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.
If 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.
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.
Don’t miss Kanika’s article on sterilisation camps in Chhindwara, which appeared in Scroll yesterday. While reading it, and when Kanika was talking about her experience, I was reminded of Deepa Dhanraj’s documentary Something Like a War.
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.
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.
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 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. 🙂
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:
‘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.
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.
In my women’s health course, we were asked to write informal and non-academic ‘think’ papers based on our readings and discussions on the subject. Its a great exercise where one gets to rant, vent out and not care about maintaining adcademic decorum. I chose to begin with the basics, and ponder over the question of ‘what is women’s health’. Here’s what I wrote and links to the articles that formed the basis of it:
What is women’s health? A simple, yet profoundly complex question.
Simple, if indicators, statistics, models, approaches, frameworks and methods of looking at this question are already pre-defined, standardized, tested, modified and accepted. Even though these themselves may not be simple enough, yet they simplify the question. Because through them, you can understand the question in only a particular way and thus arrive at only particular answer/s. The boundary is set into which this question is to be confined, and answered. Therefore, simple.
Complex, if we break these boundaries and start to really question the question itself. Who is asking this question? From what standpoint and why? What do they mean by ‘women’? What is their understanding of ‘health’? Even here, there would be some norms, for norms are everywhere, explicit or implicit. But, perhaps the acknowledgement of the complexity of the question, and the potential in the process of questioning the question may help challenge, if not annihilate, the dominant norms of defining what women’s health means. Such an approach may help accommodate the multiplicities, the conflicts, the unease, and indeed, the similarities that answers to this question may encompass. Finally, such an approach would underscore that there is no ‘final truth’ to the answer of this question, for the truth is constantly co-constituted with diverse forces that act upon/through/along with it. Therefore, ‘what is women’s health’ is a complex and discursive question, which more than anything else, should compel one to think, churn, reflect and raise more questions than simply finding ‘valid’ answers.
Inhorn’s paper flags off this process of questioning. She writes as if she is also reflecting on the question, uninhibited and unapologetic. She doesn’t mince words when she critiques the biomedical and public health establishment for having defined women’s health for/on behalf of women, rather than women defining it themselves. Her politics is evident in everything that she writes, and she beautifully blends that politics with rich academic scholarship on the subject, exhibiting a writing style that teaches much more than what the content is expected to convey.
Apart from very important points that she makes about reproductive essentialization of women’s bodies, medicialization of women’s lives, politics of women’s health, women’s local moral worlds etc., one of the key take-aways for me is this: even though many of the authors of the listed ethnographies are clearly influenced by feminist frameworks, they remain reluctant to introduce the polemics of feminism for the fear of losing academic “neutrality” or being critiqued for doing so otherwise. She herself was targeted for her book ‘Infertility and Patriarchy’. One critic attacked her for “packaging her excellent analysis within an envelope of predictable and tedious feminism, full of ‘gendered’ this and ‘patriarchal’ that”. The critic, clearly wanted her to separate her feminism from her academic analysis, as if the analyses, thoughts, ideas or research in general, exist outside ideologies/value positions/belief systems. The fact that the critic didn’t want her to explicitly associate her ideologies with her work was itself a value position, however implicit.
But what is even more important to note here is Inhorn’s response to this: she urges more and more authors and researchers to place patriarchy centrally in their frameworks and writings on women’s health. She asks us to come out with more scholarship on women’s health where discussions on patriarchy are framed around the empirical realities, and to also theorize, not just describe the lived experiences, of patriarchy’s health demoting effects.
That patriarchy is the primary lens of thinking about gender-based oppression is undeniable. It permeates into almost all spaces-personal, political, professional, and beyond. But, no longer can it be thought of only as ‘male domination, oppression and exploitation of women’ (Walby, 1990). While this is useful for initial understanding, it is also narrow in its scope in explaining complexity of notion of patriarchy. Patriarchy is a systemic and structural problem: the state can is patriarchal, Brahminical society is patriarchal, the family is patriarchal and even women are patriarchal themselves when they oppress women in lower positions than themselves or persons of marginalized genders. Central to all this is the question of power, without which we cannot understand patriarchy.
