Radical Journal of Health 1995 Vol. 1, No. 3, July - Sept
Item
- Title
- Radical Journal of Health 1995 Vol. 1, No. 3, July - Sept
- Date
- September 1995
- Description
-
- PUBLIC HEALTH BUDGETS: DECLINING TRENDS
- GENDER POLITICS IN MENTAL HEALTH CARE IN INDIA
- PLAGUE: THE SUBALTERN EXPERIENCE
- MARKET, HEALTH AND IDEOLOGY
- TB : UNREALISTIC PRESCRIPTIONS
- HEALTH, DIRT AND IMAGES OF ORGANIC FOOD - extracted text
-
New Series VOLUME I
GENDER POLITICS IN MENTAL
.
HEALTH CARE IN INDIA
PLAGUE: THE SUBALTERN EXPERIENCE
MARKET, HEALTH AND IDEOLOGY
Beet:
wai
.
*
: UNREALISTIC
‘
.
PRESCRIPTIONS
[EALTH, DIRT AND IMAGES OF ORGANIC FOOD
Pee.
|
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,
anthropology, economics, history, philosophy,psychology, management,
technology and other emerging disciplines. Well-researched 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 lyer, Asha Vadair, Ravi Duggal, Roopashri
Sinha, Sandeep Khanvilkar, Sandhya Srinivasan, Sushma Jhaveri,
Sunil Nandraj, Usha Sethuraman.
Production
Consultant: B H Pujar
Consulting Editors:
Amar Jesani, CEHAT,
Bombay
Manisha Gupte, CEHAT, Pune
Binayak Sen, Raipur, MP
Dhruv Mankad, VACHAN, Nasik
K Ekbal, Medical College,
Kottayam
Francois Sironi, Paris
Imrana Quadeer, JNU,
New Delhi
Leena Sevak, London School of
Hygiene and Tropical Medicine,
London
V R Muraleedharan, /ndian
Institute of Technology, Madras
Padmini Swaminathan,
Madras Institute of
Development Studies, Madras
C Sathyamala, New Delhi
Thelma Narayan, London
School of Hygiene and
_
Tropical Medicine, London
Veena Shatrugna, Hyderabad
Publisher: Sunil Nandraj for Socialist Health Review Trust.
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.
on
VolumeI
NewSeries
Number3
July-September
1995
Letters to Editor
170
Editorials: Market Reforms in Health Care Amar Jesani
Growing Exports, Sick Workers
Millie Nihila, Padmini Swaminathan
17]
174
Public Health Budgets: Recent Trends
Ravi Duggal
177
Gender Politics in Mental Health Care in India
Bhargavi V Davar
183
Health, Dirt and Images of Organic Food
Rahul Srivastava
209
Communications
Plague: The Subaitern Experience
A R Venkatachalapathy
Market, Health and Ideology
Ravi Srinivas
221
Reviews
Demographers and Population Policies
Malini Karkal
Health Research: Strengths and Weaknesses
Ramila Bisht, Nilambari Gokhale
228
Discussion Paper
TB Epidemics: Symptoms of a Larger Malaise
Sunil Kaul
224
L39
eed
Facts and Figures
’ Health Status of Children
240
RJH
(New Series)
Voll: 3
1995
LETTERS TO EDITOR
Roots of Research?
MRIDULA RAMANNA’s article (VollI:2) is an interesting account of
the entry of Indian elite into medical education. Itis such narratives which
give us a picture ofwho practised modern medicine in the colonial years
and how it took roots. It is also interesting to note that native medical
graduates also took a keen interest in research and participated through
the research society in what may be called epidemiological investigations. One hopes that a more in-depth study on these research studies
will be undertaken.
Madras
Rajnish P
Evolving Demands
We found the charter of demands on family planning programme
adopted by the Chengalpattu women (VollI:1) very useful. Even if
one may not adopt all its components, it is something of a guideline
for similar documents to be evolved. Can we not, at the forthcoming
meeting of either the Indian Womens Studies Conference at Jaipur
or the medico friend circle’s annual meeting, on ethics, put forward
and universalise a charter of demands similar to this on all aspects
of health programmes?
Trivandrum
Seema and Aruna Gopal
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170
RJH_
(New Series)
Vol 1:3
1995
Market Reforms in Health Care
Introducing ‘transparency’ in the matter of fees chargeable hy
doctors is an attempt at regulating the health market, not at making
care more accessible to those who cannot afford to pay.
THE Committee on Subordinate Legislation dealing with the rules and
regulations under the Medical Council Act, 1956, presented its 30th
report to the upper house of parliament on December 9, 1994. In some
of its observations, the report .is also an indictment of functioning of
the medical profession and its legally constituted self-regulatory bodies, »
the Indian and state medical councils.
Interestingly and contrary to the short lived news and debates it
generated, this report neither shows concern for the high fees charged
by doctors nor for the high cost of health care. The term price control,
in fact does not appear anywhere in their report. The parliamentarians
were actually driven by their commitment to neo-liberal market
economics. Their concern was for the market failure in health care.
After implicitly accepting that the market driven health care was a
dominant mode of providing health care in our country and without
bothering about the need to find an alternative, they endeavoured to
make the doctor-patient transaction at the market place ‘transparent’.
During the sittings of the committee, “the chairman (sic) made it very
clear that what the Committee wanted was transparency of fee and not
regulation of fee”. The report acknowledges that the present code of
medical ethics stipulates that the remuneration for services rendered
by doctor should be specifically announced to the patient at the time
the service is rendered. However, it finds this inadequate simply
because the patient would not have prior information of the fee ofthe
doctor.
-
For them, the neo-liberal
economic
criteria for sovereign
consumer are not fulfilled by the present code of ethics. Thus, the
report says that there should be some means “by which the patient
could learn in advance the fee charged by all or most of the physicians
of the type required by him, in which case he would be able to select
the physician whose fee will suit him (sic). It would also enable him
to know what services are included in the fee charged and to compare
the fee to be paid to a doctor with what others charge for similar
services.”
The recommendations of the committee obviously flow from the
same premises. It refused to accept the weak protest put up by the
representatives of the Medical Council that making known the services offered and their prices by doctors would amount to advertisement which the present code of ethics prohibits. The committee
RJH
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1995
171
eliminated this very ground of protest by recommending suitable
amendment in the code of medical ethics. It also asserted that “a directory
containing all details of the physicians and their charges should be
published by the Medical Council of India.” Further, it suggested that “the
Medical Council should make it compulsory for the doctors in private
practice to notify their fees to the Medical Council which should include
the standard charges for various services, operations etc.”
Though the report talks about people, it’s focus is the paying consumer. In fact it gives hardly any space to the health care consumer who
cannot pay. Offering little to consumers who use free services in the
government health centres. The significance of these recommendations
go beyond the Medical Council Act which was the subject of this
committee. Being a committee of politicians drawn from various parties.
it reflects a trend in political thinking. That is, in the coming time there
will be less talk about strengthening the primary health centre network for
rural areas for providing medical care or curative care. Medical care even
in rural areas would be left to the private sector. Clearly, the observations
and recommendations of the committee are meant to strengthen the
private sector and the market in health care whose credibility has taken
severe beating in last few years. The idea is to restore credibtlity by
injecting transparency in the market place transactions and at the same
time blunt the emerging demand for the control of price and cost of health
care. The wider national-level shift in policy necessarily leads to the
withdrawal from the commitment to the public sector health services and
to some attempts at putting the private health sector house in order. This
report is a reflection of such emerging change in the stated policy.
Can one really oppose these and other suggestions of ‘transparency’
and ‘abolition’ of corruption in the market place transactions in health or
other fields? The political impetus today is to ensure clean, competitive
_and corruption-free business environment. The suggestion of ‘transparency’ is necessarily tagged with the idea of providing information to the
consumer, as in this case the committee has suggested that patient should
know in advance the doctor’s fee and the price of various services offered
by him or her. This has been a long standing demand of the consumer
groups in the country. They would find it difficult not to support such
suggestion. After all, when one has no alternative but to buy health care.
itis always good to have a market where one can make a ‘rational choice’.
Secondly, once the principle of providing information to consumers is
accepted, more demands for information on other aspects of health can
be made.
While it is true that demand for information on the services provided
and about the way services are managed remain valid irrespective of the
way health care is organised (private, nationalised or in-between), there
are absolute limits on the amount and content of information actually
ia
RJH_
(New Series)
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1995
given by doctors and understood by the patients in the market based
organisation of health care services.
?
