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The unheard scream: Reproductive health and women's lives

By Laxmi Murthy

A review of a new book on the neglect, deprivation and non-existent reproductive healthcare in India

The Unheard Scream: Reproductive Health and Women's Lives in India
Edited by Mohan Rao, Zubaan Publications and Panos Institute, 2004
Pages: 312. Price: Rs 400 (Hardback)

To mark the publication of The Unheard Scream: Reproductive Health and Women's Lives in India , Zubaan Publications and the Panos Institute held a panel discussion on August 2, 2004, in Delhi. The panellists were Brinda Karat of the All India Democratic Women's Association, A R Nanda, former secretary, ministry of health and family welfare and executive director, Population Foundation of India, and Mrinal Pande, editor, Hindustan. Kalpana Sharma, deputy editor, The Hindu, who chaired the discussion, pointed out that the need for the Panos programme came about because of a lack of space in the media. Sharma, who is also on the Panos Fellowships Advisory Panel, said: "This book can even be called 'The Unrecorded Scream' because, in some cases, even full-time journalists could not find space in their publications for their essays."

The Unheard Scream: Reproductive Health and Women's Lives in India comprises 13 essays written by journalists who are winners of the Panos Reproductive Health Media Fellowships.

'Cairo and After -- Flip Flops on Population Policy', an excellent introduction by the book's editor Mohan Rao, brings together the 13 essays that touch on a range of aspects impacting women's health in India. Rao documents the 1994 International Conference on Population and Development (ICPD) in Cairo that represents a paradigm shift in the way population, reproductive heath and development are understood. "The Cairo consensus was a significant, if somewhat modest, step forward...It signalled a move away from demographically-driven population policies that attribute poverty and environment degradation to women's high fertility, and, in turn, women's high fertility to an absence of information and methods," says Rao. Yet, critics argue that in the agenda of rights of the ICPD, reproductive choice refers to the plethora of contraceptive devices that a "free" woman is supposed to be "empowered" to choose from. "Choice" is reduced to consumption that fosters a private enterprise in women's bodies. Was this, then, what all the storm and thunder of reproductive rights was about, asks Rao.

Essays by Sreelatha Menon and Rupa Chinai bring out the abysmal situation in rural areas. In 'State of the Art Cycle Pumps', Menon chronicles the horrors of the so-called "reproductive health camps" in Uttar Pradesh where ANMs (auxiliary nurse midwives) relentlessly pursue targets despite an official "target-free" approach. Chinai documents the health issues of women in remote areas of Nagaland whose situation is well captured in the chapter title: 'Even if we shout, there is no one to hear'. Cycle pumps used for insuffulation during laparascopies, and "open-air anaesthesia" in hospitals that do not have a single oxygen cylinder, make even routine surgery a matter of life and death. In fact, A R Nanda, one of the panellists, recalled his days as a district collector when it was commonplace to fudge figures to meet family planning targets. He commented that things had not changed much today. Brinda Karat, another panellist, said: " Unheard Scream is an important book because it can help change policy, especially in present times when there is a renewed consensus about population control, even to the extent of coercive measures."

Annu Anand in 'Safe Motherhood. Unsafe Deliveries' tells the same story of neglect, deprivation and non-existent healthcare in desolate parts of Madhya Pradesh's Jhabua district and the mountainous regions of Uttaranchal. Anand describes a delivery in Jhabua where the budua, or traditional healer-cum-exorcist, literally kicks the baby out of the womb. She does not analyse whether this is a positive affirmation of traditional methods or symbolic of the lack of healthcare. Swati Bhattacharjee tackles the silence surrounding issues of adolescent health and sex education. However, instead of concentrating on interviewing NGO heads and medical practitioners the author would have done well to talk to more young people to get their views first-hand.

In sharp contrast to the "primitive" conditions detailed by Anand, Chinai and Menon are the new reproductive technologies analysed by Sandhya Srinivasan. Srinivasan examines the role of corporate hospitals with sophisticated medical technologies in 'Selling the Parenthood Dream', and highlights the promotion of expensive and unnecessary fertility treatment that has adverse effects on women's health. A doctor Srinivasan interviewed provides the answer to the oft-asked question as to why the medical establishment continues to get away with excesses committed in the name of infertility treatment. "There is no anger because they never stop hoping," says Dr Puneet Dedi, a Delhi-based infertility specialist, encapsulating the desperation to give birth to a biological child.

