Abstract: Gender discrimination becomes a serious issue when it has its repercussions on the health of women and leads to unethical practices like female foeticides, female infanticides, higher death rate among women, lower life expectancy, higher morbidity and an adverse sex ratio. The 1991 census reflects the worsening status of women in Indian society despite the rhetoric about the Women’s Decade and the Year of the Girl Child. Against this background, the presence and activities of many significant gender conscious People’s Health Movements in our country provide immense relief and optimism in dealing with women’s health problems. The National Health Parliament held at Kolkata in December 2000 by a coalition of 14 health related networks covering more than one thousand non-Governmental organizations discussed the various aspects of women’s health problems and came out with concrete policy options to tackle them.
Keywords: women’s access to health, family planning programme, sex determination tests, health care system, female infanticide, gender bias, contraceptives, women’s health, invitro fertilization, sex ratio
The gender discrimination against women in society has its repercussions on the health of women as well. The consequences of the unfair attitude to women have found expression in several forms-female foeticides, female infanticide, and a higher death rate among women, lower life expectancy higher morbidity and an adverse sex ratio. In India the sex ratio is unfavorable to women 929 for 1000 as per the 1991 census. This reflects the worsening status of women in Indian society, despite the rhetoric about the Women’s Decade and The Year of the Child. Shailaja Bajpai reported earlier that in India every year 12 million girls are born; 1.5 million die before their first birthday; another 8,50,000 before their fifth and only 9 million will be alive at the age of 15. Several later studies confirmed these findings but no radical change has happened after this startling exposure of the pathetic health status of the Indian women.
The gender bias against women rests on the fact that women are seen only as child bearers and as a liability rather than as assets to the society. Contrary to popular notion, the gender bias cannot be explained away by economic reasons. In Kerala, a state with one of the lowest per capita income in the country, the sex ratio is favorable to women (1034) while in Punjab, one of India’s most affluent states, it is below the national average (879); This phenomenon can only be attributed to the cultural dogmas existing among the dominant communities in Punjab. Punjabis have one of the most imbalanced sex ratios in the country, largely because their patriarchal system necessitates a preference for the male child.
The gender bias against women starts from the unborn girl child. It is now well documented that with the help of modern technologies like ultrasound scanning and amniocentesis female infanticide is rampant in our country. This problem came to light as early as 1990 when a young scholar in the Delhi University in her M. Phil thesis entitled ‘The Silent Deaths: A Study of Female Infanticide in Delhi” focused on the widespread nature of this practice in the capital, and highlighted the brazenness with which several clinics are propagating and conducting sex determination tests, followed by abortion if the result showed a female baby. Surprisingly most of the women clients and their husbands were highly educated. Though the doctors performing the tests and subsequent abortions claimed that they chose only those women who had had two or more daughters, this claim was proved false as the researcher found that several of the women who opted for the test already had a son. The study also discovered a sinister nexus between physicians, sex determination clinics and abortion centers. Later, several other studies revealed that this problem was not confined to Delhi but was prevalent in most of the states. The Government, because of the pressure from women’s organisations and peoples’ health movements, has now come out with regulations against the sex testing in the scan centers. But whether the authorities are sincere enough in monitoring this is doubtful.
Several studies conducted in urban and rural areas in India have shown that the girl child is given less breast milk and for shorter periods than boys. It has also been shown that the girls are given less nutritious food than boys and fewer girls than boys receive timely medical attention. Since the diet is inferior, more girls than boys in the same age group suffer from malnutrition. The girl child is often given less food, eats last and obviously gets only the leftover. Despite the Child Labour Prohibition and Regulation Act, children, particularly girls, continue to work in hazardous and less-remunerative occupations. The work of girls is usually invisible, located as it is primarily in the domestic sphere, which is considered as beyond quantification. Girls help with household chores of cooking, cleaning, caring for the younger siblings and fetching water, fuel and fodder. Because of all these factors naturally mortality among the girls is more than that of the boys. The adolescent years of the girls are filled with the trauma of early sexual maturity, early marriage, precarious pregnancies and childbirths, when the girls are physically unfit as a result of malnutrition, discrimination and from overwork.
The medical profession or health planners in our country have not specifically addressed the health problems of the working women. Low wages, long and erratic working hours, deplorable working environment, absence of gender conscious workers’ union, coupled with the several survival and reproductive tasks can only have adverse consequences on women’s health. It is estimated that 94 percent of the women are engaged in the unorganized sector, of which 81 percent in agriculture and the rest in other occupations mostly unskilled and ill paid jobs. It is unfortunate that the laws and policies relating to women have been obeyed more in breach than in compliance. The condition of women in the organized sectors is also not any different. A large percentage of the women in the organized sector work as stenographers, typists and secretaries primarily because it is easier to find women to fill these underpaid jobs. Denied equal opportunities, equal wages, equal service conditions and subjected to all forms of discrimination and harassment, it is no wonder that they suffer from physical and mental trauma.
Traditionally women as mothers, wives and sisters were the providers of health care within home. Their knowledge about childcare and several home remedies was handed down from one generation to the next by an oral tradition that is part of our societal heritage. However with the ‘pharmaceuticalisation’ of health care and the medicalisation of childbirth, women have been relegated to the background. Although not less than 75 % of our health workers are women they are largely at the periphery. They have no decisive powers, acting only as agents of a system out of their control. Although 67% of the deliveries are conducted by dais they are regarded as untrained health assistants who do not form a part of the formal health care system. Even trained personnel like nurses play a subservient role vis-à-vis doctors and are given little or no support or understanding. Thus as long as caring, nurturing, nursing and healing were part of satisfying a family’s needs, women were regarded as ‘wise’ and their knowledge and skills respected. Once these activities became associated with profits and economic gains, the medical profession came to be dominated by men and capital-intensive technology. Not only were women marginalized in terms of their role as providers of health, but also their own health became the focus of warped and distorted notions. The uterus came to be looked upon as the source of all their problems which came to be diagnosed as mere ‘hysteria’ uterus centered.