In the US, for instance, ‘information’ and ‘choices’ are considered
essential elements of medical care transaction. Consumer groups are
strong and the courts and the juries sympathetic to the litigants. Hospital
prices and services are given ratings by the consumer groups and the data
on the outcome of various types of treatment provided by hospitals not so
difficult for the consumers to have. The codes of medical ethics are also
modified to allow a certain amount of advertisement, to institutionalise
peer review for assessing competency of doctors, and so on. Yet, is it
possible for the US health system to claim that the consumers are making
rational choices, the access to services is universal, the fee and price of
service reasonable and the health status of people and the quality of care
provided commensurate to the health care expenditure made by that
country? The answer is, a definite no. The US perhaps tops in the
provision of unnecessary investigations, medications and surgeries. The
health industry takes care to ensure that more and more aspects of
people’s lives are medicalised to increase demand. Though the health
expenditure of the US is the highest in the world, the health status of its
people is not. There is no universal access to health care and millions of
US citizens do not have full health insurance coverage. And finally, the
people have absolutely no control over the management of health services, the area tightly guarded by the corporations owning the system and
professionals running it.
In this situation, what should be the choice for health care reform
best suited to our country? When the committee stated that what it
“wanted was transparency of fee and not regulation of fee’, it made a
choice — to take a path in the direction the US health system. But
within the capitalist economic system, the US way is not the only
historical example available for people-friendly reforms in health care
services. Developed countries which have opted for, through national
health insurance, progressive taxation, partial nationalisation or strong
regulations, a health care system providing universal access and high
quality of care, are no less capitalist economies and they have not
completely abolished market in health care. Thus, within the market
economic framework for evolving appropriate regulatory mechanism
in health care, the country will have to choose between the principle
‘transparency in business’ and ‘universal access.’
—Amar Jesani
Have you renewed your subscription to RJH for 1996?
RJH
(New Series)
Voll: 3 1995
196)
Growing Exports, Sick Workers
The drive to expand export industries paying scant attention to
health and safety regulations is adding the burden of occupational
illnesses on those whose health status is already low.
THE East Asian Miracle, according to market-friendly assessments of
these countries, is premised largely on an ‘outward-looking’, “exportoriented’ industrialisation. East Asia has now become a model for most
developing economies that have of late, gone in for World Bank-assisted
- structural adjustment programmes, India being one of them. India’s
overall dismal record has been blamed largely on its ‘inward-looking’,
‘import-substitution’ policies underlying its development programme.
Beginning from the middle of 1980s and particularly since 1991, the
finance minister has ushered in a whole host of policies, ostensibly to
emulate East Aisa. But here the comparison ends.
An important component of the Indian liberalisatoin package is the
drive to increase export earnings through increases in both the quantum
of exports and value addition of the goods exported. The focus of the
Indian export thrust (officially and/or otherwise) (generally) only
emphasises the following points: (a) The need to diversify the exportbasket and also go in progressively for the export of more sophisticated
hi-tech products. (b) Even when it is realised that the bulk of our exports
come from the informal sector, the only point that is discussed is the fact
that the Indian share (of these goods) in the international market has been
decreasing. Hence, the only policy conclusion is that there is need to
increase our share in the international market.
What does not get emphasised in such discussions is the following: (a)
That after 45 years, almost between 55 to 60 per cent of total earnings are
made up by commodities manufactured largely in the informal sector (see
Table). These include leather and leather goods, gems and jewellery,
handicrafts and readymade garments.
TABLE: VALUEOF Exports
;
(Per cent)
Manufacturing
as Per Cent of
Total Exports
1990-9]
1991-92
1992-93
1993-94
72.91
74.23
76.00
75.56
Leather and leather products,
gems and jewellery, handicrafts
and readymade garments
53.37
53.70
56.78
56.88
75.94
72.34
74.65
75.29
Source: Compiled from Economic Survey 1994-95.
174
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(b) That many of the large business houses that have become active on
the export front are in fact mere export agents. For example, Ponds,
Hindustan Lever, Wipro to name a few, export leather goods, which is not
related to the main line of manufacturing activities of these business
houses. If at all, they get the finished leather done by job-workers
(contractors) and get them converted into leather products.
(c) The ‘export-or-perish’ policy of the government, the increasing
(because of ease of) entry of business houses into the export of these
products of the informal sector, has severe repercussions for those
employed in these industries. Unfortunately, very rarely do discussions of
export growth (and emphasis on increasing exports) really get down to
fleshing out the implications of, say, an increase in exports by 15 percent,
on those working in different segments of these industries.
The quality of leather products has a lot to do with the quality of
tanning — the most polluting, hazardous but the most labour intensive
component of the leather industry. Leather industry as such consists of
three different segments, namely, leather tanning, leather finishing and
leather products. The first two segments, that is, tanning and finishing, are
totally banned in developed countries, on account of environmental
pollution and occupational hazards. The third segment, namely leather
products is concentrated in East Asian countries mainly because, these
countries have a cost advantage because of their relatively cheap labour.
Leather industry has been designated as a ‘hazardous industry’ under
the Factories Act; leather tanning, particularly is a high-rixk industry for
the workers. The industry also has become chemical-intensive with
nearly 225 different chemicals being used in various processes of the
industry. Of these, quite a few are toxic like sodium sulfide, sulfuric acid,
formic acid, acetic acid, ammonia, chromium, formaldehyde, etc. Prolonged contact with these chemicals leads to dermatitis; conjunctivitis;
nervous disorder; itching of skin, throat, mucous membrane; chest pain;
ulcer; breathing problem; asthma; bronchitis; fissures in finger, toe,
mouth and nose; frequent fever; headache upset stomach, etc. Some of
these chemicals, if inhaled can be fatal.
Apart from chemical hazards, there are also other hazards prevalent in
this industry. Handling of raw hides/skins frequently causes anthrax
which can turn out to be fatal. Secondly, wet and greasy floors in tanning
industries cause accidents - workers falling into lime pits, between
machines,
drums, etc is not uncommon;
thirdly, moving
when
the
machine is in motion causes ‘caught between’ hazards. The non-use of
sensors while machines are in motion inflicts bruises, scrapes, crushing,
abrasions and/or amputations; fourthly, both rotating wooden drums as
- well as other machines make excessive noise - each of these make more
than 90 decibles (dBA) which is the maximum standard a normal person
can tolerate. This excessive noise can cause permanent hearing damage;
RJH
(New Series)
Voll: 3 1995
175
fifthly, improper handling of hand tools leads to callosities of hand and
finger. Last but not least, unfenced pits and machine, and spillage of
chemicals are a constant risk to workers.
It has been noted that the accident and illness rate is five times higher
in tanneries than the average for all other industries; it has also been
estimated that on an average every year, one in five tannery workers will
be a victim of work related injury or illness. Hazards have increased with
improvements in techniques of production. The brunt of these hazards is
borne primarily by workers. It needs to be mentioned that there is
concentration of women workers in the most polluting processes of the
tanning industry. Specific problems faced by women workers are menstrual disorder, dysmenorrhoea, miscarriage, still birth and prolapse of
uterus, etc. This is one industry where increasing (export) production is
accompanied by increasing risk to workers.
Like the leather industry, the gem and jewellery, handicrafts, and the
readymade garments industry are also largely in the informal sector.
Statistics show that four-fifths of the working population in these industries is constituted by women. They are mostly casual labourers and hence
have no choice but to accept the most polluting and hazardous jobs. The
working conditions in gems, readymade garments and leather products
industries are dismal; the workers are cramped in ill-ventilated spaces;
further, strict supervision in these places to increase production gives no
space for rest. The heat and humidity in the work spot leads to drowsiness
and fainting.
Almost the only way the Indian government deals with occupational
health is through the legal mechanism. There have been a series of labour
laws aimed at ameliorating the conditions of labour. There are many
lacunae in these laws which show that they are far from adequate.
However, even the few legislations enacted in the name of safeguarding
workers do not cover the casual and contract workers, who form the bulk
of the labour iorce as far as the informal sector is concerned. It is precisely
these categories of workers who work in unhealthy environments and are
engaged in dangerous processes. Thus, those who are in great need of
protection from dangerous occupations and unhealthy work environments are the least touched by any form of regulation.
—Millie Nihila
Padmini Swaminathan
Apology to Readers
This issue has been delayed due to unavoidable circumstances.
We regret the inconvenience caused.
S176
RJH_
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1995
Public Health Budgets: Recent Trends
Ravi Duggal
Since the 1980s, India’s debt burden and interest payments have.
galloped at a rapid rate. This state of the economy has had its
bearing on state spending, with the social sector being affected
the worst. While the states’ share in health spending has increased, the
centre’s has declined. The breakdown of central assistance to states
is acutely felt in the deterioration of the centrally-sponsored
programmes. Since these are mostly of a preventive and promotive
nature, they have a telling effect on the health status of the people.