There is similar poignancy in Manisha Bhalla's essay that looks into sex selective abortions in Punjab. The lush green fields of Punjab, a symbol of India's Green Revolution, are also the "ruthless killing fields of baby girls". In 'Land of the Vanishing Girls', Bhalla shows how misogyny, economic prosperity and the availability of technology for pre-natal sex selection contribute towards an alarming decline in the female to male sex ratio at birth.

HIV/AIDS as a women's health issue is highlighted in two essays. In 'Women as Vectors', Geetanjali Gangoli focuses on the targeting of women in red-light areas in HIV-control programmes. Gangoli discusses how all the other health needs of sex workers are ignored because of the overwhelming view of them as "vectors" of the HIV virus. The writer touches upon the vexing questions of de-criminalisation and legalisation of prostitution and their implication. Vasant Bhosle's 'Women and AIDS in India' offers a useful fund of statistics and a valuable analysis on how patriarchy, land ownership and caste interact to increase the vulnerability of women.

Social factors that have a bearing on women's health are explored by Dhirendra Jha in 'Grass Widows of Bihar' and K P M Basheer in 'The Gulf Wife Syndrome' -- attempts to unravel the impact of male migration on the women left behind. The rise in the number of women seeking "refuge" on the psychiatrist's couch in Kerala, says Basheer, is symptomatic of the disjunct in the lives of these young Muslim women. Jha highlights the fracturing of family life brought on by land holding fragmentation, migration and its impact on women's health.

While T K Rajalakshmi focuses on women workers in export processing zones, in 'For a Few Dollars More', she only tantalisingly mentions issues of occupational health, leaving the reader thirsting for more information on these repressive zones where unionism is forbidden and exploitation is the catchword. Rajalakshmi makes the pertinent observation: "Wage employment for women does not offer a way out of subordination, or automatically guarantee emancipation. It has the potential to do this if the repetitive and monotonous tasks in the assembly line of production represent the beginning of a longer industrial career of skill formation and promotion. But this is not so. This has also to be seen in the context of the State gradually withdrawing from social welfare and labour law commitments, thereby exposing the working class to the harsh vagaries of the marketplace."

Rajashri Dasgupta highlights another aspect of the State's withdrawal in her brilliant essay 'Quick-fix Medical Ethics' on Quinacrine sterilisation and the ethics of contraceptive trials. Dasgupta's research takes her to pokey dark rooms in rural Bengal where high-school-pass "doctors" insert Quinacrine pellets into women's uteruses to cause chemical sterilisation. Never mind that the method is banned, and never mind that it is hazardous to health. Dasgupta documents the official apathy, lack of monitoring mechanisms, ethical issues involved as well as voices of protest against using women as guinea pigs.

In her essay 'The Silent Transition' Lyla Bavadam unravels some of the myths associated with menopause and documents a range of experiences of rural Indian women and city-bred college lecturers. The placing of the debate on hormone replacement therapy (HRT) in the context of the pharmaceutical industry, as well as an analysis of alternatives to HRT, is extremely useful.

While the essays in this collection touch upon crucial issues related to women's health, it's disappointing not to find mention of the impact of the environment on health, for instance the increase in cancers related to industrial pollution. Or even a deeper exploration of "old" health issues like abortion. Violence as a women's health issue is another glaring lacuna -- be it domestic violence, as is obvious in burns and orthopaedic wards, or the more silent manifestations of mental illness.

Despite clichéd sub-titles like 'Children of a Lesser God' and 'Doubly Discriminated', politically incorrect terminology such as "AIDS victims" for people living with HIV, and euphemisms like "cohabiting" instead of sex, this collection makes interesting reading. Some of the essays characterise an unfortunate amalgam of academic jargon and obfuscatory journalese. For instance, Gangoli says: "...a large section of women interviewed". Who interviewed them? And just how large was the cross-section? Similarly, Chinai says: "Survey...reveals alarmingly high levels of miscarriage..." and provides no details about the sample size or the context in which the survey was conducted.

Yet, these are minor drawbacks in an otherwise excellent publication. Thought-provoking and sincere, the book showcases some of the finest writing on women's health. It should serve as a useful resource for journalists, activists and policymakers, and can even be used as educational material in schools and colleges. As Mrinal Pande, one of the panellists at the discussion, said: "The writings have unspoken resonance -- the silence between the words are like the space between musical notes that make up the melody."

(Laxmi Murthy is a Delhi-based journalist )

InfoChange News & Features, August 2004