Abstract: This paper is a close analysis on the developmental goals of the millennium from a perspective of differences between men and women that surpass more than just biological differences. The impact of factors such as patriarchal structures, economic structures and gender roles on women’s health is also discussed in the essay. The concepts of survival and health are closely observed in relation to the negative implications they hold over women and, aspects of their overall well-being are highlighted. The worsening scenario of availability of work and its quality within the neo-liberal economic shifts taking place.
Keywords: Millennium Development Goals (MDG), Social determinants of public health, health services, vulnerability, oppression, intersectional theories, violence against women, gender division of labour, biomedical perspective, health legislation, medicalisation, Mitanin Scheme
Women’s studies have over time influenced other disciplines substantially. The experience of these disciplines can be equated to a process of osmosis in which the permeable boundary of disciplines allows for the penetration of ideas from one side to the other. Through a prolonged process of debate and interdisciplinary studies, Women’s Studies has enriched and enhanced the sensitivities, content and debates within social science disciplines through confronting them with issues such as patriarchy and gender and becoming more cohesive in return. Mukherji called this, “the feminist constructivist challenge to social sciences that is at a fundamental normative level. It raises the issue that more often than not there is a gender subtext in research formulations and analysis, which are male-implicit” (Mukherji 2000). He summarised the theoretical contributions of feminists and acknowledged the richness and contributions of their internal debates on disciplinary boundaries, methodology, and the need for reflexivity therein.
Though most of the pure science disciplines have paid little attention to this academic churning in social sciences, there are scholars who have been looking at the gender biases within pure science and those who have shown the influence of patriarchal nature of science even though it is changing slowly. The story of Rosalind Franklin whose contribution to the discovery of double helix was significant though it was not officially recognised in her life time, she was not the only woman scientist who traversed history without experiencing the patriarchal texture of science. In her analysis of Indian science and its interphase with colonialism, caste, class and gender, Abha Sur examines the life and work of women scientists in C .V. Raman’s laboratory at the Indian Institute of Science, Bangalore to touch upon the way women scientists experienced hegemonies, hierarchies and work challenges and attempted to create a space of their own dealing with the silences surrounding gender discrimination in the institutions of science and the nature of scientific axioms that prevailed. Through the accounts of these women she underscores the “ingenuity of women for making the best of a less than perfect situation” (Sur 2011). This persistent inequality continues till date and gets reflected at times in the narratives of experiences of contemporary women scientists (Godbole 2008).
Amidst the bastion of male dominated sciences, medicine that initially accepted differences between men and women as inherent in the nature of the female body slowly began to accept that not all differences were biological. This was more evident to public health researchers addressing issues of women’s health in communities and the place of women in health provisioning of services. Rising challenges of women’s movement and a gender conscious public health movement added to the affectivity and alacrity with which the role of social determinants of women’s health was brought forward.
The differentials in health indicators among women and men have been recognised for long but not the reasons behind these. The specificity of sex and gender as social constructs was feminist scholars’ contribution to understanding nuances in health. It contributed to a better grasp of health differentials, as the two contributed differently to health and disease. The early literature on medicine and society, emphasised the biological vulnerability/ weakness of women but when these weaknesses were found to be errors of scientific judgment, it slowly turned to biological specificity and then gave space to constraints born out of economic, structural and patriarchal structures and inherent gender roles. This transformation in our understanding of the social determinants of public health touches upon several aspects of women’s health, provisioning of health services, and women’s access to health services. As women’s studies dialogued with the field of health, researchers started exploring and explaining how gender increases the vulnerability of women even though biologically it may not be as high as is evident from the differentials in health indicators. For example, despite the biological vulnerability of women to AIDS, the deaths and morbidity due to it among women, especially the poor women, are far more than expected (Farmer et al 1996). Similarly, despite a decline in child death rates in both boys and girls, the declines are higher among boys due to neglect of the girl child which now reflects in wide differences in sex ratios across states depending upon their sensitivity to existing levels gender biases (Krishnaji 2001). Scholars brought out how gender creates differentials in child mortality, increases women’s vulnerability to maternal mortality, general morbidity, reproductive diseases especially STDs, HIV, and also vulnerability of older women and the widowed (Dasgupta&Chen 1995, Shatrugna et al 2008). Others showed the biases in research (Bal et al 2008) as well as the present focus on maternity health and maternal services and the need for a comprehensive approach to women’s health.
