Kanika and Chhindwara students in the local newspaper

Last month, Kanika helped organise a training program for students in Danielson College, Chhindwara. These students, who come from marginalised backgrounds, do not get many opportunities to learn research skills such as data collection, questionnaire design, or fieldwork. Through the program, they did a survey of public health centers in Chhindwara district. Below is a photo of a Hindi news article that describes their efforts.

Kanika’s article on pain and public health in India, and a response

100_1098If you haven’t done so already, do check out Kanika’s article on pain, health systems, and gender,  which was published by Scroll.in. The article was a part of Scroll’s excellent series on pain. Responses to the articles included somewhat overwhelming stories by scroll readers of living with pain, which reinforced the value of research, public health work, as well as writing.

 

Inside a sterilisation camp

I recently went inside a female sterilisation camp in one of the blocks of Chhindwara district. It was hard to watch it happen in front of me, and I was painfully reminded of just how lucky I was to not be a poor, adivasi, dalit woman in this country and be subjected to this.

Here is what I wrote about it:  http://scroll.in/pulse/821330/two-years-after-18-women-died-at-tubectomy-camp-little-has-changed-at-indias-sterilisation-drives

Ignoring the obvious

Vyom writes about a recent field visit to a maternity centre in Delhi. The obvious and straightforward solutions such as increasing the capacity and effectiveness of primary and secondary level of health services instead of centralising tertiary care facilities are not given their due. This impacts the health of the already vulnerable the most.

We all are afraid of getting ill. But, illness impacts us as per our socio-economic background. If for me my health is of utmost importance, for those without the kind of privileges I am endowed with, health concerns may come only after concerns for food or income. Sometimes they may have to even put their health at risk for ensuring basic survival. Although an expanded understanding of health and wellbeing would include interlinkages between health, food, income, rights, democracy and much more, but often in reality, when none of this is easily available, people have no choice but to prioritize, and those priorities are reflections of our privileges. Unfortunately, good health and timely healthcare have become such privileges: while some are endowed with these, others remain deprived.

Even though basic healthcare is one’s basic right, it is routinely violated in India. Inefficient and increasingly commercialized public health settings, rampant privatization of healthcare and general apathy towards the wellbeing of the marginalized sections have increased the health inequities which now mirror the social inequities and inequalities. Excluded from the public health system, the poor have no choice but to be indebted to avail private health services or fall at the mercy of quacks, who do more harm than good to their already vulnerable health. Statistics corroborate this: India’s Out of Pocket expenditure on health is anywhere between 60 to 80 percent, whereas State’s expenditure on health is as low as 1.3 percent of the GDP. Is it still very hard to understand why we as nation fail so terribly in ensuring good health of the population?

One of the biggest challenges that public health services system in India faces is the shortage of health personnel at almost all levels, but more acutely in primary and secondary levels. My short field visit to a Maternity centre in Srinivaspuri, Delhi, substantiated this.

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Inside the Maternity Centre, Srinivaspuri, Delhi

 

Maternity centres in Delhi come under the Municipal Corporation of Delhi, which are run as per the guidelines of Reproductive and Child Health programme (RCH). RCH was launched by Government of India in 1997 with the aim of reducing infant, child and maternal mortality. Although there are many critiques of the programme, one of which is its aggressive focus on population control rather than ensuring empowering and overall healthcare to women, some believe that it is still one of the only programmes through which women have some contact with the health system, and thus is important.

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Offical logo of RCH

 

But the programme too suffers immensely from the shortage of staff. The maternity home in Srinivaspuri covered a population of around two lakh, but had only one gynecologist, one pediatrician, two medical officers, twelve staff nurses and seven ANMs. The number of health personnel was way below the prescribed guidelines. This Maternity Centre is a secondary level unit, and according to the guidelines issued by Indian Public Health Standards, a secondary level unit should have “essential and emergency obstetrics care including surgical and other medical care” for maternity care ( p 4, IPHS). However, there was no obstetrician. There were also no anesthetist, blood bank, oxygen cylinder and monitoring OT. Only ‘normal’ delivery, that is delivery without any complications, was being done at this centre, that too of second pregnancy. Rest of the cases were either prima-gravida (prima= first, gravida= number of times a women has been pregnant, that is first pregnancy), or declared complicated and thus referred to tertiary level unit, such as Safdarjung and AIIMS. In 2014-15 only 664 cases were delivered at this centre out of 2447 ANC cases registered.