How does one see patriarchy in one’s immediate context, in this case as a new student of public health? It can be seen everywhere: From the texts we read to the shared spaces we call our classrooms, to the health settings we study/observe. A doctor is always a he, and the patient he treats is always a male. “India’s health services system suffers from shortage of MANpower”. “Epidemiology is the study of disease pattern in MAN”.
At such moments, ‘public’ seems like a misnomer. If it was only the matter of problematic/sexist language, then one could still (unwillingly) manage, although as Kriger argues, “language embodies ‘important social and historical processes”. But, its not just a “word here or there” or “slip of the tongue”. It’s a discourse that reflects and is shaped by patriarchy where women’s as well as marginalised genders presence, experience, labour and voices are negated or invisiblized in the name of ‘universal’ pronouns, examples, narratives, references. Furthermore, the marginalisation of non-binary genders, sexual minorities, differently abled persons in the discussions as well as in the reading lists/texts/papers/journals is too glaring to be ignored.
Krieger too talks about this in her paper. She problematizes the fact that till 1970s, the term gender was conspicuously absent from the textbooks of public health. And today, there continues to be a confusion to whether to use sex and gender interchangeably or as distinct constructs. In particular, epidemiological and health research has been challenged by lack of conceptual clarity. Krieger’s solution to this problem is that we are both- a gendered person and a sexed organism, simultaneously. It is this different permutations and combinations of gendered relations and sex-linked biology and their synergies that determine health of an individual.
But there are more things, beyond the gender-relations and sex-linked biology, that determine women’s health, urges Doyal, and for that one needs to step outside of the ‘body’ to understand how women’s lives make them sick. In a classic political economy text, Doyal is able to weave together rich analysis of women’s oppression and role of public health in both its continuation as well as its potential in challenging it. Quoting Rubin, who writes these words as if she is writing poetry: “Female subordination has both endless variety and monotonous similarity”, Doyal argues that not all women are always worse off than all men, but in most societies, women are structurally unequal than men. This where is she rejects crude universalism as well as crude difference theories, and urges us to focus on women’s ‘common difference’.
My another favourite message from Doyal is this: “If biological finality of death can only be explained in a wider social context then the complex realities of women’s sickness and health must be explored in similar ways. In order to do this, traditional epidemiological methods have to be turned on their head.”
Tuning traditional and mainstream epidemiology on its head has been the main theme of the brilliant paper by Inhorn and Whittle where they expose the antifeminist bias in the in contemporary epidemiological research, explore the possibilities within the emerging “new” epidemiologies to incorporate an alternative feminist framework, and finally propose what they call the feminist epidemiology. Such an epidemiology would be a resistance to the marginalization as well as narrow definition of women’s health concerning only reproduction/reproductive pathology. Courageous and unapologetic, the women authors challenge the hegemonic epidemiology establishment in the US and openly name the international and highly regarded journals such as the American Journal of Epidemiology, Journal of Epidemiology and Community Health, Epidemiology, International Journal of Epidemiology, etc., for not correcting, and even perpetuating, antifeminist bias. This is a highly rare instance, hardly ever done by academics who are too conscious of their publications, promotions and prestige to risk it for politics. Writing like this is a radical act in itself, something that speaks truth to the power.
Inhorn and Whittle leave an important trail for us to discover and embark upon when they talk about the contours of a feminist epidemiology they envision. It is as if they are telling the young researchers like us where to pick up the threads from and how to weave our own journeys of research, action, politics and academics while upholding the commitment to feminist politics in intersecting spaces of personal, political, professional and beyond.
Such an epidemiology, they posit, would have no ‘universal category’ of ‘women’ in its framework. Drawing from works of black feminists and third world feminists, as also Dalit feminist stand point, such a postulation would acknowledge that even the biological similarities that are there among women are experienced differently depending upon their locations and identities.
