An investigative documentary that aired in early December has caused a firestorm of controversy surrounding Israeli healthcare for Ethiopian immigrant women. The documentary reveals that Ethiopian women may have been coerced into taking injections of the long-acting, high-dose contraceptive Depo-Provera as a condition of their relocation to Israel, demonstrating how humanitarian development’s approach to international family planning can be eugenics in disguise.

One woman said she and others were lied to about the effects of the injection. (stevendepolo, Creative Commons)

Although the documentary only interviewed Ethiopian women who immigrated to Israel eight years ago, nearly 120,000 Ethiopian Jews have moved to Israel since the 1980s under the Law of Return. Many Ethiopian immigrants begin their relocation journey in domestic transit camps run by Jewish humanitarian organizations. One such organization, the Joint Distribution Committee, runs a health clinic in Gondar, Ethiopia and has come under fire for prescribing disproportionate amounts of Depo-Provera over the past decade or more. Once Ethiopian women relocated, they often continued to receive Depo-Provera from Israeli HMOs.

Multiple testimonies from the documentary indicate that the prescription process for Depo-Provera was not entirely voluntary. Some women acknowledged that JDC offered both the birth control injection and pills in its family planning workshops, but they felt pressured to get the shot under the impression it was less expensive and more convenient. One interviewee said she and others were lied to about the shots’ purpose:

“They told us they are inoculations… We took it every three months. We said we didn’t want to.”

Another three women, who switched from the injection to the pill after three years of experiencing negative side effects, are currently suing their HMOs for not informing them about the risks of the drug: taking Depo-Provera for longer than two years is associated with increased risk of osteoporosis. The documentary also recounts outright coercion, wherein Ehtiopian women were told they couldn’t leave the transit camp for Israel without accepting the shots.

The history of the Ethiopian Jewish community in Israel is fraught with such discrimination. Israel began rescuing groups of Ethiopian Jews, traditionally believed to be descendants of the lost Israelite tribe of Dan, from war and famine in the 1980s and 1990s. Their non-traditional Judaism and characterization as refugees contributed to their failure to integrate with Israeli society. Today, many Ethiopian Jews work in low-paying menial jobs as security guards or cleaners, and roughly 41 percent of Ethiopian families live in poverty. Episodes wherein Israel's rabbis have tried to phase out Ethiopian clergy and Israel's health services have thrown out Ethiopian-Israeli blood donations for fear of African disease without testing them in advance also expose how religious and racial purity drive Israeli policy on Ethiopian immigrants.

The bodies of Ethopian women became particular sites of medical intervention largely due to Western development practices. Increased maternal health is one of the United Nations Millennium Development Goals (MDGs), but in Ethiopia and many other African nations, the achievement of multiple MDGs is often routed through an overarching policy of lowering fertility rates because family planning is considered comparatively cost-effective. While encouraging birth control is different from the historical practice of forced sterilization, the intent to decrease the future population of Ethiopians does effectively make it a eugenic practice. For Ethiopian Jews coerced into taking Depo-Provera, which can make it difficult to get pregnant for up to two years after ceasing to take the medication, health services have been able to directly control the fertility of an entire community. Birth rates for Ethiopians living in Israel have declined over 50 percent in the past 15 years to, below even the native Israeli average of 2.9.

Israel, a country founded in part as a refuge from discrimination and eugenic practices, presumably does not have malicious intentions when it comes to prescribing Depo-Provera to the Ethiopian community. Israelis have small families when compared to Ethiopians and the country has a relatively high cost of living. From the perspective of policymakers, family planning is a way to improve immigrants’ quality of life and ease their transition into Western-Israeli culture. Dr. Rick Hodes of the Gondar JDC clinic said in an email, “I do not know why offering family planning would be considered negative or even controversial,” and that his clinic was simply trying to meet the MDGs.

Still, policymakers' failure to be reflexive about the issue is problematic. Ethiopian Jews continue to receive Depo-Provera long after arriving in Israel because of medical negligence and a failure to let go of the humanitarian development perception of a pseudo-refugee Ethiopian underclass. As one medical student, Sarah Meyers, chillingly reported, doctors have told students that Ethiopian patients don't believe that they have been treated unless they are given an injection and thus they should treat them with injections instead of pills whenever possible. Meyers goes on to suggest that stereotypes stemming from development practices fill in the gaps in understanding created by language and cultural barriers.

It is important that the Depo-Provera story broke and has at last shed light on the economic, social, and religious outsider status of Ethiopian Jews that affects their medical care. The controversy of the past few months has already forced a moratorium on issuing Depo-Provera to non-native Israelis and it should encourage Israel ‘s health services to begin using Arab and Amharic translators. This issue is also important for discourse on humanitarian development because it forces practitioners to reconsider underlying cultural insensitivity and racism in cases of family planning. Because of the inevitably unequal power relations between providers and recipients of reproductive health services, a clear statement on international medical ethics is important going forward for future development practices.

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