constructed as merely an American problem, it is far more wide-reaching. Sanger wasn’t the only one who made use of eugenics in family planning.
Marie Stopes (1880–1958) also had ties with the growing eugenics movement, and her racist motivations were much clearer than Sanger’s intentions. Stopes established the first-ever family planning clinic within the British Empire, based in north London. The north London clinic still provides services today, but the organisation has now grown into a worldwide charity delivering vital sexual and reproductive healthcare both in the Global North and South. However, Stopes was incredibly vocal in her support of how contraception could be used for social engineering, regularly penning her disdain for those she saw as unfit parents in her pamphlet ‘Birth Control News’. In her book Radiant Motherhood, she stresses that birth control may be used as a solution to the “racial problem” and the importance of keeping “the physical form from utter degradation.”
In July 2020, International Planned Parenthood issued a statement, addressing Sanger’s legacy head-on, denouncing “the problematic beliefs” of their founder that “people of colour, people with low incomes and people with disabilities should be prevented from having children.” Later that year, Marie Stopes International followed suit by renaming themselves MSI Reproductive Choices, stating that Stopes’s support of the eugenics movement was in “stark contrast” to that of the organisation today, and they felt this was the correct time to commit themselves to their future vision of diversity and a global workforce.
While name changes can be helpful in showing how organisations like MSI have progressed in rebuilding trust between communities, it is important that people are aware of why these changes are made and that the history behind them is not forgotten by future generations. I am often told in my work that such harrowing accounts are better consigned to history, and that we shouldn’t drag up painful memories. But we need to carefully examine the records of our institutions and not forget the colonial and racist practices that have become cemented as scientific knowledge.
Otherwise, half-truths circulate in place of accurate historical information, and this reinforces the idea that healthcare professionals are never to be trusted, which prevents people from engaging in what may be life-saving trials and treatments.
An extract from Dr Annabel Sowemimo’s Divided: Racism, Medicine and Why We Need to Decolonise Healthcare (Wellcome Collection, £20 hardback, ebook and audio).