I came to know about the impact of high rate of referrals when I met mothers who came for routine immunization. One of them was Munga Mahto who came with her 9 month old grandson Siddhant for last round of immunization. When her daughter-in-law came for the first time at this maternity centre, she was referred because it was her first pregnancy and there were high chances of complications. For them going to Safdarjung Hospital for delivery was a herculean task, especially when the sole earning member of her family who worked in a warehouse couldn’t not afford few days of leave. To avail services without any hassle they went to a nearby private nursing home which charged them around fifty thousand rupees. Though the amount was large and pushed them in debt, they were happy that the child was safely delivered. However, for the friend of Munga Mahto, who accompanied her to the centre, her first grandson was born at Safdarjung Hospital at free of cost because one of her relatives was a government employee who knew someone at the hospital.

Near the maternity centre was a slum. There I met Ujni Devi. Ujni is 45 years and works as domestic help. She lives with her daughter and son-in-law and three grandchildren. Her first grandson was delivered by a midwife in her village in Bihar. Second granddaughter was delivered at this maternity centre. But, complications arose when her daughter was pregnant third time. As usual the maternity centre referred her. She couldn’t imagine the idea of going to Safdarjung. Private nursing home was out of question, she could have been in debt for the lifetime. Left with no other option, they called a midwife from the neighboring slum and the baby was delivered.

By the evening I was confused. At one hand there were efforts made by the government to improve ‘average’ figures of mortality. On the other hand, to avoid the stigma of maternal deaths, and also challenged by shortage of staff and infrastructure, secondary level maternity centres routinely referred large proportion of cases to even more understaffed and hugely overburdened tertiary level facilities, increasing the sufferings of poor families.

It is obvious that more efforts must be towards increasing the capacity and effectiveness of the primary and secondary levels of health services system which are closer to the reach of the population, instead of centralizing care in tertiary levels. But when has the obvious and seemingly straightforward solutions ever attracted attention of policy planners in India?!

 

 

 

 

 

 

 

A new way of doing research

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A recent article in the EPW talks about the ‘Hard Work, No Pay’ way of doing research that some of us have been part of, and have learnt a lot from. The surveys that are organised by Reetika and Jean to find out about the workings of social schemes on the ground have been immensely important interventions in research and policy as well as in initiating young individuals like ourselves into research and action.

My first survey was in 2011. I was part of the Bihar team, and went to investigate the functioning of the Public Distribution System in districts of Katihar and Nalanda. Our team’s findings have been reported here. That survey was a critical  juncture of my life, for it introduced me to extreme suffering and deprivation, but also to people’s resilience and struggle against them. Those 3 weeks challanged many of my previously held ideas and beliefs about development, caste, gender, state interventions, and much more. At a personal level, the survey was painful and confusing, as it made me uncomfortable with my privileges and demanded that I read, reflect and act to utilize these privileges in order to fight the inequalities that they entail. The survey also introduced me to people who care deeply about issues of justice, and who continue to inspire and shape me even today through their work and friendships. It won’t be an exagerration, therefore, to say that it changed my life, and that I owe much of who I am and what I do today to the ‘Hard Work, No Pay’ model of research and action. 🙂

 

Women’s reproductive health and lives

Following is a review of the book The Unheard Scream: Reproductive Health and Women’s Lives in India’, edited by Mohan Rao. It came out in 2004 and is an important political economy text on the question of women’s reproductive health in India. Here it is:

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‘Bharat Mata’, a militant symbol of the nationalism currently being revived by the present establishment, has taken over the country by a storm. Worshipping her is now the proof of one’s loyalty to ‘Akhand Bharat’, and refusal to do so automatically makes one an ‘anti-national’, a criminal, or a ‘Pakistani’. Never mind the masculinized protectionism meted out by the sons of Bharat to this Mata, some view this as a welcome postulation, because after all, respect is being paid to the mothers (and thus assumingly to women).

