Radical Journal of Health 1995 Vol. 1, No. 1, Jan.
Item
- Title
- Radical Journal of Health 1995 Vol. 1, No. 1, Jan.
- Date
- January 1995
- Description
-
Colonial health policy in Madras presidency
Women, health and development: A perspective
States’ health expenditure
Structural adjustment and health in Africa
Injured psyches: Mental health of Bhopal survivors - extracted text
-
A SOCIALIST HEALTH EEVIEW TRUST PUBLICATION
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New Series VOLUME I
COLONIAL HEALTH POLICY IN
MADRAS PRESIDENCY
WOMEN, HEALTH AND DEVELOPMENT:
A PERSPECTIVE
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STATES’ HEALTH EXPENDITURE
STRUCTURAL ADJUSTMENT AND HEALTH
ffQ AFRICA
INJURED PSYCHES: MENTAL HEALTH
OF BHOPAL SURVIVORS
Rs 25
Radical Journal of Health is an interdisciplinary social
sciences quarterly on medicine, health and related areas
published by the Socialist Health Review Trust. It features
research contributions in the fields of sociology, anthro
pology, economics, history, philosophy,psychology, man
agement, technology and other emerging disciplines. Wellresearched analysis of current developments in health care
and medicine, critical comments on topical events, debates
and policy issues will also be published.
RJH began publication as Socialist Health Review in June
1984 and continued to be brought out until 1988.
This
new series of RJH begins with the first issue of 1995.
Editor. Padma Prakash
Editorial Group: Aditi Iyer, Amar Jesani, Asha Vadair,
Ravi Duggal, Roopashri Sinha, Sandeep Khanvilakar,
Sandhya Srinivasan, Sushma Jhaveri, Usha Sethuraman.
Production Consultant: B H Pujar
Consulting Editors: Manisha Gupte (Pune); Dhruv Mankad
(Nashik);Veena Shatrugna (Hyderabad); V R Muraleedharan
(Madras), ImranaQuadeer(NewDelhi);CSathyamala(New
Delhi); Binayak Sen ( MP); Francois
Sironi
(France).
Publisher: Sunil Nandraj for Socialist Health Review Trust.
We are grateful to Kanchan Puri-Sbetty for designing the cover.
All communications and subscriptions may be sent to :
Radical Journal of Health,
19,June Blossom Society,
60-A Pali Road, Bandra,
Bombay 400 050.
Typsetting and page layout at the Economic and Political Weekly.
Printed at Konam Printers, Tardeo, Bombay 400 034.
1
Volume
I
Number
1
Letters to Editor
2
Editorials: Atomised Approach
3
5
7
Aditi Iyer
Beyond Economics
Through a Bhdpal Prism Padma Prakash
I\
January 1995
Disease, Death and Local Administration:
Madras City in Early 1900s
V R Muraleedharan and D Veeraraghavan
9
Women, Health and Development
Malini Karkal, Manisha Gupte and Mira Sadgopal
25
Health Expenditure Patterns in Selected Major States
Ravi Duggal
37
Structural Adjustment and Health Policy in Africa
Rene Loewenson
49
Document
Charter of Demands on Family Planning Programme
63
Communications
Injured Psyches: Survivors of Bhopal Disaster
Satinath Sarangi
66
Reviews
Women’s Testimonies vs Medical Opinion
Swatija and Chayanika
71
Victims or Perpetrators
• Sandhya Srinivasan
76
Facts and Figures
Health and Welfare: Comparative Indices
Sandeep Khanvilkar
RJH
Vol 1
1995
79
Letters to Editor
Messages from Friends
Journals of this kind require the humanpower and clientele support, in
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10 to 15 locations supporting the central idea of the journals, but going
their own ways in understanding cunrenl local realities. How do you get
such ‘friends' of the RJH ? That dialectical mode needs to be reinvented,
where Gandhiji and the Naxalnes left it. It would be flaltering to re-launch
the journal with such an ambitious co-objective, in which endeavour count
on the support of this retired person living in Delhi.
New Delhi
R Srinivasan
I am so pleased to learn that RJH is going to be published once again.
...I dream of a society which results out of integrated and sutainable
development where medicine is redundant because health will have
become inevitable.
Kozhikode
Mundol Abdullah
We are glad to learn that RJH will make its appearance soon. Il is a
welcome step as there are very' few journals at present focusing on inter
disciplinary approach to social sciences and health.
Wardha
S N M Kopparty
I am happy to learn that you are restarting RJH. I hope you will be able
to publish it for a considerable lime despite the odds at play in our society.
Nellore
MSP Rao
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2
RJH
Vol 1
1995
Atomised Approach
The new approach to the control of tuberculosis is yet another technomanagerial fix.
THE recent resurgence of communicable diseases for long thought to have
been brought under control, is an expected outcome of a combination of
factors: falling living standards due to decreasing real wages, freezing of
employment opportunities, dipping nutrition levels, breakdown of sanitary
measures and debilitated public health services under the auspices of
adjustment policies. However, a morbid population in the long run is
economically unproductive and provides, eventually, a mass base for coa
lescing people’s demands and protests. And that is not exactly part of the
blueprint of the institutions which are prompting third world countries to
adopt new economic policies. The World Bank for instance, has responded
in a typical fashion; it has constructed social safety net programmes and
fashioned ‘new’ approaches to disease-control, which seek to resolve in a
techno-managerial fashion, problems which are rooted in the larger socio
economic situation. The revised strategy for tuberculosis control, termed
directly observed treatment (DOT) proposed in consultation with the World
Health Organisation is one such international prescription.
This new strategy, which derives its urgency from the AIDS/HIV
epidemic, is being popularised and enforced in various quarters since
1992. It has a strengthened leadership from a central unit, standardised
short course regimens under direct supervision for all patients (but
especially those confirmed as sputum positive cases), regular supply of all
essential anti-tuberculosis drugs and diagnostic material and a monitoring
system for programme supervision and evaluation following WHO guide
lines. The ultimate objective of the revised strategy is to cure 85 per cent
of newly confirmed sputum positive cases and detect 70 per cent of
existing cases by 2000 AD.
Mehsana district in Gujarat, one municipal ward in Bombay and one chest
clinic area in Delhi arc three venues in which pilot projects are being run
with funds from a previously underutilised SIDA grant. The larger project
for the World Bank will be established in the states of Gujarat, Kerala,
Himachal Pradesh, Bihar, West Bengal; in metropolitan cities like Banga
lore, Bombay, Calcutta, Delhi, Hyderabad, Madras as well as Bhopal, Jaipur,
Lucknow and Pune, which are cities of intermediate size. This will be
financed by a loan from the World Bank to the tune of US $ 20 million.
It is a matter of concern that the India’s tuberculosis control programme
whose excellent design grew out of sociological, epidemiological and
technological insights, is being overturned without adequate justification.
The programme, which is integrated with the general health services, was
RJH
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1995
3
expected, from the start, to sink or sail with it. If it is has failed to live up
to expected levels of efficiency, it is because of the socio-political and
operational problems that beleaguer the public health services; namely,
irrational and inadequate funding, misplaced programme priorities and the
undermining influence of an unregulated private sector. The last factor is
crucial and explains why an identical control programme works in an
underdeveloped district but fails in a developed district.
The imposition of DOT is set at a time when health care is no longer
viewed as a right but as a priviledge that a certain section will be entitled
to. Cutbacks in public spending along with privatisation and cost recovery
schemes arc resulting in curbs on the expansion of infrastructural facilities
and making health care only more inaccessible and beyond the reach of a
large section of the population. In the absence of universal coverage, even
the most well laid out strategy runs the risk of failing.
DOT is partly concerned with the standardisation and rationalisation of
treatment regimens. This is an honourable enough objective. However,
the new regimen being proposed is expensive and its inclusion is indefen
sible unless the added costs can be absorbed entirely by the state and not
passed on to patients through the imposition of user charges.
Equally, the emphasis on supervision of treatment poses a number of
operational, social and ethical problems. While a concern about the
patients’ adherence to treatment regimes is natural from a clinical and
public health point of view, the objective goes a step further and is founded
on the premise that patients cannot be trusted to take their medicines unless
they are monitored by an external agency. Al one end of the spectrum are
the hapless patients who now become targets in much the same fashion as
‘eligible couples’ do under the family planning programme. However.
there is a qualitative difference here as the state does not restrict itself to
the role of a persuader but becomes an enforcing agency. The visible
presence of a health worker during the consumption of every dose during
the intensive phase of treatment militates against the principle of confiden
tiality between patients and the medical profession. Considering the fact
that tuberculosis is known to create or aggravate the social disadvantages
that certain sections of the population (such as women, disabled persons,
non-wagc earners) face in families and in communities, the repercussions
of this loss of privacy for patients are tremendous. And at the other end
of the spectrum are the supervising agents, the community level health
workers (health post workers, multipurpose health workers, etc.) who arc
already laden with the task of meeting unrealistic family planning and
health programme targets under adverse working conditions. Under the
circumstances, the necessity of supervising treatment will not only be
additionally burdensome but will engender an atomised understanding of
health that will only alienate them from the community.
—Aditi Iyer
4
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Vol 1
1995
Beyond Economics
The debate on structural adjustment programmes has so far sidelined a
most significant factor: India's political system which by its very nature
ensures that the vast masses remain disenfranchised.
IN India the structural adjustment and economic stabilisation programmes
were set in motion in 1991. It may be argued, therefore, that it is too soon
to assess the Indian experience. However, for a large part of the develooing
world the 1980s was a decade of adjustment. And there are enough
pointers available from the experience of other countries. What stands out
is that the performance of structural adjustment programmes (SAP) in
terms of their own objectives — rectifying fiscal and balance of payments
imbalances and raising the rate of growth — cruelly affects the social
consequences of these programmes.
Among the countries following SAP the experience has been mixed;
Indonesia has combined SAP with rising investment and growth; on the
other hand, in Argentina and Zambia there has been a decline in per capita
incomes and investment. Despite the variations, the balance of experience
in Latin America and Sub-Saharan Africa, two major areas implementing
SAP, has been negative. Each region taken as a whole exhibited declining
per capita incomes and investment and accelerated inflation in the 1980s.
Among countries implementing SAP in Sub-Saharan Africa, three-fourths
had declinig per capita income and half, declining investment and accel
erating inflation. In Latin America and the Carribbean, more tha 4/5ths of
countries had negative performance in terms of per capita investment and
incomes.
How SAP affects the condition of the mass of the people is determined
by three principal factors: (a)through incomes, which are affected by
changes in employment, wages and income from self-employment; (b)
through prices of basic goods, especially food; and through the availability
of essential services normally provided by the state notably health and
education. In Latin America the GDP per capita fell in 18 countries and
rose or remained the same in five. In Africa the GNP fell in 26 countries
and rose or remained unchanged in 12. The overall experience has been
that SAP tended to depress real wages as control over money wages is
combined with devaluation and price decontrol. Evidence for Latin America
shows that average real wages declined in the majority of the countries. In
Africa real wages declined in 16 out of 18 countries.
Stabilisation and adjustment policies lead to reduced employment and
fall in real wages in the short run; but the hope is that new, more productive
employment opportunities will come up over time. However, evidence
shows that employment growth slowed down in most countries in Latin
America and Africa in the 1980s. For Latin America as a whole it has been
RJH
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1995
5
estimated that in the 80s four million fewer jobs were created than if pre
SAP trends had continued. In both Latin America and Africa, in response
to the slow growth of employment in the formal sectors, the proportion of
the labour force engaged in the informal sector rose significantly in the 80s.
This led to depressed average wage and income levels.
Coming to government expenditure on social services, (he evidence
shows that aggregate per capita government expenditure declined in both
Latin America and Africa. Within this there was a decline in the proportion
of expenditure on health and education. As many as 60 per cent of the
countries experienced cuts in per capita expenditure on health and education.
On the basis of all this evidence, which incidentally is from evaluations
of SAP by organisations such as the World Bank and the UNICEF, do we
then take a stand against the implementing of SAP in India ? But take a look
at India’s own record after four decades of economic planning and state
regulation, a large public sectorand an economic policy with social justice
and equity as conscious objectives.
In terms of the UNDP’s human development index India ranked 123rd
among 160 countries in 1990. Other facts are wel 1 known and hardly need
to be reported here. The employment growth has barely kept pace with the
growthofthe population, and over long periods it has fallen short of it, such
as in the period since the mid-1980s. In 1991, only one half of the
population were literate with two-thirds of women illiterate. The average
number of years of schooling is 2.4 compared to 8.8 in South Korea and
5.3 in Malaysia. The infant mortality is 79 per thousand. There are vast
variations in these indices over the country, with the situation being much
worse in some of the biggest states such as Uttar Pradesh, Bihar and
Madhya Pradesh. There has been a slowing down of employment growth
to 1.8 percent in the second half of the 1980s from 2.1 percent earlier.
These statements are not intended to be comprehensive, but to drive
home the point that if the performance of SAP has been dismal, our own
performance has been nothing much to write home about. How can we
explain that the share of primary education in total government expendi
ture in edualion has dropped from 58 per cent in the First Five Year Plan
to 29 percent or in health, the comparable neglect of preventive and social
medicine ?
The current debate on economic development has tended to focus on
issues — planning versus free market, open economy versus import
controls, export-led growth versus import substitution Or public sector
versus private sector — which largely leave untouched the abysmal
performance of the Indian state. There are yawning gaps created and
perpetrated by the Indian political system. A system geared to constituting
the political authority al the naiional and slate level, nothing below that,
with many of the slates as large as countries. The result is that despile
universal adult franchise the vast majority of the people are effectively
disenfranchised. But no parly is seriously concerned with this; no fuss is
6
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1995
being made over (he fact that in many states local elections as required in
the 73rd and 74th Constitutional amendments have not been held. This
then is the central issue in Indian political economy, and it is time we
grappled with it.
Through a Bhopal Prism
The experience of the victims of Bhopal is being mirrored everywhere:
the powerless continue to be victims of disasters—chemical, natural,
economic and social.
OVER the last decade literature on the critique of health has accumulated
at a rapid pace. This has led to a qualitative change in the outlook of the
social sciences towards health care and medicine. While many factors
have contributed to this, the cumulative experience of NGOs, health
activists, trade unionists, medical professionals and the progressive move
ment in Bhopal has been a major contributor to the deepening of our
understanding of the political economy of medicine and health care. In the
microcosm, Bhopal illustrates several elements of the progressive critique
on health.
First the disaster itself. Let us look at the ‘ifs’: if the Union Carbide had
not found it necessary to use and store toxic chemicals; if the rules of
industrial safety were more stringent the disaster would not have occurred.
If the industrial locational policy had been better structured then the
juxtaposing of habitats and a hazardous industrial plant would not have
occurred, and then, even if a disaster had occurred, it would not have
affected such large numbers. If the state had taken its ‘development’
concerns more seriously there would not have been the population of
under- and unemployed who had migrated in search of work and were
managing to eke out a living—unhealthy, unhappy— in the vicinity of the
factory.
Events immediately after the noxious gases escaped illustrate well just
how anti-people the collusion between the medical establishement, corpo
rate interests and the state can tum out to be—neither the state nor the
medical establishment, beneficiaries of the Union Carbide’s generosity at
various times, were in a position to insist on information regarding the
nature of the fumes, the antidotes and the method of treatment.In the
following months the scientific and medical research establishment showed
its incompetence. A country with ‘the one of the largest community of
scientists’ could not put together relevant studies and surveys — not
because it lacked expertise, but due to the fact that the scientific and
medical research infrastructure had long lost the flexibility, the creativity
and the sensitivity necessary for the furtherance of knowledge. Again, the
delinking of medical research from health policy had been a matter of
RJH
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1995
7
concern for many years before Bhopal, a concern expressed in several
expert committee reports. It was in Bhopal that the consequences of such
a development became obvious.
In the 10 years since the disaster, the world has seen the Indian state’s
concern for the victims dwindling. The provision of medicare has followed
set patterns of focusing on superspeciality care rather than ensuring that the
day-to-day needs of the victim population is being met. The authorities could
well have evol ved a different ‘community-based’ approach to medicare here,
but did not do so for more or less the same reason why the approach is given
such desultory treatment in the country’s health care system: it is not visible;
it means that control of services, however minimal, passes on to the people,
and; the health bureaucracy experiences loss of control and power, following
upon which, the political leadership loo cannot use the provision of services
as a pawn in petty games.
Similarly, little serious attempt has been made to equip the victims with
new skills and provide them with opportunities for economic self-suffi
ciency. The land and infrastructure set aside for the purpose of providing
employment to the victims are, according to reports, being sold al high
prices to entrepreneus who have no intention of creating jobs for the
victims. No serious thought has been given to improving the living
conditions of victims: al one point the local administration demolished a
section of the baslis of the victims, and those remaining are in a worse
slate than before; the water supply such as there is, has been further
contaminated.
One may justifiably say that the non-establishment health and medical
community has not exactly covered itself with glory in Bhopal. The private
health sector is booming: fortunes it is said have been made by doctors and
lawyers in Bhopal. Why did the conscience keepers of the medical
community, presumably, the Indican Medical Council not ever examine
the large-scale unethical practices in Bhopal? Nor have the NGOS in
health shown either the maturity or the concern which should have
overridden petty considerations.
What is chilling is that what is happening is Bhopal is happening in a
slow and long-drawn out fashion all over the country. The powerless and
those without a voice are becoming victims of continuing disasters, small
and large, within factories and outside. The fragmentation in welfare
services is more or less complete and is today further detached from
provision of basic economic necessities: by the rules of the current
eonomic policy regime, welfare services form part of the ‘safety net’
which is to lake care of those affected by supposedly short term con
sequences of the new policies. The truth however, is very different. And
it is more than likely that Bhopal will not be a unique occurrence, but will
be repealed many times in many developing countries.
—Padma Prakash
8
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Disease, Death and Local Administration
Madras City in Early 1900s
V R Muraleedharan
D Veeraragahavan
A complex of forces contributed to the shaping of the contours of
colonial health policy. This article, which looks at the process ofpolicy
making in the port city of Madras in the early J 900s, explores the
following: the different opinions which prevailed among municipal
councillors regarding the effectiveness of certain policy measures,
such as the maternal and child health scheme, the need for a special
infectious diseases hospital, etc and the real and imagined constraints
to the intervention of the colonial state in public health.
WHILE the broad outlines of the development of colonial health policy
bpth at an al 1 -1 nd i a level and at regional levels have been fairly well drawn,
the policies pursued in certain important urban centres, such as in the port
city of Madras, have received far less attention.[1 ] Such micro-level
studies can provide a better appreciation of the nexus of forces that shaped
the policy making process and the decisions that emerged ultimately. In
this paper, we take up the case of the colonial port city of Madras in the
early decades of the present century, and give an account of the role of the
municipal council of the corporation of Madras in shaping the nature and
direction of its public health policy. We do not attempt here to evaluate the
impact of the policies pursued by government. We are more concerned
with understanding the perceptions of policy makers’ on the nature of
health problems specific to urban centres and the basis on which certain
decisions were made. The following are some of the specific questions we
are concerned with: what were the different positions adopted by the
municipal councillors regarding the effectiveness of certain specific
policy measures?; how much of importance did they give to prevention?;
what sorts of constraints did they foresee and did they advance as reasons
for supporting or opposing certain policy measures?, etc.
I
Concern over High Mortality
The question of high mortality rate in the city of Madras often drew the
attention of the municipal council but with little K C Desikachariar, a vocal
members of the council, demanded an explanation for the increased
mortality rate in the Madras city in the year 1904, the president of the
RJH
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1995
9
council stated that it was due to the increasing population of the city,
insanitary living conditions and overcrowding. This was, in fact, a stock
explanation often given tojustify the govenment’s inability to improve the
health of the city. These apart, sometimes, the sudden peaks in mortality
rates were also explained by the councillors in terms of outbreaks of
epidemics such as the influenza of 1918 or famines.
The councillors’ concern for poor state health of the city is evident from
the nature of discussions that took place in the council. There were
considerable differences amongst them as to the causes for the poor state
of health. Consequently, their policy prescriptions to improve the health
of the city also differed.
While in general the councillors accepted the fact that the overall
insanitary conditions of the city was largely responsible for the poor
health, they felt inapt to do anything as it was basically a consequence of
the low level of living standards of the various sections of the people. For
example, the Paracherries (slums where only the socially low class people
lived), which numbered 105 in the city in 1910, were viewed by many
council members as hot beds of diseases. The government did make a few
but unsuccessful attempts to erect model Paracherries in the city. There
were three model Paracherries in the city by 1910 which was claimed by
the Corporation to be “ undoubtedly a success from every point of view
except the financial one”[l]. The remaining 102 Paracherries privately
owned, were in the “populous parts” of the city. The corporation often
complained that it could exert only little pressure on these private
Paracherries to improve their sanitary conditions. Only in two cases the
owners provided drains “at the instance of the Corporation”.
As mentioned earlier, while the council unanimously accepted that
the city’s health was poor and was deteriorating over the years, the
members differed as to what they should do to improve the situation as a
result of what they ‘perceived’ as constraints in implementing various
policy measures.
Broadly speaking, the dicussions that took place in the council in early
the decades of the century can be summarised as follows: since clearly it
was not possible to expect the colonial government to effect significant
changes in the socio-economic structure, the council had to limite options
for improving the health of the city: one option was to reorganise the
health department in such a way that would increase its efficiency, and
and other was to initiate certain measures that would directly help reduce
deaths due to specific causes.
A section of the councillors felt that the health of the city rested fully
on the health of the health department. Hence, they argued that, only if the
department was improved could the city’s health be improved. One of the
ways by which they sought to improve the efficiency was to get rid of the
excess staff. A committee was appointed in 1906 by the council to decide
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the extent to which the department could cut down on the number of health
peons employed in the city. The question was, did the 250 health-peons
employed by the department justify their existence. E S Lloyd, the
president of the council in 1906, had categorically stated that,
Neither I nor the Health Officer nor the commissioners think for one moment
that they are all alike useless. That will be going too far but our opinion is they
are not useful enough to deserve the large amount of money spent upon them.
What we mean to do is to get nd of them and put men holding higher
appointments in their position. The opinion of many of us is that we have too
many subordinates and not nearly enough of highly paid officers [2].
The committee thus suggested a reduction in the number of health
peons, while at the same time recommended an increase in the number
of sanitary inspectors and an additional health officer [3]. Another
suggestion for improving the efficiency of the department was to effect
a “complete separation between conservancy and sanitation works”[3].