It would have a new episteme, a new theory and a new methodology that empower women to take part in knowledge production, where they themselves talk about their lives or are being emphatically listened to instead of being talked about or on behalf of; that documents their health and diseases in their entirety; that places gender oppression in the centre of analysis of women’s health; that links their local experiences with geo-political forces.
Such a framework would require us, the students, the researchers, the teachers, academics, activists, epidemiologists, policy makers, development workers- to be critical of our privileges and positions in the spaces we are part of. It would require us to see how we and our work are implicated in perpetuating hierarchies and structures of domination, and it would require us to challenge them, break them and/or replace them with new and alternative spaces.
Finally, with the question we began this paper with, such a framework of an emancipatory feminist epidemiology or public health broadly, would necessitate radically questioning and critical rethinking about ‘what is women’s health’.
PS- Apologies for not being to upload Doyal’s book here. I had read the hard copy of it and I am not able to find it online.
Mehnatkash Mahila Sangathan, Delhi, has come out with an important report on the effects of the ongoing epidemics of fever, dengue and chikungunya on the working class populations in Delhi’s industrial areas and slums. The report highlights the inadequacies of the healthcare system as well as the administration to address the suffering of this marginalised section on whose labour the city is built and running. The report concludes by making demands towards urgent action in these areas and to ensure that health and wellbeing of the working classes is not compromised in the present times of underperforming public health services and increasing privatization and commericalisation of healthcare. Two video testimonies are also provided at the end of the report.
Since the past one month, entire Delhi is in the grip of fever. Diseases like Dengue used to break out every monsoon, but this year, Chikungunya and Malaria have been added to the list. While no section of the city is left untouched, the worst affected are the poor and the working classes. At this time, we will hardly find any person in the slums of Delhi who isn’t affected by fever, joint pain. But this aspect caught the attention of the media only when a large number of workers started missing work because of illness and this disrupted construction work and production in the factories.
According to the government figures in Delhi, 15 people have died due to dengue so far, and 1300 cases have been reported, while 1500 cases of chikungunya have been reported and 6 people have died of malaria, till now. But the ground reality is very different from these statistics. It is clear that the government and the municipal corporation is trying to suppress the seriousness and vastness of the problem. In East Delhi’s Jhilmil Industrial area, in three slums alone, there have been 3 deaths in the last week due to high fever. There isn’t a single house here, where you would not find anyone suffering from high fever, joint pain and body pain. It is common to find homes with all members ill, so much so that there is no one left to take the ill to the doctor. Only in a single slum, atleast 2000 of 2500 people are suffering from fever. Clearly such numbers are being kept of the official statistics.
The condition of the nearby hospitals is so bad that after waiting in the queue for hours, the doctors get rid of the patients by just handing them 3 paracetamols. People are thus being forced to go to private hospitals and clinics where the charges to get a single patient treated is a minimum of Rs.1000; if you add to this, blood tests and pain-killing injections, then some people have even had to pay around Rs.3000.
How will people earning daily wages between Rs 50 to Rs 300-be it factory workers, hawkers-vendors or women domestic workers- be able to afford such expensive treatment? Especially if many members of the same family are unwell. If they do not get treatment, how will they go for work, and if they are unable to go for work, where will the money for family’s treatment come from? Most of the people are trapped in this cycle of helplessness, and as a result, they have to sacrifice their health. Another important aspect is that such diseases require long periods of rest and consumption of juices and fluids for recovery, both of which are far beyond the reach of the working classes. It is impossible to take long leaves as the fear of losing their livelihoods is always looming large. Many families have been forced to return to their villages and quitting their work due to the increasing expenses on treatment and medicines. Children are also not being able to go to school and many of them have had to miss their exams. Many in the slum will also tell how difficult it has become to do any daily work because of acute joint pain. Many people can be seen limping.