THE state committment to provide health care for its citizens is reflected
not only in the inadequacy of the health infrastructure and the low levels
of financing but also in the declining support to various health care
demands of the people, and especially since early 80s when the process
of liberalisation and opening up of the Indian economy to world markets
began. This is evident from the data in Table 1.
Medical care (hospitals and dispensaries) and control of communi-
cable diseases are crucial areas of concern both in terms of what people
demand as priority areas of health care as well as what existing socioeconomic conditions demand. As with overall public health spending both
_ these programmes also show declining trends in fiscal allocations in the
1980s and 90s. In fact in the case of disease programmes this decline is
surprising because of the large foreign assistance for AIDS and blindness.
control — this then means that other crucial diseases like tuberculosis,
malaria, leprosy, diarroheal diseases, ARI, etc are being further neglec-
ted. This increasing disinterest of the state in allocating resources for the
health sector is also reflected in investment expenditure — there has been
a very large decline in capital expenditures during the 1990s. Further,
when we look at the growth rate of health expenditures we also see a
declining trend and if we correct this absolute growth rate for inflation we
even get a large negative growth for the most recent years.
When we look at these same ratios across states not one state
government shows a significant trend different from the overall trends
[see Duggal et al 1995]. This only goes to show how strongly the central
government influences the states’ financing decisions even in a sector
where the constitutional responsibility is vested with the state
governments and the centres grants are only about 10 per cent of state
government spending. This ‘united action’ has been possible because
health care policy-making and planning is largely done at the level of the
central government and hence the latter can use arm-twisting tactics. This
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177
structure of planning reduces any initiative that a state government may
want to take for reallocating resources to favour the demands of people
for health care. The result is that people do not get satisfactory services
from the public system and hence get discouraged to use it.
Low levels of public spending for health and low levels of utilisation
of public health services are closely linked. The 1987 NSSO survey on
utilisation of health care facilities revealed that for outpatient care public
services were utilised for only 26 per cent of the cases. But it also reveals
that states with a higher per capita public health expenditure had better
rates of public facility use. Further, states having a weak penetration of the
private health sector had very high public health facility utilisation
[NSSO 1987]. Similar trends have also been found in studies done
byNational Council of Applied Economic Research (NCAER),the National Institute of Health and Family Welfare( NIHFW),the Foundation
for Research in Community Health (FRCH) and others [see Berman et al
1992; World Bank 1994]. However, for hospital care the use of public
hospitals is as yet higher but that is because 70 per cent hospital beds are
in the public domain. But with 80 per cent of hospitals being in urban
areas the rural residents, who constitute 3/4ths of the population, have
tremendous difficulties in obtaining such care.
During the 1980s the state did put in genuine efforts at expansion of the
rural health infrastructure (even though for strengthening the outreach of
family planning), but it is precisely during this period, as we have seen
TABLE 1 : SELECTED PuBLIC HEALTH EXPENDITURE RATIOS 1981 - 1995
Year
198081
198586
199192
199293
199394
Health expenditure as per cent
|
of total govt. expenditure
Cw! aia 8 gmp iabybaysdino See tg |
Expenditure on medical care
as per cent of total health
expenditure
43.30 37.82. 26,78. 27.06)° 2046.
Expenditure on disease
programme as per cent of
total health expenditure
12.96
Capital expenditure as per cent
of total health expenditure
S152
Absolute annual per capita
growth rate of health
expenditure in per cent
15
11.69.
10.59
10.84
10.41
9.25).
S843)
4 Zee
21
1]
13
17
27S
2a
O20
= 7 1s
199495
2.63
*2aive
re? |
4.46
7
Total Health
Expenditure(Rs bn)
Hibs.
Source: Duggal R, Nandraj S and Vadair
2 ee
A ‘CEHAT Database-Special Statis-
tics: Health Expenditure Across States-Part I’, Economic And Political
Weekly, 30:15, April 15, 1995
178
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above, that there was a declining trend in public spending on health care.
This same period also witnessed a massive growth rate of expansion
of the private health sector [Jesani et al 1993]. The database of the NIIPFP
shows that real growth rates of public health spending have declined
rapidly during the 1980s, and more so for central government spending
(Table 2).
Since the 1980s India’s debt burden and interest payments have
galloped at a rapid rate. It is this state of the economy which has had
its bearing on state spending and social sector are the first to get the
axe. Under structural adjustment since 1991 there has been further
compression in government spending in an effort to bring down the
fiscal deficit to the desired level. The GOI budget expenditures have
declined from 19.8per cent of the GDP in 1990-91 to 16.58per cent in
1993-94. This compression again has been more severe for the central
health sector. The NIPFP database gives evidence for this compression that has taken place over the last decade. It shows that the states’
share in health expenditures has increased and that of the centre
declined drastically. Further, the breakdown of central assistance to
states reveal that central programmes or centrally sponsored schemes
are the most severely affected. And since most of the centrally funded
programmes are of a preventive and promotive nature a decline of
spending on these programmes means serious consequences for the
health of the nation, especially given the fact that the private sector has
_ no interest in preventive and promotive care (Tables 3 and 4).
Another serious problem in public health spending is the large and
increasing proportion of the expenditure on salaries. This in part
explains the poor utilisation of public health services because nonsalary components
like medicines,
fuel, equipments,
etc are inad-
equately funded. The NIPFP database shows that commodity purchases declined steadily from 29 per cent of total expenditure in 1978
to 22 per cent in 1988 as did capital expenditures from 9 per cent to 7
per cent. It also revealed that real growth rates in salary expenditures
during that period was 9.8 per cent and that of commodities was 5.3
per cent [Tulasidhar 1992]. NCAER also found in a district and
municipal level study in four states that non-salary inputs ranged
TABLE 2 : REAL GROWTH RATE (PER CENT) IN HEALTH CARE EXPENDITURE
1974-1982
1982-1989
Major States (15)
i be
8.42
Central Government
Centre + States
P13
10.03
3.44
8.22
Source: Tulsidhar, V B, State’s Financing of Health Care in India: Some Recent
Trends, NIPFP 1992.
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between 5 per cent and 21 per cent [World Bank 1994]. This declining
share of non-salary spending will only further aggravate the inefficiento the already poor
cies within the system causing further secs
reputation of public health services.
The analysis and evidence presented above clearly indicates the
urgency of stemming declining public spending on health care and taking
appropriate fiscal actions to improve the efficiency and effectiveness of
the public health care system.
The major problem of health sector development in India, especially
in the last two decades, has been that new programmes are begun and new
facilities started with plan funds (and an increasing amount with foreign
borrowings) but their future sustenance is not completely assured by
additional non-plan allocations. Health being a state subject, its
sustainability is dependent on allocations made by the state. The centre
_has major control of plan resources and the states want to grab as large a
share as they can. Therefore, states in the initial years of the plan scheme
are willing to provide matching grants but when time comes to take charge
of the programmes they throw up their hands and hence the programme
continues to drain a part of the plan resources. The effect of the latter is
that new investments get affected because of these old plan commitments
not being transferred to non-plan budgets. Further, states have a tendency
to divert programme funds away from components for which they are
earmarked. This is largely due to the restricted role that states play in
policy-making and planning.
This mismatch of centre-state priorities has proved very expensive as
funds are wasted on inadequately provided tasks causing allocative
TABLE 3 : SHARE OF CENTRE AND STATES IN HEALTH EXPENDITURES (PER CENT)
1974-1982
1982-1989
1992-1993
State’s Own Funds
Grants from Centre
71.6
19.9
79.9
5.8 -
85.7
5:3
Centre’s Expenditures
8.5
14.3
11.0
Source: Tulsidhar, V B, Structural Adjustment Program: Its Impact on the Health
Sector, NIPFP, 1993.
TABLE 4 : SHARE OF CENTRAL GRANTS IN STATE HEALTH SPENDING (PER CENT)
Medical and _— Public
Public Health
Health
1984-1985
1989-1990
1992-1993
6.73
eR
3.70
27.92
16.66
LA17
Disease
Programme
Family
Welfare
41.47
29.12%
18.50
99.00
74.51
88.59
* figure for 1988-89; Source : Same as Table 3
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“
inefficiencies and failure of the programme to fulfill fully its objectives.