Women’s access to health services is vital. Because women have the responsibility of caring for the health of her entire family, her knowledge of nutrition and health is important both for herself and the health of the family. Hospital records from several states in India have shown more male admissions than female and more hospital beds being earmarked for men than for women. Women’s access to health services is constrained by several factors. First, the time spent on child care, house work and workplace leaves them with little time to think about their health, often resulting in their illnesses at early stages. Second, the clinics offer women no privacy. Third, most clinics are staffed by men, and women show a reluctance to be treated by men. Finally, the women’s awareness of available medical facilities is lower than that of men.
The new reproductive technologies (NRTs), which are fast gaining ground today, are equally degrading to women. They are primarily post-natal technologies many of which are introduced as a therapeutic cure for infertile women. The NRTs include: Artificial Insemination of Donor Sperm (AID), Invitro Fertilisation (IF) and IFET (Invitro Fertilisation and Embryo Transfer (IFET) etc. These technologies are beyond the reach of most people. Yet, because of our patriarchal society in which the son is seen as critical, even those who can least afford will try every means to be able to use these technologies. Women’s groups are rightly questioning the ethical, legal, social and economic implications of such technologies. Just as amniocentesis was initially promoted to detect birth defects, NRTs were introduced as an answer to infertile mothers; But as amniocentesis has become a sex determination test, fertile couples who wish to rent the womb of a surrogate mother and yet own the baby produced by the fertilization of their ovum and sperm are increasingly using NRTs. With the introduction of NRTs, childbirth has become yet another business venture, even a profession among some in metropolitan cities. With the number of couples willing to pay handsomely for the services of a womb, it is no wonder that less affluent women from the developing countries are more than willing to become surrogate mothers. It is interesting to note that adoption has never been seriously regarded as an alternation
In the area of family planning also women bear the responsibility, with scientists focusing their research on female contraception and government policy promoting terminal methods involving women. Moreover, several contraceptives developed in the West, totally unsuitable to the Indian context, were introduced without adequate trials in India. The women in the West have a free and informed choice regarding contraceptives and the efficient medical services there ensure proper screening to exclude women unsuitable for a particular contraceptive. Proper follow-up to ensure timely treatment in the event of any side-effects are available in those countries. Introducing such methods without any of these facilities is definitely hazardous to the health of our women. In a number of states illiterate women were subjected to the trial of long-term injectable contraceptives. Appropriate use of new contraceptive technologies depends on the context in which the method is used. The long-term health related economic and social consequences of the methods must be examined and prerequisites and conditions for safe use determined before distributing them on a wider scale. If the method is used in a relatively coercive family planning programme, then a woman’s right to choose freely from a range of contraceptives and her right to discontinue the method are likely to be violated.
In this context the family planning or rather the population control programme in India should be analysed from a gender perspective. A dispassionate assessment of the family planning programme in India in its four and half decades of existence raises many interesting issues. Experiences within, as well as outside the country, show that a reduction in population growth rates follow an overall socio-economic development. Except in conditions of war and famine, they seldom precede such development. Yet this has largely been ignored during our planning process, possibly as it prevents our planners from blaming the country’s tardy development rates on the pressures posed by population increase. As a result, family planning strategies have tended to be paternalistic, prescriptive and coercive. It is a strategy, which starts from the belief that the poor breed prodigiously and it is the nation’s duty to cap their unbridled fertility. Thus programmes are aimed at the poorest sections, and more specifically at women. Tubectomy rates in the country are fifty to hundred times higher than vasectomy rates, though the latter is a far simpler and safer procedure. Hormonal methods aimed at women find precedence over propagation of condoms, in spite of widespread reports that the former are associated with a large number of health hazards. In this whole process the supposed beneficiary — the impoverished rural woman — has virtually no choice. She is at the receiving end of technologies which the state or society believe are necessary. Such programmes are inappropriate not only because they victimise women, but also because they are not efficient. Such a strategy has undermined the effectiveness of the general health care infrastructure as well as the faith that women have in this infrastructure to address their real concerns. Most programmes tend to view women as assembly line appendages required to produce babies.
New strategies have to be designed to increase women’s access to and role in the health care system in order to ensure better health for the women, as also better child survival. The World Conference in Nairobi to review and appraise the UN Decade for Women put forth the following recommendations:
• Creating and strengthening basic services for the delivery of health care
• Increasing the participation of women in higher level health institutions through legislation and training
• Integrating fully and constructively female traditional healers and birth attendants into the health system
• Strengthening promotive, preventive and curative health measures through supportive health infrastructure, free of commercial pressure
• Designing and constructing accessible and acceptable health facilities in harmony with patterns of women’s work, needs and perspectives
• Encouraging local women’s organizations to participate in primary health care activities and devising ways to support women in taking responsibility for self-care. Though made in 1985, these recommendations are still relevant. The presence and activities of large number of Peoples’ Health Movements with gender consciousness in our country gives us a lot of optimism in tackling the women’s health problems in India.
(I express my gratitude to Dr. Mira Shiva of the Voluntary Health Association of India and Dr. Amit Sen Gupta of the Delhi Science Forum in helping me to prepare the article.)
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B.EKBAL Eminent neuro-surgeon and health activist. Chairman, Health Subcommittee, Kerala Sastra Sahithya Parishad and National Convener, Jana Swasthaya Abahayan.