T M Nair, one of the councillors (and a medical practitioner in the city)
was a staunch supporter of this kind of change in the department. He
argued that the system as it existed in 1907 resulted in one set of peons
to supervise the removal of night-soil and another to supervise the
removal of rubbish. He, hence, suggested pruning of staff besides merging
some of the temporary plague establishment with a large number of
vaccinators with other staff of the department. By 1907 there were 24
vaccinators in the city but they were not engaged in vaccination work the
whole day[3]. Much of their time was spent on hunting for the
unprotected children. This, he suggested, “the Sanitary Inspector ought
to be able to do .... as he goes around his division” in the city. “He has
facilities for ascertaining where there are unvaccinated people. If thiswork is done by the Sanitary Inspector the work of the Vaccination
Department becomes so little that eight vaccinators would be quite
enough”. According to Nair, the government could also gain financially
if the department were to be reorganised as proposed by him. But such
arguments and suggestions were not always received favourably by other
members of the council since they were not convinced of any positive
impact such measures would have on the health of the city.
A severe criticism on the efficiency of the health department came
from U Rama Rau, a member of the council, in contrast to the widely
prevailing perception that the root cause of ill-health of the city lay with
people’s life style. While he did accept that “want of sufficient quantity of
good water, and good drainage system [was] responsible to a certain extent
for this state of affairs”, he believed very firmly that the inefficient
management of the health department “as it exist now is one of the main
causes”[4]. It is worthwhile to give some details of his argument since it
reveals to a large extent the how policy makers often perceived certain
issues and as a result what they prescribed as remedies.
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Rama Rau’s main worry was to explode the myth that the city’s poor
state of health was due to the faults of the people. T M Nair went a bit
further saying that the health department was inefficient because they
themselves “have no sanitary knowledge”, which stood in the way of
improvement [4]. Sanitary executives often blamed the people for home
sweeping whereever they liked. “But the fact”, Rama Rau pointed, “is
enough dust bins are not supplied. Such being the case it is but natural that
people who are ignorant of sanitary principle throw rubbish outside the
dust bins”. Hence, he argued, “the fault lies in the Sanitary Department”.
Similarly, drains were rarely cleaned and never flushed. If by chance they
removed the drains, the silt deposited by the sides of the drains remained
there for days and sometimes for weeks. Besides, because of the habit of
walking barefoot, people tread on silt and carried germs into their houses.
That was one way of carrying contagion. The other way of carrying the
contagion would be, when the silt dried when left for days “it gets blown
all over the streets in the form of dust”. This would affect “meat sellers
and trash selling women who invariably keep their bazaars near or over
the’ gutters with eatables”. So, Rama Rau argued, the original cause was
the lack of frequent cleaning of drains by the department and not the
insanitary' habits of the people. The latter only aggravated the situation.
Similarly, Rama Rau identified the problem of adulteration of food sluffs
as another cause for the poor state of health of the city originating from
the department for the poor state of health of the city. There was hardly
any inspection of vendors of foodstuffs though the corporation had the
authority, under section 353 of the Madras City Municipal Act of 1904,
“to make provision for the constant and vigiliant inspection of animal’s
carcases, meal, poultry, flesh, fruit, milk, ghee, butter, oil, and any other
articles exposed or hawked about for sale”[4].
Disinfection of houses also, according to Rama Rau, did not take place
in any useful manner. He cited many instances where disinfection was
carried out six days after the occurrence of cholera. In addition, “the
health subordinates exercise their authority and frighten people with
different motives”. When they do house to house inspection, “the people
who are in his good graces are let off, while others are worried and dragged
to the Court unnecessarily”.
Rama Rau’s criticisms were designed to impress upon the executive of the
council that the city’s poor health was due more to the inefficiency and
mismanagement of the health department than due to other factors. A
committee was appointed as a result to look into the working of the depart
ment and suggest ways by which its efficiency could be improved. But his
scathing criticisms of the functioning of the department hardly had any effect
on E S Lloyd, the president of the corporation in 1909, who retorted thus:
Madras will not improve for another hundred years if people do not improve...
It is true that we work with inefficient tools. It is true that some of the sanitary
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staff are not very best possible men that you get... They are human beings like
the Commissioners, but they do their best... If you become the executive you will
be just as bad as we are [4].
Yet another retort came from R M Savage, a member of the council,
who questioned the very purpose of Rama Rau’s review of the functioning
of the department. Savage bluntly said, “there is nothing new in what Mr
Rama Rau has told us; he only repeated what we knew, and it is all ancient
history”[4], He thus maintained that the defects pointed out by Rama Rau
“can never be remedied unless we are prepared to employ more expensive
men... But we can not afford to pay... The department is absolutely helples
so far as funds are concerned”. The executive even went to the extent of
saying that some of the councillors were against the wonderful work done
by the department because they were greedy to become the executives
themselves and have power. Indeed there was nothing new in Rama Rau’s
review of the department since these were often dicussed in the council
in one context or another. However, the central question remained
unanswered was: what are specific measures were that should be
introduced by the corporation within the overall financial constraints that
often supposedly stood in the way of improving the health of the city.?
In what follows, we give an acccount of the measures contemplated
and introduced by the municipal corporation of Madras in order to contain
the high level of infant and maternal mortality and deaths due to smallpox
in the city.
II
Maternal and Child Health Scheme
Increasing infant and maternal mortality in the city had always
received a wide publicity. One of the earliest steps taken by the corpora
tion of Madras specifically to counter the upward trend in infant and
maternal mortality was to appoint lady sanitary inspectors (LSI) to teach
infantile hygiene to “ignorant mothers”. By 1910 there were three LSIs
in the city; each was expected to work in an assigned division of the city
[5]. U Rama Rau had repeatedly questioned the usefulness of having the
LSIs, since the infant mortality continued to increase even in those
divisions where they were employed. He hence observed that “the efforts
of the LSIs had no effect in reducing infant mortality”. His argument was
more substantial in that he questioned not so much the idea of having LSIs
as the way in which they had been trained. He argued, “the curriculum to
train midwives and sick nurses does not include infantile hygiene... [they]
know nothing beyond midwifery and sick nursing. Besides they don’t
inspect houses and teach infantile hygiene as they ought to do.” Besides,
each of them was able to visit only three houses a day on an average. How
they utilised their time “God only knows!”[6]. Rama Rau’s criticism was
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13
mainly against the lack of knowledge and training of the LSIs employed
by the corporation. In his view , it was, therefore, a wasteful exercise and
a waste of “poor rate payers' hard earned money.’’
However, much against such criticisms the corporation continued to
employ more LSIs in the city, and in 1917 it inaugurated a new scheme
called child welfare scheme (CWS). Introduced initially in only two
centres in the city, the scheme was extended to six more centres in the
following five years and gradually established outside Madras city as well.
Its objects were “not to relieve Municipal Councils and District Boards of
their responsibilities, but rather to guide, advise, and assist these local
bodies in theireffort to ameliorate theconditions”[7]. Under this scheme,
each centre would be provided with a trained midwife who would attend
to deliveries in a particular region within the city. In addition the midwife
was also expected to visit the houses of puerperal women and keep a record
of their progress. Administratively, all these centres were under the care
of a lady superintendent, who was a medical doctor. Although this scheme
became popular over the years, its progress was slow in its early years. The
superintendent of the scheme as well as the surgeon-general with the
governmentof Madras felt that the scheme needed a thorough overhaulling
of its defects before expanding it further. The superintendent wrote deary
in one of her letters to the surgeon-general in 1923 that,
...in 98 percent of the cases registered at the CWCs it is not possible for the nurse
or the doctor to treat the patient in the home owing to lack of accommodation,
filthy habits and ignorance of the people and to the crowding in of equally
ignorant relatives, each with his or her advice as to what the doctor should do,
not to mention the want of aclean linen, suitable food and (what most disgraceful
to this Corporation) even a clean supply of water. Under these circumstances,
it is in the interest of the patient to get her to hospital where she will have the best
treatment under the best possible conditions [8].
Some of the councillors felt that there was more talk than action in this
regard. While some of them were disappointed (that in their divisions)
where such centres were located infant mortality did not decrease appre
ciably, there were others who felt that but for the CWS the mortality might
have gone up still higher. But the opposition to the scheme came from
another set of councillors who were “perfectly convinced that CWS was
not doing good work.”[8]. B S Mallayya, a very vocal member in the
council, who was also a medical doctor practising in the city, was against
any expansion of the scheme on the existing lines. He was not against the
scheme in principle fbut he was not happy about the kind of workers
employed under the scheme. His argument was to replace the existing
midwives with good workers: “[otherwise] it is no good wasting the
Corporation money on the scheme.”
These midwives were trained only for a year but, as Mallayya argued,
were given “powers far beyond their scanty knowledge justified”. They
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had been allowed to act on their initiative during childbirth and had been
“the cause for many diseases.” Maliayya thus suggested that these mid
wives should be always accompanied by a medical officer. What would
happen otherwise was difficult to imagine, Maliayya feared:
...some of these nurses are adacious enough to bring on labour pains by giving
quinine pills, pull on the chord and invert the uterus in their attempt to deliver
a placenta, treat a case of Pneumonia complicating child birth with purgatives
and pour plenty of tincture of iodine into the ear of the ailing infant and all this
in the name of the Corporation [8].
Cleaniness and asepsis were dreamt of, rather than experienced by the
midwifery practice of the corporation child welfare and maternity scheme.
“It is high time to stop them... I do not want the fair name of the Corporation
to be run down by these midwives... If midwives cannot practice asceptic
midwifery how arc they better than the Barber Midwives?”, reflected
Maliayya. Conflicting figures were given by various members of the
council, depending upon their position for or against the continuation of
the scheme. However, it is difficult for us to comment here on the impact
of this scheme on infant and maternal mortality rates.
Those in support of extending this scheme (such as Natesa Mudaliyar,
a member of the council) argued that since the need for this scheme had
been felt ralher deeply, we must “have them first and then mend them”
slowly over a period of lime [8]. They argued that it was not necessary
to wait until a special committee evaluated the working of the scheme
and made corrective measures, since “(the Corporation has] no right to
keep the people waiting”. As V Tirumalai Pillai, president of the council
in 1924, put it: “half a loaf is better than no bread”, meaning that higher
efficiency could always be achieved as more experience was gained over
aperiodoflime [9]. But inefficiency ofmidwives was not the only account
on which this scheme was opposed. For instance, some of the members in
the council also argued that the scheme was not cost-effective. Mallyya
argued that it was hardly more cost-effective than the institutional care
given by the corporation maternity hospitals in the city. His calculation
showed that “on an average a delivery al home costs a poor man Rs 30, and
the Corporation has to spend another additional Rs 12 on it, if it is
conducted by our Child Welfare workers, while the average cost of
confinement in the Corporation Maternity Hospital with lodging, feeding,
linen and all including was only Rs 14”[8]. The amount spent by a poor
man if the delivery took place at home would include basically the cost of
lodging and feeding the barber women and the cost of medicines and other
things required for the health of the mother and the child. Besides, there
was no assurance of the quality of care guaranteed in state-maintained
hospitals, Maliayya argued:
The object of eliminating the barber wife (commonly known as
maruthuvachi) and replacing them with trained midwives was not easy to
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achieve in practice as long as deliveries were conducted in private houses
and as long as the corporation employed inexperienced midwives with
little training whose utility, however, was constantly questioned. The only
alternative for improving the matemal and health, according to those
aganist the existing CW scheme, was to open a number of Maternity
Homes in the city, each with about 10 beds, staffed by “the very best and
highly trained nurses.
While some of the doctor-members of the council themselves differed
on the usefulness of opening more such centres in the city for want of
‘competent staff, the scheme nonetheless expanded slowly and became
firmly a part of the matemal and child health care policy for the entire
Madras Presidency. The problem was essentially one of finding a balance
between quality of care and quantity of care. This tussle troubled the
councillors. Quality of care suffered not only from the inefficiency of the
department and lack of financial resources. Often, it also suffered from
hesitancy on the part of the policy makers in adopting certain medical
interventions available and known to be effective against specific diseases
such as the policies pursued for controlling smallpox in the city of Madras
in the 1920s.
Ill
Smallpox Control
Frequent occurrences of smallpox in the city of Madras despite the on
going work of the vaccination department, raised several important
questions. Typically, the following cryptic comment of T M Nair made in
1911 in this respect illustrates the the perception of many concerned
authorities:
We have unfortunately got into a groove so far as vaccination is concerned. We
are running into that groove without attempting to consider the scientific aspect
of it. The question is whether our vaccination is satisfactory ; whether we have
vaccination which will prevent smallpox ? Vaccination as conducted now does
not produce requisite immunity from smallpox [10].
Nair supported his view with figures that could hardly be contested by
anyone in the council. His figures for 1911 on deaths in Madras city due
to smallpox revealed that except among those aged less than one, deaths
among the unvaccinated was always lower. The council was puzzled as to
why there should be this preponderance of deaths among the vaccinated.
He explained this phenomenon by blaming largely the ineffective han
dling of the lymph resulting in loss of potency before use.
It was in such an atmosphere of scepticism that the corporation of
Madras tried (in vain) to make revaccination compulsory. The council was
not unanimous in supporting the policy of compulsory revaccination.
While some of them were highly apprehensive about people’s acceptance,
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others were not even convinced of its scientific status as a preventive
measure against smallpox. This is evident from the discussions that took
place in the council during 1923-24 which show clearly how factors other
than financial constraints shaped the evolution of public health policy in
colonial India.
In May 1923 the council was debating whether or not to enforce the
compulsory revaccination of children at the age of 10 in the city of
Madras. A standing committee appointed to study this subject recom
mended that revaccination “may be made compulsory between the age
of 7 and 10 on the basis that smallpox is a disease of childhood”, since
rarely did an adult suffer an attack [II]. The health officer of the
corporation remarked in 1923 that,
the best rule would be to revaccinate everyone living in Madras once in seven
years. There must be a general legislation by the Provincial government insisting
upon revaccination being made compulsory on every individual once in 7 years.
But my proposal was restricted to the first 10 years because if we are able to
vaccinate children within 10 years of age it would be effective in warding off
attacks in the case of a large number of children who are likely to get
affccted[l 1].
There were also other important reasons to make revaccination
compulsory, as argued by B S Mallayya. According to him, smallpox
seemed to have a cyclical reappcarence in the city. He observed that “it
assumes severe epidemic form once every five years. The next was
expected in 1927... The present policy of waiting for the epidemic to
develop before any preventive measures are taken to keep it down, always
leads to criminal waste of 1 i fe”[ 11 ]. He was convinced that no amount of
lecturing, pamphlets, leaflets, evacuvation, removal to islolation hospital
or disinfection would stop it. All these would only scare people even
more. “Protection derived from vaccination against smallpox lasts for 7
years. If everyone born or living in Madras is vaccinated or revaccinated
once in every 7 years, Madras will be free from smallpox epidemics,” he
opined. There was yet another reason, he explained, why smallpox
returned in epidemic form though some vaccination work had been going
on for some years in the city. That was because “the work turned out by
the vaccination staff al present [in 1923] is inadequate to meet the demand
of the city. They vaccinate 27,000 persons annually (ie, 5 per cent of the
total population of 5,25,000).” In five years, they would have vaccinated
25 per cent of the total people, which left 75 per cent unprotected. “So
smallpox steps in and tries to finish the work left undone by the vaccina
tors, and this accounts for the quinquennial periodicity of smallpox
epidemics in Madras”. Therefore, Mallayya argued, revaccination at the
age of 10 was desirable. Mallayya was. of course, aware that legislations
alone would not prevent an epidemic: “What is wanted is mass education,
public cooperation and solid work by our vaccinators.” In fact the health
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officer opined that vaccination could be done al any age, citing the
experience of Germany where even at the age of 60 people were revacci
nated compulsorily.
But such views were also questioned by many members in the council.
While there were a few who found it difficult to accept the scientific
basis of revaccination, there were others in the council who called it
useless and were ready even to challenge any authority on this matter. For
example, V Ramakamath, a medical doctor from the city and a member of
the council in 1923, questioned the wisdom of making revaccination
compulsory:
[the council should first] make up its mind to find out the efficacy of vaccination
in protecting children or the adults before we rush into legilation. 1, as as
practising doctor, find it rather delicate to give my opinion about this because
men more eminent than myself have come to the conclusion that vaccination is
the only method of preventing smallpox. But I feel at the same time to bring it
to the notice of the house that there have been cases which have come to my
notice where children who have been vaccinated have suffered really from a
very severe attacks of smallpox[ 11 ].
The best thing to do before rushing into legilation under such circum
stances, according to Ramakamath, was to enquire into the state of affairs
in England and other places, particularly the state of legislation there and
how things were managed . The health officer of the corporation admitted
that “the immunity given by vaccination is certainly a matter of great
controversy” but held that “vaccination is certainly a protection against
smallpox...[only] the figures collected [by the government] probably go
against the theory of vaccination ... because of lack of reliable statistics.”
He used the statistics at his disposal to support his position: about 8 to 10
per cent of the vaccinated children under 10 years suffered from smallpox
if vaccinated, while it was 16 per cent if unvaccinated; the mortality in
unvaccinated cases was something like 35 to 40 per cent, whereas the
mortality in the vaccinated was invariably less than 10 percent[l I].
Often the use of ineffective lymph also raised doubts about the principle
of vaccination itself. There were occasions when the director of the King
Institute admitted that the lymph produced by the Institute was “distinctly
bad”[ 11]. But the government would not own such mistakes and invari
ably blamed the vaccinators for deaths among the vaccinated.
However, the question remained as to what was the ideal age group in
which revaccination should be done. As a result
a series special
committees appointed to decide on this issue, it was finally decided:
[that] all persons who have attained the age of 21 years and who have not been
revaccinated within the last seven years be at once revaccinated and that every
individual should be revaccinated on occasions during his or her life time,
namely before the age of 1, 10, and 21 years and at any age when epidemic of
smallpox is prevelant.[12]
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The concern for quality of care in the case of smallpox was not confined
to the application of vaccination alone. When it came to providing
institutional care for the smallpox patients in the city, the question of
physical accessibility to hospitals brought out clearly again the council’s
policy of compromising quality of care for quantity.
We trace a series of interesting events that took place from the time the
government of Madras and the corporation of Madras began to evince an
interest in constructing a separate hospital for treatment of infectious
diseases in the city of Madras. Although on a number occasions prior to
1898 the question of providing special care for people suffering from
infectious diseases engaged the attention of the government of Madras, it
only acted in 1898. Prior to that, the contagious wards at the General
Hospital in Madras were used only to accommodate cases accidently
arising in the hospital itself. This policy, carried out under the orders of the
surgeon-general, denied accommodation not only to the natives but also to
the European patients suffering from contagious diseases. Binny and
Company, representing the European and Eurasian patients, brought to the
notice of the government in early 1898 the “danger and inconvenience”
arising out of such a policy. As a result, the government consulted the
surgeon-gencral as to what should be done to provide care for such
patients. The surgeon-general suggested construction of a “proper isola
tion hospital” for all classes in the city for treatment of contagious diseases
[13]. But the corporation of Madras pleaded ‘impecuniosity’ and said that
the erection of the proposed hospital for contagious diseases fell more
within the scope of the Imperial funds [14]. The city was certainly
suffering from a heavy outbreak of plague during late 1890s causing huge
expenditures for the municipality. Hence they argued that “the construc
tion of the hospital was beyond their means and that they could do no more
than add more wards at the Moneger Choultry or Kistnampet (where some
temporary tents were erected to accommodate the natives]”; and as for the
European and Eurasian patients, the corporation suggested that they may
be received at the General Hospital whenever accommodation was avail
able. The council thus resolved that such a practice should continue “until
all fears of plague vanished”! 15]. The surgeon-general who was disap
pointed with the response of the council remarked thus:
In my opinion the matter docs not appear to have received that attention which
the importance of the subject demanded. The commissioners [i e, the members
of the municipal council of Madras] appear to me to have failed to realize their
responsibility in providing the city with such an institution which is necessary
to avoid the more important hospitals at the Presidency being required to admit
contagious cases into their wards for want of other suitable accommodation...
I need hardly point out that expenditure in this direction is conducive to the
health of the population and certainly of a much more urgent and useful nature
than providing the city with gas light[ 14],
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The last line in the above quotation acquires importance since steel
lighting in the city of Madras was becoming an important activity for the
government and was being carried out quite intensively during 1890s.
The surgeon-general found it difficult to convince the council of his views.
Instead, he suggested that the government should constitute a committee
to draw up a scheme “which might be taken on hand as soon as the pressure
on municipal finance was over”[15]. A committee was thus formed in
October 1898. But there were many who questioned the usefulness of such
an exercise. As R E Ellis, the acting president of the Madras municipality
in 1898, who also headed the committee, himself put it:
1 fail to see what benefit will be derived by the formation of a committee We all
know that it is most desirable that there should be a hospital for the accommo
dation of contagious diseases. We all konw that the municipality has no funds
The question is who is to provide the hospital. If the committed can settle that
point, by all means let it be assembled [16].
However, the committee submitted its report in April 1899, suggesting
postponement of the issue, for the following reasons:
...the question of constructing a contagious diseases hospital for the city of
Madras be deferred in view of the fact that the establishment of the George town
hospital was practically in abeyance, of the stress under which the Municipality
was labouring owing to plague expenditure and of the practical impossibility of
constructing and maintaining such hospitals;
and
that when Madras was declared free from the danger of plague and the existing
precautions were suspended, the plague hospitals and camps could readily and
economically be adapted for the purpose [17].
Such recommendations were readily accepted by the government since
expenses as a result could be postponed at least for the time being. Thus
the government refrained from taking any action in this respect until 1905,
when an European suffering from smallpox living in the premises of P Orr
and Sons was denied accommodation both in the Genearl Hospital and in
the Isolation sheds at Rayapuram, even though it was available [18]. The
Madras Trades Association, through whom this matter was brought to the
notice of the government, urged that the govemement should impress upon
the Corporation the necessity of providing accommodation for infectious
cases, quoting section 362 of the Madras City Municipal Act, 1904, “ that
the Corporation, when and as required by the local government, shall
construct and maintain hospitals”! 18].