For example, a recent GOI-WHO-SIDA
.
evaluation of the tuberculosis
program revealed the following:
—inadequate coverage of TB services in peripheral health institutions
—underfunding of drugs to the extent that the effective supply was for
only one-third of the cases dectected
—over-reliance on X-ray diagnosis With the result that cases tended to
concentrate in district TB centre
—ineffective laboratory services due to insufficient human-hours of the
microscopist at the PHC
—inefficient drug distribution mechanism which results in a very high
drop-out rate after initial symptomatic relief to the patient
Thus, apart from substantially enhancing resources for the publicm
health sector, there is also an urgent need to reorient spending and remove
the allocative inefficiencies. This is possible in many ways :
i) If the states play a more significant role in health care planning and _
measure the cost-effectiveness of intra-sectoral allocations within the
programme so that they can assure long-term sustenance and make the
programme meaningful
ii) By assuring that the non-salary inputs are maintained at an adequate level, especially stocks of essential drugs, maintenance of facilities and equipments, fuel, etc, whichis efficient enough to attract patients.
ili) By rationalising the use of hospitals through a referral system.
This can be achieved if primary care facilities are well-equipped and
better funded to meet demands of basic health care.
iv) By improving the mix of health care staff in the various facilities
and programmes. For instance, improving the nurse : doctor ratio in
hospitals can bring down considerably the unit cost of hospital services.
v) By improving drug management, assuring that only rational and
essential generic drugs are purchased. International experience shows
that this results in reducing drug costs by half.
vi) And by assuring that allocations are based on actual requirements
or needs and that once committed, funds are not diverted for other
expenditures.
In conclusion we must reassert the importance of much larger resources being allocated for public health care. Every effort must be made
to approximate the guidelines suggested by WHO for spending 5 per cent
of the GDP on health care. But this will not be possible if the private health
sector is left unregulated and has no links with the public system. The
consequence of leaving the private health sector out of the ambit of state
planning has been that with the rapid growth of the private sector, which
is fuelled by supply-induced demand, the wealthier and the articulate
increasingly seek care in the private sector and any support socially and
politically for a national health system which may be there will get buried
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in demands for privatisation, etc further running down the public sector
and hence the poor. The global trend is to evolve an effective publicprivate mix which functions under a single umbrella of amonopoly buyer
of health services, which can either be a statutory body constituted by an
act of parliament, or an insurance group, or the state or some combination.
This creation of a single system which assures universal coverage with
equity should be the not too distant goal in the reorganisation of the
country’s health care services. Such reorganisation will bring a tremendous saving to the economy both in terms of cutting down wastage of
expenditure, especially in the private sector (over-prescriptions, unnecessary tests, procedures and specialist referrals etc), and in improving the
productivity of the population by assuring equitable access to health care
for all.
References
Berman, Peter and M E Khan (eds)(1992): Paying For India’s Health Care, Sage
Publications, New Delhi.
Duggal, Ravi, Sunil Nandraj and Asha Vadair (1995): ‘Health Expenditure
Across States - Special Statistics’ Part I and Il, Economic and Political
Weekly, 30:15 and 16, April 15 and 22, 1995.
Jesani, Amar and Saraswathy Ananthram (1993): Private Sector and Privatisation
in Health Care Services, FRCH, Bombay.
NSSO (1987): Morbidity and Utilisation of Medical Services — Report No 364,
National Sample Survey Organisation, GOI, New Delhi.
Tulasidhar, V B (1992) : State Financing of Health Care in India, NIPFP, New
Delhi.
World Bank (1994) : Policy and Finance Strategies for Strengthening Primary
Health Care Services — India, Report No 13042-IN, World Bank.
Ravi Duggal
CEHAT
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Gender Politics in Mental Health
Care in India
Bhargavi V Davar
Studies in the area of physical health show how the organisation
of health care in the country has been designed to privilege
a certain class at the expense of others, depending upon the
socio-economic status and thefunction of individuals in a society.
It is well-documented that women in particular, have been the
enduring victims of this political organisation of health care.
This paper aims to explore gender politics in the area of mental
health care in the country, an area which has, to date, received
scant attention from women’s organisations and health organisations alike. The information has been structured to include four
gendered areas of the public domain: the social, the institutional,
the planning and the legislative areas.
HEALTH care as an institution is organised according to the
socio-political priorities as perceived by the state, health planners,
health professionals and other interested institutional administrators of different health service outlets. Studies in the area of physical
health show how organising health care in the country has been
designed to privilege a certain class at the expense of others,
depending upon the socio-economic status and the function of individuals in a society. It is well-documented that women, in particular,
have been the enduring victims of this political organisation of
health care.
This paper aims to explore gender politics in the area of mental
health care in the country, an area which has, to date, received scant
attention from women’s organisations and health organisations alike.
The information has been structured to include four gendered areas of
the public domain: i) the social ii) the institutional 111) the planning and
iv) the legislative areas. A very important dimension, highly relevant
to the politics of gender in the causation and treatment of mental
illness, is the private domain; that is, the family. However, this is a
topic that requires comprehensive treatment by itself and hence has
not been included in this paper. This paper addresses only the public
dimension of mental health care in the country from the viewpoint of
gender politics.
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I
Society and Mentally Il] Women
An analysis of the interaction of society with mentally ill women may
be treated in three parts; first, by processing information on the utility of
and access to available mental health care facilities by women; second, by
examining the social perceptions relating to end the treatment of mentally
ill women; and third, by showing how our social organisation affects the
access to such treatment by women.
UTILIry
OF MENTAL HEALTH SERVICES
Secondary data [Davar 1994] on the prevalence of mental illness in the
community show that women are more frequently ill than men, with 15
per cent of them being ill as compared to only 11 per cent among men. In
the West, the percentages of prevalence of mental illness among men and
women are 12 per cent and 22 per cent respectively.
Institutionalised mental health care is available at different ‘levels’ in
our society [Goldberg and Huxley 1992:4]: The community at level 1
through primary health care, identification of illness in general practice,
psychiatric clinics and nursing homes, and finally, at level 5, in-patient
psychiatric wards in hospitals and mental hospitals. In India, access to
care is complicated by the availability of non-professional options such
as native healers, exorcists, mystics, healing temples, and so on. The
diversion of mentally ill persons to non-psychiatric professional care,
such as general practice, also confounds the issue of the utility of mental
health services in the country.
Studies [Parthasarathy, et al 1981] show that between one-third to one-
half of patients admitted for treatment drop out early and eventually only
one-third of the original lot remain till the end of their treatment. The poor
attendance and follow-up at professional mental health facilities is often
linked to social perceptions about the mentally ill, other than the often
deplorable, or otherwise uninspiring and irresponsible methods of providing care at many of the mental health care facilities, particularly the
hospitals and primary health care centres.
In general, therefore, the utility of mental health services is not
commensurate with the prevalence of mental illness in the community.
Gender further heightens this discrepancy between prevalence and
utility. While in the west, more women report at psychiatric facilities, in
India the trend is reverse. The proportion of women attending the
facilities is very low, as compared with men. This low attendance is partly
explained by the non availability of resources for women. The traditional
mental health services appear to primarily cater to the needs of male
patients. Primary data shows that mental hospitals and private psychiatric
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centres with in-patient facilities show gender-based discrimination in
terms of availability of beds [Channabasavanna et al 1981]. The
male:female ratio in the allotment of beds in government mental hospitals
with only service is 73:27. The ratio is 66:34 in the case of government
mental hospitals with service, research and training facilities. Private
psychiatric centres show a 60:40 ratio, while at NIMHANS, Bangalore,
the ratio is 59:41.
|
The rates of admission to the different mental health facilities also
show a marked gender difference, a difference not in keeping with, but
rather the reverse of, the difference in prevalence of mental illness at the
community level. In other words, even though women are more frequently ill in the community, their utilisation of mental health services
is significantly less than men. N S Vahia and others (1974) note that at
KEM Hospital, Bombay, the male:female attendance ratio over a period
of twenty years has consistently been 2:1. This figure is consistent with
data reported from other places. Sethi and Gupta (1972) when comparing
the profiles of hospital patients with private patients, note that female
patients are under-represented in both the groups. According to this study,
the male:female ratio is around 59:41 per cent in the case of the hospital,
whereas the discrepancy is higher in private practice, the ratio being
62:38 per cent. At the mental hospital, Hyderabad, the number of female
and male patients for the year 1990 are 488 and 1066; for 1991, the figures
are 716 and 1925; and for 1992, the figures are 702 and 1880 respectively.
But at the community health care unit of this mental hospital, there is
parity of attendance by male and female patients.
|
Even though there is no significant gender difference in the prevalence of mental handicap in children, access to mental health care
shows great gender-based inequity. Narayana Reddy (1991) notes that
the male to female ratios in the utilisation of available facilities range
from 6:1 to around 3:1. At the National Institute for the Mentally
Handicapped, Hyderabad, there were only 566 female admissions in
a total of 1638 for the year 1993. At the mental hospital, Hyderabad,
there were 10 male children as compared to one female child with a
mental handicap for the year 1991; for the year 1992, 24 male children
reported for treatment as compared to only 11 female children. In
many of the special day care schools in Hyderabad, male children far
outnumber female children.
