Thinking about women’s health: insights from some important texts

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Women’s workshop on equality, body, health and rights. PC: JJSS, Bihar

 

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’.

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PC: Jan Jagaran Shakti Sangathan, Bihar

 

 

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.

 

 

 

 

 

The city’s workers in the grip of fever and the deplorable condition of our healthcare system

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.

Video Testimonies:

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

Reading and seeing public health

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.

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Foundation Stone of RHTC, Najafgarh

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”.

 

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Patients waiting to see the specialist

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.

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Patients queuing up to receive medicines

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!

 

 

Someone just covered the failure of the health system and unspent welfare funds in Chhindwara!

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Its always exciting to see news from your hometown in the national media. But more often than not, in case of Chhindwara, its for all the bad reasons. Last time when the district got some coverage in the national media, it was about the gang-rape of a 15 years old adivasi girl with disabilities and how the police and administration failed to do their job to ensure justice.

This time, it is about how the health system has failed the adivasis. Writing about how the welfare funds meant for dalit and tribals have been unspent for years, the article reports on the conditions of poverty, lack of basic facilities such as electricity and roads, and  difficulty in accessing healthcare in villages of Pachkol and Jad, in Tamia block of Chhindwara.

Jad is one of the villages that are part of the Patalkot valley. Until recently, the villages inside the valley were inaccessible by road and the only way to reach there was the long walk on the dangerously mountaneous paths. I worked in one of the villages of the valley, Chimptipur, in 2014, for my MA dissertation. Life is difficult there, to say the least.

From Chimtipur, which was the first village in the valley in terms of geography and thus closer to the main road than the others, the nearsest PHC was at least 7 kms away at Chhindi, the small market town that catered to all the 13 villages of the valley . And without fail, that PHC remained shut. The only option that the villagers had was to see the ‘Bengali doctors’ and the ‘Jholachhaps’. They had opened their ‘clinics’ in the market where they saw patients and even administered IV on the benches. It was a profitable business: they charged between 50 to 100 Rs as consulting fee and sold medicines they had prescribed themselves. Many of them were in fact medical representatives turned doctors. People also seemed to think that since these medicines cost more, they would be more effective than the ones they got from the PHC for free, if at all it remained open.

Interestingly, Patalkot is home to a rich traditional health knowledge system. Some of the rarest medicinal plants are found in the valley and used for traditional herbal preparations. This has made Patalkot a site of curiosity among scientists, media and general public at large.

The valley also has a large population of the Bharias- a purticularly vulnerable tribal group, in whose name a lot funding comes but never really reaches them, as the article also points out. On top of that, the government has begun an annual adevnture tourism festival to incash the scenic beauty and tribal idenity of the valley, in the name of boosting local economy and providing employment. However, till 2014, not one person from Chimtipur had been provided any employment, nor had any other benefit from the festival reached the locals.

Instead of such grand plans, if only the government could focus on ensuring the basic rights that the adivasis are entiled to, things would have been much better!

 

 

 

 

 

 

Dr. Ambedkar on discrimination by medical doctors

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In Waiting for a Visa ( available here ), Dr Ambedkar writes about an incident that highlighted caste discrimation that dalits faced from upper caste doctors. In this case, a young mother and her child died because the  upper caste doctor refused to touch and thus properly diagnose the patient. This was in 1929.

Today, in 2016, has the situation improved as much as it should have? I am not sure how to answer that.

Here’s what Ambedkar wrote:

 

A doctor refuses to give proper care, and a young woman dies

The next case is equally illuminating. It is a case of an Untouchable school teacher in a village in Kathiawar, and is reported in the following letter which appeared in the Young India, a journal published by Mr. Gandhi, in its issue of 12th December 1929. It expresses the difficulties he [=the writer] had experienced in persuading a Hindu doctor to attend to his wife, who had just delivered, and how the wife and child died for want of medical attention. The letter says:

“On the 5th of this month a child was born to me. On the 7th, she [=the writer’s wife] fell ill and suffered from loose stools. Her vitality seemed to ebb away and her chest became inflamed. Her breathing became difficult and there was acute pain in the ribs. I went to call a doctor–but he said he would not go to the house of a Harijan, nor was he prepared lo examine the child. Then I went to [the] Nagarseth and Garasia Darbar and pleaded [with] them to help me. The Nagarseth stood surety to the doctor for my paying his fee of two rupees. Then the doctor came, but on condition that he would examine them only outside the Harijan colony. I took my wife out of the colony along with her newly born child. Then the doctor gave his thermometer to a Muslim, he gave it to me, and I gave it to my wife and then returned it by the same process after it had been applied. It was about eight o’clock in the evening and the doctor, on looking at the thermometer in the light of a lamp, said that the patient was suffering from pneumonia. Then the doctor went away and sent the medicine. I brought some linseed from the bazar and used it on the patient. The doctor refused to see her later, although I gave the two rupees fee. The disease is dangerous and God alone will help us.The lamp of my life has died out. She passed away at about two o’clock this afternoon.”

The name of the Untouchable school teacher is not given. So also the name of the doctor is not mentioned. This was at the request of the Untouchable teacher, who feared reprisals. The facts are indisputable.

No explanation is necessary. The doctor, in spite of being educated, refused to apply the thermometer and treat an ailing woman in a critical condition. As a result of his refusal to treat her, the woman died. He felt no qualms of conscience in setting aside the code of conduct which is binding on his profession. The Hindu would prefer to be inhuman rather than touch an Untouchable.

 

 

Research and Action belong to a common cause

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There seems to be a wide gap between activism and research in India. When I worked as a full-time activist, I encountered ( and even started to be influenced by) the suspicion towards research that my fellow activists had. I think they felt that research, at the most, only hinted at the problems but never attempted to solve them. On the other hand, as a student-researcher in a university today, I see the disregard that researchers and academics have towards activism and activists, often labelling them as too headstrong and difficult-to-work-with, devoid of objective and rational approaches and outlooks.