Garbage dumps and contaminated water is logged everywhere near the slums. The drains are so dirty that they are ideal breeding grounds for mosquitoes. Is the MCD not responsible for the cleanliness of slums and working class areas? Fogging has been done only once for namesake, that too only in some parts of the slum. Apart from that there hasn’t been a single effort from the corporation that has been taken to maintain cleanliness throughout the year. Has the government been spending the large amounts gathered in taxes in the name of ‘Swach Bahrat Abhiyaan’ only on false advertisements!
> Looking at the serious condition in the capital as well as in the whole country, it can be said that it is not going to subside only by calling for “Protect yourself from mosquito bites”, a few weeks every year. These diseases and their outbreak can only be stopped when health-care system and institutions become the priority of the government, when treatment, medicines and tests would be free and universal. The class-character of the understanding of ‘cleanliness’ in our society and cities also needs to be changed.
This isn’t the story of just one slum. The situation in every slum in the city is the same. Most of the population of the country and especially cities is living in poverty despite working hard and labouring day and night. The struggling population constitutes the majority of the country, and the children living here are its future. The most hard-hit is the city’s Dalit population which is involved in the work of picking, segregating and cleaning waste and the city’s trash with their bare hands. The development model has left this entire class to suffer in suffocating, small damp rooms and on the streets and footpaths. Garbage, dirty sewage and factory smoke has become such an integral part of the environment that getting inflicted by diseases is natural. This leads to a drastic drop in the immunity levels of the labouring masses. The most important thing is that untill this majority gets fair and equitable wages, dignity for their labour, and freedom from exploitation, their health will keep suffering and the country will move towards weakness, malnutrition and diseases.
Keeping this situation in mind, we are making the following demands to all levels of the government and administration (central government, state government and municipal corporation):
1. This outbreak of Dengue-Chikungunya- Malaria should be declared as an epidemic and all required necessary official steps should be taken to control this epidemic.
2. The wages of workers who are not being able to work due to this disease should not be cut.
3. All workers, including domestic workers and contractual labourers, should be given the ESI facility as a matter of right. The conditions of ESI hospitals should be improved and the provision of required appointment of doctors, treatment facilities and cleanliness should be ensured.
4. The MCD should fulfil its responsibility of cleanliness in all the areas, especially working class areas and slum communities. Regular fogging should be ensured, all through the year and not only during an outbreak of these diseases.
5. The number of beds in all the existing government hospitals should be increased and the number of labs for blood tests should be significantly increased, immediately.
6. Private hospitals and clinics should be brought under strict regulation, so that the race for profit-making out of people’s health and helplessness can be stopped. For the coming few months, the tests and treatment related to these diseases must be provided for lower affordable rates for all the patients, and free of cost for the poor patients, in private hospitals. Hospitals and clinics extorting higher fees should be severely punished.
7. The private hospitals constructed over concessional land and which are not providing reserved beds for poor patients should be punished. The legally reserved beds for EWS patients and provision of free treatment and medicinal facilities for them in these hospitals should be increased. (For in-patients it should increase from 10% to 25% and for out-patients it should be increased from 25% to 40%)
8. Expenditure on health should be increased 10% of the central budget. The privatisation of health facilities should be immediately stopped and all primary to higher levels of health facilities should be made public.
ASHA worker Neelam, speaks about the outbreak of fever in her basti and the deplorable condition of health system : https://youtu.be/Ip3djqgVa5g
Murari, resident of jhilmil industrial area, Delhi speaks about the outbreak of fever in his basti and the deplorable condition of health and sanitation faced by the working class: https://youtu.be/4VFTbDKXdJg
Our friend Vyom recently visited the Rural Health Training Center (RHTC) in Najafgarh in Delhi as part of field visit in the first semester of his public health course. He shares some of his observations from the classroom and the field. Many thanks to him!
For a new student of public health, understanding the functioning of the health system on ground is crucial. It is an exciting exercise, where you relate what you learn in the classroom with what you find in the field. It helps us evaluate how theories and concepts of public health apply to the real world situation, and how the experiences, situations and practices on the ground in turn inform the discourses around health.