Parents with handicapped girl children are less motivated to send
them to these institutions for rehabilitation. There are no economic gains
in doing this, as there might be in the case of boys, who can still be trained
for some useful employment. The mentally handicapped girl child is
_ useful around the house, helping out with the household chores. As she
is unlikely to get married, the parents would think it a waste to expend
resources, material or psychological, on her. Parental anxieties about
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protecting her modesty against possible violations is also very high.
Institutions also are wary about taking mentally handicapped female
children because it heightens their moral responsibility. Thus, the handicapped female children are ‘somehow managed’ within the confines of
their homes.
The institutional treatment of these children also shows gender discrimination. More passive and less creative treatment methods are adopted
by these institutions with respect to girl children, who are in a minority.
No vocational training is given them and play is not suited to their needs.
The recent abuse of professional authority on mentally retarded girls in
Sirur, Maharashtra, and the institutional defense of clinically unjustifi-
able hysterectomies performed on them is only an acute symptom of an
established syndrome of gender discrimination in the institutionalised
care of mentally retarded girl children.
‘ SOCIAL PERCEPTIONS
In general, the mentally ill, whether male or female, are forced to suffer
a social stigma in addition to their incorrigible psychological suffering.
Prabhu et al (1984) provide a good review of studies on public attitudes
towards the mentally ill in Indian communities. The authors note that
several studies by them in Delhi generally showed that
the educated lay persons viewed the mentally ill as aggressive, violent and
dangerous. Optimism about the outcome of treatment was not high. There was
a lack of awareness about available facilities to treat the mentally ill. Pervasive
defeatism and a tendency to reject the mentally ill existed in the sample
study (p 7).
Another study in Raipur Rani showed pessimistic attitudes of the
community towards mental illness. Even though the urban, literate
sample showed a more benevolent attitude towards the mentally ill, they
also showed a lack of awareness about illnesses and different psychiatric
facilities. Boral, and others (1980) showed that more individuals accepted
and preferred magic healers, ayurveds and homeopaths to psycho-therapists. A majority believed that marriage will cure mental illness, though
paradoxically, a majority also did not want to form matrimonial alliances
with a mentally ill person.
Social attitudes towards and understanding of mental illness in women
are much more pernicious than that towards men. Veida Skultans’ (1991)
study showed this. She evolves a ‘hydraulic model’ of illness: the
explanatory models that a community offers for mental illness in an
individual and the subsequent approach towards treatment of the illness
depends upon the social position that he or she occupies in that community, so that there is a multiplicity of explanations contingent upon the
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community’s hierarchies and attitudes towards the individuals in these
hierarchies.
Thus, mental illness in women and men is perceived and explained
differently by Skultan’s community sample in Maharashtra. A mentally
ill man was an economic burden, but a mentally ill woman was an
economic as well as a moral burden. Mentally ill women in her sample
were severely condemned for any behaviour that could be perceived as a
violation of feminine nature and modesty, such as tearing off clothes,
violence towards others, lack of attention or irreverence towards the
preparation or consumption of food, neglect of children, etc. Mental
illness in women
was seen as a moral disgrace to the family, so that
censure, neglect, rejection and isolation was commonly associated with
her illness. Not so in the case of men. Mental illness in men was a cause
for sorrow, but not disgrace.
In terms of ‘cure’ too, at the native healing temples where Skultans’
study was based, gender differences were seen. Most of the informants
felt that the responsibility of care of amentally ill woman, even if married,
will fall upon her own family and not her husband’s or her in-laws’.
Because of this attitude, it is likely that many mentally ill women receive
no social support, either from their own family, or from the family into
which they marry. For, in the perception of their own parents and siblings,
they would be considered as belonging to their husband’s family. There
would be a clash of interests and betrayal of responsibility by both the
families in the event of her mental lness. In Skultans’ sample at the
temple too, it was seen that men had greater social support than the
women.
All the men,
but only half the women
in the study were
accompanied.
In Skultans’ study, to bring about the cure of the menfolk, the women
accompanying them tranced. It is often considered the duty of their
women to trance, in order to share or take over the ‘pida’ of the men they
accompany. Women, relatives, in-laws and other kinsfolk all participated
in the cure of the afflicted man. Mentally afflicted women, on the other
hand, tranced on their own behalf and others did not participate in the
sharing of their ‘pida’. Thus, the occurrence of mental illness ina woman
is considered a moral violation for which she is solely responsible,
whereas such illness in a man is not interpreted likewise. In his case, it
becomes a community responsibility with women again bearing the
moral burden of his ‘cure’.
Afflicted women are seen not only as a threat to domesticity and its
routines, but also, as a threat to its valour and its honour. Married and
mentally ill women are more likely to be sent back to their natal homes,
abandoned, deserted or divorced. Greater social losses, such as loss of
- spouse, family, children, befall mentally afflicted women more than men.
Neglect and rejection as the aftermath of stigma better characterise the
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status of amentally ill woman than that of aman. The psycho-social stress
acting on a mentally ill woman is likely to be greater than that acting on
a mentally ill man, for his role in the family has always been minimal and
restricted to its economic upkeep. Women, on the other hand are seen as
being at the centre of domestic life, maintaining its care-giving, nurturing
and moral functions. The pressure on them against relinquishing these
functions during illness episodes would be high. Despite this, the loss of
a woman to the family is not perceived by our community as being very
great unlike the loss of a man, for the latter implies deviance from the
patriarchal stereotype of being male-headed. Thus, a mentally afflicted
man would still be cared for and would still retain some amount of human
dignity and integrity within the household unlike a mentally afflicted
woman. She would very likely not only be abandoned or rejected, but also
more stressed because of her perceived guilt in having relinquished her
role-related functions.
The gross neglect of mentally ill women is also evident from the way
society treats chronically ill women in mental hospitals. Studies from the
West [Bachrach and Nadelson 1989] show that two-thirds of the chronically ill in the US are women. Thirty to 90 per cent of homeless women
in the West are mentally ill, some of them severely ill [Martin 1989].
Geller and Munetz’s (1989) study on 22 chronic institutionalised women
showed that during institutionalisation, five lost contact with their husband, and were divorced or separated; another five lost contact with her
family and their siblings; seven lost custody of their children. There were
some with multiple problems, such as loss of employment, loss of
housing, and so on. Inexplaining the reasons for prolonged stay of women
in institutionalised care, the authors stress economic reasons, such as
the fact that men are more indispensable to a family than women. The
authors suggest that women may be more willing to take care of their
mentally ill or ex-patient husband than men. Their study corroborates
this, for while six of the women were married at the time of admission,
five of them were divorced after admission, and only one married during
hospitalisation.
In our own context, there are few comparable studies on long-stay
women patients in mental hospitals or about destitute and mentally ill
women abandoned in hospitals, or living on the streets or inside
supposedly healing temples as beggars. An early study by Gupta and
others (1968) at the Ranchi Mental Hospital showed that even though
the female to male ratio upon admission to the hospital was only
29:71, long-stay patients showed a preponderance of women — 67 per
cent were women as compared to 33 per cent men. The trend indicates
that fewer women get admitted for care, but once admitted, a large
proportion stay back as long stay patients as compared to men. The
authors write:
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The community seems to be one that takes the male patient back once he has
improved or has recovered. The dependent status of the women in the Indian
setting, the not too uncommon phenomenon of de facto separation of the
husband and the wife on account of wife’s mental illness leading to the
exclusion of the women from the family constellation probably contribute to
their prolonged stay in the hospital [Gupta et al 1968: 159].
Noting that there were almost as many married women in their sample
as single women, the authors lament that this could be because of “the
double standards of morality in our society”, for a man with an afflicted
wife would remarry leaving her to her fate in the mental hospital. A
woman with an afflicted husband would still want to restore him back in
her home.
are
Studies show that mentally ill women receive fewer visitors than
similarly ill men. A greater number of women patients are certified rather
than voluntary, whereas the trend is reverse for men, indicating perhaps
that it is more difficult to hospitalise a man against his will than of
women. Gupta’s study of the long-stay patients showed that a greater
percentage of women did not require hospitalisation as compared to men,
though maladjustment was high in both groups, which the authors
attribute to the drab conditions of the mental hospital. It is pertinent to
note Geller and Munetz’s (1989) observation that in the hospitals, women
are seen as ideal patients by the staff, for they are compliant, passive,
dependent and submissive. In their own study, most of the women longstay patients were contributing to the hospital activities, like running the
cafeteria, etc.