It was no longer possible for the government to defer a decision on this
matter. The difficult conditions which justified postponement of the issue
in 1899 had not improved even by 1905. The financial position of the
corporation in 1905 continued to be in the same stale as in 1899. The
expenditure on plague by the municipality, had in fact, increased, and there
was no possibility of reducing any expenditure on plague which had
become indigenous in the city itself. The government accepted that:
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this matter should no longer be deferrd, as the supply of a hospital for the
treatment of infectious diseases constituted one of the most pressing wants of
the city, and could not be indefintitcly be postponed ...if action is to be deferred
until all danger of plague ceases, it may be deferred for ever (18].
But such an acceptance by the government did not bring any im
mediate relief and care to the patients. It took almost a decade to begin
the construction work for the proposed hospital. Having accepted that
the construction of an isolation hospital could no longer be postponed,
the government reassembled in 1905 the committee appointed in
1898 to prepare “practical proposals” in regard to the site and con
struction of the hospital, and to draw up the necessary plans and esti
mates! 18].
The committee recommended a “distinct smallpox hospital” for the
City, besides two hospitals for other infectious diseases (one in the north
and one in the south of Madras). The committee also suggested a separate
site for each of these hosptials. The existing smallpox hospital, to be
located north or north-west of the Lunatic Asylum, was to consist of 30
beds for native males, 20 beds for native females, 12 beds for European and
Eurasian, six each for males and females. As for the other two hospitals for
other infectious diseases, it recommended that one should serve the needs
of the north Madras and the other of the south. While the committee
suggested a new site for the north, it considered the existing Isolation
Hospital at Kisnampet to be adequate for the south of the city [19]. But
these sites were not favoured either by the sanitary commissioner and the
Madras government’s sanitary engineer. They objected to the site pro
posed by the committee north or north-west of the Lunatic Asylum on the
ground that it had already been selected by the government to locate the
head works of a new water supply scheme. Their objections to the location
of a hospital for infectious diseases in the north of the City was on the
following grounds: (a) that the site was too small; (b) that the site was in
the midst of the densely inhabited part of Georgetown of the city; and (c)
that it was entirely surrounded by buildings preventing any ventila
tion! 19]. The sanitary commissioner instead proposed a larger site near the
Rayapuram Military Hospital for both smallpox and other infectious
diseases. This new site was roughly three times the size of the site
suggested by the committee for the infectious diseases; the new site was
“open to the breeze from the north, west and south and had no dwelling
houses in its vicinity”! 19]. But this time it was the turn of the corporation
of Madras to object to sanitary commissioner’s proposal:
the Corporation disapprove of the site recommended by the Sanitary Com
missioner as being in too crowded a locality for a hospital for infectious diseases;
they also disapprove of the amalgamation of a cholera and small-pox hospital
on one site; they recommend that two small-pox hsopitals of 40 beds each be
built, one for the northern and one for the southern portion of the city; they
approve of the construction of quarters for a hospital staff?
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This new site recommended by the sanitary commissioner, “must be
dcfintcly abandoned", the corporation argued, since, apart from the fact
“that it would be extremely inadvisable to place both hospitals permanent
ly on the same site", a model Paracherri to the north of this site was coming
up, and to the west of this site extensive quarters for the Railway servants
was under construction [20].
The corporation after much deliberation agreed that, .
...there was no immediate necessity to consider further the question of a hospital
for infectious diseases apart from small-pox. The old military hospital [in the
north of the city] is now in use for the purpose and is capable, if necessary, of
considerable extension, while the Kistnampet hospital supplies the needs of the
southern part of the city. The evil at present is that small-pox cases have also to
be admitted to these hospitals and the first thing to do is obviously to provide for
such patients elsewhere.[21 ]
The question now before the corporation and the government of Madras
was to decide whether to have two separate smallpox hospitals (one each
for the northern and southern parts of the city), or, to have a single central
smallpox hospital for the city.
The issue was ultimately linked to the availability of funds. It was
around this period (1905-1910) that the corporation had decided to
implement huge drainage and water-supply schemes in the city, but it
could not at the same time ignore the pressing need for a smallpox hospital.
The corporation now had to consider the possibilites of raising additional
capital for constructing and sebsequently maintaining two hospitals. It
could not find an answer and therefore agreed to having a single smallpox
hospital for the present. It accepted that in view of the constraint posed by
lack of funds, “a single hospital is desirable if a suitable site can be found
at a site sufficiently central to serve the requirements of the whole
city”[22].
From now on, for nearly a decade, the issue became one of finding a
suitable and centrally located site in the city for the smallpox hospital. It
was difficult in the first place to identify a site that the government and the
corporation would agree upon. After a long search, a place was found in
1907, but there were difficulties in obtaining sanction for the alienation
of the site from the military department to whom it belonged. Besides,
every time a new site was proposed, it had to be accompanied by an
estimate of cost of costruction and corresponding plans, the preparation
of which caused further delay in deciding one way or another. It ap
peared as though there would never be any agreement on identifying a
convenient central site in the city for the hospital. The government
conceeded in April 1912 in the legislative council that it “was not possible
to frame any anticipation as to when the hospital will be completely
constructed". [49]
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IV
Concluding Remarks
While tracing the role of the municipal council in shaping the nature
of public health strategies adopted during the early decades of this century
in the city of Madras, we observe that the council more often slowed down
the pace of development. Some of the members of the council were
positively against expansion on existing lines. This was because they were
more skeptical of the efficacy of certain (available) medical interventions.
Il is interesting to note that there was not a single member in the council
during the period of this study who argued for introducing indigenous
medical care facilities either as an alternative or as a complement to the
allopathic system. While one set of councillors blamed the inefficiency
of the health department for the poor state of health of the city, others
ascribed it to lack of finance and prevailing social conditions.
What appears important in explaining the slow development of public
health policy in the city of Madras in the early decades of the century is not
so much the financial constraints per se as the council’s perception of the
nature of the problems, and more importantly, the council’s reluctance to
accept certain existing potentially useful interventions. A closer look at
the discussions amongst the policy makers in colonial India will be of
value to the public policy analysts of today in that it could throw light on
how ideas, values, prejudicies, expectations, and power of the individuals
involved in the policy making process within the government get ex
pressed and result in specific policy outcomes. Such case studies as we
have presented here, we believe, are needed for a proper understanding of
the evolution of health policy in India.
Notes
[This is a revised version of a paper presented at the 54th annual session of the
Indian History Congress, Mysore, December 16-18,1993.]
[All the proceedings of the meetings of the corporation of Madras referred to below
are available at the archives of the corporation of Madras.]
1 For an outline of the history of health policy in colonial India, the reader may
refer to (a)David Arnold (ed), Imperial Medicine and Indigenous Societies, New
Delhi, Oxford University Press, 1989; and (b)Radhika Ramasubban, Public
Health and Medical Research in India.'Their Origins under the Impact ofBritish
Colonial Policy, Stockholm, 1982. There are also a few region-specific
studies:(a)J C Hume Jr, ‘Colonialism and Sanitary Medicine: The Development
of Preventive Health Policy in the the Punjab, 1860 to 1900’, Modern Asian
Studies, 1986, 20:703-24; (b)Poonam Bala, Imperial Medicine and Bengal,
1850-1947, New Delhi, Sage Publications, 1991; (c)Chnslopher J Nirmal, ‘A
study of public health in the Madras Presidency, 1882-1912’, Ph D thesis,
University of Madras, 1970; and (d)V R Muraleedharan, ‘Development of
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23
Health Care System in (he Madras Presidency, 1919-1939’, Ph D thesis, Indian
Institute of Technology, Madras, 1988.
2 The number of peons of seems to have been reduced from 250 to 150 within the
year 1906.
3 The resolution was proposed by T M Nair, refer letter from E S Lloyd, acting
president, corporation of Madras, to the secretary to the government, local and
municipal, dated August 31, 1906, in notes to G O 1975, MD, November
13,1906.
References
Proceedings of the General Meeting of the Corporation of
Madras
(hereafter, PGMCM), 21 June 1910.
[2] PGMCM, February 1, 1907.
[3] PGMCM, July 16, 1907.
[4] PGMCM, May 4, 1909.
(5] PGMCM, February' 15, 1910.
[6] PGMCM, May 4, 1909.
[7] Government Order (GO), 1437 (Public Health Department) August 28,1923
(Tamil Nadu Archives (TNA], Madras).
[8] Proceedings of the Special Adjourned Meeting of the Council November 17,
1923. •
(9) Proceedings of the Special Meeting of the Council, July 22,1924.
[ 10] Proceedings of the Special Meeting of the Corporation of Madras, October 3,
1911.
[11] Proceedings of a General Meeting of the Council (hereafter PGMC) May 15,
1923.
[12] PGMC. January 15, 1924.
[13] G O 1393, Municipal Department (MD), August 8 1898, TNA.
[14] Letter from the Surgeon-General, C Sibthorpe, to the Secretary to the
Government of Madras, dated October 11,1898 in (13).
[15] GO 1812, MD, October 25. 1898, TNA.
[16] Letter from R E Ellis, Acting President, Corporation of Madras, to the the
Secretary to the Government of Madras (Local and Municipal), dated
September 7, 1898, in G O 1833, MD, October 27, 1898.
[17] G O 750, MD. May 25.1899, TNA.
[18] GO909, MD. May 11, 1905, TNA.
[ 19] G O 1062, MD, June 8, 1906, TNA.
[20] G O 613, Revenue Department, July 3,1906, TNA.
[21] G O 1975, MD, November 13,1906, TNA.
[22] G O 846, MD, April 22, 1907, TNA.
[23] GO677, MD, April 11, 1912, TNA.
[1]
24
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Women, Health and Development
Malini Karkal
Manisha Gupte
Mira Sadgopal
The pace ofmarginalisation of rural people, women, tribals, dalits, etc
has accelerated with the adoption ofstructural adjustment programmes
in many countries. If we ae to assess its impact in the coming times, we
need to be aware ofthe deterioration in their health and welfare status,
already becoming visible. Women are especially affected by these
policies given that their health status has shown little improvement in
recent decades.
THERE is enough evidence to show that often, development policies
adopted by governments have widened the disparities amongst sections of
people. Analysis of the data shows that over the years, urban areas, as
compared to the rural, and men as compared to women, have benefitted,
and the gaps between these have widened (Karkal and Rajan 1988). Since
poverty does not merely deprive individuals of the basic needs for survival,
but makes them powerless to even take advantage of the available
resources, the plight of the deprived sections has become more miserable
over years. In tum, those in power continue planning such that small
sections of the advantaged continue to reap benefits at the cost of the
majority of Indian people.
Marginalisation of rural people, women, tribals, dalits, etc, not only
continues unabated, but vested interests are promoting social and cultural
practices which disadvantage marginalised groups. In fact, one can see the
negation of progressive altitudes that were promoted through earlier social
reforms. Selective abortion of female foetuses, female infanticide, sati,
crimes against women, religious fundamentalism, and so on, are examples
of this regression. The New Economic Policy (NEP) encouraging struc
tural adjustment programmes (SAPs), liberalisation and export oriented
policies, are expected to benefit those who already have a larger share in
the nation’s resources whereas they will push the deprived into lives that
will be more miserable. There is already evidence that liberalisation
policies have increased the hold of foreign capital on the Indian market,
pushing the interests of the Indian ‘common man’ into the background.
Privatisation of the economy has resulted in the virtual takeover of the
process of development by the private sector. Mechanisation has driven
out unskilled and semi-skilled workers from gainful employment. Women
constitute a large proportion of these groups. In the absence of land reform,
modem agricultural ‘revolutions’ (green, white, etc.) tend to result in
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falling employment per hectare as land ownership becomes more unequal,
farms become larger and large-scale mechanisation takes over. Tens of
millions of small holders, tenant farmers and agricultural labourers have
found themselves without sufficient land or sufficient work. In India,
unaccounted numbers of rural families have become landless in the last
three decades alone, turned away from the fields that they once tilled and
harvested. At the root of this process lie investment policies which are
capital-intensive rather than labour-intensive and they are being accentu
ated by the new economic policies.
It is now widely accepted that women contribute extensively to social
processes through their involvement in production and reproduction. Yet
women’s access to resources is low; furthermore, even within deprived
households their access to existing assets and resources is much lower than
that of men. Stale policies moulded by class and gender bias adversely
affect people’s (especially women’s) access to resources for this very
reason. Class factors, household politics and childbearing have a profound
and distinctive impact on ayoung woman. She is simultaneously a worker,
a bearer of male heirs for the continuity of the husband’s family line and
of future workers for the nation’s economy. It is thus inappropriate to
analyse domestic organisation separately from the sphere of production.
Biological reproduction may seem ‘natural’, but its social construction
must still be analysed from a women’s perspective.
While easily accessible, rational and humane medical services must be
made available to all people irrespective of their capacity to pay, normal
biological functions or social issues are seen as problems requiring
medical solutions. The medicalisation of the human body complicates the
health problems that people suffer fiom. Medicalisation is a cultural
process with political implications, especially as more and more of
everyday life comes under medical influence and supervision. This leads
to serious loss of control over and confidence in women's own capacities
and in their own bodies e g IVF promoted without adequate efforts to
prevent infertility such as measures to diagnose and control pelvic inflam
matory diseases (PIDs) and STDs and the unscientific use of IUDs. The
medical profession has taken excessive charge of health concerns of
people, irrespective of its ability to deal with them. Essentially non
medical states are increasingly defined in medical terms, for example
technological devices are promoted even with uncomplicated births e g,
prenatal screening and menopause. Thus, medical interventions are used
to ‘treat’ these conditions, and a medical framework is adopted to under
stand them. Unnecessary and invasive interventions such as high-tech
diagnostic procedures, drug and hormone therapies, and surgeries are thus
routinely justified. There is an urgent need to develop alternative policies
and programmes that will correct the disparities that prevail and reverse
the human and environmental degradation accentuated by the new poli
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cies. Actions in this direction are needed not only because they are in
keeping with the objectives of the Declaration of Human Rights, to which
India is a signatory, but because such a perspective has to be at the root of
any efforts for human development.
Health Status of Indian Women
The death rate for 1991 in India is 10 (per 1000 persons), which is close
to 9 for the populations in the developed, industrialised countries [World
Bank 1993]. However, this does not mean that the health status of people
is the same or even comparable. The question is not so much ‘how many’
people die, but ‘who’ die? The infant mortality rate (IMR) for 1991 in India
is 90 whereas the lowest known IMR in the world (in Japan) is 5 (per 1000
live births). Similarly the mortality rate among children below age five
in India is 124. Reported estimates for deaths due to maternal causes in
India vary from 390 to 2000 (per 100,000 live births). Deaths due to
maternal causes have virtually disappeared in the developed industrialised
countries.
Such comparisons discuss only the deaths, not the poor health or the
morbidity situation of the people. For instance, for each maternal death in
India it is reported that 17 women suffer serious health damage. (Dutta
1980). Such a morbidity pattern is not prevalent in the developed
industrialised countries. To understand the morbidity conditions there is
a need to review some of the work of nutritionists and other health
scientists and to undertake appropriate research. The World Health
Organisation (WHO) has developed an index known as disability adjusted
life years (DALYs). This index measures the loss of life years due to deaths
earlier than the expected life-span. Of the total DALYs lost in India, 56 per
cent are lost in ages under 15 years. In contrast, in the developed
industrialised countries, the loss of DALYs in ages under 15 is only 8per
cent. Most of the DALYs lost in the developed industrialised countries are
in advanced ages (World Bank 1993). In simple terms this means that of
those who die in India, more than half die even before they have reached
adulthood. People in the West not only live much longer, but the majority
of them live until old age.
Table 1: Ratio of Deaths of
Besides the anomalous pattern of
Females to Males
deaths by ages, differences also prevail
between the deaths of men and women.
Age Groups
Ratio
Women are generally believed to be bio
0-4
1.11
5-14
1.22
logically stronger, and given equal
15-34
1.31
chances of survival, women live longer
35-49
0.72
than men. In developed industrialised
50+
0.86
countries women have lower death rates
at all ages. In contrast among Indian
Source’. Registrar General of •
women death rates, higher than those for
India, 1983 and 1988.
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T1
the men till their reproductive ages are over. Till 1971 this limit was up to age
44 years. Ever since the FP programme has been aggressive in India, a change
in the pattern of childbearing has occurred through terminal methods for
women at an earlier age. It is now observed that until the age of 35, women
experience higher death rates in comparison to men. Beyond 35, that is, after
the completion of women’s reproductive career is over, it is the men in India
who have higher death rates as compared to the women.
With higher death rates for the younger ages, it is observed that age-groupwise the number of persons goes on decreasing as the age advances. In other
words, the larger number of persons is in the younger age group. Since
women have higher death rates in younger ages, their numbers in the
population decrease more in comparison to men. Consequently in India there
are fewer women in the population than men. Expressed as ‘sex ratio’, the
number of women per 1000 men in the population is low in India. Over years
the sex ratio of the Indian population has shown a declining trend. In 1901
there were 971 women per 1000 men. and by 1971 this ratio came down to 931.
The census of 1981 showed an improvement and the ratio was 934. However
recent figures available (for 1991) show that the sex ratio in India is 929.
Social customs reinforce and perpetuate the dependent role of women and
deny them basic needs, influence their chances of survival. The pattern of
higher mortality among women than among men, observed in India and in
populations of other countries in the Indian sub-continent (except in Sri
Lanka), is rather uncommon when compared with other regions. Higher
mortality in general, or higher prevailing death rates, do not explain the dif
ferentials that are unfavourable to women. The highest mortality in the world
is observed in the African countries, where women live longer than men.
A study by the UN (1988) based or. the analysis of 78 life tables for the
period 1945 to 1981, showed that the differences in mortality of the two
sexes observed in the Indian sub-continent, were mainly because women
had life expectancies much lower than values expected in all other
countries. In other words, it is not as if men in India are in enviable
situations, but that women are significantly neglected. The bias against
women is expressed in denial of their due share in the social resources.
Denial of adequate nutrition and medical attention, when needed, has
resulted in higher mortality among women.
The undervaluation of women is at the root of the neglect resulting in
higher mortality. Scrimshaw (1978) argues:
the traditional assumption that high mortality leads to high fertility must be
questioned. Often the reverse may be true. High fertility may be accompanied
by the acceptance or even unconscious encouragement of high mortality.
Unregulated fertility accompanied by neglect of unwanted (girl)
children is used as a way to regulate family size. Using data from the
National Sample Survey, Malakar (1979) showed that this argument using
selective neglect of girls for regulating family size was supported by the
Indian data. Simmons and colleagues (1982) from their data concerning
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post-neonatal mortality from Uttar Pradesh show that parents desire sons
more than daughters. Their data also show that the girl infants are more
likely to die in families where the wife had expressed a preference for no
additional children or especially no additional girl children. Wherever an
older male sibling aged less than three years was present, girls were found
to be at a disadvantage.
That women suffer critical nutrient deficits from girlhood onwards is
shown by ample available data. A study by ASTRA in rural Karnataka
state showed that, of the total human energy contribution to the village
‘energy matrix’, the respective contributions of men, women and children
were 31 percent, 53 percent and 16 percent, indicating that women worked
harder than men. Batliwala (1987) reports that she tried to calculate the
energy expenditure for individuals in terms of kilocalories and compare
it with the food intake. However, she was faced with problems since
...nutrition textbooks provided calorie costs for piano-playing and typewriting
(but) they did not mention fetching water or gathering firewood. Secondly, only
a limited number of agricultural activities were measured, compared with over
70 industrial and military activities. Finally, it was found that even for these no
female equivalents were available. The few energy cost figures available for
women, included such middle-class activities as sewing and singing, and
women on the whole were listed under the heading of ‘sedentary people’.
Batliwala says that the study pointed out with statistical evidence that
the expenditure of energy by women on a day to day basis may be higher
than that of men. Furthermore, in rural setting men’s work is seasonal,
whereas women perform not only seasonal activities (transplanting, weed
ing, harvesting) but the perennial, life-supporting tasks like fetching water
and fuel, cooking and looking after children and old people in the family.
The final computation of calorie expenditure on various agricultural and
domestic activities by men and women, was found to be: 2473 calories per day
per man and 2505 calories per day per women. In contrast the estimated intake
of calories was 3770 per day per man and 2410 calories per day per woman.
Thus women faced not only a relative deprivation in comparison with men, but
also absolute deficit vis-a-vis their calorie expenditure [Batliwala 1987:261]
Batliwala refers to Shatrugna’s observations: (1) Women may not
continuously lose weight, but they are definitely lighter than their desired
weights; (2) Women have no energy reserves for emergencies such as
illness, etc so that their mortality rates are higher in the event of an
epidemic compared to well-fed women; (3) Women try to conserve as
much energy as possible by cutting out on the quality of life. Of course they
are called lazy, inefficient, slow and even cheats. But what they are trying
to do is exist and work at basal metabolic rate(BMR) level, because they
do not have surplus energy for briskness; (4) It is also possible that their
cells are converting food into usable energy more efficiently. This could
result in early wearing out of the cells and early aging.
Son-preference takes its largest toll in ages 1 to 4.The impact of
discriminatory treatment to girls in allocation of food and in medical
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29
attention is highest in these early ages of childhood. Impact of these
discriminatory treatments is also observed in ages 5 to 14 and then during
child-bearing ages. Inadequate medical care takes greater toll of these
women of poor health. The first childbirth is particularly hazardous.
Neglect of girls in the early ages is reflected in the high incidence of low
birth weight babies for the survivors among these girls. Most childhood
diseases have greater impact on male children when children of both sexes
receive no discrimination in food and in medical attention. This is obvious
from the fact that wherever the improvement in chances of survival of
female infants had taken place they were without any special medical
inputs for the female children.
The social definition of the appropriate age at which reproduction
should commence also influences the expected social costs of rearing the
child. Parents can reduce their economic liability by marrying off
daughters at markedly younger ages. Data from countries that have shown
improvements in the survival chances of girls, also invariably show a rise
in age at marriage of girls.
For women another area of inequity comes from the society’s refusal
to acknowledge and reward the services that women render to the society.