The added social vulnerability was explained by psycho-social factors by some, in the gendered existences of women and men whose socialisation in specific cultural settings prescribes certain roles, expectations and values (Verbrugge 1985) to them. Others moved beyond the socio-psychological and saw this added vulnerability of women due to the patriarchal family structures that centralise power in the hands of the male patriarch and generates a series of controls over women’s labour, sexual relations, paid work, access to facilities like health and education, her mobility and her relations within social and cultural institutions and organisations outside home (Walby 1990).
As the depth of understanding of the dynamics of gender improved, so did the grasp on the social complexity of differentials between men and women. Though patriarchy and ensuing gender roles clearly played a key role, it became evident that gender or the prescribed social roles were not static entity or an isolated construct. Caste and class that was being addressed as determinant of health independently were visibly interlinked and articulation of gender varied with the changing social and economic context of families (Chakravarti 2009). Thus the role of gender in health itself had to be seen in its dynamic interaction with caste, class, ethnicity and religion.
This enriched the debates in health research and impressed upon public health researchers the criticality of exploring the permeability of the boundaries of these social constructs that are in a state of permanent engagement. A shift from isolated to multiple analytical social axioms and their changing historical nature due to mutual interactive and transforming relationships became an accepted challenge for researchers. The new approach could address the complexity of contextual social reality where gender as a vertical social division often played the cementing role and strengthened horizontal hierarchies of caste and class (Qadeer 2002). In the process, gender becomes instrumental in intensifying oppression of the marginalised and making women the bearers of the heaviest burden of such oppression of the marginalised (Jha 2004; Thresia 2007). It was also used as an instrument of war in conflict situations-be they political, social or religious(Kannabiran 2008; Rao 2004). Several researchers, using the new interdisciplinary perspective to the unity of caste, class and gender as the determining factor, explored its implication for health of the marginalised women (Soman 2011; Qadeer 2012). These studies in gender and health attempted to identify the interwoven threads of socioeconomic and cultural factors.
The changing expression of gender across social and economic classes had to be captured and required a suitable methodology (Sen et al 2002). Given the range of stratifications and the limitations of available macro-data, a deeper understanding of linkages required fresh thinking on methodology. This search took women’s studies into exploring intersectionality theories of the black feminist intellectual activists who offered three different approaches to complexities of categories and different methodologies for their study. These are the anti-categorical, intra-categorical and inter-categorical approaches, the first uses the methodology of deconstructing analytical categories of social life which is considered to be irreducibly complex and fluid, and it in fact rejects categories. The intra-categorical approach grants the stability and durability of relationships between social categories at a point of time but maintains a critical stance towards categories which themselves have a historical and contextual content. It interrogates the making and defining of boundaries within categories. The third, inter-categorical approach accepts existing social categories but its focus is on the relationships between these and transformation of relationships in the study of inequality in complex socialsituation (McCall 2005). Except for the first approach, intersectionality approaches accept the stability of existing categories of social analysis at a point of time, emphasises on changes over time and their interrelationships. They focus on inequality and oppression, their differentials or grades within subcategories, and the processes that generate inequality within these. Its use has helped some to adopt empirical methods of defining subcategories and measuring differentials in health status that reveal the importance of gender and its role in determining differences across subgroups or strata (Veenstra 2011; Sen and Iyer 2013). While through measurements and statistical analysis, the empirical method establishes beyond doubt the differential, it still leaves the process or the dynamics unexplained. Others therefore focus on the complexity of categories, processes within causing inequalities and the use of relational and experiential aspects at the methodological level in addition to historical methods to study change (Walby 2012) and elaborating the processes that create inequality as well as possibilities of resisting