Feminists, however, find it deeply problematic, and even anti-feminist (John, 2016). They argue that this discourse is an attempt to undermine the questions that they have been raising against the rape culture, state repression, brahminical patriarchy, oppression within family and marriage, neo-liberal onslaught and curtailing of freedoms to love, choose and desire (ibid). The ‘Bharat Mata’, however, does not raise these questions, for she is too content to first be exploited and then ‘saved’ by those very sons of hers. She does not seek justice, as for her, fervent chanting of ‘Bharat Mata ki Jai’ is more than enough!

To counter this celebration of ‘Bharat Mata’ which glosses over the hard realities of gender-based exploitation and oppression, it is imperative that issues, concerns, questions and struggles by millions of women in this country are highlighted. ‘The Unheard Scream: Reproductive Health and Women’s Lives in India’, edited by Mohan Rao and which came out in 2004, does precisely that.

The book, a collection of essays written by thirteen journalists and edited by Mohan Rao, is an honest attempt in documenting the various aspects of women’s health as embedded in their lives. This anthology of writings by journalists is particularly important today, when journalism in India, as also the world over, is visibly losing its depth, commitment and independence to cover the issues of common people. Dreze and Sen (2013) also reported that out of more than five thousand articles appearing on editorial pages of leading English newspapers in last six months of 2012, only about one percent covered health-related issues.

Not only is there a serious dearth of good reportage, the mainstream media now also join the ruling forces in manufacturing consent (Herman and Chomsky, 2010), producing hysteria over trivial issues at the cost of crucial ones and making journalism, the fourth pillar of a democracy, anti-democratic. This book, however, helps restore some faith, if not in the media establishment but at least in the journalists who are writing on issues that matter, one of which is women’s health.

What makes women sick? Like Doyal (1995), if we too were to ask this question, then we would have to adopt the political economy of health framework to situate the question of women’s health in their socio-economic and political contexts (Rao, 2004). This is the main message that the book tries to convey, by looking at multi-level factors intertwining and affecting women’s reproductive health and their lives through stories, data and arguments from the ground.

It is often pointed out that much of the discussion on women’s health is dominated by themes around reproduction, making some critics call it reproductive essentialization of women’s lives (Inhorn, 2006).  Despite this constraining approach, reproductive health services continue to be the only point of contact that most women have with the health system (ibid), and therefore, while sustained efforts must be made to highlight and work on overall (other than reproductive) health needs of women, reproductive health continues to be an important lens to look at women’s health as well as to understand the health system’s responsiveness to gender issues. This book too studies reproductive health so as to ensure both specificity of it as well as to use it as a frame of analysing women’s overall health and well-being, thereby becoming one of the guiding texts in understanding political economy of women’s reproductive health in India.

The book’s introduction poses the central question that keeps recurring as one navigates through the pages: are reproductive rights universally about the woman’s freedom from subjugation by family, community, religion and the State, or can they also be guised as means of population control, disproportionately affecting the oppressed women, thereby, demanding that reproduction be connected with wider socio-economic concerns?

This question is asked at the backdrop of the “Cairo Consensus”, often celebrated as a paradigm shift in the way population, development and reproduction were approached. Rao (2004) problematizes this consensus by showing how seemingly opposed groups, the reproductive rights feminists on one hand, and the World Bank along with population control establishment on the other, decided to be fellow-travellers to merely replace population control with population stabilisation, paying little to no attention to the neo-liberal onslaught on the health of women, particularly of those in developing countries. While a feminist language of reproductive rights was adopted to whitewash the over-population argument, nothing much changed at the grassroots in the following years, as the chapters in the book demonstrate.

One of the most visible violations of the Cairo consensus by the Indian state is what is infamously called the ‘camp’ approach. Menon (2004) reports from inside such camps, which she titles ‘State-of-the-Art Cycle Pumps’, to show how under the garb of sophisticated ‘emancipatory’ rhetoric of the Reproductive and Child Health (RCH) programme, cycle pumps were being used to inflate women’s abdomens for laparoscopic sterilizations!

Anand (2004) too argues that RCH is the same old wine in new bottles, as targets are still present, only they may now be self-generated or undeclared (ibid). In places where this camp approach is not doing the harm, there are other ways to commit medical atrocities, one of which is quinacrine sterilization, known as the “quick fix” method in rural parts of Bengal (Dasgupta, 2004). These hugely popular “injections” were preferred by generations of women, for the method required no surgery or hospitalisation, something that rural poor women usually find hard to afford. Thanks to the official apathy and negligent monitoring mechanisms, a whole racket of “rural practitioners” with international links continued this banned and highly unethical contraceptive trial on women, making their bodies the sites of experiment, “data collection” and control without their consent and adequate disclosure of possible effects, all in the name of providing reproductive choices (ibid).