In the developing countries non-monetised sector, traditional labour
intensive agriculture and subsistence production play an important role in
the activities of the people. These activities take place mainly at the
household level. Krishnaraj (1989) points out that,
Data systems whose concepts and methodologies were derivedfrom the market
system, did little justice to the altogether different mileu of the Third World
economies, and especially the rural economies. Women are not present in the
paid labour force, which is visible to the statistics, but are engaged in productive
activities of household level, mainly the non-monetised or subsistence sector
that render them invisible to statistics. Invisibility of women in data systems has
come to be understood as caused mainly by the limitative definitions and
Table 2: Current Body Weights (kg) of Indian Women and Girls of
Different Socio-economic Groups
Group
Body HIG
Weight
Infants: 0-1 year
7.2
Children: 1-3 years
11.8
4-6 years
17.7
7-9 years
25.9
10-12 years
35.0
Adolescents: 13-15 years 47.8
16-18 years
49.7
Adult women
50.0
6.2
11.2
15.7
19.6
26.4
39.5
43.8
50.3
Rural
Urban
MIG
LIG
IL
Slum
5.9
9.5
14.0
18.8
25.4
35.4
41.7
43.5
5.9
9.5
14.3
18.7
25.4
35.7
41.6
44.6
5.7
9.0
13.6
18.3
24.0
33.8
40.8
41.9
6.0
10.6
14.4
19.9
27.3
37.5
43.1
48.2
5.8
9.1
13.6
18.3
24.6
34.7
41.1
42.5
Source: Nutrition Foundation of India, Women and Nutrition in India, Special
Publication Series 5, New Delhi, 1989.
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concepts employed that are particularly unsuitable to women. By leaving out
much of what women actually do, because they do not fit the definitions,
women’s contributions go unrecorded. This invisibility contributes signifi
cantly to the lowering of the status of women. Women’s work that is crucial to
survival, becomes marginal and they are believed to be ‘dependent’.
This bias against women also comes from cultural factors that find
women reported as being an ‘outside labour force’ because they find very
little prospect of finding work. Many women who are officially classified
as being ‘unavailable for work’ would be available to take up work only
if their domestic responsibilities were made lighter through reducing the
drudgery of household activity by the sharing of work by family members,
especially men.
In agricultural countries such as India, the participation rales for women
are influenced by their participation in the agriculture. In the third world,
unpaid family work, traditional labour-intensive agriculture and subsis
tence production constitute the major economic activities of the people.
These activities take place mainly at the household level.
The role of women in agriculture is crucial not only because of their number
engaged in it but also because of the variety of activities which they perform.
Except for ploughing, women are involved in all the operations required for
growing foodgrains and vegetables and rearing livestock. Their involvement in
the agriculture can be observed in compost preparation and application, land
preparation, specially clod breaking and land levelling, sowing and transplant
ing, weeding, harvesting, cleaning, drying and market-produce selling. In
livestock-keeping they collect fodder, clean animal shed, milk milch animals
and process dairy products. All this in addition to their regular household duties
such grinding and dehusking grain, fetching drinking water, collecting fire
wood, preparing family meals and looking after children and the old. In reality
women work harder than men and get little economic credit for doing so.
Women are also seen carrying basketsful of vegetables, fruits and other
agricultural produce on head or back for marketing or for door to door selling.
[Bhattarai and Karmacharya 1981]
Technological developments have also harmed the interests of women.
Because of rapid industrialisation and mechanisation that have destroyed tradi
tional crafts, poor women in the Third World face extensive and acute unemploy
ment. Retention in traditional ‘unorganised’ units where they are not covered by
the factory laws and their absorption into new type of unorganised units appear
to be because of the special difficulties women face such as illiteracy, low
technical skill, lack of opportunities into the more structured units. Over and
above these, women’s mobility is restricted due to family obligation as well as
attitudes regarding what is permissible work for them. The major problem for
women seems to be not so much being pushed out, which is true in some sectors,
as staying where they are. While men move up through education to higher jobs,
women continue to hold traditional occupations that ensure bare survival for the
family, but do not assure adequate economic returns. Women’s employment
provides men and society in general an assurance against unemployment and
sickness, against inflation and wage cuts in their petty ventures [Krishnaraj 1989].
In agriculture, high yielding variety (HYV) technology, along with
irrigation, led to increased use of labour time per unit area cultivated
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31
because of higher labour use in the application of new inputs, higher
cropping intensity and higher yields. However Dasgupta( 1977) observes:
...evidence from some village surveys (in India) shows that the demand for hired
labour goes up with agricultural prosperity and irrigation, but such evidence
shows only a shift from family labour to hired labour and not an increase (in fact
decrease) in the overall rate of participation of the village population in the
workforce.
Studies have also shown that, as the economic conditions of the
families improved, women in the families withdrew from the workforce.
This is supposed to have happened because of the demand for more skilled
work and this being fulfilled by hired labour rather than providing skills
to the family labour, especially women. Another argument forwarded is
that as economic conditions of the families improved, men considered it
necessary to withdraw their female family members from labour force as
a sign of their (men’s) improved status [Dasgupta 1977].
Acharya and Bennet (1983) made an interesting observation that
women’s involvement in market activities gives them much greater power
within the household in terms of their input in all aspects of household
decision making. Limiting women’s involvement to the domestic and
subsistence sectors reduces their power vis-a-vis men in the household. Il
is important to note that in patrilineal systems land is owned by men and
as such the subsistence production assets are owned and controlled by
men. Women in market economy on the other hand generate their own
production assets, and improve their own status.
Access to Health Care
Inherent in each system of health care is a specific attitude towards
people and their bodies. The allopathic system tends to view people as
composed of distinct mechanistic organ systems like the gastro-intestinal
tract, the cardio-respiratory system, the uro-genital tract, the nervous
system, etc. The Indian indigenous and homeopathic systems, in contrast,
see human health more in terms of balances and flows of doshas and
energies. They are less concerned with the physical boundaries and
connections of organs. The allopathic approach to medical treatment is
characterised by attempts to fight, remove or eradicate causative agents
(germs, allergens, defective parts) and to suppress symptoms. On the
other hand, the indigenous and homeopathic systems, aim towards restor
ing balances and flows in the person without considering the parts
separately. The latter approach is called holistic. Realistically speaking,
each approach has certain strengths and weaknesses.
Whatever the particular health system, the healer (doctor, vaidya,
hakim, vaidu) can exploit his (or rarely her) power over the sick person
(patient) and relatives, and often does. Even when benevolent, the
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relationship is usually patronising. It is doubly so with women who are
sick. In this respect, there is little difference between practitioners of the
holistic and non-holistic systems. Women sometimes tend to prefer the
holistic approaches, perhaps because allopathy is understood to be too
‘strong’ and invasive. However, this comparable gentleness is no guard
against patriarchal attitudes which have become embedded even in
holistic health systems.
In spite of the fact that women are producers and reproducers, their
access to health care is extremely poor. Various reasons account for this
low access. Firstly, women are seen either as mothers or potential
mothers by the public health services. Any problem related beyond that
(such as mental health or marital violence, for example) are not seen as a
priority by the health services for healing women. In India, where the
obsession of the state is in reducing numbers of people, infertility also is
not the concern of the government heath services, in spite of the socio
logical consequences of the same for women. On the other hand, invasive
reproductive technologies are peddled in the name of giving infertile
women choice. The question of reducing potential infertility among
women through the prevention or early treatment of TB, pelvic inflam
matory diseases, undernourishment and complications from hazardous
contraceptives, is not considered.
The state’s undue emphasis on population control also reduces the
access of women to health care services, especially in the crucial years of
pregnancy and childbirth. When health workers are busy ‘cultivating’
farpily planning cases, it is difficult to imagine that women will feel
comfortable seeking ante-natal or post-natal care from them. The watereddown programme of maternal and child health (MCH) suffers a major
obstacle. With regard to quality of service, even the record of the favoured
‘family planning’ programme is unsatisfactory. The Indian Council of
Medical Research reported a study of 43,550 hospital deliveries where 52
of the women had given birth after sterilisation (33 tubectomies and 19
vasectomies) [ICMR 1990]. Another 22 women reported having con
ceived while using an intra-uterine device [ICMR 1990].
Locations of the PHCs also make it difficult for women to avail of
health services. The OPD of most PHCs functions between 8:00 am and
12:00 noon and reopens from 4:00 to 6:00 pm. PHCs serve several villages
and villagers have to commute to reach to the PHC. Often state transport
buses do not reach the PHC village well in advance for patients to receive
medical treatment and often the last bus from the village leaves before the
OPD closes. Both patients as well as many of the PHC staff (including the
doctor, sometimes to whom the government provides residential quarters
near the PHC) travel by the same bus to and fro, and so the delivery of
health care suffers. Short supply of health personnel and of drugs makes
the journey to the PHC futile. [Avasthi et al, 1993]
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The private sector on the other hand is totally unaccountable to people’s
real health concerns. The treatment is expensive and not always rational or
ethical. In one of the studies it was found that women suffer more often
from chronic ailments (such as anaemia, backache, white discharge,
weakness, etc as compared to the men in the family. Most of people’s (and
especially women’s) illnesses are a result of over-work, undernutrition
and poverty. The health services cannot cure women of these problems. In
reality what happens is that the family realises that women don’t get well
easily and so the access of women to medical care, especially that which
requires more time and money gels reduced in the cases of women [Guple
and Borkar 1987].
The current health policy of the Government of India evolved under
pressures from the World Bank is to restrict government health services to
preventive care and allow the private sector to take over all other health
sendees. This policy will also allow multinational pharmaceutical indus
try free access to the Indian market. Thus, the prices of drugs which are
already beyond an average Indian’s reach will spiral. Cuts in the health
budget are squeezing out the poor from access to ordinary health services.
This changed situation will further increase the burden of women who care
for the family in sickness.
A low self-perception of women as well as the culture of silence’ in
which they are brought up makes them endure the physical and mental
suffering they experience and this further reduces their access to health
care. Taught to believe that menstruation is dirty, a woman is hardly in a
position to seek medical intervention for white discharge or for menstrual
disorders. Personnel in public services have little patience to listen to
stories of side-effects of contraceptives or of a woman’s husband's
impotence. In fact, once she is terminally sterilised a woman is virtually
struck off the mental registers of the health service providers. The private
sector then steps in when a tubectomised woman suffers menstrual chaos
(maybe related to hurried sterilisations in camps), and offers hysterectomy
as the solution at a price that is a few years of daily wages of the woman.
The health of ‘deviant’ women, (who include single, disabled, wid
owed, deserted, lesbian, mentally handicapped and so on) is a matter of
negligible concern to the public health services that rightfully belong to the
people. In the same light, sexuality of women (and men) is never ad
dressed, much less the adverse consequences of having neglected the
same. Thus women suffer silently of depression, anxiety or of more severe
mental disorders because they have not received either the physical or
emotional support from medical personnel at the required time.
The system does not locate the health problems of women in the real
context of oppressive man-woman relations. Treatment ignores the need
to change these relations. Ill-effects to women’s health arising out of such
relations, such as reproductive tract infections or injury and mental trauma,
34
RJH
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1995
are not treated seriously enough. The effect of gendcr division of labour
on women’s health is unrecognised, including the health costs of invisible
work at home and in the informal sector.
Instead of increasing the access of women to health care and to
rcproductve rights, one observes the trend to decrease it. The move to
withdraw maternity benefits for women beyond the second child or of
advocating hormonal implants and injectables as contraceptives, should
be seen in the same light. On the one hand there are the women who have
little or no access to trained medical supervision at the time of childbirth,
in spite of high gestational risk; on the the hand, urban middle class
women frequently undergo repeated Caesareans during childbirth.
The fact that the same illness for a woman very often poses quite a
different problem than it does for a man has also to be fully understood.
Tuberculosis for a man is bad enough, but for women not only does the
continued treatment or stigma reduce her status at home, but the possible
infertility resulting from the illness can cause untold misery. Marital
violence, desertion and death become real possiblities for this woman. The
social sanction for these crimes is more overt when the woman fails to
perform her expected duties at home, namely housework and bearing of
male children.
Women’s indigenous knowledge of health care has been marginalised
or lost, and their continuing role in maintaining the health of their families
and communities has been devalued. Self-help measures and remedies
that address women’s ailments, passed down through generations, are
being replaced by mystifying pharmaceutical and high-tech parapherna
lia. Not surprisingly, this leaves women with a sense of separation from
their own bodies.
In the name of increasing access of women to medical care, there is
further medicalisation of women’s bodies and functions. When we con
sider the immense potential of the multinationals/ pharmaceuticals to
make profit by peddling drugs and contraceptives to healthy women for
birth control, menopause and so on, it is of no great surprise that the
argument of giving women more ‘choice’ would be popular even among
the establishment. We have to view pre-natal sex-determination, hor
monal replacement therapy and the indiscrimante use of tranquilisers for
women in this light.
Privatisation would only reduce women’s right to existing health
services. We can demand good quality services from the public sector
because they are funded through the indirect taxes that the people includ
ing the poor pay. The private sector is kept in some check because of the
mere existence of the public health services. Once the private sector takes
control over the public arena, there will be no end to the greed of profitmotivated medical personnel. Compounded with the New Economic
Policy, structural adjustments and intellectual property rights (including
RJH
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35
the patent laws for drugs), one can foresee a gloomy picture for women’s
health unless we plan effective strategies to resist anti-people moves of the
government, the private sector and imperialist nations. We have also to
view with some concern the sudden interest of funding agencies in the
reproductive and sexual health of our women. Our plan for the next decade
has to take into account the feminist interpretation of sexual rights and
reproductive health.
References
Acharya, Meena and Lynn Bennet (19S3): Women and the Subsistence Sector:
Economic Participation and Household Decision-making, World Bank Staff
Working Paper No 526, World Bank, Washington.
Awasthi, Ramesh et al (1993): Strengthening Health Education Services - An
Action Research Project in Three PHC Areas of Rural Maharashtra, FRCH,
October.
Batliwala, Srilata (1987): ‘Women’s Access to Food’, Indian Journal of Social
Work 18(3): 1987.
Bhattarai, Achhut Nath and Chiranjibi Karmacharya (1981): ‘Women and Agri
culture’, in report of national seminar on ‘Integration of Women into the
Mainstream of National Development’, Women Services Coordinating Com
mittee, Kathmandu, June 9-11, 1981.
Dasgupta, B (1977): Village Society and Labour Use, Oxford University Press,
Delhi.
Gupte. Manisha and Anita Borkar (1987): Women’s Work, Fertility and Access to
Health Care, FRCH, October.
Dutta, K K (1980): ‘Morbidity Patterns Amongst Rural Pregnant Women in Al war,
Rajasthan -A Cohort Study, Health and Population Perspectives 3.
Karkal, Malini and S Irudaya Rajan (1991): ‘Provision of Basic Needs in India’
Economic and Political Weekly, February 23, pp 443-45.
Krishnaraj, Maithreyi (1989): ‘Methodologies for Improving Visibility of Women
in the Economy and Society: A Survey of Current Attempts’ Background Paper
at Workshop on ‘Visibility of Women in Statistics and Indicators: Changing
Perspectives’, UN/INSTRAW/GOI/DWCD/SNDT, Bombay, 3-7 July, (mimeo)
Malakar, C R (1979): ‘Child Mortality and Fertility in India’, Document No. 9,
Proceedings of Conference on Child in India, Indian Association for the Study
of Population, New Delhi.
Registrar General of India (1983): Sample Registration System - 1981 Vital
Statistics, New Delhi.
Registrar General of India (1988)
Registration System - 1986 Vital
Statistics, New Delhi.
Registrar General of India (1990): Sample Registration System -1989, New Delhi.
Scrimshaw, Susan C M (1978): ‘Infant Mortality and Behaviour in Regulation of
Family Size’, Population and Development Review 4 (3).
Simmons, George B et al (1982):‘Post-neonatal Mortality in Rural India: Implica
tions of an Economic Mode’ Demography 19: 3.
United Nations (1988): ‘Sex Differentials in the Developing World: Levels,
Trends and Regional Patterns and Demographic Determinants’, Population
Bulletin 25, New York.
World Bank (1993): World Development Report 1993, Investing in Health, Oxford
University Press.
36
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Health Expenditure Patterns
in Selected Major States
Ravi Duggal
State sector investment in public health is miniscule compared to the
demandfor health care in the country. Inter-state comparisons show a
direct correlation between levels of public health investment and the
health status ofthe population, and rural-urban variations indicate the
gross neglect of the countryside with regard to public health services
and facilities.
f
ACQUIRING complete knowledge about health expenditure patterns in
India is at present a near impossible task. This is largely due to the fact that
about three- fourths of such expenditure is being incurred privately. While
state sector expenditures are documented in budget papers, one can only
make estimates for the private sector.
Here we attempt an analytic review of the public health expenditures
for selected major states of the country from the available latest budget
documents (1992-93). The states included have not been selected on the
basis of any specific criteria but purely because of availability of budget
papers at a given point of time. A more detailed analytic paper is planned
which would include all states with time series data. However, the states
included presently may be considered representative as both geographical
spread and various socio-economic levels of development are covered.
Private sector expenditure are excluded from the scope of this paper.
Our analysis clearly establishes the low level of investment in the public
health sector. The investment is miniscule compared to the demand for
health care in the country. While inter-state differentials bring out sharply
a direct correlation between the level of public health investment and the
health status of the population, rural-urban variations indicate the gross
deprivation of rural populations with regard to public health care. The
paper further highlights that an unusually large proportion of the available
funds goes to support salaries, especially, so in the rural health services and
the disease control programmes.
The main source for the data included in this paper is the 1992-93
budget documents of the various states, the detailed demand for grants.
This document includes a three year record of expenditure - 1990-91,
1991-92 (revised estimate) and 1992-93 (budget estimate). From these
budget papers most of the relevant (and more or less comparative) heads
and subheads of expenditure have been included in the analysis as
explained in the next few paragraphs.
In spite of a national system of classifying heads and.subheads of accounts
there is still an incomplete standardisation in presenting budgetary informa
RJH
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1995
37
lion. Though the major and minor heads are the same across states the
placement of the latter under the former is not standard. For instance the
subhead PHC is under rural health services of the ‘medical’ head in some
states, and under the head ‘public health’ in other states. Similarly, sub
centres are under family welfare in some states and under public health in
others. ESIS in many states is under urban health services under the medical
head, in others under medical education and in still others outside the ministry
of health under labour welfare. A few states include water supply under the
ministry of health whereas most show it under rural and urban development.
This variation, to some extent, creates problems in comparison across
states as well as in presenting analysis of data by major heads. Another
problem is caused by the separation in plan and non plan spending. This
spreads the expenditure figures across the 200-300 pages of the ministry of
health budget. Again, there are as many ways of presentation of plan/non plan
figures as there are states. This compounds the problem of compilation for the
purposes of analysis. As a consequence one is not sure that the figures one
compiles are complete, especially with regard to plan expenditures which in
some states are shown under many catego ies like state plans, Seventh Plan
committments, Eighth Plan committments, centrally sponsored schemes,
central schemes, etc, and often in separate volumes. The result is that to
compile the total expenditure, for instance, on National Leprosy Eradication
Programme the hunt is an extremely time consuming task.
Further, a few states even show expenditures for health sector incurred
outside the ministry of health, like construction of buildings for health
facilities spent under department of public works or upgradation of PHCs
in tribal areas under the tribal development plan etc. Most states do not
show such expenditures under the ministry of health. What does one do?
Table 1: Input and Output Indicators and Ranks of Selected States
Input
Output
1992-93 1990
1989
1988
1988
Health Beds Doctors IMR Per Child
Exp Rs
Per
Per
1000 Mortality
Per
100,000 100,000 Live Per 1000
Capita Popln Popln
Births 0-1 Yrs
Punjab
86(1)
Kerala
78(2)
Tamil Nadu
67(3)
West Bengal
58(4)
Maharashtra
57(5)
Gujarat
55(6)
Andhra Pradesh 49(7)
Madhya Pradesh 35(8)
116(4)
263(1)
88(5)
83(6)
147(2)
129(3)
62(7)
36(8)
76(2)
55(4)
75(3)
47(7)
86(1)
50(6)
52(5)
15(8)
62(2)
28(1)
74(5)
69(4)
68(3)
90(7)
83(6)
121(8)
21(2)
8(1)
21(2)
22(4)
22(1)
31(7)
27(6)
51(8)
Input
Rank
Output
Rank
1
1
4
6
3
5
7
8
2
I
3
5
3
7
6
8
(Figures in parentheses are ranks).
Source: Compiled from Health Information of India 1991, MoHFW, GOI.
38
RJH
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If all major heads of health (a/c nos 2210, 2211,2251,3606, 4210, 4211,
6210,6211) are to be considered as the basis for health expenditures, rather
than what the ministries of health spend, then one will have to scan the
budgets of most ministries and departments to get a complete coverage of
the health account heads. We confine this discussion to the ministry of
health spending and within that exclude family welfare. The effort here
will be to analyse the expenditure on selected major health programmes/
interventions for which data can be standardised across the states to reveal
patterns and permit comparison.
In the analysis of health expenditure below we are looking only at
revenue expenditures, both plan and non-plan, under the major head
medical and public health (a/c 2210 of the ministry of health) of the
consolidated fund. Thus family welfare and water supply and sanitation
arc excluded, as are all capital expenditures.
Health Expenditures and Health Status
If
The overall health status of a population is closely linked with overall
socio-economic development. This does not need to be proved because it is
well recognised globally. That investment in health care can independently
improve health status has also received wide recognition. China, Sri Lanka,
Costa Rica, Mongolia, Nicaragua and Kerala are well known examples
where health status has improved substantially with economic development
remaining at very low levels [World Bank 1993]. This statement in no way
intends to discount the importance of overall economic development, espe
cially income growth and distribution. Health services data from these eight
states also lend support to the hypothesis of the importance of increased
investment in the health sector. It clearly establishes the link between health
care investment and health status. Table I shows the close correlation
between input variables (health expenditures, availability of hospital beds
and doctors) and output variables (IMR and child mortality) - higher the input
rank of a state better the output.
The relationship is especially stronger between public health care
spending and output rank. Thus, among the eight states Punjab, Kerala and
Tamil Nadu have the highest health expenditures as well as the best health
status measured in terms of infant mortality and child mortality rates.
These states also have the most developed health infrastructure along with
other states like Karnataka and Maharashtra. In 1992-93 the overall public
health expenditure in the country (excluding family welfare and water
supply and sanitation and capital expenditures) is estimated at Rs 5000
crore or Rs 58 per capita (Table 2). If we add family welfare, water supply
and sanitation and capital expenditures, as is traditionally done, then
public health expenditure at Rs 8500 crore works out to Rs 99 per capita
in the same year [Ministry of Finance 1992].
