Pubdate: Sun, 23 Jul 2000 Source: New York Times (NY) Copyright: 2000 The New York Times Company Contact: 229 West 43rd Street, New York, NY 10036 Fax: (212) 556-3622 Website: http://www.nytimes.com/ Forum: http://www10.nytimes.com/comment/ Author: Jeff Stryker UNDER THE INFLUENCE OF GIFTS, COUPONS AND CASH IF money changes everything, why not use it on people? It is the cash the women want, says Barbara Harris of Anaheim, Calif., founder of Children Require a Caring Kommunity, known by its acronym Crack, which since 1997 has paid drug users $200 to be sterilized or to use contraception. Not only cash but discount coupons, gifts and vouchers have become incentives in programs to encourage healthy behavior, whether the issue involves reproduction, drug treatment or even organ donation. Yet some experts question whether such methods actually work in the long term. At least 246 women have taken up the offer, according to Crack's Web site: www.cracksterilization.com. Ms. Harris hopes a new $50 referral bonus will bring in additional clients. Crack's promotional slogan -- "Don't Let a Pregnancy Interfere With Your Drug Habit" -- bluntly conveys why cash can be such a powerful motivator for drug addicts, many of whom become pregnant repeatedly and whose babies are underweight and at risk for birth defects. Although Ms. Harris does not track how the women spend the money, she said, "Sure, some use it to buy more drugs." A few years before Crack began its program, a dollar-a-day program was established in Colorado to persuade young women to delay pregnancy. The cash is part of a program that includes weekly support-group meetings. But criticism has dogged international population-planning efforts. Widespread condemnation followed revelations in 1998 that Peruvian women were being sterilized in exchange for dresses, T-shirts and food in cases where informed consent was doubtful and post-operative care inadequate. In March, members of Congress questioned whether aid to Peru was violating prohibitions against the use of federal funds for forced family planning abroad. Incentives have also encouraged women to have children. In Scotland, the Catholic Church undertook an initiative in 1997 to pay women not to terminate their pregnancies, in one case paying the family of a 12-year-old girl. Elsewhere, moral objections over abortion are not the issue; low birthrates are. In Japan, private companies are offering cash bonuses to employees who have more than one child. Whether cash is an undue inducement depends on the circumstances. "Cash is a very effective incentive that we use all the time," said Bonnie Steinbock, chairwoman of the philosophy department at the State University of New York at Albany, who has studied incentives in reproductive decision-making. "It isn't necessarily coercive." Offers of cash to do good are nothing new. And paying donors for plasma, for example, has caused officials at blood banks to worry about needy participants lying about their health histories. But do incentives involving reproductive decisions really work? Sometimes, say Cheri Pies and Sarah Samuels, researchers with the Incentives Project, a two-year program of the School of Public Health at the University of California at Berkeley. They found only 11 rigorous studies of such inducements, which varied from cash and small gifts to coupons for infant formula combined with education, support and counseling. The cash incentives could not be linked to the success or failure of the programs in the studies, said Dr. Pies and Dr. Samuels, who advocate using money for achievable short-term outcomes. Cash has also been dangled to keep teenagers off drugs. In Florida, Arkansas and Pennsylvania programs, participants get discounts at local shops and exemptions from curfew rules when they pass a voluntary urine test and agree to future random tests. Charles Schlichter, a financial adviser and member of the Chamber of Commerce in Chambersburg, Pa., lobbied to bring the Arkansas antidrug program Truce, the acronym for Teens Resisting Unhealthy Choices Everyday, to his rural community. About 20 percent of the students in grades 8 through 12 have been voluntarily tested. "It was the first program we heard about that involved a carrot and not a stick," Mr. Schlichter said. Although federal law prohibits commerce in human organs and tissues (with an exemption for replenishable material like blood, plasma, sperm or eggs), Pennsylvania health officials attracted attention last year with a proposal that circumvented the 1984 statute. They designed an experimental program in which families of organ donors would receive a $300 reimbursement for funeral expenses. Fearful of violating the law, they recently scaled back and now propose paying some hotel and travel costs for donor families directly to the lodging and transportation providers. Critics argue that the introduction of cash incentives could result in fewer people donating their organs. Money has the potential for dirtying the process, said Bob Spieldenner, a spokesman for the United Network for Organ Sharing. "Paying might very well drive out altruism," Mr. Spieldenner said. One aspect of the debate about money versus altruism might be gullibility as far as organ donation is concerned. The Department of Health and Human Services recently began to investigate certain practices in harvesting tissues, including skin, tendons, bones and foreskins. Many people may be unaware that their freely given donations may end up fattening lips or enlarging penises in what has now become the vast, lucrative enterprise of cosmetic surgery. Federal rules limit reimbursement for tissue to reasonable administrative and processing costs, although some interpret those rules expansively. Although the examples of cold, hard cash enlisted to encourage health and good works is growing, one particular program has failed to catch on. The Frederick Christian Fellowship in Frederick, Md., gave $10 bills to first-time visitors in 1994, which succeeded in almost doubling attendance. Few churches, though, have followed suit. - --- MAP posted-by: Derek