If we thought this was only a thing of the past, since the book came out a decade earlier, the atrocious death of 13 women and complications in many other in one such ‘camp of wrongs’ in Bilaspur, Chhatisgarh in 2014 reminds us otherwise (Sama et. al, 2014). Even talks to introduce the highly controversial drug Depo Medroxy Progesterone Acetate (DMPA) in the form of injectable in the National Family Planning Programme resurfaced in 2015 (Jan Swasthya Abhiyan et. al, 2015). These recent developments testify that there is no stopping of mutilation of women’s bodies by medical malpractices in the name of family ‘welfare’.

Interventions on women’s bodies take an entirely different form when the attempt is not to control the fertility but to enhance it through assisted reproductive technologies, showing how complex the whole spectrum of reproduction is. Srinivasan (2004) discusses how the Parenthood Dream is packaged and sold by the flourishing fertility industry, flouting ethical norms, coaxing huge sums of money for potentially hazardous treatments on desperate women and playing with cultural aspirations of the couples to produce a commodity, i.e. a baby, for consumption.

That growing commodification and consumerism in neo-liberal times affect women disproportionately is further revealed in the case of Malappuram district of Kerala where the money flowing in from the “Gulf Men” helped the Muslim community of the area to economically progress but also led to increase in teenage marriages and pregnancies and “gulf wife syndrome” among young girls who found it hard to psychologically and emotionally deal with changes in their identities (Basheer, 2004). Discussing migration of male agricultural labourers from North Bihar villages, leaving behind ‘grass widows’, to deal with disease and deprivation all alone, Jha (2004) in his brilliant essay shows how the age-old structures of caste and landlessness collude with neo-liberal assaults of soaring prices and complete withdrawal of State in welfare measures, hitting women the hardest, as always.

But, perhaps one of the most direct assaults of the neo-liberal economic policies that advocate aggressive growth strategy by ‘disciplining’ labour can be seen on women workers. Rajlakhsmi (2004) goes inside two Export Processing Zones (EPZs) to show that unmarried young girls did monotonous work standing for at least eight hours with an additional three hours ‘compulsory over-time’ with no extra pay.  A total of five minutes was allotted for going to the toilet, exceeding which could invite expulsion (ibid). This description alludes to the feminist debate on women and work where women entering the workforce, owing to capitalism, could be seen by some as a step ahead to evade the drudgery and often the violence of households to some extend but the nature and conditions of work, as shown in case of EPZs, as well as devaluation, casualization and sustenance of gendered role even in occupational spaces can be far from empowering.

Discussion on women and work becomes further complicated when it revolves around the theme of sex work, where ‘the range of options available to anyone wanting to take a stand on the issue is confusing’ (Gangoli, 2004:108). The sudden health care attention given to sex worker is only due to the scare of HIV whereby women in sex work are seen as “vectors” but there legitimate health needs remain cruelly unaddressed (ibid). Irrespective of the position, the article urges to listen to the women in the profession and help enlarge the options they can choose from.

Listening to women, lifting the veil of silence, hearing their scream, and thereby acknowledging their voices and issues is the final plea of the book. Chinai (2004) writes about the war-struck, economically stagnant, invaded by drugs and aids, non-existing healthcare and neglected by the ‘mainland’- Nagaland- where ‘even if we (women) shout there is no one to hear’ (ibid). Bhattacharjee (2004) dwells on the sensitive topic of sexual health of adolescents to argue that unless sexuality of the younger persons is demystified and an environment of openness, acceptance and creative and empowering engagement with adolescents is ensured, the ‘politics of silence’ will continue to do more harm than good. Finally, silence around menopause, as captured by Bavadam (2004) throws more questions than answers- is it the medicalization of a natural bodily process which also is deeply linked with socio-cultural aspects that is causing an anxiety over the silence or is it indeed another oppression which invisiblises women’s health problems amidst other oppressions? Only listening to women emphatically can provide answers.