:
There are problems associated with being a long-stay patient, other
than the loss of social contact and the sense
of loneliness and isolation.
Most long-stay patients tend to be on some minimum dosage of drugs,
even though they may be asymptomatic, because of a growing dependency on them and the anxiety of relapse. These drugs in the long-run
produce irreversible side-effects, such as tordive dyskinesia. Their physical, especially gynaecological problems and problems associated with
aging are usually neglected. It is unfortunate that very little information
is available on the plight of chronic and long-stay women patients in
mental hospitals in India. Research should be initiated in this area, to help
us understand better the physical, economic and social misfortunes that
befall seriously ill women.!
’
SOCIAL HIERARCHY
In order to delineate the context within which we may discuss the
effect of social hierarchy on the access to mental health care by women,
we need to understand the established distinction between the ‘severe’
mental disorders and the ‘common’ mental disorders.
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Disorders such as schizophrenia, depressive psychoses, mania, epilepsy, mental retardation, and organic brain disorders can usually be
treated as severe mental disorders. Neurotic disorders, major depression, hysteria, obsessive-compulsive disorders, anxieties and
phobias, somatisation disorders can be classified as being common
mental disorders.
The clinical picture between these two categories of disorders varies
remarkably. The severe disorders often include symptoms of marked
cognitive impairment, such as auditory and visual hallucinations, para-
noid delusions, thought disturbances and loss of reality. Often, there is
also associated hostility and overt aggression. The degree of cognitive,
personal and social impairment is very high in the case of the severe
mental disorders.
In the case of the common mental disorders, even though personal
distress may be very high, there is often no significant cognitive breakdown. Manifestation of illness can be physical, such as in the case of
hysteria and somatisation disorders. Mood changes, anxiety, gloom,
misery and hostility might be present in these disorders also to some
extent, but not to the level of a personality breakdown. Usually social
functioning is seriously impaired, and family discord and maladaptive
family interactions may be common.
The characterisation above is a phenomenological description of
illness behaviour. The distinction between severe and common mental
disorders also becomes apparent in diagnoses. Severe mental disorders
have a stable symptomatology. Disease entities are clearly demarcated
and usually no overlap exists. Diagnostic categories are also stable over
time and. retain their reliability between observers following different
categorical systems of diagnosis. For common mental disorders, however, most of these criteria do not hold and a multi-axial model
of
diagnosis is more suitable [Goldberg and Huxley 1992].
It is important to note that calling a class of disorders as ‘common
mental disorders’ does not necessarily imply that they are mild or
that they cause very little personal suffering. They can cause enormous suffering, including chronicity. They often cause irreparable
social alienation, loss and damage. Social networks and relationships
can suffer.
It is now accepted, and my own report [Davar 1994] also corroborates
this, that about twice as many women suffer from common mental
disorders than men, even though in the severe mental illness category, the
prevalence of illness is homogeneous across gender. Between 7-10 per
cent of women in the community may be suffering from common mental
disorders. Somatisation disorders, neurotic and major depression and
phobias are especially more frequent among women [WHO Report
1993]. Men are more frequently ill only in the category of personality
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_
disorder, but the status of this disorder as a kind of mental illness is
questionable.
That the common mental disorders are by and large undetected in the
community is shown by an interesting study by Isaac and Kapur (1980).
The study itself had the aim of comparing the cost-effectiveness of three _
different methods of psychiatric case identification in the community. It
was to find out which method was the most cost-effective. The three
methods used were: (i) asking about 5 per cent of the patients attending
the PHC about other patients they know who might be suffering from
mental disorders; (11) asking the head of each family, presumably male;
and finally iii) a full-fledged community survey.
Data from this study suggests that the professional evaluation of
disorders, as shown by the community survey, differs markedly from the
social evaluation of disorders, as shown by the other two methods. This
is especially true of the common mental disorders. Epilepsy and psychoses were detected equally well by all the three methods. In the case of
mental retardation, it was intriguing that the heads of families reported 15
cases, whereas actual prevalence, by professional estimates was only
four. Community survey showed 31 cases of depression, of which only
five were reported by the method (ii). Of the 20 cases of hysteria and
possession present in the community, only nine were reported by the
heads of families. Anxiety neuroses, other neurotic symptoms, somatisation
disorders were not reported at all by the heads of families, whereas the
community survey showed 25, 78 and 159 cases respectively. From this
data, we see that of the
313 cases of common mental disorders, only 14
were reported by the heads of families. That is, as little as 4.4 per cent
cases of common mental disorders were detected or reported by the
heads of families. From my secondary data on the wide prevalence of
common mental disorders among women, we can safely assume that a
large majority of these undetected cases were women.
We must speculate why these disorders are not detected. Lack of
awareness about mental illness is often cited as a reason by professionals,
but this alone is not enough. We must include, as an important explanation
of the reason for this neglect, the widely prevalent insensitivity to the
health needs of women. It is quite possible that even where mental illness
is grossly evident in women, it is neglected. Any understanding of the
neglect of mental health care of women must emphasise this genderrelated aspect of prioritisng health care among members of the family.
The decision about providing health care to the members of a family
usually rests with the male heads of families. They are more preoccupied with their jobs and other practical matters of managing the
family. Lack of awareness of mental illness is complemented by a lack of
attention to the psychological and in general, the health needs of the
womenfolk of the household. It is not surprising then, that Issac and >
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Kapur’s study showed such a gross neglect of common mental disorders
by the heads of families.
But more importantly, in large joint families, where hierarchy and
power equations are very strong, women usually reside in a very inferior .
place, especially younger women in the reproductive age group of 16 to
40 years, who, as my report showed, are more vulnerable to the common
mental disorders. Interaction, even intimacy, between spouses is by
protocol and is restricted to minimal and necessary contact. Women by
and large occupy the inner recesses of the household, isolated from the
men of their own families and other outsiders. Thus, a rigid hierarchy
defines gender interaction both spatially and functionally. Any profound
interaction between the sexes is often negligible and discouraged, and
expressed emotion is very low. Verbalising problems and conflicts is
rare, so that it is very unlikely that men will know of the stresses or
inner conflicts of the womenfolk. Acknowledging the existence of such
‘inner’ problems is considered taboo and have a low priority compared
to physical problems.
It is inconceivable, and would be aggressively thwarted in case it
happened, that in a joint family, the youngest ‘bahu’ will confess to her
father-in-law, the decision maker, about her sleep or thought distur-
bances, her weepiness, her irritability or about her vague somatic
symptoms. The elderly women, especially the mother-in-law and the
elderly ‘bahus’ in the household are most unlikely to listen to or under_ stand the psychological needs of the younger ‘bahus’. Hierarchy among
women in these households are also very rigidly defined and discussing one’s innermost turmoils would be considered impertinence.
Further, acknowledging inner conflicts usually connotes, in our culture,
a sign of weakness, which is tolerated philosophically but not treated
as a health need. Especially in women, the acknowledgement of such
problems would be construed as selfishness. Thus, social hierarchy in
Indian families would ensure that women’s mental health needs are
neglected.
Common mental disorders, as mentioned above, are not crippling:
they do not cause a major cognitive breakdown. But this does not imply
that they do not cause immense suffering to the ill woman or stress in the
family. Family discord, isolation of the ill woman, maladaptive ways of
crisis resolution, bad parenting and a limited social life are possibly the
long-term consequences of neglecting these mental illnesses. Eventually,
they can cause chronicity in the woman, aggravate her sense of isolation,
cause adjustment and maturation problems in her children and alter their
perception and ways of social, and more importantly, gender relations.
For example, the mother’s rather bizarre behaviour would contribute and
mould the sons’ perceptions of women in general, and eventually determine his attitude towards his wife and other women that he comes into
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contact with. This is especially true in the case of major depression, which
is very Common among women.
Where common
mental disorders are not identified as illness, and
further, chronicity sets in through its continued neglect, the illness
behaviour itself can become established as a way of life. It then becomes
impossible for a close family member to differentiate her personality
from the symptoms. Functionally they become identical, so that an ill
woman is labeled as a virago, ahysteric, a violent woman, a trouble maker
and so on, and these are used to describe her personality itself. Her illness
behaviour will be construed as her nature. The chronicity of a mental
illness begins to get treated as a personality problem. This possibly leads
to further alienation and avoidance of the iil woman by those around her,
re-establishing the illness pattern. For example, having to live with a
depressed woman who weeps all the time and persecutes others during a
depressive episode might result in the husband or grown up sons staying
longer hours away from home, and maintaining little inter-personal
contact with her.