RJH
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39
Among the states, as mentioned earlier Punjab and Kerala have the highest
expenditures averaging Rs 86 and Rs 78 per capita, respectively in 1992-93.
They also have one of the best developed health infrastructures in the country
(Maharashtra has the highest per capita availability of doctors but nearly half
of the doctors in Maharashtra practice in Bombay city alone) (Maharashtra
Medical Council list 1992). The lowest health care spending among these
eight states is in Madhya Pradesh with an expenditure of only Rs 35 per capita.
Andhra Pradesh (Rs 49 per capita), Gujarat (Rs 55 per capita) and surpris
ingly Maharashtra (Rs 57 per capita) fall below the all-India average of public
health expenditure as defined here.
The central government expenditure shown in Table 2 is mostly (86 per
cent) on central government hospitals, medical colleges and hospitals and
Table 2: Health Expenditure in Selected States 1990-1993
1990-91
91-92
92-93
Kerala
1990-91
91-92
92-93
Tamil Nadu
1990-91
91-92
92-93
West Bengal
1990-91
91-92
92-93
Maharashtra
1990-91
91-92
92-93
Gujarat
1990-91
91-92
92-93
Andhra Pradesh
1990-91
91-92
92-93
Madhya Pradesh
1990-91
91-92
92-93
Central Government 1991-92
92-93
93-94
(Excluding grants)
All India
1992-93
Punjab
Health Expenditure
*
(Rs Lakh)
Health Expenditure
*
(Rs per capita)
14,671
17,593
17,663
17,698
19,288
22,909
31,318
34,531
37,720
37,700
36,891
40,477
40,396
44,105
46,209
19,543
21,690
23,205
26,531
28,780
33,360
19,451
21,757
23,630
38,174
51,166
52,996
74.10
87.09
85.74
61.88
66.28
77.92
57.15
62.00
66.76
56.86
54.25
58.16
52.67
55.97
57.19
48.49
52.65
55.26
40.94
43.34
49.13
30.20
32.87
34.80
4.52
5.94
6.02
*
5,00,000
58.14
* Only Revenue expenditure of A/C 2210 of Ministry of HealtfiT^~
* Estimated by author based on figures published by Departmenfof Economic
Affairs and the Reserve Bank of India.
Source: Detailed Demand for Grants, 1992-93, respective states.
40
RJH
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1995
medical research. The central government does spend substantial sums on
various health programmes, mainly national disease programmes, but that
is mostly as grants to the states and accounted for in the state expenditures
— of the total central health department budget in 1993-94 grants to states
and union territories worked out to 32.5 per cent of the centre’s health
department budget (excluding family welfare and water supply).
The first fact evident from the data discussed above is that the public
health sector is a very small component not only of the overall economy
(less than 1 per cent of GDP) but also of the public sector as a whole (which
accounts for over one-third of India’s GDP). As a consequence of the
insufficient investment in the public health sector the private health sector
has seized the advantage and has grown very rapidly, especially in the last
two decades and that too with support and subsidies from the public sector
[Jesani and Ananthram 1993]. For a poor country like India where nearly
two-thirds of the population lives at or below the subsistence level such a
development may not be the best thing for the health status of the people
- in fact evidence is indicative of slowing down of decline in mortality rales
in the last decade or so [Ministry of Home Affairs 1992]. Another fact
emerging from the data presented above is the considerable variation
across slates in health care spending—between the lowest (MP) and the
highest (Punjab) spender the difference is nearly 2 1/2 times. As men
tioned earlier the level of spending gels reflected in the level of develop
ment of the health infrastructure — generally, higher the health expendi
ture better is the reach and spread of the health infrastructure.
We are well aware that rural-urban differences in the distribution of
health care services are extremely sharp. Table 3 shows clearly the wide
variation of availability of hospital beds and doctors in rural and urban
areas of the country. There is also a wide variation in the availability of
health services in the rural and urban areas as of the eight states under
discussion (Table 4). Kerala and Punjab have extremely low disparities in
infrastructure availability between rural and urban areas whereas Madhya
Pradesh has the highest disparity (of course, among all stales Bihar is the
worst off with urban/rural disparity being 81 times for hospital beds). In
Table 3: Rural-Urban Disparities in Health Care Services, 1992
Hospital Beds Allopathic Doctors
Per 100,000
Per 100,000
Population
Population
Rural
Urban
Total
Urban/Rural Disparity (times)
17
254
76
15
12
151
47
13
All Doctors
Per 100,000
Population
37
307
105
8
Source: Estimates based on information published in Health Information ofIndia
and theEconomic Tables of Census of India.
RJH
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41
Bengal, Maharashtra and Gujarat the national average holds good for
hospital beds, whereas for doctors only Madhya Pradesh among these
states is worse than the national average in rural-urban disparity.
Disaggregating public health expenditures in rural and urban areas is a
difficult task because separate accounting of expenditures for rural and urban
areas is done only selectively in the budgets. It is only for medical care
services (under the medical major head of a/c 2210) that a more or less clear
demarcation between urban hospital and dispensary expenditures on one
hand and rural hospital, dispensary and PHC expenditures on the other hand
i§ available. Hence rural-urban differential analysis is restricted to only this
component of health expenditure. But it may be noted that these expenditure
account for between 74 per cent (Andhra Pradesh) and 90 per cent (Kerala)
of all health expenditures as defined for the present analysis. Rural and urban
health expenditures vary considerably across states both in terms of volume
as well as disparities within the state (Table 5).
The highest expenditures on urban medical care (including medical
education and ESIS) in 1992-93 are in Kerala (Rs 195 per capita), Punjab
(Rs 149 percapita), West Bengal and Tamil Nadu (Rs 142 per capita each)
and the lowest (surprisingly) in Maharashtra (Rs 75 per capita) and
Madhya Pradesh (Rs 79 per capita). Table 5 also reveals that the growth
in urban health expenditures between 1990 and 1993 has been negligible,
both in per capita and percentage terms. Where rural health expenditures
are concerned (rural hospitals, dispensaries and PHCs) Punjab outscores
all the states with a rural health expenditure of Rs 44 per capita, followed
by Maharashtra (Rs 27 per capita) and Kerala (Rs 23 per capita) in 199293. In the same year the lowest rural health expenditures were in Andhra
Pradesh (Rs 10 per capita), Madhya Pradesh (Rs 13 per capita) and West
Bengal (Rs 14 per capita). These level of expenditures clearly support the
earlier discussion relating to health infrastructural disparities; the states
Table 4: Rural-Urban Disparities Across States
Hospital Beds Per 100,000
Doctors Per 100,000
Population (1988)Population (1990)
Rural Urban Urban/Rural Rural Urban Urban/Rural
Disparity
Disparity
(Times)
(Times)
Andhra Pradesh
Gujarat
Kerala
Madhya Pradesh
Maharashtra
Punjab
Tamil Nadu
West Bengal
9
22
198
4
21
68
12
17
203
346
481
145
308
233
237
264
23
16
2
36
15
3
20
15
13
20
39
3
24
76
18
27
144
115
117
55
117
260
202
155
11
6
3
18
5
3
11
6
Source: Same as Table 3.
42
RJH
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*
having higher rural health expenditures are the same ones which have a
higher level of health infrastructure development in rural areas.
With regard to the share of rural and urban health expenditures in total
health expenditures Kerala (68 per cent) and West Bengal (67per cent)
have the highest urban health expenditures whereas Punjab (36 per
cent),Maharashtra (28 per cent) and Madhya Pradesh (27.6 per cent) have
the highest rural health expenditures.
We have seen earlier the rural-urban disparities in health care provision
(Table 4). The states having high disparities in provision (Tamil Nadu,
Andhra Pradesh and Madhya Pradesh) also show relatively high dispari
ties between urban and rural health expenditures. However, states like
Kerala and Bengal, though having a relatively better distribution of
provision, also have high disparity between rural and urban health spend
ing, the former with relatively high per capita rural spending and the latter
with low rural spending. Punjab and Maharashtra have the lowest disparity
in urban-rural health care expenditures (Table 5) and both states (along
with Kerala) have relatively well developed rural health services. Another
aspect of urban-rural disparity in health care provision is related to the role
played by local governments. The rural- urban disparities discussed above
exclude provisions by local bodies like municipal corporations,
municipalities,district panchayats, etc.
The participation of the local bodies in provision of health care services
has not helped in reducing rural-urban inequalities. On the contrary the
gap has widened because the urban local governments make significant
investments in the health sector — as much as one-fourth to one-third of
their budget — whereas for rural local bodies health care is not an
important function because of the extremely limited resources at their
disposal [NIUA 1989; Duggal 1992].
Major Health Programmes
Since there is a wide variation in presentation of expenditure data in the
budgets across states only a few major sub-heads are amenable to
standardisation and facilitate a comparison. Table 6 gives percentage
share for six sub-heads of public health spending. It comes out very sharply
from the data presented in Table 6 that little variability across states exist
in distribution of resources for various programmes. Urban hospitals and
medical education take a more or less similar share of the health care
budget in all states.However for PHCs and disease control programmes
there are some exceptions. For instance, both Punjab and Kerala spend a
very small proportion on disease control programmes in comparison to
other states. This may partly be due to the fact that both these states have
brought under control most of the diseases under the national programmes
and therefore presently manage with lower allocations for disease control
programmes.
RJH
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43
In case of expenditures on PHCs Punjab spends one-fourth of its health
budget under this subhead. As discussed earlier this is because Punjab has
the most developed rural health infrastructure. Kerala’s share for PHC
expenditures is low perhaps, because it spends a larger proportion on rural
hospitals — Kerala has an exceptionally high rural hospital bed : popula
tion ratio (see Table 4).
The only other unusual fact revealed by Table 6 is the very high
administrative cost in Maharashtra which takes away a whopping one-fifth
of the health budget. One plausible explanation is that Maharashtra has an
elaborate and large health bureaucracy. Another explanation perhaps may
lie in accounting jugglery with Maharashtra including a large part of the
Table 5: Rural-Urban Differentials in Health Care Spending
Urban Health Services
*
Rs Per
Per Cent of
Capita
Total Health
Punjab
124
1990-91
91-92
147
92-93
149
Kerala
1990-91
171
91-92
169
92-93
195
Tamil Nadu
109
1990-91
91-92
120
92-93
128
West Bengal
142
1990-91
91-92
133
142
92-93
Maharashtra
76
1990-91
91-92
77
92-93
75
Gujarat
84
1990-91
91-92
91
96
92-93
Andhra Pradesh
92
1990-91
96
91-92
106
92-93
Madhya Pradesh
68
1990-91
91-92
75
79
92-93
Rural Health Services Urban/Rural
Rs Per
Per Cent of Disparity
Capita
Total Health (Times)
50
50
52
38
47
44
36
38
36
3
3
3
70
68
68
16
20
23
20
22
22
11
8
8
65
66
66
14
15
15
17
16
15
7
8
8
68
67
67
13
13
14
17
18
17
11
10
10
55
53
52
19
23
26
22
25
28
4
3
3
59
60
60
15
16
16
21
19
19
6
6
6
59
60
59
9
9
10
16
16
15
10
11
11
51
53
53
12
12
13
31
27
28 ■
6
6
6
0 includes medical education and ESIS.
Source: Detailed Demand for Grants, 1992-93, respective states.
44
RJH
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t
programme staff under the head direction and administration in contrast to
other states which may show them under the respective programmes. This
is only a hunch and can be sorted out with a more closer look at the detailed
notes to the state accounts.
Special attention for selected diseases has been a constant feature of
India’s public health intervention strategy. A special characteristic of
these programmes has been the significant role which the union health
ministry has played in providing additional resources (sometimes comTable 6: Percentage Share in Expenditure of Selected Subheads
Urban
Med
Disease PHCs Direction Others*
*
Hospitals
Education
Control
and Ad(Allopathic) (Allopathic) Programmes
ministration
Kerala
40.44
1990-91
91-92
36.01
92-93
38.25
Gujarat
1990-91
32.16
91-92
32.16
92-93
33.36
Andhra Pradesh
1990-91
40.39
91-92
39.84
92-93
37.71
West Bengal
1990-91
39.42
38.34
91-92
92-93
37.94
Punjab
1990-91
16.25
91-92®
16.16
92-93
16.23
Tamil Nadu
1990-91
43.82
91-92
43.50
92-93
40.70
Maharashtra
1990-91
30.44
91-92
29.10
92-93
28.82
Madhya Pradesh
1990-91
34.79
91-92
34.76
92-93
35.02
10.00
9.67
10.25
4.97
5.45
6.11
9.99
8.85
9.03
1.83
1.64
1.74
36.13
38.82
35.02
13.81
15.01
15.36
6.61
8.41
8.63
*.
12.11
9.94
9.54
1.92
1.95
1.77
30.01
32.09
30.94
8.51
8.79
8.96
20.19
20.46
21.61
14.91
14.32
13.83
2.49
2.40
3.84
13.51
14.19
14.05
8.29
7.56
7.36
11.40
10.73
11.16
12.77
12.29
12.01
6.73
7.17
7.14
21.39
23.91
24.39
NA
NA
NA
9.26
11.37
11.38
25.25
26.29
23.52
2.23
• 2.04
2.18
47.01
44.14
46.69
9.37
10.09
9.57
14.55
14.04
13.10
11.35
11.00
10.58
3.19
2.94
3.22
17.72
18.43
22.83
8.42
8.35
7.38
15.41
13.98
14.48
NA
11.45
11.25
19.57
20.59
20.80
26.16
16.53
17.27
6.21
6.79
6.77
15.01
14.09
13.06
20.38
17.31
17.89
1.62
1.55
1.49
21.99
25.50
25.77
® Urban hospital exclude teaching hospital for which data was difficult to
compile; others in the case of Punjab includes Medical education and teaching
Hospitals and disease Control refers to Public Health major head.
* Others includes ESIS,rural Hospitals, CHCs and dispensaries, non allopathic
systems, grants to local bodies and NGOs etc.
Source: Same as Table 5.
RJH
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45
plctc) to the states in the war against these diseases, mainly smallpox (in
the past), malaria, leprosy, tuberculosis and now AIDS. Further, in recent
years substantial international assistance has been mobilised for increas
ing resource allocation to these disease control programmes.
In Table 6 we have seen that states like Andhra Pradesh (22 per dent),
Gujarat (15 per cent), Maharashtra (14 per cent), Tamil Nadu and Madhya
Pradesh (13 per cent each) spend a higher share of their budget on disease
control programmes. In terms of per capita expenditures Andhra Pradesh
(Rs 11 per capita), Punjab and Tamil Nadu (Rs 9 per capita) have higher
expenditures and Madhya Pradesh and Kerala the lowest (Rs 5 per capita).
In all the states the National Malaria Eradication Programme takes
away the largest share of expenditure on disease control programmes
averaging 55 per cent of such expenditures. This however does not mean
Table 7: Share of Selected Disease Control Programmes
Disease Control
Rs Per Capita
Kerala
1990-91
91-92
92-93
Gujarat
1990-91
91-92
92-93
Andhra Pradesh
1990-91
91-92
92-93
West Bengal
1990-91
91-92
92-93
Punjab
1990-91
91-92
92-93
Tamil Nadu
1990-91
91-92
92-93
Maharashtra
1990-91
91-92
92-93
Madhya Pradesh
1990-91
91-92
• 92-93
46
Percentage Share in Disease Control
Malaria
Leprosy
Tuberculosis
3.08
3.61
4.76
36.3
32.1
30.0
25.1
31.4
29.3
6.3
6.3
6.1
6.70
7.90
8.49
42.2
3&6
47.7
16.4
14.1
14.3
22.8
21.9
21.4
8.27
8.87
10.62
62.8
59.9
56.6
28.7
28.6
26.6
2.5
3.2
3.1
6.48
5.82
6.49
56.6
47.3
45.0
20.2
20.7
19.5
8.6
13.0
12.5
6.86
9.90
9.76
NA
NA
NA
NA
NA
NA
NA
NA
NA
8.31
8.70
8.75
NA
NA
NA
32.3
33.1
32.3
9.5
10.8
10.9
8.12
7.83
8.28
59.8
59.1
59.0
20.9
23.0
24.0
10.0
7.5
6.9
4.53
4.63
4.73
56.4
54.7
54.9
20.2
20.5
20.2
1.1
1.3
1.3
RJH
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that the malaria programme gets all the funds. This is again an accounting
problem. The malaria workers of the erstwhile vertical malaria program
constituted the largest paramedic workforce. After integration of health
programmes in the mid-19970s these workers (and other staff) who are
now multipurpose workers carrying out tasks related to the various disease
and other programmes continue to get their salaries from the ‘malaria’
account head. This is the reason why allocation to malaria appears this
huge in comparison to other disease programmes. Across states there is
some variation with Kerala (30 per cent) recording the lowest proportion
of expenditure for malaria and Maharashtra (59 per cent) the highest.
The National Leprosy Control Programme gets the next largest allocation
with 25 percent of the share on average. Tamil Nadu (32 percent) and Gujarat
(14 per cent) have the highest and lowest share of expenditure, respectively,
for leprosy. Like malaria, variation in leprosy expenditure is small across
states because leprosy continues to be a vertical programme with strong
central control. Tuberculosis control, except for Gujarat (21 per cent), gets a
very low share and appears to be the most neglected disease control
programme averaging less than 1 Oper cent of the share of disease programmes.
Among all the diseases covered by national programmes tuberculosis is the
most prevalent as well as the most fatal one but it gets one of the lowest
allocations. In fact a national evaluation of the TB programme by ajoint GOIWHO-SIDA team revealed that TB cases tended to concentrate in the district
TB centre and the drug supply was so poor that effective supply was available
for less than one-third of the registered cases.
The preceding discussion has highlighted the low level of public health
spending in most states, the wide rural-urban disparities in spending and the
large variation in spending across the states for most health programmes.
How effectively is this allocated amount spent? Here we look at the line items
Table 8: Ranges (1992-93) and Means (1990-93) of Expenditures on Salaries
etc of Selected Programme
Salaries
Range
Malaria
(MP) 65-95 (KE)
Leprosy
(MH) 76-89 (TN)
(MH) 25-94 (MP)
Tuberculosis
Urban Hospitals
(GJ) 63-77 (AP)
Teaching Hospitals (TN) 48-66 (AP)
Rural Hospitals
and Dispansaries (KE) 64-88 (PJ)
Primary Health
Centres
(AP) 74-89 (KE)
Mean
Materials and Supplies
Range
Mean
79
83
55
66
58
(KE) 0.5-30 (MP)
(TN) 4-10 (KE)
(MP) 0.7-73 (KE)
(AP) 19-31 (TN)
(AP) 13-50 (TN)
14
6
40
24
25
73
(GJ) 2-34 (KE)
15
83
(WB)6-17(AP)
10
The abbrevations in parentheses are names of states with the minimum and
maximum range values.
Source: Same as Table 5.
RJH
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47
of the major health programs, that is salaries and materials and supplies.
Disaggregating the expenditures on selected major health programmes
into salaries and materials and supplies we find that in general salaries take
away an exceptionally large proportion of the expenditures in all the
activities under the public health sector. The ranges (1992-93 budget) and
means (three-year average) of the proportionate share for both categories
of expenditures in the eight states for selected programmes is given in
Table 8. It is evident that disease control programmes and rural health
programmes have very high salary expenditures which leaves a very small
sum for other supportive expenditures without which the health care
programmes are rendered ineffective.The urban hospitals and teaching
hospitals are relatively better looked after and this is reflected in their
overutilisation which creates its own problems. In contrast the gross
underfunding and the poor allocative efficiency of rural health programmes
leads to very low levels of utilisation of these facilities, thus causing a lot
of wastage of the assets created and personnel employed.
In conclusion one can add that rural health care programmes are grossly
underfunded, and what little resources are deployed are inappropriately
utilised leading to the poor efficiency and use of the rural health infrastucture.
At the other end, though urban areas are better endowed and allocations have
relatively a much better mix, the urban health care system suffers from an
unnecessary pressure, including an influx of patients from less endowed rural
areas leading to overcrowding, which also makes it inefficient. If even the
existing resources available are better distributed both geographically and in
terms of input composition of expenditure (salaries, materials & supplies,
maintenance, equipment, etc) the present system too can become more
effective and responsive to the health care needs of the people. B ut this should
not be taken to mean that the public health sector does not need more
resources. On the one hand allocative efficiencies need to be drastically
improved but perhaps more importantly the overall resource allocations to
the public health sector, especially to rural areasxneeds a substantial enhance
ment if people have to be served better and more effectively.
References
Duggal, Ravi (1992): Health Financing in India: A Backgound Documentfor the
World Bank Health Financing Mission in India, FRCH, Bombay.
Jesani, Amar and Saraswathy Ananthram (1993): Private Sector and Privatisation
in Health Care Services, FRCH, Bombay.
Ministry of Finar^e (1992): Public Finance, Department of Economic Affairs,
Ministry of Finance, New Delhi.
Ministry of Home Affairs (1992): Sample Registeration System - 1992, Registrar
General of India, Ministry of Home, New Delhi.
NIUA (1989): Upgrading Municipal Sendees, National Institute of Urban Affairs,
New Delhi.
World Bank (1993): World Development Report, World Bank, Washington.
48
RJH
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Structural Adjustment and Health
Policy in Africa
Rene Loewenson
World Bank-International Monetary Fund structural adjustment
programmes (SAPs) have been introduced in over 40 countries of
Africa. This article outlines the economic policy measures and the
experience of the countries that have introduced them, in terms of
nutrition, health status and health services. The evidence indicates that
SAPs have been associated with increasing food insecurity and under
nutrition, rising ill-health and decreasing access to health care in the
two-thirds or more of the population ofAfrican countries that already
lives below poverty level. SAPs have also affected health policy, with
loss of a proactive health policy framework and a widening gap
between the affected communities and policy makers.
Adjustment programmes are rending the fabric of African society. Of the
estimated half a million child deaths in 1988 which can be related to the reversal
or slowing down of development, approximately two-thirds were in Africa.
UNICEF 1989.
THE economic structural adjustment programme, ESCAP or SAP has
many names in Africa. To banking and financial interests, these words
spell economic growth and development. For the poor majority of Africa,
they spell hardship and struggle.