them. An early proponent of this methodology, Patricia Hill Colin argued that for a collective consciousness to emerge, the differences of lived experiences within subcategories must be recognised, to arrive at a collective strategy that works a consensus by dealing with tensions within and equipping and inspiring them to resist oppression(Collin, 2000: 71). The multiple intersecting oppressive forces may vary in nature and severity in different contexts, but they organise and operate collectively through different domains of power. These domains are structural, disciplinary, ideological and cultural (hegemonic), interpersonal and represent the matrix of oppression (Collin, 2000: 66-69). She considers experience not as an exclusive or exclusionary strategy for analysis but as the basis of a dialogue with those outside this experience. Thus bias, value, emotions and personal ethics and accountability become the basis of dialogue rather than excluded from it to retain the objectivity of main stream science. This way of understanding does not privilege one kind of experience within a given context but is the best way of creating a ground for arriving at a shared, collective stand point. Thus, instead of making innumerable subgroups on the basis of class, race, ethnicity and gender, the intersectionality of these forces can be assessed through experience and the basis of these experiences can be explored through a comparison of contextual differences.
These debates of the black feminists are useful for the central issue of understanding linkages between class, caste, ethnicity, religion and gender in the Indian context. A better grasp of these dynamics also contributes to our understanding their implications for health differentials in different social groups, and the nature and content of services as well as women’s access to it (at a point of time and in history). This current issue of Samyukta presents studies from the field as well as historical reviews that address these issues. Some of the papers deal with health and others with health services and their social determinants. In some the focus is how convergence of various social determinants leads to new types of health problems or worsening of women’s already poor health in the face of inadequate relief. In others, the researchers attempt to show the implications of work availability and its nature for both survival and health. As a means of survival it is a necessity but the type of work available may actually negatively impact health. The worsening scenario of availability of work and its quality within the neo-liberal economic shifts taking place in India is examined in the context of poor women’s lives. Another couple of papers look at health from the perspective of marginalised women who despite consciousness of their deprivation and exploitation – in absence of any organisation – are unable to break the structural, political and social bondage that traps them. These constraints also influence the services run by providers rooted in the same socio-political and cultural milieu and the political processes that govern the emergence of legislation for health.
While most of them use the broad framework of political economy of health within which caste, class and gender are used as basic analytical categories, attention is paid to the cumulative effect of various other social and political factors such as religion, migrant status, professionalisation and access to and nature of markets in technology, as well. Though not directly using the intersectional theories, these works come very close to the inter-sectional and intra-sectional theoretical approaches where class occupies a critical space among the intersecting analytical categories as emphasised by Walby (Walby 2012). The volume thus brings together a set of researchers who, using both the broader political economy perspective and a more intensive socio-anthropological perspective delve into different domains of social determinants. In their exploration of these non- bio-medical determinants at the micro and macro levels, they bring out their variations, interconnections and the way these influence the heath of women (and men).
C. U. Thresia presents the structural constraints of women in Kerala who despite early improvements in health indicators due to better distribution of resources in the State’s democratic political environment, now face a different set of issues in the changing contemporary milieu. It has rising violence against women, high incidence of suicide, increasing medicalisation of women’s bodies reflected in frequent Caesarian sections and increasing use of assisted reproductive technology all rooted in its increasing liberalisation with ensuing shrinking work spaces for women who have low wages, and are being pushed into unskilled work and unorganised sectors. Added to this are the political forces that not only ignore women’s political participation to protect their rights but, also impact health care system through a push towards privatisation, undermining of primary health care, and high price for healthcare.