While the book attempts to capture the wide breadth of issues surrounding reproduction, some indispensable ones have been missed out, without which understanding of women’s reproductive health in India is incomplete. One such theme is violence. That violence against women is pervasive, a rallying point of women’s movement for a long time, was reiterated empirically by the National Health and Family Survey – 3 which found that every third woman between the age group of 15 to 49 reported having experienced physical or sexual violence in her life time, with number of women experiencing sexual violence by intimate partners being forty times the number of women who experienced sexual violence by non-intimate partners (Gupta, 2014). This clearly has serious health impacts on women, particularly on their reproductive health, which should have found a place in the book.

The book is also conspicuously silent on issues of mental health which have both direct and indirect association with women’s reproductive health. History is full of examples of how reproductive wrongs have been committed on women with mental illnesses or disabilities in the name of ‘disciplining’ them or ‘maintaining hygiene’ and sometimes without any reasons at all.

The book also does not discuss the reproductive health, as well as the overall health of the lesbian, bisexual, Trans and queer (LBTQ) women. Written in early 2000s, when the discourse as well as the movement around queer rights had perhaps not as strongly emerged in India as it is today, the book could have at least attempted to problematize the heteronormativity as well as sexism rampant in the health system which further marginalises identities that are variant from the norm.

No one book can do justice to the full spectrum of issues in women’s health, which are diverse, complicated, yet extremely important. Even though some topics such as mental health, violence against women and health issues of LBTQ women are neglected, The Unheard Scream: Reproductive Health and Women’s Lives in India does a remarkable job in highlighting women’s health needs and their neglect in India. Ideally, there should have been more policy discussion and action related to these concerns, and much more research and action related to women’s health. That this is one of the few books paying careful attention to women’s health is the real tragedy.

 

 

References

Anand, A(2004): Safe Motherhood, Unsafe Deliveries in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Basheer, K P M.(2004): The Gulf Wife Syndrome in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Bavadam, L.(2004): The Silent Transition: Indian Women and Menopause in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Bhattacharjee, S. (2004): The Politics of Silence: Introducing sex education in India in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Chinai, R.(2004): Even If We Shout There is No One to Hear: Reproductive Health Issues among Marginalized Population of Nagaland in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Dasgupta, R. (2004): Quick-fix Medical Ethics: Quinacrine Sterlization and the Ethics of Contraceptive Trials in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Doyal, L. (1995): What Makes Women Sick: Gender and Political Economy of Health. Macmillan.

Drèze, J., & Sen, A. (2013). An uncertain glory: India and its contradictions. Princeton University Press.

Gangoli, G.(2004): Women as Vectors: Health and the Rights of Sex Workers in India in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Gupta, A. (2014). Reporting and incidence of violence against women in India. Available at: http://riceinstitute.org/wordpress/wp-content/uploads/downloads/2014/10/Reporting-and-incidence-of-violence-against-women-in-India-working-paper-final.pdf (accessed on 6th April, 2016).

Herman, E. S., & Chomsky, N. (2010). Manufacturing consent: The political economy of the mass media. Random House.

Jan Swasthya Abhiyan et al. (2015): Statement protesting approval to introduce Injectable contraceptives in the national family planning programme, Kafila. Available at: http://kafila.org/2015/09/24/a-statement-protesting-approval-to-introduce-injectable-contraceptives-in-the-national-family-planning-programme/ (accessed on 6th April, 2016).

 Jha, D.K. (2004): Grass Widows of Bihar in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

John, M. E. (2016): Feminism, Freedom and Bharat Mata. Public Lecture Delivered in Jawaharlal Nehru University. Available at: https://www.youtube.com/watch?v=iVo8msMZWKI.

Menon, S. (2004): State-of-the-Art Cycle Pumps in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Rajalaxmi, T.K.(2004): For a Few Dollars More: Women in Export Processing Zones in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Rao, M (2004): Cairo and After: Flip Flops on Population Policy in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.

Sama et al. (2014): Camp of Wrongs: Mourning afterwards- Fact Finding Report on Sterilization deaths in Bilaspur. Available at: http://sites.hampshire.edu/popdev/files/2015/02/camp-of-wrongs.pdf (accessed on 6th April, 2016).

Srinivasan, S.(2004): Selling Parenthood Dream in Rao, M. (Ed.). (2004). The unheard scream: reproductive health and women’s lives in India. Zubaan.