Africa is a continent that is often portrayed as being at best irrelevant
to the international economy. It has been commented that if Africa north
of Johannesburg sank below the seas, the international markets would not
notice. It is true that Africa provides a small fraction of the global gross
national product. But Africa is also a continent of social ideas, aspirations,
and struggle. It is a continent where ordinary peasants and workers have
in this century waged successful liberation struggles to shake off centuries
of colonialism and racism and where a second wave of democratic action
is being waged against one-party or one-man governments. Africa is a
crucible of change, fertile ground to nurture the best that human develop
ment has to offer, but often victim to the worst that it imposes.
This is particularly important for people working in the health sector.
Health is a product of material well-being, but it is also a consequence of
the social organisation to obtain or produce those material resources.
There are many examples of how popular organisation and community
mobilisation have contributed to health, even against a background of
scarce material resources. They exist in the primary health care gains in
Mozambique in the early years of its independence; in the substantial
RJH
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49
reductions in infant mortality in many African countries in the early post
independence period; or in a rate of expansion of primary education in
Zimbabwe in the 1980s that is unequalled in the world[l). These achieve
ments were a product of the combined impact of resource allocation and
social mobilization. How have SAPs affected health policy and the social
development central to improvements in health ? The answer cannot be
found in policy documents, where harsh reality is often disguised in
acceptable policy terms. While producing a wake of retrenchment, price
increases, social decline, and hardship, the Zimbabwean SAP states its
commitment to “improve living conditions, especially for the poorest
groups” [2]. It is more relevant to examine actual changes in health and
social organisation after the introduction of structural adjustment, and
from this derive the de facto impact on health policy.
The World Bank and the IMF are in breach of the Charter of the UN in that they
have not promoted higher standards of living, full employment and conditions
of economic and social progress and development, nor have they promoted a
universal respect for the observance of human rights and fundamental freedom
for all.
-Verdict of the Permanent People's Tribunal on the Policies of the IMF,
September 1988 [3].
Since 1980, money has been flowing internationally from South to
North. In 1979, there was a net flow of U.S. $40 billion from North to
South. Today about $60 billion are transferred from poor to rich countries,
excluding the repatriation of private profits. From the 28 least developed
countries in the world, their foreign debt equals 91 percent of their gross
domestic product. The African debt has become totally unpayable; in subSaharan Africa it represents over one-third of export earnings[4]. With
rising political and economic tensions, developing countries have been
encouraged to adjust their economies to increase their external funds for
debt repayments, mainly through cuts in domestic expenditure and an
increase in exports. This has led to a tide of International Monetary Fund/
World Bank SAPs across the continent. In the first half of the 1980s, threequarters of African countries had implemented IMF/World Bank SAPs. In
many African countries, so called “homegrown” SAPs have included
classical World Bank policy measures that have been allied in an almost
uniform form in over 40 African countries, as well as in countries in Asia
and Central and South America. Under SAPs, the economy is adjusted
structurally to manage the balance of payments, reduce the fiscal deficit,
increase economic ‘efficiency’, and encourage private sector investment
and export-oriented production.
The major measures include:
Currency devaluations and control of the money supply;
Reduction of public borrowing and government expenditure, particularly
in the social sectors;
50
RJH
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Trade liberalisation, reduction of tariff rates, and other incentives for
foreign investment;
Abolition of price controls;
Privatisation of public enterprises or reduction of subsidies to parastatals;
Withdrawal of subsidies on food and other commodities; and
Retrenchment of workers; wage freezes, and deregulation of laws protect
ing job security.
In 1989, based on the experience of countries already implementing an
SAP, the UN Economic Commission for Africa outlined the potential
negative economic and social impact of these policy measures, as shown
in Table 1 [5]. The World Bank (and many of the implementing govemTable 1: Structural Adjustment Policy Measures and Their Impact
Policy Instrument
Budget reductions, espe
cially on social services
and essential goods.
Indiscriminate promotion
of traditional exports;
price only to tradeables.
Across the board credit
squeeze.
Currency devaluation.
Unsustainable high real
interest rates.
Total import
liberalisation.
Effect
Undermines human conditions, especially the
environment and future potential for development;
necessities massive sector retrenchment.
Undermines food self-sufficiency; can lead to
environmental degradation; oversupply can
reduce prices.
Overall contraction of the economy; decline in
capacity utilisation; closure of enterprises;
accentuated shortage of critical goods and
services.
Socially unsupportable increases in prices of
goods and services; raises domestic cost of
imported inputs; triggers inflation; diverts foreign
exchange to speculative activities and enchances
capital flight; worsens income distribution
patterns.
Shifts the economy toward speculative and
trading activities and fuels inflation.
Leads to greater and more entrenched external
dependence; intensifies foreign exchange
contraints; jeopardises national priorities such as
food self sufficiency; erodes capacity of infant
industries.
Dependence on market Worsens inflation through sharp rises in produc
forces for getting prices tion costs; distorts production and consumption
right in structurally distor patterns and may derail transformation.
ted and imperfect markets.
Doctrinaire privatisation.
Undermines growth and transformation;
jeopardises social welfare and human conditions.
Source: References [5].
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51
ments) warn of the short-term harsh impact of SAPs: retrenchment,
cutbacks in public expenditure and social services, charging fees for social
services, rising prices, and shrinking real incomes. The palliative is that at
some undefined point in time the economy will “pick up” and the growth
generated will not only pay back the debt but will also trickle down and
improve the lot of the poor.
By the mid 1980s, increasing evidence began to emerge of these
negative effects of SAPs on the conditions of the poor majority.
Falling real incomes, higher costs of living, and reduced government
expenditures on social services produced a severe deterioration in the
living standards of the majority. In sub-Saharan Africa, percapita incomes
fell by over 25 per cent in the 1980s, and unemployment increased in
most countries [6, 7]. In UNICEF’s 12-country study of the impact
of SAPs, unemployment increased, to over 25 per cent in Jamaica, 16 per
cent in Chile, and from 5 to 11 per cent in Peru. Declining formal sector
employment was reported to push people into the informal sector [8]. The
special session of the UN General Assembly on International Economic
Co-operation on April 23-28, 1990, concluded that SAPs had in many
instances exacerbated social inequality without restoring growth and
development and with threats to political stability. The brunt of the
programmes has been acknowledged to fall on the poorest, who have been
repeatedly urged to “tighten their belts”. In many African countries, this
constitutes that two-thirds of the population already impoverished by
economic inequities and recession, whose response is often, “we have no
belts left to tighten!”
Impact on Health
“Belt tightening” has been a euphemism for a fundamental attack on the
basic elements of social well-being. African countries undergoing an SAP
have been reported to have experienced rising rates of ill-health and
mortality in both the urban and rural poor. Diseases that had reportedly
been eliminated, such as yaws and yellow fever in Ghana, reappeared
during the SAP period [4,8,9]. Not only have SAP policies ignored this
increase in ill-health, but they do not include the profound economic and
social impact of the AIDS epidemic at the household, community, or
national level.
Infant and child health, often taken as a sensitive indicator of com
munity well-being, has shown marked declines. The infant mortality rate,
which had begun to decline in many African countries, rose by 4 to 54 per
cent in the SAP periods of the seven African countries shown in Table 2[6].
Increases in under-five-year mortality rates of 3.1 to 90.9 per cent were
observed in these countries in the same period[6]. In 1988, the UN was
informed during the review of its Program of Action for African Economic
52
RJH
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Recovery that one million African children had dies in the ‘debt war’
(quoted in 7).
Nutrition and food security are major contributors to the health of the
population. Although one of the major policy tools of an SAP is to raise
producer prices of export crops to stimulate production, there is evidence
that poor rural house-holds have not benefitted from these measures.
Producer price increases have been offset by increases in costs of inputs to
production. In Zambia, for example, maize producer price increases of 142
percent dropped to a real increase of only 6 per cent after taking input cost
increases into account! 10]. There are no incentives for food crop pro
duction, which occupies the majority of the poorest peasants, parti
cularly women farmers, and provides for a substantial part of rural food
security! 1 1-13]. In addition, incentives are often given through credit
facilities, which lend not to be used by the poorest farmers.
Real wage reductions, rising prices, especially for food, and the cut
back in public subsidies have stressed the ability of urban incomes to meet
minimum subsistence needs. In Mozambique, for example, removal of
food subsidies caused a real increases in food prices of 400 to 600 per
cent. In January 1989, a kilogram of tomatoes or onions cost 5 per cent of
an office worker’s wage[ 14]. Any real increase in food prices take a heavy
toll on low-income groups, some of whom spend up to 80 percent of their
income on food. The mid-1980 average wage in Ghana was sufficient to
buy only 30 per cent of food needs[8]. Households try to cope with their
declining purchasing power by shifting food consumption to poorer
quality, high-bulk, and low-energy food, leading to chronic nutritional
deprivation, particularly in young children.
In some countries governments introduced food ration systems as part
of a “safely net” for the poorest. In Zambia a coupon system was
introduced for maize meal, initially for urban households, and then for
those earning below K 20,500 (kwacha) a year. Many problems were
experienced with the coupon system. It was restricted to certain outlets,
Table 2: Infant Mortality Rates in Countries with IMFAVorld Bank
Programmes
Ethyopia
Mali
Madagascar
Uganda
Tanzania
Somalia
Kenya
RJH
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Infant Mortality Rate
1980
1985
Percent Change,
1980-85
165
200
na
121
138
165
112
146
154
71
97
103
146
87
168
174 ■
109
108
110
152
91
+ 15.1
+26.5
+53.5
+ 11.3
+ 6.8
+ 4.1
+ 4.6
1995
53
limiting the access of low-income house-holds, and it left out rural
consumers and those in the informal sector, among the poorest Zambian
households! 15]. A more direct subsidy on roller meal in Zambia, thought
to be of more direct benefit to low-income groups, resulted in millers
shifting production to more high-cost cereals and meant that roller meal
became unavailable! 16].
A 10-country study published by UNICEF on the effects of adjustment
on health concluded that the nutritional status of children had declined in
all but two of the ten countries[8]. Data from Zambia indicate that at the
height of the adjustment period between 1980 and 1984, hospital deaths
due to malnutrition increased from 2 to 6 per cent in the 0 to 11 month age
group and from 38 to 62 per cent in the 1 to 4 year age group! 17]. In a 1987
survey in the University Teaching Hospital in Lusaka, almost 60 per cent
of the child admissions were from the low-income areas of Lusaka and 37
per cent were from malnutrition! 15].
Despite increased ill-health, health sector expenditure has been cut
under SAPs. For example, per capita expenditure on health was
reported to have fallen by 40 per cent in Jamaica, 23 per cent in Ghana
and 8 per cent in Brazil[8]. Cuts in public expenditure have been
associated with the introduction of ‘cost recovery’ - a World Bank
euphemism for fee charging. In Ghana for example, fee charging was
introduced for ward admissions, first-visits to specialist clinics, casualty
and polyclinic services, drugs and tests. Fees initially introduced at low
levels immediately rose rapidly, with increases of 800 to 1000 percent in
1985 alone[ 18].
Fee charging has been reported to improve the quality of services and
provision of drugs, but it has also decreased accessibility, particularly in
low-income groups. In Mozambique, for example, fee charging was
reported to depress outpatient visits in Maputo by 24 per cent between
1986 and 1987, while contributing to a minimal 1.6 per cent of the state
health budget! 14]. While many countries (including Mozambique and
Ghana) have exemptions for the poorest, in practice poor households have
found these difficult to claim.
Health workers have also been affected. Cutbacks in public expenditure
have in many countries squeezed expenditures on salaries, while price
increases have reduced real earnings of health workers, so that there has
been a loss of personnel, particularly from the public health sector. In
Ghana, for example, of 1,700 doctors working in the public health sector
in 1982, only 665 were in post in 1987, most having left for Nigeria and
Saudi Arabia! 18]. Health workers in the public sector are increasingly
pressured to perform private work for extra income, and use public
resources to support these practices! 14]. Many skilled and experienced
professionals, in health and other sectors, move to donor agency employ
ment, where their incomes, conditions of work, and facilities are much
54
RJH
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better. Donors in their turn provide selective support to sepcific programs
under their own management, many without addressing broader
infrastructural support of the public sector[19]. With declining public
sector infrastructures and worsening conditions of service, demoralized
health workers have resorted to strike action, such as in the health worker’s
strikes in Mozambique in 1990 and Zambia in 1991.
The negative impact of SAPs on health and health care described above
is an indication of a profound, if unstated, change in health policy. The
detailed measures and effects vary, but there are consistent broad features
of this change: A proactive health policy is replaced by health sector
measures to accomodate the SAP. There is a widening gap between
affected communities and policy makers, leading to alienation and
social tension, with the social response ranging from individual coping
mechanisms to social resistance; and health as a right (with its inherent
principles of equity) is changed to health as a commodity (for the rich) or
a charity (for the poor).
Nowhere is there articulation of the new ‘Health policy under SAPs’,
not surprisingly as it generally implies a reversal of principles of equity in,
participation in, and access to health care that were fundamental to health
care progress in Africa. Ministries of health arc not being asked to shape
policies for the health sector, but rather to define ways of making the health
sector accommodate to the economic policy measures in the SAP. One
effect of an SAP is thus perhaps the loss of a proactive health policy. The
policy debate in the health sector shifts markedly from demand-oriented
questions on what the population needs and what would be feasible and
effective to meet those needs, toward supply-oriented questions of what is
affordable and cost effective.
Individual versus Social Roles in Health
Health is both a product of and a contributor to social development. A
central aspect of health policy in post-independent Africa has been the
importance of social and community mobilisation. The introduction of
SAPs has affected this social element in two major ways.
First, it has placed amuch greater emphasis on the individual household’s
ability to buy services or to find ways of dealing with economic problems.
The rising cost of living and problems in obtaining employment and basic
needs under an SAP preoccupy households, often to the exclusion of other
social activities. Economic poverty creates psychosocial stress even
within households, between men and women, as well as between different
sections of family or community[20]. Individualism is fostered in the
market place, where competitiveness is more appropriate than coopera
tion. Workers and peasants are easily divided by selective benefits to the
better off, and by the fear of economic insecurity. Social mobilisation is
RJH
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55
more difficult to achieve under conditions where every service has its
price.
These individual responses are summarised in Ghana as “suffermanagc; beat-lhc-system; cscape-migrate and return-to-the-farm”[9].
Suffcr-managO refers to the endurance strategy of cutting back, while
beating-thc-system refers to finding ever)' possible way of cheating the
state or exporting others. The escape-migration solution is to leave the
country in search of brighter prospects, while the back-to-the-farm group
packs up and returns to peasant life, in the hope of avoiding the price war
of urban areas.
The retreat to individualism is reinforced by the declining role and
credibility of the state. In post-independent Africa, the state was the major
instrument for social transformation through public sector driven reform.
The state was the arena for idealism and policy change. Unfortunately, the
slate, in many African countries, also monopolised this role, to the
exclusion of the development of civic society. As S APs “disrobe” the body
of the state, cut off its “excess fat”, and reduce it to a shrivelled and mean
miser, ordinary people are left in bewilderment without effective social
organization to protect their interests.
Second, SAPs have distanced the policy makers from the community.
Planning has become the prerogative of the very few who sit at the same
table and cooperate with the international finance institutions. Even senior
national civil servants and professionals with local skills an experience are
reduced to ‘managers’ of policies developed by international consultants,
whose exposure to local conditions is a one or two week ‘mission’. The
population is the last to know the programme. The unpopular measures in
an SAP produce a combination of secrecy and lack of consultation that
make implementing governments appear authoritarian to ordinary people.
The World Bank euphemistically calls for ‘strong government’ to imple
ment these top-down programs! 16], while local scientists see it differ
ently. As Matlosa writes about the introduction of the SAP in Lesotho,
“The reliance of the smooth operation of SAP on authoritarianism may be
the reason why the IMF loan and its conditionality was never subjected to
national debate in Lesotho”[21].
Denied the opportunity to influence policy, individual coping is matched
with social resistance to the program. SAPs have led to unrest in almost all
countries where they have been implemented. As hardships have in
creased, people have taken action with varying degrees of organisation or
spontaneity. In Nigeria in 1988, petrol price increases and transport fare
increases were met with a spontaneous uprising against the SAP, followed
by a second demonstration in July 1989. In Cole d’Ivoire, students and
workers in 1990 demanded an end to the SAP and for the president to step
down. Similar demonstrations look place in Togo, Senegal and Sierra
Leone. In Zambia in December 1986 and early 1987, demonstrations
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broke out over the Copper Bell when maize meal price increases were
announced. Ten workers were killed in these demonstrations. In July 1990,
food riots in Zambia again broke out, leading to an abortive coup and about
26 people killed. Lesotho construction workers went on strike to demand
reinstatement of 400 retrenched workers and wage increases, the state
reacting with police force, shooting two workers and detaining others [21].
When the labour movement in Zimbabwe announced a day of protest
marches against the ESAP and its consequent changes in labour laws, the
state mounted one of the biggest security build-ups the country had
witnessed since 1980. This relationship between resistance and stale
control further distances the state from the people.
The combined effect of individual coping, social resistance, and the
centralisation of planning is one of alienation from and distrust of the sale
and mounting social tension. Where civic society is active, this can
motivate much more community-based discussion, which may generate
new alternatives for health policy. In most African countries, however,
civic organisation is weak, and people are pushed into increasingly
individual methods of coping, or not Coping, as the case may be.
With the overbearing social costs of adjustment leading to social
resistance and tension, the World Bank began to include as an adjunct to
its SAP an additional component called the ‘Social Dimensions of Ad
justment (SDA)’ or the ‘Social Development Fund’. This was an attempt
to implement “adjustment with a human face”. The SDA funds aim to
both protect “poor and vulnerable population groups” from “transi
tional hardships,” and “alleviate transitional social hardships” seen to be
temporary in nature[22]. Included in SDA measures are (a) employ
ment and training programmes for retrenched workers and those in the
informal sector, together with small-scale venture funds for small busi
nesses and for labour-intensive, low-wage public works projects in rural
and urban areas, and (b) targetted programmes for disadvantaged groups,
including the urban and rural poor usually providing funds for health and
education fees.
The PAMSCAD programme implemented in Ghana in late 1987 invested
$90 million several years after the introduction of the SAP to deal with its
social casualties. The programme included redeployment of the un
employed, improved health care, nutrition, literacy, and water supplies. In
Mozambique, attempts were made to follow the IMF package with a series
of compensatory measures to deal with the negative social impact two years
later. These approaches were based on a principle of ‘targetting’ affected
groups, at a time when two-thirds of Mozambicans lived in poverty! 14].
Such programmes aimed at mitigating the effects of adjustment are
often introduced some time after the introduction of an SAP. They are
criticized as having a marginal effect at best, and at worst obscuring the
fundamental causes of poverty and ill-health.
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They regard vulnerable groups as targetable al a lime when 50 per ceni
or more of lhe population is living in poverty. They direct resources to the
poor as an act of charity and not a basic right. Without challenging the
patterns of distribution of wealth, these programmes are criticised as being
unstable in lhe long term, and for increasing dependence on outside
financing[23]. SDA programmes reinforce a two-tier system : one tier of
service provision according to ability to pay and a second tier according
to need, funded from lhe social fund. The two tiers are segregated,
obstructing equity or redistribution of social resources. Health is thus
transformed from a social right to a marketed commodity for one section
of lhe population or a largettable charity for another.
Health: Cost or Benefit?
It is evident that there is a deep contradiction between lhe SAP as an
economic policy and those policies aimed at building lhe health of lhe
population. Health workers who point to the social upheaval and human
misery around them are faced by smug economists who say, "We told
you this would happen, but it’s lhe price you pay for economic growth”.
For those in the health sector, this raises two challenges: to make
human resource development and thus health a more central element
of economic planning and policies, and to contribute toward social
organisation that will ensure lhe advocacy and implementation of those
policies.
While paying lip service to the importance of health, the SAP has raised
a challenge to the social welfare model of health. It has become increasingly
clear that it is not enough in these cynical times to have a health policy that
strives for social justice. Only if the health of lhe people is viewed as a
necessary input to economic growth and social stability will it be protected
and developed. Health becomes an important element of economic growth
when human resource development is central to such growth.
One such economic policy, for example is the high skills strategy
toward economic growth. Competitive advantage in an economy can be
derived from access to natural resources, marketing strengths, technologi
cal sophistication, labor skills, lhe costs of capital inputs, and wage and lax
rates. There are usually three main strategies for competitive advantage;
resource-based strategies, low-wage strategies, and technological and
skill-intensive strategies. As resources have themselves become less
important in recent decades than what is done with them, it is to the latter
two options that we should pay attention.
Low-income/low wage strategies involve low-skill production
methods; use informal sector, part-time, and casual labour; and involve
weak environmental and health standards, poor social investment, and
limited infrastructures. Low wages are maintained by unemployment
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and poor social development of labor, which contributes to the erosion of
workers’ bargaining power. Low wages also lead to a widening inequality in
the distribution of incomes and wealth. From the measures described
earlier, it is evident that the SAP is a new form of the old low wage/cheap
labor that has marked African economies since colonialism.
The second approach to economic growth involves a high skills
strategy, which shifts the emphasis to the source of wealth. The high
skills strategy emphasises increasing the value added, rather than dimi
nishing labour’s real share of the existing value added. In contrast to a lowwage ,approach, which is based on skirmishes over a static pie, a high skills
strategy is based on sustained increases in the pie.
Sustained increases in wealth arise from increases in productivity and
in the value added to goods, (hat is, the difference between the cost of raw
materials and of products. Value added comes primarily from techno
logical innovation. However, sustainable innovation can only be based on
the growth of skills in the workforce. In Japan, for example, the high skills
option was successfully used to penetrate markets dominated by US
companies. In Germany and Sweden, public policy has made it impossible
to pursue low-wage options and has forced high skills strategies and
technological innovation. In Africa, where there are limited resources to
import new technology, the need for a sustainable strategy for indigenous
technological innovation is even more extreme.
Because the high skills strategy emphasises human resource develop
ment as a means to technological innovation and increasing value added,
it is consistent with higher wage payments, better working conditions,
belter social sector provisions, and a reducing inequality in incomes.
While this has led to higher quality of life and health indicators, it has also
led to economic and productivity growth[24]. In such an economy, health
and health care become contributors to development, and not costs. This
important choice of a human-centered path to growth and social develop
ment was recognised in the Lagos Plan of Action signed by African Heads
of State in 1980, which states that, “since Africa’s greatest asset is its
human resources, full mobilisation and effective utilisation of the labour
force for national development and social progress should be a major
instrument of development”[25]. These resolutions were further devel
oped in the 1989 UN Economic Commission for Africa’s Alternative
Framework to SAPs for Socio-economic Recovery and Transformation:
(AAF-SAP)[5].