Our social way of life, its hierarchies, gender relations and social
structure,
other than our perception of mental
illness, all contribute
towards the large scale neglect of mental illness in women. Where illness
is recognised, great social and economic losses typically characterise the
society’s response to it. Utilisation of services by these women is
negligible, showing that when a woman needs care, she does not get it. On
the other hand, institutionalised settings shelter clinically cured women
who are not claimed by their families, showing that providing care in
hospital settings actually hampers their further chances of re-habilitation
and re-socialisation in the society. Under the present social circumstances
where mentally ill women are condemned whether they get professional
care or not, it is very hard to make intelligent choices about the approach
to their illness.
II
Institutionalised Mental Health Care
That science is gendered has been partly acknowledged for some
time now. Mental health sciences are no exception to this, and several
studies in the West have emphasised different aspects of this gender
bias in the theory, practice and planning of these sciences. The discussion here will not review or elaborate all these different aspects of
gender bias in institutionalised mental health care, but only those which
have repeatedly cropped up in the Indian context from my study of the
literature.
One important issue which requires definite mention and debate is the
attribution of personality in the explanation of mental illness. This is a
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well established tradition in the West, the claim being that the cause of
illnessis not social, butrather psychological. Certain predisposing factors
in an individual result in the illness, in an otherwise benign and lifeenhancing environment.
Personality attributions, however, usually take the form of circular
definitions, claiming, for example, that a hysterical personality causes
hysteria, or a neurotic personality causes neuroses. While some studies
show that cognitive factors are indeed associated with the cause and
course of illness, studies on personality are riddled with methodological
difficulties and are often inconclusive. Sometimes explanations of mental
illness by referral to personality attributions can be carried far beyond
what the science warrants. When this happens, we must conclude that it
is not science, but rather politics which has inspired the explanation. The
explanation must, in other words, be rejected as being pseudo-scientific
and political.
For example, it has often been claimed by professionals that women
are more frequently ill because they are naturally more dependent, more
submissive and more introverted than men and all these factors makes
them more vulnerable to affective disorders. Henderson (1981) explicitly
gives a biological and genetic basis to personality in women to explain
greater neuroses in them. For him, women are prone to neuroses because
bio-genetically nature predisposes them towards this disorder. In our own
context, Ponnudurai (1981) in explaining greater frequency of hysteria in
women notes that “the feminine role inherently sanctions greater reliance
on others for love, affection and solace” (p 50).
There is no empirical warrant to suggest that dependency, introversion, passivity, “need for love’, moral rigidity and other allegedly
feminine attitudes which predispose her to mental illness, are in any
way natural. Any bio-genetic explanation of this naturalness would
have to be extremely complicated\indeed. Such an explanation, if
possible at all, belongs in some distant future in any case. The point is
that many of these supposedly feminine attributes have, not a
natural, psychological basis, but rather a psycho-social basis. They
are given a primary place in the socialisation of girl children and in their
sex-typing, the acculturation of individuals within a gender type beginning very early in development. The so-called naturalness of the feminine
personality which makes her eventually ill has a social genesis, deriving
from the patriarchal model of child growth. Itis not fair, and not scientific,
to use a social explanation as a bio-genetic one. This only shows the
gender bias in the professionals’ model of explanation of illness. It is
cruel irony that women must first be forced into valuing certain stereotyped concepts as virtues during the process of their socialisation, and
later on, when they are ill, be damned for these very same values by
professionals.
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Another commonly cited ‘natural’ feminine attribute which is causally
associated with mental illness is their ‘need for love’ and ‘care-eliciting’
behaviour. Henderson, for example, (1983) favours the view that neurotic
behaviour, which is common among women, is
a communication of affective discomfort which carried a corrective effect by
bringing about an increase in the caring behaviour shown by others to the
patient. It is not a new idea that psychiatric symptoms or behaviours act as
operants and are reinforced by the responses they elicit in those around the
patient (p 13).
Neurotic illnesses and depression are seen by him as “socially disruptive care-eliciting” behaviours (p 14).
Treating the cause of mental illness as a form of care-eliciting makes
it appear as if the ill woman is indulging in some form of malingering and
pretense or is demanding more attention than what she should objectively
need. This view of mental illness gives one the impression that, contrary
to the reality of the social situation, and contrary to average individual
expectations from this situation, some women demand more attention,
love and caring. The view implies that it is not the social environment
which is violating a woman’s integrity, but rather, it is the woman who
indulges in ‘socially disruptive’ behaviour. In other words, while the
world is in paradisical harmony with her being, it is she who disrupts this
tranquility with her own greedy and voluptuous need for love and caring!
Sometimes this view can border on the grossly sexist: Bagadia and
others (1973), for example, explain mental illness among young married
women by referring to their immature personality and “marked pampering at parents’ place” (p 182). They imply that the ill women’s marital
homes left nothing to be desired, and if, despite this, they were ill it was
because they were not mature and had been too pampered at their parents’
place! Further, in explaining greater hysterical illness among women,
they note that most of the ill women were from outside of Bombay and had
an unconscious desire to stay with their husbands, who were all working
in Bombay. Therefore, these women had an “important secondary gain”
in being hysterics.
From the women’s perspective, we must strongly reject these kinds of
pseudo-scientific explanations. The description of women as being more
demanding, more emotional, more care-eliciting and more dependent,
which characterises the professionals’ perspective and approach to the
treatment of mental illness in women, reflects only our own culturally
pervasive gender biases and cliches. The need to be loved and cared for,
which the professionals claim predispose the women towards illness, is
a genuine need. A woman who expresses this, even through illness, is not
exhibiting any natural psychological deficits, incommensurate with her
social situation. Rather she is only saying that she is a victim of certain
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pervasive social deficits that so grossly characterise the lives of so many
women. It is not so much the case that women are demanding more than
their fair share of affection and love, but rather, their social status in
society denies them that which any individual rightly deserves. Men, by
virtue of being the eldest son, the only son, the bread-winner, the head of
the family, in short, by virtue of being male, are automatically taken care
of and given all the caring that they need for adequate emotional strength.
The entire family consolidates to give the psycho-social support that a
man needs. This is hardly descriptive of the average Indian woman’ life,
where she is to be an unstinting care-giver without demanding care in
return.
It is women who are the typical victims of domestic violence, molestation, verbal and mental abuse, eve-teasing, rape, childhood
sexual
abuse and other forms of violence. These acts of male aggression are
blatantly violative of individual integrity and can hardly be described as
normal care-giving behaviours. Depression, shock, trauma, somatisation
disorders, phobias, anxieties, sleeping and eating disturbances, and other
common mental disorders are the common consequences of male violence against women. In explaining illnesses in these victimised women,
can we Say, as the professionals often insensitively do, that these women
are somehow expecting more than what they deserve? Are the professionals infact saying that women deserve only these kinds of behaviour from
society and their male partners, and cannot expect anything more? We
must question the professional viewpoint that it is the women who are
behaving in socially maladaptive ways by expecting more from their
loved ones. Rather, some kinds of mental illnesses in women is a logical
response to the programmatically violent ways in which the society and
their loved ones treat them.
We see that it is culturally backed gender bias which colours these
professional perspectives, ironically twisting the fate of the victim of
illness in such a way that she becomes her own tormentor, while the actual
tormentors get away scot-free. It is this attitude by professionals which
has elicited the wrath of thinkers working on women’s health issues. They
point to the double victimisation that women are subjected to: first, social
imperatives, values and expectations make women respond by adopting
symptomatic behaviour; and when their behaviour reaches diagnosable
levels, they are further subjected to treatment methods that presuppose
the very same values that led to the illness in the first place. Broverman,
Broverman and Clarkson’s (1970) study showed that clinical practice is
often determined by the “highly consensual norms and beliefs about the
differing characteristics of men and women” (p 1).
Social workers and marital counsellors have also come under attack
for perpetrating social inequalities through their treatment methods,
which implicitly acquiesce to the existing loci of power [See, for ex196 ©
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ample, Maynard 1985]. Maynard’s study of cases shows how these
professionals treat violence as an individual’s problem, specifically, the
victim’s problem and not as a social problem. Shabby housekeeping or
appearance, bad cooking, etc. are seen as valid justification for wifebeating, even though the pattern of violence is well-established and goes
beyond these instances. Social workers label the battered women in terms
of their appearance and behaviour and deconstruct their stories and lifeexperiences as a battered wife, thus questioning their credibility. They
disbelieve their story, analyse their personality and pass judgments on it,
minimise the husband’s excesses, try to see wife-beating as an accident,
not as a pattern, and believe the husband’s reasons and justify them. By
making the woman culpable, they further diminish her already battered
self -esteem and do not provide the care or protection for which they were
approached iin the first place by the battered women. Flavia (1988) notes,
in the Indian context, that in our society
A woman who does not accept the traditional role of submissiveness
and subordination needs to be ‘advised’ or ‘tamed’ into accepting this position, and any means including violence is justified in achieving this goal.