Indira Chakravarti focuses on one aspect of the structure of power by focusing on the role of work in people’s lives. She emphasises the role of work in determining health, argues that having work is the precondition for ensuring resource and therefore access to health and health care in a neoliberal society. She spells the woes of those who do not have this luxury. By examining the terms and conditions of work of the working class, the nature of the work and safety and security, wages and risks involved, she points to the hazards it creates for health and questions the absence of work as a factor in most official discussions on health. She argues that compared to men the risks involved are higher for women workers given their vulnerability due to their weaker social position within patriarchal relationships of the family and community. Their vulnerability varies with their class and caste location. Also, organisational support, nature of work, and choices available to women are more restrictive and make women more vulnerable.
Anamika Priyadarshi presents the story of lives of women in the silk industry in the city of Bhagalpur. In this home based industry the role of women was primarily in spinning, reeling and washing yarn and starching prepared yarn and textile. The shift to mechanisation has taken this work away from them and those who still do it are gradually not only shrinking in numbers but their conditions of work have also worsened given very high competition with machine made yarn. Thus lack of work as well as conditions of work lead to to poor health.
In contrast to the above three papers that look at social determinants of women’s health through national, state or regional perspectives, Sylvia Karpagam and Sidarth Joshi examine all spheres of power, structural, ideological, organisational, and interpersonal, by presenting a case study of demolition of a Bangalore slum. Using the matrix of oppression, she brings out the experience of the marginalsed to underline the cumulative impact of interwoven inequalities. The simultaneous assault of the powers completely destroys the thin balance of the lives of the poor. Given their vulnerabilities, gender bias, a marginalised social, economic and political identity, the poor women suffer the most, especially if they are old , single, very young and unable to defend themselves, or pregnant. She presents data on the rise in illnesses immediately after the event and traces the processes for the same.
Ramila Bisht, using a political economy perspective in combination with historical materialist feminist analysis, presents an ethnographic study across three generations. This study of continuity and change in two villages of Yumkeshwar block of Uttarakhand district explores how patterns of health and illness are shaped by evolving modes of economic and patriarchal organisation and the gender division of labour. Women’s health is examined as a complex concept encompassing biological, psychological, social and cultural dimension. Her analysis forcefully brings out the fact that in the areas from where resources are drawn and economies decline in the service of capitalist growth, traditional gender relations are used to further enhance the exploitation of women who not only now run the declining economies of the area through very hard labour, but also carry the day to day double burden of running homes and caring for the old and the young while the persistent patriarchal ideology does not give them any power or dignity as workers and care takers. The implications for health are vividly presented in this paper.
Alpana Sagar’s paper makes the same point as to how women are devalued by patriarchal structures, how their perception of self compels them to accept denial of justice as a part of day to day living and how work, even though paying, in certain conditions instead of liberating becomes more oppressive and conducive to ill health. The paper is located in the urban milieu of a Delhi slum where through a survey of 3,000 households she highlights the woes of the poor migrant working women and young girls who learn in early life not to rebel against the social norms. Their vulnerability is located not only in the social situation but also in the problems they face with the middle class health providers for whom their illness can only be explained in a biomedical perspective. Hence, it is either rejected and remains undiagnosed or treatment is delayed only at the cost of their health.
The next three papers look at the service dimensions from three different perspectives. Each emphasises the policy issues in the liberalizing state that are pushing towards organisational changes that in the name of coverage and protection of mothers, in fact, go against the interests of the marginalised women, especially the low caste, the very poor, and those living in the poorly developed areas. Bijoya Roy looks at the popularisation of institutional deliveries, to achieve which the state has initiated several schemes of public private partnerships, assuming that this will enhance coverage and delivery of basic care. The reality however does not bear this out as she reviews the available information to show how a segmented market for maternity services remains unmonitored, provides services but lacks quality and in the name of free services costs the exchequer huge amounts which could be easily curtailed by well monitored public services. Its biggest limitation is that this policy further reduces the access of the poor given the organisational biases to protect the private providers rather than the patients. The schemes thus become instruments of profit rather than safe delivery and health for women.