These documents contain noble intentions, but successively stated at
the beginning and end of a decade that saw three-quarters of the same heads
of state implementing SAPs, with their trail of human waste and misery.
This failure of African leaders to implement their own stated policies
makes it evident that human-centred policies will not or cannot be
implemented without an active and democratic civic society.
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59
This raises (he second issue for health workers. Il is evident that civic
society is beginning to emerge in Africa, in an environment complicated
by the poverty and social disruption partially described in this article.
Health workers arc one section of that civic society. Whether within their
own health-related organisations or in support of other representative
organisations - including women’s groups, resident associations, trade
unions, peasant and other producer groups, professional and human rights
groups - the extent to which those in the health sector contribute toward,
nurture, and advance civic, community organisation may be one of their
most important contributions to health.
[This article was presented at the International Association of Health Policy
Conference, Bologna. Italy, October 6-10. 1992 ]
References
[ 1 ] Government of Zimbabwe/UNICEF (1991) Situation of Women and Chil
dren in Zimbabwe 1985-90. Jongwe Piners. Harare.
[2] Government of Zimbabwe (1991): A Framework for Economic Reform,
Government Printers, Harare.
[3] Permanent People’s Tribunal (1988): Tribunal on the Policies of the Inter
national Monetary Fund and the World Bank. West Berlin, September 26-29
Verdict, Int J Health Sen-, 20: 329-347.
[4] Kanji, N, N Kanji and F Manji (1991): From Development to Sustained
Crisis; Structural Adjustment. Equity and Health. Soc Sci Med33 : 985-993.
[5] United Nations Economic Commission for Africa (1989). African Alterna
tive Framework to Structural Adjustment Programmes for Socio-economic
Recovery and Transformation. Addis Ababa.
[6] Commonwealth Secretariat (1989): Engendering Adjustmentfor the 1990's,
Commonwealth Secretariat Publications, London.
[7] Ommodc, B (ed)(1989): The IMF, the World Bank and the African Debt,
Vols 1 and 2, Zed Press, London.
[8] Comia, G, J Jolly, and F Stewart (1987): Adjustment with a Human Face',
Clarendon Press, Oxford.
[9] Jonah, K (1989): Crisis and Response in Ghana. Paper presented at the
UNRISD Conference on Economic Crisis and Third World Countries:
Impact and Response, Jamaica. April.
[10] Elson, D (1989): The Impact of SAP on Women : Concepts and Issues in
B Onimode (ed) The IMF, the World Bank and the African Debt, Vol 2,
Zed Press, London.
[11] Lesley, J. M Lycette, and M Buvinic (1986): Weathering Economic Crises:
The Crucial Role of Women in Health in D Bell and M Reach (ed) Health,
Nutrition and Economic Crises: Approaches to Policy in the Third World,
Auburn House.
[ 12] Tibaijuku, A (1988): ‘The Impact of Structural Adjustment Programmes on
Women : The Case of Tanzania’s Recovery Programme’, Mimeo, Dar es
Salaam CIDA.
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[ 13] Kanji, N (1991): Gender Specific Effects of Structural Adjustment Policies
: Shifting theCostsof Social Reproduction Paper presented at the SCTU/UZ
Economics Department Workshop on Structural Adjustment and Health,
Harare, February.
[14] Cliff, J (1991): Destabilisation. Economic Adjustment and the Impact on
Women, Paper presented at the ZCTU/UZ Economics Department Work
shop on Structural Adjustment and Health, Harare, February.
[15] Kalumba, K (1991): Impact of Structural Adjustment Programmes on
Household Level Food Security and Child Nutrition in Zambia. Paper
presented al the ZCTU/UZ Economics Department Workshop on Structural
Adjustment and Health. Harare, February.
[ 16] Loxley, J (1990): Structural adjustment in Africa: Reflections on Ghana and
Zambia, Rev African Polit Econ 47:9-27.
[17] Allison, C (1986): The Social Impact of Expenditure Reform. Mimeo.
London School of Economics and Political Sciences, London
[18] Aninyam, C A (1989): The Social Costs of the International Monetary
Fund’s Adjustment Programs for Poverty : The Case of Health Care
Development in Ghana, Ini J Health Serv 19: 531-547
[19] Wuyts, M (1989): Economic Management and Adjustment Policies in
Mozambique, Paper presented to the UNRISD Conference on Economic
Crisis and Third World Countries: Impact and Response, Jamaica, April.
[20] Kanji. N (1992): Gender Effects of Structural Adjustment. Paper presented .
to the ILO African Regional Meeting on Trade Union Action in Occupa
tional Health, Harare, July.
[21] Maltosa, K (1990): Structural Adjustment and the Employment Challenge in
Lesotho, Unpublished working paper, Lesotho,
[22] Government of Zimbabwe (1991): The Social Dimension ofAdjustment and
Social Development Fund, Government Printers, Harare.
[23] Baldwin, S( 1991): The Social Dimensionsof Adjustment. Paper presented at
the ZCTU/UZ Economics Department Workshop on Structural Adjustment
and Health, Harare, February.
[24] United Steel Workers of America (USWA)( 1991): Empowering Workers in
the Global Economy, report of a conference, Toronto, October.
[25] Organisation of African Unity (1980): Lagos Plan ofActionfor the Economic
Development of Africa 1980-2000, Nigeria, April.
(Slightly abridged and reprinted from International Journal ofHealth, Volume 23,
No 4, pp 717-730, 1993.]
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1995
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Document
Charter of Demands on Family Planning
Programme
About 40 women activists and women leaders from
grassroots organisation from 10 organisations representing
almost all the districts of Tamil Nadu, participated in a two-day
meeting hosted by Rural Women's Social Education Centre
(RUWSEC) Chengalpattu. Participants of the meeting spent a
day working in groups to evolve proposals for changes in the
family planning programme. The outcome of these discussions
are presented here.
1 ‘No’ to incentives at all levels; and a call to invest, instead, on
comprehensive reproductive health care of sound quality, for both women
and men. Treatment for infertility and contraceptive services to be part of
comprehensive reproductive health care.
2 Access to information on a wide range of contraceptive methods
including natural methods; and the option to choose any of these, (or none
at all).
3 Access to safe and affordable abortion services, without attaching
conditions such as sterilisation or adoption of a method of contraception.
4 ‘No’ to demographic targets being the indicators for evaluating programme
performance.
5 ‘No’ to any form of overt or covert coercion, including disincentives to
non-acceplors, and disincentives to service-providers.
6 Mechanisms for monitoring and redressal in case of negligence or abuse
to become an essential part of the programme at all levels.
The call to invest on comprehensive reproductive health care was
further elaborated, into the kind of changes this would require overall, and
specifically at the sub-centre/PHC levels.
(1) Health personnel at all levels should be sensitised to women’s health
needs. Taking women’s concerns and needs seriously should become a
norm, not the exception.
(2) All the non-functioning PHCs and sub-centres should be made func
tional. Adequate resources should be invested to make this possible.
(3) Sex education and education on contraceptive methods and devices
should become a top priority for sub-centres and PHCs. Posters, pamph
lets and other educational material should be prepared, which give de
tailed and objective information. These could be displayed/dislributed
RJH
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63
through out. patient clinics in PHCs, MCH clinics and the like; introduced
as part of adult and non-formal education classes and in high schools, and
so on.
(4) Inter-sectoral coordination for promotion of health, should be trans
lated from slogans intor practice. There should be a district level commit
tee with representatives from various departments, as well as representa
tives from local organisations, to ensure that communities have access to
basic needs and amenities.
(5) Sub-centres, instead of being only MCH centres, should provide
general preventive and curative health care to all members of the commu
nity. It should have both male and female health personnel, and regular
out-patient clinics.
(6) The sub-centre would be the focal point from which health education
and extension activities are initiated. Among its activities would be sex
education for adolescents (both boys and girsl. conducted by the male and
female staff respectively if necessary); premarital counselling of couples,
and broad-based information dissemination on all methods of contracep
tion. including natural methods.
(7)
The PHC would be better equipped, and provide a comprehensive
range of services. It would minimally have adquate water supply and
sanitation facilities, a clinical laboratory', and a vehicle for transporting
serious cases to the referral hospital.
’ (8) A regular ‘reproductive health care’ clinic catering to both men and
women would be an essential component of every PHC. This clinic would
be open on all days and would provide:
(a) Counselling for contraception to both menl and women, and would
cater to unmarried and adolescent groups as well, and not only to married
women. Information would be provided on all modem methods of
contraception, both temporary and permanent, and also on natural
methods, without demanding that any of these be adopted.
(b) Comprehensive reproductive health care including treatment of
sexually transmitted diseases, treatment of infertility and screening of
women ‘at risk’ for breast cancer and cervical cancer.
(c) Antenatal, natal and postnatal care, including surgical and other
facilities to deal with complicated deliveries and health problems that
may ensue as a consequence of complications in delivery.
(d) Medical termimanation of pregnancy, and sterilisations for birth
control, in addition to IUD insertion, and dispensing other methods of
contraception. There should be no more sterilisation ‘camps’ performing
hundreds of sterilisation operation with scant regard to quality, and no
provision for follow-up. Instead, sterilisations should be available on a
regular basis at the PHC.
(e) All necessary check-ups before a method is adopted, to rule out any
contradindications.
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(f) Follow-up care for anyone who is practising contraception, irrespec
tive of where the original services were received from. Fortnightly
domiciliary visits at least for the first six weeks should be part of the
follow-up package for sterilisation and IUD insertions performed in the
PHC.
(g) Medical help and the option of discotinuing the method, together
with choice of an alternative method, for those approaching the clinic with
problems following adotion of a contraceptive method.
There was a lively debate on alternative indicators to assess the
performance of the FP programme. It was agreed that since family
planning is seen mainly as a means to the larger goal of improving the
health of women and children, indicators of women’s and children’s well
being would be the most appropriate assessment indicators. Some of the
FP assessment indicators suggested for localised collection and analysis
of data are:
— improvement in infant and child survival rates
— decrease in maternal mortality
— decrease in maternal morbidity
— improvement in the rate of safe abortions, i e decrease in the
proportion of deaths/serious health problems from unsafe abortions
— decrease in the proportion of women in reproductive age groups
suffering from anaemia
— outreach of information on contraceptives, and availability to
women of a method of their choice.
(Financial support for this meeting was provided by the Ford Founda
tion and the UNFPA, India.)
Note to Contributors
We invite contributions to the RJH. Original research articles,
perspectives, field experiences, critiques of policies and
programmes in health care, medicine and allied areas are
welcome. Please send manuscripts, preferably typed in
doublespace. If the material is on a word processor, please
send us a hard copy along with the matter on a diskette
preferably in WS4. Address all communications to the editor
at the address on the inside front cover.'
RJH
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65
Communications
Injured Psyches
Survivors of Bhopal Disaster
A decade after the Bhopal disaster,survivors are struggling to
make peace with themselves and sense out of the confusion
around them.
IT is a decade since over 40 tonnes of lethal gases leaked out from Union
Carbide Corporation’s Bhopal-based pesticides factory and affected over
500,000 people. Most of these gases which included methylisocyanale,
hydrogen cyanide, mono methylamine have caused permanent damage to
the respiratory, gastrointestinal, reproductive, immunological, nervous,
musculo-skeletal and other systems of the body and over one-fifth of the
affected population continue to suffer acutely from exposure-related
illnesses. Reserach conducted by the Indian Council of Medical Research
has indicated chromosomal aberrations among the gas exposed and
physical and mental retardation among the children bom in the subsequent
years to exposed parents. The damage to the immune system and
consequent proneness to secondary' infections has given rise to an alarming
rise in the incidence of pulmonary tuberculosis and other infectious
diseases. As can well be imagined there is a high incidence of mental
health problems among survivors. With the collection of medical data
almost abandoned it is not possible to estimate the numbers of survivors
who continue to suffer from anxiety, depression, insomnia, emotional
disturbances and other psychiatric disorders. Impressionistic accounts,
however, suggest that the numbers have gone up over the years and not
come down. Yet no efforts have been made by the government to provide
professional support to the mentally ill; nor are doctors, government or
private, familiar with ICMR’s ‘Manual on Mental Health Care’ — a
unique work because of its sensitive and sympathetic approach to the
problems. Further, in a sharp departure from legal principles, accepted
everywhere damage to menial health of the exposed people has not been
regarded as compensable injury, while these issues of concern require to
be addressed, the purpose here is to outline the medical, social, economic
and political circumstances that, over the years, have given rise to a
situation which has been detrimental to the mental health of the Bhopal
survivors. An overwhelming degree of uncertainily arising out of a near
complete lack of information leaves many questions unanswered for the
survivors.
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What has happened to my body?
It would not be an exaggeration to say that ever after all these years not
a single suvivor knows what damages have been caused by exosure to the
gases. What is it that makes them breathless, fatigued and too weak to carry
on with usual chores ? UCC’s refusal to divluge information about the
medical consequences of the leaked gases is major reason for these
uncerlainities. However, researchers of ICMR and other agencies too
have not exactly covered themselves with glory in this respect. Volumes
of ICMR publications produced after studies that hae been done on blood,
urine, semen, tissues and other samples from these victims continue to be
‘classified’ for mysterious reasons. No attempt has yet been made to
disseminate any information that has been generted. Government doctors
treating survivors dre wont to ascribe most of the survivors’ problems to
their imagination and efforts to explain the nature of the damages wrought
on their bodies are absent. To be fair to them, often doctors are as much
in the dark regarding the patient’s illnesses as the patient herself, but such
shared ignorance provides little comfort. Many survivors suffering from
these probleks are misdiagnosed as patients of tuberculosis and sent to the
TB hospital, only tobe brought back after several months and advised to
discontinue anti-tubercular treatment. For some more unfortunate, the
cycle is repeated. The trauma suffered by such patients have been
glaringly demonstrated in many instances where gas-exposed young
male patients in the TB hospital have doused themselves with kerosene
and set themselveson fire in the very wards where they were admitted.
Unfortunately non-govemment voluntary efforts towards dissemination
of medical information too have been inconsistent and inadequate.
What will my future health condition be ?
Despite the passage of nine years and expenditure of crores of rupees
(from the public exchequer) medical treatment of the gas-affected people
continues to be the same as it ws on the day after the disaster, namely
prescription of symptomatic-supportive drugs. It is common to find
ailing survivors indicating the amount of capsules and tablets consumed
by them not in numbers but kilograms and it is extremely rare to find cases
where such consumption has provided anything but short-lived relief.
That substantial portion (nearly 37 per cent according to a 1990 study) of
these drugs are unnecessary and/or hazardous is yet another serious issue.
It is indeed unfortunate that researches conducted by the ICMR and other
agencies have contributed very little towards the treatment of the
survivors. Possibly the search for a cure has been abandoned even before
it was begun. One is led to suspect that had the victims belonged to an
affluent and powerful class the situation with regard to medical treatment
would not have been so bereft of hope in Bhopal today. The inefficacy of
treatment, deterioration of health condition and manifestation of symp
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67
toms by survivors who had earlier been asymptomatic as well as the
likelihood of subsequent complications — all these present an uncertain
future for a large number of survivors.
Is the Carbide factory still a threat?
Il is indeed unfortunate that the causal factors behind the world’s worst
industrial disaster continue to be shrouded in mystery to this day. While
Union Carbide has changed its story' on what led to the disaster twice so
far, scientists employed by the Indian government have made no attempts
to adequately publicise the findings of their investigations into this
matter. Little is known of the dangerous chemicals that remain inside the
factory till today except when they have emitted (thrice so far) and caused
nausea, unconsciousnes, giddiness cough, large scale panic and at least
one reported death due to shock. In the absence of information regarding
the safety (or the lack of it) of the factory, in the minds of the neighbourhood
population it stands as an ogre that visits their dreams. Analysis of
samples of soil and groundwater in the vicinity of the factory has indicated
the presence of seven kinds of chemicals that cause damage to the kidney,
liver and the respiratory system. Caused due to routine dumping of toxic
wastes in and around the factory, these chemicals continue to pose a
serious hazard to the neighbourhood communities. The need for dis
semination of scientific and technical information was possibly never
better illustrated than during ‘Operation Faith’ when survivors fled
Bhopal as the government announced plans to utilise the chemicals left in
the tank.
How will I sustain myself and my family ?
Incapacitation as a result of exposure and the abyssmal failure of the
government in the area of economic rehabilitation has made a large
number of survirors dependant on monetary relief provided by the
government. Such relief however is not a life lime assurance and had
actually been discontinued in May last. As estimated 50,000 survivors
are unable to continue with the physically strenuous jobs that earned them
a living and are likely to face starvation if monetary relief is stopped.
The worksheds in the special industrial area built with an investment of
Rs 6 crore and intended to provide jobs to al least 10,000 survivors are
now being sold off to private industrialists ( at one-tenth the cost price)
who have offered that 10 per cent of jobs would be reserved for survivors.
Sewing centres run by the government provided employment to 2,300
gas-effected women but now lie closed, for unexplained reasons. Eco
nomically thus an uncertain future awaits the survivors.
When will I receive compensation ?
Il has been more than 20 months since disbursement of compensation
has begun in Bhopal. The number of claims that have been adjudicated in
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the period by the claims courts is about 6,000, while the total number of
claims is more than a hundred times this. There arc,as yet, no indications
of any governmental concern over this impermissible delay in compensat
ing the survivors. At the current pace of distribution of compensation and
the estimated current deaths attributable to exposure being 10 to 15 every
month, a major percentage of the survivors would be dead before compen
sation reaches them. Ironically the union government had justified its
settlement with Union Carbide on the grounds that this would enable
survivors to receive compensation early since litigation to establish
liability takes many years.
Apart from the delay in disbursement, compenstion is being unjustly
denied to the majority of the claimants. Official figures indicate that over
70 per cent of the death claims, adjudicated so far, have been rejected.
most of these rejections can be ascribed to the ignorance of the judges of
the claims courts regarding the medical consequences of Carbide’s gases.
Inordinate delay and unjust denials in compensation disbursement have in
the minds of the survivors raised uncertainities not only about ‘when’ but
also about ‘whether’. Alongwith these uncertainities there are endless
assaults on the psyche of the survivors due to reasons associated with the
disaster. Primary among these is the loss of dignity and self-respect
suffered by the survivors caused in several ways.
Over 80 per cent of the gas-affected population is composed of people
who, prior to the disaster, earned their livelihood through such jobs as
daily wage labour, pushing hand carts, carrying loads, doing construction
work, rolling beedis, as mechanics, vendors, etc. Debilitation caused due
to exposure related illnesses have rendered a large number of affected
people incapable of carrying on with such work. While such incapaci
tation has affected both women and men workers, the effect on the male
psyche has been more acute, possibly because supporting the family is
associated almost exclusively with the male identity. Instances of gasaffected men going out to work despite their feeble condition and being
confined to bed as a result of the induced stress after a few days of such
risky endeavour are common. Of course, the lack of the means to satisfy
the bare needs of the family is possibly a greater driving force than the
need to prove one’s maleness, but the failure to continue with one’s usual
job has both economic and psychiatric repercussions.
Dole may seem a softer option for the survivors but actually survivors
have long been demanding provision of jobs and cessation of monetary
relief distribution, primarily because of the humiliation in negotiating the
bureaucratic procedures and being subject to the harassment of red tape.
Through various ways a survivor is often reminded that what she is
receiving as dole is by the grace of the government and any objection to
her being treated as a beggar would be considered a serious transgression
of an assigned role. Unfortunately; the government’s neglect in the crucial
RJH
Vol 1
1995
69
area of economic rehabilitation leaves the survirors with hardly any
options but to suffer the indignities of dole distribution.
As per the guidelines followed by the claim courts, survivor claimants
have to prove their cases beyond reasonable doubt to be able to receive
compensation. Given that medical prescriptions issued to the survivors
rarely mention history of gas exposure and that in many instances prescrip
tions have not been issued by doctors, it becomes difficult for calimants to
establish their case, this is further compounded due to the deep suspicion
with which thejudges view each case. As a result, claimants in death cases
have to face interrogations that require them to recall and repeat details of
the pain, suffering and death of their loved ones under humiliating
circumstances. This has led to some survivors to remark that instead of
Union Carbide it is the victims of the multinationals who are being treated
as culprits. For each case of claim, hearings continue for as long as a year
and the psychiatric consequences of such prolonged humiliating and
brutalising experience are bound to be serious.
Survivors have also to cope with the gradual development of a macabre
scenario that surround them. They see doctors making money as do
lawyers government officials, medicine shops money lenders, photocopy
‘wallahs’, etc while the patients get no belter; they find Warren Anderson,
the former chairman of the Corporation charged with manslaughter with
a non-bailable arrest warrant issued against him and still being able to
avoid the courts while their sons get locked up at the police station for
protesting against such unlawful behviour, and so on. They find them
selves a part of a black comedy. Such an existence is bound to have an
impact on the minds of the survivors.
- Satinath Sarangi
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70
RJH
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1995
Reviews
Women’s Testimonies vs Medical Opinion
Swatija
Chayanika
The Hysterectomy Hoax by Stanley West with Paula Dranov; Doubleday,
New York; 1994; pp 214; price not mentioned.
Hysterectomy:Whose Choice? by Valerie Colyer Farfalla; Random
House, Australia, 1990; pp 126; price not mentioned.
IN the past few years there has been an attempt to look at reproduction,
reproductive technology, women’s body and biology from women’s point
of view. There have been many individual and collective efforts in this
direction all over the world including different parts of urban and rural
India. Yet there are issues which have not yet been thought of, probably
because of the the urgency other issues demand. And then it is incidents,
sudden and important, that begin a number of new debates. For example,
the horrible act of mass hysterectomies on mentally handicapped women
from a government-run home in Shirur, Maharashtra, has raked up the
issue of hysterectomy as a surgery. These hysterectomies performed on
very young women (one of whom was just 13 years old) had also raised the
question of what could be the effects of removal of the uterus. Was the
uterus, removed apparently in these cases to help these women look after
their menstrual hygiene, only there for the purpose of reproduction? Did
the uterus or other reproductive organs have no role and interaction with
the other systems in the body? Did the organ play no active role in the
overall health of the woman?
