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Health and the other half

By Imrana Qadeer

Women’s health is much more than their reproductive health, but this is the only aspect public health policy focuses on. Unless the social determinants of a woman’s health, including her secondary status in the family, are addressed there will be little change in the falling sex ratio, malnutrition and maternal mortality

Health has to be seen within the various structural components of society, which includes gender of course, but also categories like caste and class. The tragedy is that the health data that we have always addresses differentials and single variables. Looking at only male-female differentials and wrongly terming them ‘gender differentials’ will give you an inaccurate reading. If, however, you bring in the other categories of caste, class and location, you get a better idea of the differentials.

To me, that is the crux of the issue. Because if you look at just mortality, even reproductive mortalities, and compare them with those related to communicable diseases you will find that communicable diseases have a much higher load for general mortality among women when compared to reproductive diseases. In fact, reproductive mortality among women accounts for about 2% of deaths. So the personal circumstances of women and their social backgrounds account for a big chunk of mortality.

I am not undermining the specific issue of reproductive health by any means; what I am underlining is that women’s health is much more than their reproductive health.

Health has been simplified so much into a bio-medical model that access to it is immediately seen in terms of morbidities, and if women are not accessing services the argument made is that they are ignorant. So it is important to ask: How does one understand health? There are two ways to do so: one is the technical bio-medical view wherein you have standards against which you measure, and you say, okay, these are the diseases that are prevalent. The other is a more social definition, wherein you bring in the subject as somebody who understands her own health and you also bring in the collective perception of health.

Here we come to the tragedy of the WHO definition of health which is so broad and general that it becomes impractical. Health is seen as the ‘absence of disease’. In fact, there can never be absences, and not only can there never be absences, the presence of diseases can be very different among different classes. If we are to understand health as a collective phenomenon within the public health perspective, I would insist that we bring in the other social determinants. Are we talking of individual health? Are we talking of collective health? Are we talking of the health of the poor? How do different sections perceive their own health? How do doctors perceive their health? How do policymakers perceive their health? The definition of health has to be dynamic and multi-layered.

Today, in India, fertility control still is the most critical aspect of health delivery services despite policy claims to the contrary. From maternal and child health, we have moved to reproductive health, and reproductive health has taken over the National Rural Health Mission, which is supposed to approach health in its totality. The views of doctors and experts are divided on this. While the health movement people are talking about broader perspectives, health personnel, especially gynaecologists and obstetricians are still predominantly looking at women from a very narrow perspective -- her reproductive role.

 The interesting issue is how women, especially poor women, look at themselves and analyse their experiences. Within the international health movement, much has been made of the ‘silence’ of women. But some of us are saying that the fact that women are ‘silent’ needs to be looked at more carefully. You have to see what they are doing, not saying. After all, not all of us have the option of speaking out. Silences are interpreted as suffering about which women do not talk. But if we look at political movements in third world countries, women are talking all the time. They are talking, not just about their reproductive health; they are talking about work; they are talking about wages; they are talking about the education of their children; they are talking about food. There are so many things that women are talking about. Unfortunately, the notion of health for those who have the privilege of having all these aspects of life looked after, is ‘not having to go to the doctor’. But the idea of health for poor women is very different. It is about whether they have shelter, whether they have the next day’s meal. That is why it is so crucial for us to understand that all this is health.

Of course, this is not to undermine the importance of health services. But we have to see the constraints under which people live, the way they perceive issues, and what they want in terms of facilities. They know what their priorities are -- ensure the basics of life and then talk services. There is no doubt that women also want services, but look closer at the system and see how much primary healthcare has really been provided. It is almost non-existent. Even the National Rural Health Mission, which is supposed to have done all right, is not delivering on what it had promised.  It too is focusing on reproductive health through accredited social health activists (ASHAs). Here again, hierarchies are being created: corporate hospitals for the middle and upper middle classes, and ASHAs for the poor. Is this part of a short-term plan so that, over a few years, everybody gets into the same service system? Or is it going to be a permanent divide? I see it as a permanent divide. I don’t see a long-term planning process wherein India builds an integrated health service. If you look at the draft Twelfth Plan, everything is going to be privatised. I am afraid that even primary healthcare as conceptualised at Alma Ata by the WHO is going to be privatised. So the taxpayer’s money will be used to fund the private sector.

How do you expect the poor to have access to such facilities? Already we know that 40% of personal debt is because of health issues, and things are only going to worsen. In terms of access, I believe there are two issues: one is the kind of services and mindset of the providers who do not see women’s general health issues as a key area, whether it be tuberculosis or malnutrition. Two is the family itself, where gender inequality is very visible. The sick man will go to the best centre locally available to avail of services; if not, he will go to the city in search of a better doctor. The woman will depend on a local provider.

Everywhere, women carry a double burden and this is reflected in healthcare as well. Because the existence of the household depends on her, she will not say that she is unwell until it becomes physically impossible for her to carry on. So, partly it is her socialisation that does not permit her to speak, but when she does speak the family has other things to do and their responses are delayed. Then she is taken to a place that is badly run. We see therefore the multiplier effect of her secondary status.