In such a depressing scenario, to find some motivation I turn to an article that Jean wrote many years ago. There is no point in summarizing it, for one must read it, entirely, word-by-word. Jean has promised to write the much-needed second part of it, so fingers crossed! 

Here is the original one. 

Public health literature, pedagogy and classroom as a shared space

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Few months ago I wrote a small article for a student magazine. It was on how classrooms need to be more inclusive, sensitive to issues of marginalizations and empowering. I also vented out my frustation with the discriminatory nature of some of the readings and examples I often come across in my class as a public health student. Here it is:

 

“Epidemiology is the study of disease patterns in man.” “Disease is what a doctor diagnoses after seeing signs and symptoms of a patient, illness is what he (a patient) feels and experiences, and sickness is what the society ascribes him.” “A doctor should be sensitive to the socio-economic conditions of his patients.” “Health services in India face massive shortage of manpower.”

These are some of the common sentences I regularly hear and read in my classroom where I am trying to learn about public health. Every time I read or hear such a sentence, I cringe. Do you see why? If you don’t, read them again.

“Epidemiology is the study of disease patterns in MAN.

“Disease is what a doctor diagnoses after seeing signs and symptoms of a patient, illness is what HE (a patient) feels and experiences, and sickness is what the society ascribes HIM.”

“A doctor should be sensitive to the socio-economic conditions of HIS patients.”

“Health services in India face massive shortage of MANpower.”

 

At such moments, ‘public’ in public health seems like a misnomer to me. Exclusive male pronouns or examples are often attempted to pass off as ‘universal’. I sometimes argue and even protest, but mostly, I sulk. A friend of mine tells me that I am overreacting and that it is not the linguistics – a ‘he’ here and there (or everywhere?) that should bother me. Rather, I should focus on the content. Okay, for a moment, I consider the argument, knowing very well that it’s a ‘he’ telling me not to bother too much about exclusive use of ‘he’. I try to take refuge in the academic works that a novice in public health like myself is supposed to revere. But there too, I end up being frustrated.

Take for example, the Bhore Committee Report of 1946 that foregrounded the field of public health in India. It was much ahead of its time when it talked about social determinants of health, occupational health, mental health and various other measures. However, one of its recommendations was that more women should be recruited for nursing jobs as they were more ‘fit’ to do that. Another milestone, the Sohkey Committee report of 1947 went a step even further in suggesting that more women were needed in medical profession so that men could be free to do the ‘more’ important works related to nation building! Interestingly, the Bhore Committee was influenced by the Beveridge Report of 1942 which founded the Welfare State in England. I wonder what stopped the Committee to be influenced by the women’s movement of that very country which was also raising important questions during those very times.

Another example is that of what is commonly called the ‘Ratcliffe study’. Indeed, this study is one of the finest in health research, breaking myths of ‘objectivity’ and stressing on value criticality and systems approach in research processes. But what is hardly ever noticed is that the study was co-authored by John W. Ratcliffe AND Amalia Gonzalez-del-Valle. How come, then, the study is exclusively called the ‘Ratcliffe study’ and not the ‘Ratcliffe and Gonzalez-del-Valle study’? If the first author logic is to be applied here, why do we still call many co-authored seminal works such as the Banerji and Anderson’s study of Tuberculosis or the recent Dreze and Sen’s book and so on and so forth? Just wondering.

To be honest, I do not intend this write up to be feminist critique of the mainstream public health literature since I have no qualification to write one. Rather, this is an unapologetic rant about how our collective, co-created and shared spaces which we call our classrooms, deemed as sites of empowerment and learning, can be hierarchical, marginalising, devaluing and discriminatory. Our classrooms and the processes that lie within them can be as much a reflection of patriarchal social processes as any other space. While we may spend semesters after semesters analysing what rots the ‘outside’ spaces or the systems, in our case the health system, we do not do enough of looking inwards or ‘within’. By not doing so, we breed, sustain and even strengthen the privileges and capital of all kinds that are unequally bestowed upon some at the cost of many others.

The language we use, the jokes we crack, the assumptions we make, the groups we form, the questions we ask, the friends we make, or the readings we like – these are not random processes but are very much shaped by our caste, class, gender, religion, ‘ability’, geographical and other locations.

For instance, as a highly privileged ‘upper’ caste, ‘upper’ class, ‘able’ bodied, urban educated and cis-gendered woman, I find myself more vocal than I should be in my class. The reason I  can comprehend, articulate, write or even score better than many hard working friends of mine is because the rules of the game called institutionalized ‘higher’ education were decided by the elites of my kind with similar privileges, and that is why I am able to ‘perform’. Even if all the rules of the game in themselves are not discriminatory, unequal endowments mean that some people find it much easier than others to do well.

We need to begin asking the hard questions around these themes. We need to interrogate our spaces, our words, our privileges and also ourselves. Every time we exclusively use a ‘he’, we discriminate against persons with other gender identities. Every time we insist on speaking a ‘common’ language, be it the ‘official’ language or the so called ‘national’ one, we intimidate and oppress persons from vernacular backgrounds. Every time we express unhappiness about reservations or argue that it should be based only on ‘merit’ or suggest that caste-based discrimination is a ‘thing of the past’, we commit an atrocity. And then there are many subtle forms of discriminations too, or the forms that I am unaware of but contribute in their perpetuation, nevertheless.

Finally, I do not claim to have solutions. Because we all need to think about them and find them together. And for that, we need to have open, frank, and deep conversations. Lots and lots of them!