Doctors carrying out the surgery were insistent that hysterectomy was
a common enough surgery; and, that the uterus had no other role than
creating a nuisance for these ‘mentally retarded girls’. While defending
this ‘common’ practice their logic was that one had to weigh the risks of
the procedure against its possible benefits for ‘these’ women. The major
benefit, they reckoned was relieving the women of the ‘unnecessary filth’
of menstruation and helping those looking after these women to cope with
the ‘dirty’ excretion of menstruation. In the understanding of the medical
practitioners and those supporting them, these women were not fit to
reproduce and so for them the uterus was redundant, it just had ‘a nuisance
value’. Hence nothing could be more beneficial than removing the uterus
at whatever cost.
We, however, fail to look at any of these as benefits for the women. For
us the debate rested on issues of responsibility of the state and society
RJH
Vol 1
1995
71
towards these persons with special needs. Such reductionist technological
solutions could not in any way resolve the social problems involved, they
could just provide convenience to others around these women. This also
showed a very restricted view of the human being and the human body,
both.
»The trouble further was that the medical practicioners kept insisting that
there was no surgery-related risk with hysterectomy. They insisted that it
was an operation routinely carried out and had hardly any side effects.
Knowing the way medical profession and medicine has ignored women’s
experiences with regard to the use of other medical interventions, espe
cially those related to reproduction, we were wary of these claims. We
started looking around for testimonies of women who had undergone the
surgery' and came across the two revealing books, under review here. One
was The Hysterectomy Hoax by Stanley West (with Paula Dranov, a noted
infertility specialist and chief of reproductive endocrinology at St Vincent’s
Hospital in New York city and the other, Hysterectomy.Whose Choice? by
Valerie Colyer Farfalla, a Melbourne journalist writing extensively in the
area of women’s health.
West’s book begins with the following sentences:
You don’t need a hysterectomy. It can do you more harm than good. Those are
strong words, but the fact is that more than 90 per cent of hysterectomies are
unnecessary. Worse, the surgery can have long-lasting physical, emotional and
sexual consequences that may undermine your health and well-being.
With these startling statements, the book goes on to explain what is
hysterectomy, what its possible after effects are and the available
alternatives for the disorders that could lead to surgery otherwise. He
states that women have reported effects of the surgery time and again but
the medical experts have dismissed these as psychological. In fact, he says
that
except when dealing with women’s problems, doctors are trained never to
attribute symptoms to psychological factors unless we have ruled out all
possible physical causes
Our complaints being termed psychological is common experience for
us as women. Be it dysmenorrhoea or menopausal problems we had
always been told it was in our mind and had nothing to do with the physical
state of our body. Yet now reasons are being found also in the changes in
the body which even gave rise to the psychological states of depression
and mental tension.
In the case of removal of the uterus there is yet another aspect. Modem
medicine as practised today ascribes only one function to the uterus, that
of conception. So all women who are over the reproducing age or all those
who are not considered fit for reproduction like the mentally handicapped
are recommended removal of the uterus as a solution to most of their major
or minor reproductive health problems. Without hesitation we are also told
that there is no ‘need’ for the uterus in the body so why leave it behind and
72
RJH
Vol 1
1995
be exposed to the possibility of contracting cancer. The fear of cancer and
the faith in the doctor’s knowledge, opinion and ability is what convinces
women to undergo surgery in cases where their opinion is sought. There
arc many instances, as in the case of the women from Shirur, when even
this consent is not considered to be important.
West narrates the incident of a 22-year-old woman who came to his
clinic with a complaint of not getting her periods since she was 19 when
she underwent a surgery for ovarian cysts. She had also not been feeling
well with complaints of hot flashes, joint aches fatigue, headaches,
depression, no urge for ’sex’ because it hurt, and so on. She had moved
residence and so could not go to the hospital where the earlier surgery was
performed. On examination West found that she did not have any pelvic
organs at all. her uterus, fallopian tubes, ovaries, all were missing. During
her previous surgery everything had been removed and she had not even
been told about it. Appalled, West tried to find out why this had been done.
There was no pathological problem and yet the surgery was performed
probably to give some practice in hysterectomy to some student attending
the clinic.Besides the horror of this uninformed surgery, West says that
the incident provided him personally with new insights.
Although this young woman was unaware of the fact that she was
hysterectomised, the complaints that she was reporting were the same as
that of other women who had undergone hysterectomies. They were
similar to the complaints that were being brushed aside as psychological
with no basis. This incident became a starting point for West who then
seriously started following up the complaints after hysterectomy. He
found a pattern in the complaints and he reports that today there
exists evidence that when the ovaries are removed, the absence of
estrogen creates a number of problems like increased risk of cardiac
diseases, depression, reduction in bone density and reduction in libido.
These are in addition to the complications that may arise due to the surgery
itself.
What then has come to light in the last few years is that even if the
ovaries are not removed, their functioning deteriorates faster than usual
until most of the above symptoms are also seen in women whose ovaries
have not been removed. The implication of this sudden induced meno
pause especially on young pre-menopausal women can be quite alarming
and distressing. And yet these operations continue to be carried out.
According to West between 1965 and 1987, the mean age of women
undergoing surgery was done was 42.7 years.
West gives the various reasons for which hysterectomies are normally
done and also lists the other viable, effective treatments for these condi
tions. In the US 30 per cent of the hysterectomies are for benign fibroids
many of which would respond to medication or subside on their own. The
other major reason accounting for almost 25 per cent of the operations is
RJH
Vol 1
1995
73
endometriosis, a complaint that is becoming more widespread in recent
times. Recurrence of endometriosis after the hysterectomy is quite com
mon and so the surgery' offers relief in only a few cases. Besides this in 20
pcr cent of the cases the surgery is done to remove a prolapsed uterii, a
complaint which can be treated by alternative means.
The only condition in for which, according to West, hysterectomy is
inevitable, is cancer, and only 10 percent of the operations are done for this
reason. He claims that the surgery' is obsolete and ‘‘does not even necessar
ily give relief’. In the bargain it can result in new problems induced by the
surgery'. Throughout his book West has tried to provide information
needed to ‘avoid hysterectomy’. This information provided by a doctor
along with the full acknowledgement of the commercial interests of most
doctors who insist on hysterectomy, would be vital to all women. And as
he rightfully concludes,
Just as basic to full autonomy is control of your body and the right to make
decisions about your health and health care on the basis of all available
information, free from pressure, scare tactics, and outdated doctor knows best
paternalism. It is time we doctors stopped deassembling healthy women. But
nothing will change until more women look their doctors in the eye and calmly
stale their determination to remain intact women.
This collective consciousness and an effort to generate knowledge
through our shared experiences finds expression through Valerie Farfalla
in Hysterectomy .Whose Choice? West is a sensitive doctor no doubt,
sensitive to women’s pain and relationship with their bodies but the
approach and analysis yet remains confined to the medical aspects of
hysterectomy. But hysterectomy is not just a medical option. It is an
intervention into a bodily function which almost determines women’s
existence in society. And so, as in the case of other technologies related
to reproduction, the issue is not just of medical after effects.
The complex interaction of our body, its biological function and
ourselves, the socially defined selves determines also what would be the
after-effects of the surgery. Even if the womb is not consciously related
to our identity as a woman, it needs a special effort to suddenly get used
to the absence of menstruation, a process that has been an indicator of our
womenhood. Similarly, even if heavy bleeding due to benign fibroids
may not be an indicator of a fatal state as in cancer, the discomfort of that
bleeding could be quite detrimental to the person herself.
In such a situation although it is important to know the medical and
physiological aftereffects of the surgery, this is not sufficient information
and preparation in case one has to go in for a surgery, even the process of
taking the decision is facilitated with knowledge of all these other
influences and reasons that affect all our bodies. Valeria Farfalla’s book
written with support and information from Hysterectomy Support Group
in Melbourne, Victorian Endometriosis Association and Cervical Cancer
Support Group serves this purpose.
74
RJH
Vol 1
1995
The first pari of the book deals with topics similar to those dealt with
in The Hysterectomy Hoax, that is, information about what is hysterecto
my, when is it necessary, what are the alternatives to it, what arc its
physical complications. Then arc sections that are important and different
which deal with topics like ‘Facing the Personal Consequences’ and
‘Changes in Life’. These arc crucial in dealing with hysterectomy because,
While physical complications can be a problem after hysterectomy,
sexual dysfunction, loss of self-esteem and alteration in a woman’s percep
tion of her own femininity may have more serious long term consequences.
These experiences arc very subjective and quite often conflictng. They
are very dependant on the reasons why the surgery is decided upon, the
alternatives available to the woman, the support and counselling she is able
to gel before and after the operation a number of factors all of which have
to be taken note of before making such a major intervention into a person’s
body, into her life.
Judith, in her early forties, said she was devastated after her hysterectomy for
cervical cancer because the biopsy report she tracked down after the operation
showed no sign of cancer ... She still has ambivalent feelings about sex,
reproduction and her psychological life... Sara now unable to have children after
her hysterectomy, feels guilty because her husband won’t have the joy of
parenthood unless they adopt a child... On the other hand, Eva, a German bom
dentist, has never looked back since her hysterectomy 18 years ago. “It has been
a good thing. I have a very good sex life — even better than before.”
The book abounds with such experiences of women—experiences
reflective of the state of preparedness for each woman. And through these
apparently contradictory experiences the book clearly highlights the
importance of taking all these factors into account while arriving al a
decision and while evaluating the after-effects. Il clearly emphasises that
we have to accept not only as a physical side effect but also as a stale of
mind that has to be dealt with when losing organs that are part of one’s
body; organs, which society almost makes us believe, that are the reasons
for our existence. However rational and radical our individual thought
process, the impact of these messages from society cannot be just ignored
and forgotten. Il has to be taken cognition of and dealt with first.
The feeling of grief, a changed outlook towards one’s body, especially
towards sexuality, a new experience of living — all of these are issues that
need to be addressed and efforts made to deal with them positively. This
is the contribution that women’s health groups have made in all areas of
women’s health and so loo in hysterectomy. Our bodies live in a socio
cultural reality and so the impact of all changes in it has also to be seen in
this reality and efforts have to be made to make living a positive experience
in an overall sense.
Realising this we feel there are two important aspects of this whole
debate. Hysterectomy is a major physiological intervention and the physi
cal implications of removing the uterus have also not been fully explored.
RJH
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1995
75
In the light of this it is extremely irresponsible on the pan of those
proposing hysterectomy for the women with a mental handicap, to say that
this is a common surgery and has no side effects. For some women taking
these risks without adequate information, and without trying out other
methods of dealing with the so-called problems is even more questionable.
Such callous indifference on the part of the doctors has to be challenged.
Al the same time it is important that we investigate what is the impli
cation of hysterectomy for any woman living in this socio-cultural
milieu. We also need to find out the extent of its prevalence and the reasons
for which it is performed. Only through this process can we evolve our
own mechanisms and processes to be able to extend support and
strength to each other while facing a situation in which this choice has to
be made.
Victims or Perpetrators?
Sandhya Srinivasan
Medicine Betrayed: The Participation of Doctors in Human Rights
Abuse, Report of a working party of the British Medical Association; Zed
Books in association with BMA, London; 1992.
MEDICAL training does not include a study of the political and social
circumstances in which doctors practice. And rarely does it dwell on ethics,
on educating doctors of their special responsibilities to their patients, the
dangers of misusing their special skills. And the potential for abuse is carried
to the extreme when the doctor becomes the accomplice of the state.
Medicine Betrayed is the British Medical Association’s second publi
cation on doctors’ participation in human rights abuses. The first,
published in 1986, established that such involvement was not all that rare.
Doctors were known to participate in planning and assisting torture;
mistreating prisoners; committing healthy people to psychiatric care, etc.
This second report takes a closer look at the circumstances in which
torture, and medical involvement in it occurs and at the different ways in
which doctors can get involved in torture, both judicial and extra-judicial.
The working group received written and oral testimony and interacted
with individuals as well as medical and human rights organisations. After
discussing the different aspects of such abuses, it makes recommendations to
doctors and medical associations on how to prevent them. The appendices
list the stands of various international organisations. The essence of these
recommendations is the principle that the doctor’s paramount interest is in
the patient’s welfare, and not the objectives of the state.
The book discusses a number of reasons why doctors get involved in
torture — from fear of punishment to the belief that the victim deserves it.
76
RJH
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1995
Besides (hcsc explanations, which could apply toanyonc,lhcburcaucratisation
of the doctor’s role often allows him/her to avoid taking a stand.
There are many degrees and types of medical involvement in torture, but
the most obvious — and easiest to condemn — is the direct form, when s/he
uses skills to inflict pain, mental or physical. But the more insidious role a
doctor plays is as the torturer’s accomplice — ensuring that torture is carried
out without killing the victim. This could be confirming that a victim is fit
to undergo further torture, or monitoring the torture to make sure it is not
overdone, or treating the victim in between sessions, to enable him to undergo
further pain. There is also the doctor who turns a blind eye to evidence of
torture, whether by ignoring substandard care to prisoners or giving false or
deliberately inconclusive post-mortem reports.
While much torture is done with the tacit, but not open, approval of the
government, it is equally important to look at the role doctors play in statesponsored and socially legitimised violations of human rights. The report
looks at three examples in particular — corporal punishment, capital
punishment and force-feeding of hunger strikers — where alleviating the
distress of a legal act could involve a compromise of medical ethics.
In the first case, doctors arc kept on hand, to certify the prisoner fit for
punishment, to determine when the prisoner can no longer tolerate the pain,
and to treat the injured prisoner. The committee points out that doctors cannot
ethically be part of this or any other punitive machinery. Everyone is ready
to call amputations and public whippings barbaric, feudal practices. But
capital punishment is practised by ‘civilised’ societies. The examples cited
here are primarily from the US, where doctors have participated in executions
despite the American Medical Association’s opposition.
Il might be argued that doctors should be involved to make the death as
painless and swift as possible. But even when a doctor docs not administer
capital punishment, s/he can be made to aid the procedure — by certifying
a prisoner fit to undergo capital punishment; treating the prisoner to
make him fit for execution; witnessing the execution to confirm that it
has succeeded. The BMA condemns all medical participation in all
aspects of capital punishment, save the final certification of death, insist
ing that this lake place some lime after the execution, and away from the
execution site.
On the question of medical treatment of hunger strikers, it is seen as a
doctor’s duty to revive a critically ill person. When that person chooses to
die, should a doctor stand by and watch, revive the hunger striker, even
against his/her wishes ? The BMA asserts the patient’s right to refuse food
to the point of death, as a method of protest. Doctors should keep in mind the
best interests of the patient, not of the stale. And a doctor who feels unable
to follow the prisoner’s wishes should hand over charge to another doctor.
While noting doctors’ extensive involvement in human rights viola
tions, the BMA acknowledges that they are often unwilling accomplices
RJH
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1995
77
to torturers, and arc even victims themselves. For this reason, international
medical associations must extend support to lheir colleagues who cannot
speak up against the government.
The report dwells extensively on documented violations outside
western Europe and the US, but records the growing erosion of civil rights
in the UK — repressive legislation, maltreatment of IRA prisoners,
conditions in prisons and mental health facilities, etc. And in an early
chapter it explains the relatively slack follow-up of medical atrocities in
the name of research after the second world war. A senate sub-committde
explained that “...the value to the US of Japanese biological warfare data
is of such importance to national security as to far outweigh the value
accruing from war crime prosecution...’’
The wealth of information here would have gained focus if other
human rights violations referred to here had also been discussed.
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78
RJH
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1995
Facts and Figures
Health and Welfare: Comparative Indices
THIS set of tables compares data on key components of socio-economic
development for India and selected developing countries. Among the
developing countries India is assigned a low HDI rank of 135 in an array
of 173 countries in descending order of the human development index, as
defined and computed by the United Nations Development Programme.
Adult literacy rates in India and Sri Lanka and China show the poor
progress made in India on this count. As we see in Table 1, in 1992, the adult
literacy in India was 49.8 per cent, while that for Sri Lanka was 89.1 per
cent and China 80 percent. For Kerala it was 89.79 percent. Literacy rates,
particularly amongst the women appear to play vital role in reducing the
birth rates. Kerala’s high female literacy rales occurs with low crude birth
rates (18 per cent) as compared with rest of the selected developing
countries.
MM R or maternal mortality rate which measures the numbers of deaths
among women due to pregnancy-related causes per 100,000 births, was
as high as 550 as compared with China and Sri Lanka where it was 130 and
180 respectively. The lower maternal mortality rates in China and Sri
Lanka is perhaps linked to large proportion of births attended by health
staff which were 94 and 87 respectively; vis a vis India which was only 33
per cent.
India has achieved a life expectancy 59.7 which is much lower than that
of other comparable countries. Human development index which is a
composite of life expectancy at birth, literacy rate and income ($ PPP/
capita- purchasing power parity per capita) Kerala 0.775 retains its top
position on these composite indices followed by Sri Lanka and China.
The remarkable improvement on health status in China, Sri Lanka are
attributable in part to government policies that emphasised the financing
of cost-effective clinical services. An important factor in India lagging
behind other countries in social development has been the level of
governmental expenditures for health and education sectors as compared
with that in other countries.
There is a significant relationship between the HDI and GNP per capita.
For countries such as China, Sri Lanka the HDI Rank is far better than
their income rank (i c GNP rank). The highest positive difference between
HDI and GNP ranks is for China (+49), and Sri Lanka (38) shows that these
countries have made more judicious use of their income to improve the
capabilities of their people, as compare to India (R) which is fairly
significant.
RJH
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79
Table 1: Human Development Index: Key Components
Life expectancy at birth (92)
Adult literacy (per cent) (92)
Female literacy (per cent) (92)
HDI (92)
Total fertility rate (92)
Crude birth rate (92)
Maternal mortality rate (88)
Births attended by health
staff (85)
Infant mortality rate (92)
Contraceptive prevalence
rate (per cent)
HDI rank (92)
India
Sri Lanka
China
Pakistan
Kerala
59.7
49.8
35.0
0.382
4.0
30.0
550
71.2
89.1
85.0
0.665
2.5
6.0
180
70.5
80.0
68 0
0.644
2.4
7.0
130
58.3
36.4
22.0
0.393
6.3
11.0
600
70.76
89.76
86.13
*
0.775
2.0
6.1
NA
33
89
87
24
94
27
24
99
NA
17
43
135
62
90
83
94
12
132
NA
—
Kerala
Table 2: He/XLth Profile
Population per doctor (90)
Population per nurse (90)
Nursc/doctor (90)
Education as per cent of total
government expenditure (91)
Defence as per cent of total
government expenditure (91)
India
Sn Lanka
China
Pakistan
2440
2220
1.1
7140
1400
5.1
730
1460
0.5
2940
1720
1.7
1.6
4.8
NA
1.0
17.0
9.4
NA
27.9
Table 3: Income; Poverty Level of Selected Countries
Real GDP/capna (SPPP)
People in absolute poverty (92)
Rural
Urban
In millions. Total
Population (91) (In millions)
GNP per capita (91) US S
GNP per capita minus HDI rank
*
GNP/capita rank
HDI rank
India
Sri Lanka
Pakistan
China
1150
2650
1970
2946
270.0
6.3
24.3
105.0
350.0
866.50
330
12
147
135
7.0
17.20
500
38
128
90
35.0
115.80
400
8
140
132
105.0
1149.50
370
49
143
94
* HDI rank in better than the GNP per capita rank
[All data are from World Dvelopment Report, 1993 and Asian Development Report, 1994.]
Some definitions:
GNP: Total domestic and foreign value added claimed by residents. It comprises GDP plus
net factor income from abroad which is the income of residents from abroad.
GDP: Total output of goods and services for final use produced by residents and non
residents. regardless of the allocations to domestic and foreign claims.
PPP per capita: Purchasing power parity per capita is the no of units of a country’s currency
required to buy the same amount of goods and services in the domestic market as one dollar
would in the US.
—Sandeep Khanvilkar
80
RJH
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Ewia
wn®
AND
POLITICAL
December 17-24, 1994
INDIA’S POPULATION : HEADING TOWARDS A BILLION
Heading towards a Billion
Irudaya Rajan
Census 1961: New Pathways Asok Mitra
Census of India: Challenges and Innovations
A R Nanda
Sex Ratios: What They Hide and What They Reveal
K Srinivasan
On the Demography of the 1991 Census Tim Dyson
Data Collection in Census: A Survey of Census
Enumerators Murali Dhar Vemuri
Development and Women’s Work in KeralaJnteractions
and Paradoxes Rachel Kumar
Anomaly in Employment in Some Modern Sector
Occupations D Radha Devi
Dependence on Agricultural Employment
Sumati Kulkarni
Urbanisation and Socio-Economic Change in
Tamil Nadu,1901-91 R Rukmani
Levels and Trends in Indian Fertility : A Reassesment
P N Mari Bhat
Demographic Transition: Accelerating Fertility Decline
in 1980s Pravin Visaria, Leela Visaria
Price: Rs 30 + Postage
For Copies, Write to:
Circulation Manager
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Hitkari House
284 Shahid Bhagat Singh Road, Bombay 400 001
Now, since the might of the peop.
. s brought about
the acceptance of the democratic >riricipie, the time has
come to demand its implementation in all instances and
without reserve by the free word, written or spoken. Physicians everywhere already meet in assemblies to determine
in common consultation the needs of their profession, their
art and their science, and to take their interests out of the
hands of ‘superiors’ who too frequently, alas, considered
.
s
J
J
j
J
|
■
|
I
I
the antiquated rococo systems of their desks as the natural
expression of justice, or even opposed the legitimate
wishes of their contemporaries with the tenacity of utter
selfishnes. But the press also has now assumed a new
position. No longer does it suffice to see the wishes of
individuals brought before the public in the form of mono
graphs. There now exists a need for periodical organs that
aim to present and balance out the desires of the majority,
if possible even of all who watch the measures taken by the
legislative authority...This applies in particular to the mea
sures taken by the executive branch, not because we have
a historical right to distrust it, but because it is a self-evident
right of free men to look after their own affairs themselves.
.. .The place to which fragmentation , apathy and isolation
have led us is amply illustrated by the sorry state of our
medicine. Let us now try for once where unity, enthusiasm
and closer contact can take us.
—Rudolf Virchow,
Medicinishce Reform,
No 1, July 10,1848.
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