This impacts girls as well. In Haryana, I once saw a two-month-old baby crying and I asked why. Her grandmother laughed and said: “Let her get used to it. In any case, how does it matter?” This is a social issue, not a health issue. Take violence against women as an example. I am talking here not just about domestic violence but general violence, the violence caused by conflict, the destruction of one’s home, the destruction of one’s confidence. We all know that violence against women is an instrument of war and it has huge implications on health. Then there is the abuse of young girls within the family. There is no recognition of this happening. In fact, society denies that such things can happen. Instead of looking at the social determinants of such developments, we push them into the arena of health and services. You are actually expanding the responsibility of the medical community, but you are not thinking about preventive measures.

It is similar when it comes to malnutrition. We are socially producing malnutrition by adopting certain agricultural policies, undermining the public distribution system, paying poor wages, and when women or children suffer from malnutrition we put tubes into them and say that the family is not eating right. The same holds true for environmental pollution. Take the Bhopal gas disaster. It had such adverse repercussions on women’s reproductive health, but they were not adequately addressed. Only a few researchers like Dr C Sathyamala paid attention to this aspect.

At this point, I believe, many hundreds of thousands of women in the country are dissatisfied with the services they are getting. We have been told that because of the Janani Suraksha Yojana there is data to prove that more and more institutional deliveries are taking place. Has anyone analysed these figures to find out whether maternal mortality and infant mortality have come down as a consequence? That data never emerges. At the same time, there are case studies to show that the very poor treatment women are getting when they access services discourages them from going back to those institutions. What then is the point of access to such services? If the services are good, they will come. If not, they will choose a local dai to assist them in the delivery. They get cash for accessing these services, but that cash comes after the baby is delivered so it doesn’t go towards the nutrition of the mother or into antenatal care; it goes into transportation, it goes into the bribes they sometimes have to pay. Cash transfers do not resolve the problem of women’s health.

We also need to look at the skewed sex ratio against this background. It reflects the status of the girl within the family. By and large, she is still seen as a burden, with the transfer of wealth done mainly through the male gender. Unless this changes, as long as old burdens like disproportionate marriage expenses remain, falling sex ratios will be a part of India’s reality. Medical personnel are exploiting these social constructs for profit and then privately justifying their behaviour by saying that they at least did the procedure correctly and gave the woman a safe option. But they are clearly not ready to fight the trend. So we see professionals, social structures and patriarchal attitudes contributing to declining sex ratios.

Our medical establishment has shifted from being a service within welfare planning to an instrument of revenue-creation. This is what corporatisation of the medical services has meant. It is against this background that surrogacy has emerged as a big, money-spinning project -- not because it necessarily meets an epidemiological need but because the upper middle class and the international community desire such a service. The international dimension is very critical in this. If you surf the Net you will be amazed to see how clinics in India are being advertised. There is information about how the service-seeker can get ‘fair’ surrogates, ‘educated’ surrogates. For national users, caste is a factor that is highlighted. In fact, every obscurantist, gender-biased requirement is being catered to. I am not against surrogacy, per se. Anyone who wants a baby has the right to use the available technology; it is the commercialisation of surrogacy and the exploitation of surrogate mothers that is the problem. Also, when we ask ourselves what kind of health services the country needs on the basis of epidemiological priorities, surrogacy services do not figure high up on that list, except among a tiny elite. Most infertility is secondary and therefore preventable if women get access to good primary healthcare. 

Surrogacy services impact women in different ways. The majority of women who sign up for being surrogate mothers are those who are economically wanting and need money to cope with various problems. Sending children to school, repairing a leaking roof, getting the husband a scooter so that he can earn better -- these are the kinds of needs for which women agree to sign up for surrogacy. It is very interesting therefore that the state seems to regard surrogacy as employment for women. The minister for social welfare argued this when the law was being framed for the first time. We responded at that point saying that we were not against surrogacy, but introducing it as a strategy because you cannot give work and wages to people is clearly unacceptable.

There are different issues that the practice of surrogacy in India raises, including ethical ones. Surrogate mothers are not told about the risks. In fact they are reassured that it is a very safe procedure and that it is “just like a normal experience of having a baby”. They are not told about the reactions that could happen; that sometimes women can hyper-ovulate; they don’t know that they can go into shock and that it is sometimes life-threatening. And, although these women are extremely vulnerable, they do not receive legal assistance. Ultimately, it is a transaction between the doctor, the bank, and the couple seeking the service. It is a bit like saying that life in India is cheap. The state could ensure that the doctor makes less out of such cases and surrogate mothers make more, but that of course does not happen.

Surrogacy reflects the new direction of health delivery in India. Health services no longer respond to what we, in public health, call ‘epidemiological needs’ -- the objective requirements of the community, whatever they may be, whether it is diarrhoea, communicable and non-communicable diseases, or malnutrition.

Today, planning for health means asking which service will bring in the most revenue.

(Imrana Qadeer is a retired Professor of the Centre for Social Medicine and Community Health. She is presently a Fellow with the Council for Social Development)

Infochange News & Features, December 2012