After adopting several children of a drug addicted mother, Barbara Harris devised a radical programme to reduce the number of drug affected pregnancies. Vittal Katikireddi investigates

I wish you had come to me with your birth control offer years ago so I wouldn't have had 14 babies," Sharon says. She has experienced a new approach to dealing with children of drug addicts that is sweeping across the United States--prevent their birth.

The programme, known as Children Requiring a Caring Kommunity (CRACK), aims to "offer preventive measures to reduce the tragedy of numerous drug affected pregnancies" by paying drug and alcohol addicts--both men and women--to use birth control or be sterilised, in the hope of preventing them from reproducing. The organisation, which now has 23 branches across the United States, believes that not only are developmental and health problems prevented, but also the difficulties of raising a child in the environment of drug misuse is avoided. Studies suggest that babies born to mothers who use cocaine are at an increased risk of intrauterine growth retardation, congenital abnormalities (including central nervous system defects, urinary and genital conditions), impaired behaviour and learning development, prematurity, and fetal death.¹

Conceived in California

In 1990, a Californian couple decided to become foster parents. They took care of an 8 month old baby girl, who they learned was the fifth baby born to an addict from Los Angeles. Four months later, a phone call from a social worker offered them the baby's younger sibling, only recently born. They agreed. This second arrival needed hours of care to help him withdraw from crack and help overcome the problems ensuing from his lack of antenatal care. After adopting two more children from the same mother, Barbara Harris and her husband decided that they were not prepared for this to keep happening. After a failed attempt at trying to get Californian legislation passed which would make it mandatory for drug addicts to get long term birth control after giving birth, they decided to form CRACK (also known as Project Prevention).

As of 14 January 2004, CRACK has paid 1141 clients to get birth control.² The rates of pay depend upon the method used and the length of time they use it. Current rates are $200 (£110; a160) for an intrauterine device, a vasectomy, or tubal ligation. But injections of medroxyprogesterone acetate (Depo-Provera) are more lucrative with women getting $50 every three months for as long as they stay on it. "Many women who get Depo injections have been paid $600, $800, even $1000 so far by us," Harris says.

According to CRACK's client survey, their clients had previously had a total of 3870 births, 220 of which were stillborn, and a further 2139 children were put into foster care.² And for Harris this is clear evidence in support of her programme. "This is about preventing unwanted pregnancies in addicts or alcoholics. It does not benefit the addict to have multiple infants taken away from her at birth or to see them die as a result of the prenatal neglect and lack of antenatal care," she says.

Drug users in need of cash

So where do drug users wanting a bit of extra cash hear about the scheme? According to Project Prevention, social workers, probation officers, jails, drug treatment programmes, methadone clinics, and police officers pass on CRACK's phone number to prospective clients--although there are no direct referrals.² If interested, the clients contact CRACK directly and receive some paperwork, which is valid for the next 60 days. They then contact a mainstream family planning provider, who helps them to choose an appropriate family planning method. After receiving the services, the paperwork is returned to CRACK in exchange for the cash.

Funding for the programme comes from "private donations from foundations and individuals who support our work." But what happens to the money? Will it just get spent on drugs? According to its website, CRACK does not monitor where its money is spent "any more than the government monitors where welfare or other related money are spent."²

The programme has received backing from some of America's most influential people. Laura Schlessinger, a popular radio talk show host in the United States who is syndicated to approximately 300 stations, is perhaps the best known. As a licensed counsellor (not a medical doctor) Schlessinger regularly campaigns on issues that vex her including "Parents! Abstinence--not condom use," "Help for families with members in the military," and "Parents! Don't like what they're teaching your children in school? Opt out form here."³

Simply un-American

But there are many people who disagree with the aims of the programme. Lynn Paltrow, executive director of the US based National Advocates for Pregnant Women says, "We support contraception and birth control services. But we also believe that targeting any one group of people for those services is simply un-American." She also adds, "The greatest threat to children in America today is not drugs and it is not their parents who may or may not use drugs. It is that millions of hardworking families who don't have access to health care, housing, and drug treatment."

The advocates' website believes that drug problems are reversible and sterilisation at taxpayers' expense is inappropriate.⁴ They also claim the lack of funding for treatment has prevented drug users from getting the help they need--help which they are even more motivated to seek when pregnant.

CRACK has also drawn criticism from medical organisations. The American Public Health Association, the oldest and largest association of public health professionals in the world, concludes that "programmes such as CRACK violate principles of human rights, civil rights, and reproductive freedoms" in a policy document in 2001.⁵

Propagating fallacies

Perhaps more importantly, however, is the widely propagated fallacy that most children who are exposed to drugs are permanently damaged or are likely to die. Although users of drugs are at increased risk of many conditions, most come to no long term physical harm.⁴

In fact, many of these increased risks are experienced by many other groups as well. The pressure group Campaign for Tobacco Free Kids claims, "Smoking during pregnancy creates a more serious risk of spontaneous abortion and a greater threat to the survival and health of newborns and children than using cocaine during pregnancy." Smokers are at an increased risk of intra-uterine growth retardation, increased congenital abnormalities (including anencephaly, congenital heart defects, and orofacial clefts), deficiencies in growth rate, intellectual development and behaviour--indeed, many similar conditions to children of drug users.¹

The advocates also dispute CRACK's claims that children of drug addicts are often put into foster care: "This claim is made without any reference to supporting scientific data, and it ignores a multitude of well documented studies regarding the actual abilities or inabilities of drug users to parent."⁴

Neo-Nazi eugenics

But Harris refutes these accusations: "My personal opinion is that smokers who even smoke around children are putting innocent children at risk. Our focus is on this one problem drug addicts and alcoholics getting pregnant. We are no different than other organisations that have one focus or goal. You would not ask an organisation working to cure AIDS why they aren't working to cure cancer, right?"

Historically, many segments of society have been targeted for sterilisation, and some of CRACK's critics have drawn comparisons with the eugenics movement. The Nazi's eugenic sterilisation law of 1933 called for compulsory sterilisation of, among others, all "who suffered from... severe drug or alcohol addiction."⁴ Interestingly, by the same year, California (where CRACK originated) had subjected more people to compulsory sterilisation than the rest of the United States combined.⁶

Although the ethical issues in this debate are considerable, CRACK seems to be going from strength to strength. As Barbara Harris points out, pregnancies for drug addicts are "a worldwide problem." Maybe one day a new branch may open near you.

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