I observed some aspects of this relationship between theory and practice during the visit. For instance, our readings and discussions so far have taught us that government health institutions have important social goals and they serve as the backbone of public health measures in any country, due to their reach and inclusionary set-up. And therefore, despite the problems within them, their importance cannot be undermined. The RHTC in Najafgarh exemplifies this.
Located at borders of Delhi and Haryana, RHTC Najafgarh was the first public health center of India. It was started with financial assistance from Rockefeller Foundation in 1937, and was taken over by Govt. Of India in 1942 and later turned into RHTC in 1960. The centre covers the population of over 1,60,000 and heads six sub-centres. Though it falls under the jurisdiction of Govt. of Delhi, which has entirely different structure of health service system, a PHC and sub-centres were the exceptions here. Apart from OPD, emergency and outreach services, the centre also has specialist care units. I spotted long lines of patients outside the ophthalmic, pediatrics and orthopedics wards. Specialist care in a PHC is a rare occurrence in India and that’s why one of doctors commented, “it’s a PHC but it’s more like a CHC”.
Along with preventive and curative health services, this facility also provides training to nursing students from government and private colleges. This is significant, because although many tertiary level institutions such as district hospitals and medical colleges provide this combination of service delivery and teaching, doing this at the primary level enhances the quality of work at the primary health institutions, which are in fact the first contact points between the community and the healthy system.
The interface between the health system and community/patients became clearer when I began interacting with patients. My joy was doubled when I came across a group of women who were from my hometown Siwan and Chhapra. Rapport building techniques of social work were not required here, greeting them in bhojpuri and calling them chachi (aunt) worked quite well. After an informal introduction they told me about their experience of that day. For them taking out a day for their health needs was a luxury. They had to wake up at 5 in the morning, do all the household chores and reach the centre by 9. They walked to the centre which took around half an hour, as they could not afford transportation. It took them the entire day, from registration to meeting the doctor and taking the medicine.
When I asked them about their illness, they said that they didn’t have any specific ailment but they constantly felt weakness, fatigue and joint and body pains. One of them reported that the doctors don’t even consider it as illness and ask them not to burden the PHC. That ‘unmeasurable’ health problems, such as pain, is a neglected area, especially in case of women, gets exemplified here.
A woman informed that she was advised to drink milk regularly, to which she smiled and said, “only if we could afford”. The connection between undernutrition and ill-health has been well established in public health but what is less investigated is the intra-household distribution of food: exactly how much are women and girls eating in a household. Food habits are culturally and socially defined and gender plays a significant role: women eat the least and last, they fast regularly and some food items are prohibited to them during menstruation, pregnancy, widowhood and other events. Add to this the gendered division of labour in the household where women do the most strenuous work for the longest hours. Not surprisingly then, despite the growth in economic assets for a large number of households, majority of women are still so under-nourished, thin, and anaemic in India.
Adjacent to PHC was the JJ slum where Harish, a vegetable vendor from Ballia (U.P) lived. Seeing the slum dwellings, I couldn’t help but be reminded of Engle’s essay on the living condition of working class England in the 19th Century that we had read in the class. While there was a lot of difference between Engle’s description and what I was seeing in front of me, mostly because the contexts were so different and centuries apart, the denial of dignity to the residents and its dangerous consequences was common in both. Harish narrated that they had no option but to drink the water that sometimes got contaminated with sewage water. The sewage pipeline was broken and since it ran parallel to the pipeline that supplied water used for household purposes, it often contaminated the water used for drinking and cooking.
Hearing this, I was reminded of John Snow and his work, something that every public health student reads. Snow, using epidemiological techniques and data, investigated the cause of outbreak of Cholera in London in 1850s and found the connection between the contaminated water source and the outbreak. Owing to his pioneering work, administrative measures were taken towards ensuring better sewage systems and efficient water supply as a public health goal in London more than two centuries ago.
But JJ slum is not London, nor do we have a John Snow by our side. Worst of all, we lack the willingness to learn from the years of public health research and action. So, maybe it will take some outbreaks and deaths before we turn any attention to the health problems that the marginalized populations are forced to face!