Mithun Som presents a study from Chattisgarh that looks at the fate of the female health volunteer- the Mitanin schemes- conceptualised to provide door to door basic health services to people in the villages. This study reveals that despite careful visualisation, the implementation of the scheme could not escape the power network of structures, operative ideologies, organisational dynamics of control and interpersonal forces operating between Mitanins and the community. The paper highlights the lapses in implementation at different levels, the social causes for these, and the implications of the same for the nature of services provided. Given the domination of the medical care system and lack of support from the authorities to retain the comprehensive content of services visualised initially, the scheme not only reduced into a purely maternity focused service but also became extremely medicalised with no element of the initial vision of Mitanins being community representatives and pressurizing health workers to deliver. Instead, they became appendages for them.
Janet Chawala brings in a very different perspective from the traditional providers of four different states where in contrast to the officious attitudes of the formal care providers and their tendency towards control and domination, one comes across traditional birth attendants who offer an alternative model of service. This empowers the poor birthing women, is supportive, skillful, caring, easily accessible and does not make money the centre of social exchange (though it is not excluded). Based on a study covering marginalised population clusters from four states of India, this paper presents an insight into the perspectives, skills, values and resources with which the traditional Dais serve the unreached of backward regions of rural India. The contrast to the controlling, all knowing and arrogant approach of the formal providers becomes sharper when one confronts the sensitivity and the skill of these women, their familiarity, cultural rootedness and empathy with the poor women.
Arathi P. M. brings in from the larger structural domain the complex reality about legislation and its role in health. She argues that legislation has been overpowered by medicalisation of the modern variety thus excluding all other forms of health care. Also it is lacking in its grasp of the social causal linkages of health, marginalisation of women in society and the division within them reflecting various forms social stratification. This together has influenced the evolution of health legislation. To illustrate her point she examines the emergence of legislation regarding abortion and its implementation. She shows how unsafe and unhealthy abortions are protected as they happen under the protection of modern health service institutions while the traditional methods remain suspect. She examines the parliamentary debate around the issue to show the strong inclination of the parliamentarians towards medicalisation as reflected in their support of legalisation of abortion not because of high maternal mortality due to abortions but, forced sex and failure of contraception! This she argues exposes their medical and Malthusian bias.
Most of these papers are based on primary research and field based studies of women’s experiences highlight the limitations of the official policy which heavily depends upon technological interventions, withdrawal of state services in favour of private services or public private partnerships and a complete neglect of social reality wherein the poor are either falling into debt traps or succumbing to paying high costs for care due to illness, catastrophic expenditures (Government of India 2011: 3-40), or withdraw from accessing services increasing the numbers of untreated patients among the poor as families get pushed to cut consumption for survival. This brings to the fore, the reasons behind India’s inability to meet the goals of the MDG, a failure that has now been officially accepted but not clearly understood. These papers are a reminder that having social determinants of health as a political slogan and campaigns based on techno-centric interventions instead of regular services cannot replace the need to face the challenge of convergence through comprehensive, intersectoral planning.
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IMRANA QADEER. Started her professional career as a paediatrician and then moved to public health by joining at Centre of Social Medicine and Community Health, Jawaharlal Nehru University where she taught for 35 years and retired as a professor. Since then she has been J.P. Naik Senior Fellow at the Centre of Women’s Development Studies (CDWS), New Delhi and currently a Visiting Professor at Council for Social Development (CSD), New Delhi. Her areas of interest are Organisational issues in health services in South Asia with special focus on India; social epidemiology and political economy of health; and women’s health and research methodology with an emphasis on interdisciplinary research methodologies. Other than teaching, research guidance and research activities, she worked with independent grass root organisations and supported their research and service delivery efforts. She has also worked with the Ministry of Health and Family Welfare, the Planning Commission, Population Commission, the advisory and monitoring bodies for the National Rural Health Mission (NRHM) and University Grants Commission (UGC) Standing Committee on Women’s studies. Her major published work includes Public Health in India and her major area of interest is the relationship between Gender and Heath.