Counsellors and social workers also contribute implicitly towards this ideology when they question a woman who gets beaten: ‘What did you do to
provoke him?’ (p 152).
Gender bias in professional mental health has not been studied comprehensively in the Indian context and is an issue of great concern. The
fact that research and professional attention has not focussed at all, until
very recently, on women’s mental health issues is itself symptomatic of
the gender-bias which exists in the professions. As recently as 1990,
Somasundaram (1990) elaborates what, to any individual minimally
sensitive to the politics of gender, appears to be crudely sexist. In the
official mouthpiece of the Indian Psychiatric Association, he whole-
heartedly writes in approval of Vatsyayana’s conception of a virtuous wife:
She should act in conformity with his (the husband’s) wishes as if he were a
divine being, and with his consent should take upon herself the whole care of his
family. She should keep the whole house well cleaned and make the floor
smooth and polished so as to give the whole a neat becoming appearance. She
should surround the house with a garden. She should behave with decorum
towards the parents, relations, friends, sisters and servants of her husband. She
should always be accompanied by her husband, properly attired while visiting
friends, relatives and temples. She should avoid bad expressions, sulky looks,
speaking aside, standing in the doorway, and looking at passerby, conversing in
the pleasure groves and remaining in a lonely place for a long time. She should
always keep her body, her teeth, her hair and everything belonging to her tidy,
sweet and clean (p 258).
The author further exposes his ignorance of the contemporary
woman’s social problems by recommending this traditional view of the
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ideal wife as being an universal and eternal one. As if it were not enough
that he alone should hold and defend this noxious view, he urges other
family and marital therapists to adopt it in their day-to-day dealings with
their patients!
il
Mental Health Policy and Women
Our current National Mental Health Programme (1982) also reflects
this culturally pervasive insensitivity towards the mental health needs of
women. This policy prioritises epilepsy and psychosis, the severe mental
disorders; whereas, as noted above, it is the common
mental disorders
which are frequently found among women in particular, and in the
community in general. Harding et al’s (1980) study showed that the
frequently reported disorders at the community level are the common
mental disorders and not, as NMHP assumes, the severe mental disorders. Harding and others therefore rightly question the discrepancy of
our policy with the needs of the community.
Our national policy reflects only the priorities of the WHO recommendations, which is informed by cost-effectiveness of implementation of
policy rather than community need. The severe mental disorders are more
easily managed through the infrastructure presently available for addressing the health needs. It is notable that the NMHP,
as per the WHO
recommendations, ties the mental health programme to the already
existing primary health infrastructure in the country. So the mental health
programme does not need extra investment in terms of infrastructure. The
severe mental disorders respond more effectively to drugs, ECT and other
psycho-pharmacological methods of treatment. Short-term interventions
are usually adequate, recovery is often swift and relapse predictable. Even
though social support is important in maintaining mental health, no
radical changes need be made in social support or networking systems.
Long-term professional or para-professional investment is not required in
the management of these disorders. Limitations in infrastructure and
personnel, especially para-professionals are ground realities of the mental health care movement in the country.
Common mental disorders on the other hand, even though their
frequency is much greater than the severe mental disorders, are not cured
by short-term interventions alone. They usually require deep insight into
the social reality of the patient, their socio-cultural background, biases,
imperatives and expectations, their social networking patterns, and so on.
At the community level, understanding the regional cultural ethos might
be essential, requiring study of the acceptable ways of social networking,
the stress points of this networking and working out effective, therapeutic, culture-relevant options. Psycho-pharmacological interventions can198
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not be used in isolation for treatment, and often, counselling, family
therapy, group therapy, etc. may be required. All this needs long-term
social planning and additional infrastructure, especially augmenting the
medically trained psychiatrists and doctors with adequate para-professionals such as psychiatric social workers, psycho-therapists and counsellors. The proportion of para-professionals to professionals in our
country is very low. The NMHP (1982) is heavily dependent, for its
success, upon the PHCs staffed by medical personnel. Even elementary steps in mental health care management, such as case-identification
become complex problems in the hands of the PHC staffers [Srinivasa
Murthy et al 1987]. Prioritising common mental disorders will therefore
involve re-organising the existing mental health care infrastructure in a
radical way. It will at the very least require additional training to mental
health professionals and para-professionals in treating the social basis of
these problems, other than treating their purely physical basis. Targeting
the common mental disorders, in other words, will require a social
commitment from the professionals, rather than the hitherto practiced
clinical commitment. The latter alone is sufficient in the treatment of the
severe mental disorders. Therefore, even though only a very small
percentage—around one per cent, is severely mentally ill, and an even
smaller percentage is ill with the specific disorders targeted by the
NMHP, the mental health policy of our country is in its entirety geared for
the treatment of this population. The policy is grossly disproportionate to
the needs of the community.
Our current mental health policy claims to codify a radical shift from
the medicalised traditional mental health practices, such as the mental
hospitals, to the social model of community care. In making this shift, it
has been hailed as a landmark in the history of our health programme.
However, in practice, it seeks to make minimal changes in the overall
perception and management of mental disorders. By prioritising epilepsy
and psychoses, it retains the orthodox medical approach to the treatment
of the mentally ill. Even though the policy pays lip-service to community
care, in actual practice it targets only those disorders which will respond
easily to the established medical models of treatment.
Further, by tying the mental health programme to the already existing
health infrastructure, our mental health policy becomes a mere appendix
to the health policy. Thereby, it aggravates the problem of medicalisation
of our approach to mental illness, ignoring altogether the psycho-social
bases of mental disorders. This approach of the NMHP must be questioned by those sensitive to women’s issue, because it is women who
suffer more from common mental disorders at the community level. It is
women’s psycho-social status which requires urgent professional attention and commitment. From the point of view of women’s mental health,
the NMHP leaves a lot to be desired, which cannot be rectified bymaking
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a few marginal alterations in the clauses, but rather only by altering the
entire foundations of the programme-from being based on cost-effectiveness to being based on community need; from being a medical model to
being a psycho-social model; from making a purely clinical commitment
to making a social commitment. The community care philosophy explicitly defended by the NMHP must be implemented as such, as promised,
and not in ways so as to establish the status quo.
The NMHP, by prioritising the severe mental disorders and further
medicalising our approach to mental health, promotes psycho-pharmacological methods of treatment, such as drugs and ECT. Gender discrimination in the treatment methods adopted have been emphasised in the
West. Studies have indicated that women are given more psycho-active
drugs than men; Hudson’s (1987) study also showed that women are
more frequently the victims of leucotomy than men. In our own context,
we have no information on any of these issues, though Smita Vir Tyagi
noted in an orally presented paper (1987) on ‘Women’s Issues in Mental
Health’ that Indian women got 60 per cent of the prescription for nonpsychoactive drugs and 67 per cent of the prescription for psycho-active
drugs.
|
Studies [Tyrer, et al 1993, 1988] show that there is no justification
for the greater preference for psycho-pharmacological treatments, especially in the case of neurotic disorders, which are more common among
women. Drug use may be justified in the case of neurotic individuals with
personality problems, but usually, there is no overall significant difference in the outcomes of drug treatment, behavioural and cognitive
therapies. This is true of anxiety disorders, panic disorders and some
kinds of depressive disorders.
It is often claimed, as a justification of the use of drugs and ECT,
that psycho-therapy is expensive. Our own mental health programme
seems to presuppose this by privileging only those disorders which are
responsive to chemo-therapeutic cures. The programme encourages
psycho-pharmacological alternatives rather than psychotherapeutic
ones. However McGrath and Lowson (1986) argue that in the long run,
it might be more economical to adopt psycho-therapeutic approaches:
somatisation and the consequent medicalisation of mental illness
uses up a lot of useful resources from general practice. Studies show
that introduction of psychotherapeutic intervention reduces 20 per
cent of the costs of medical services. Counselling may reduce GP
consultations, may avert hospitalisation and reduce relapses, and does
not require professional investment. These considerations are relevant in our Own context, where somatisation disorders are very
common in general practice, especially among women. From the
economic point of view, these somatisers are using up professional
time and resources. But more importantly, from the ethical point of
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view, they are probably being given hazardous and totally unnecessary medication.
The vicious embroilment of somatisers in general practice and the
medicalisation of a psycho-social problem has been emphasised by
WHO. The iatrogenic damage that can be caused by unnecessary and
prolonged use of drugs is especially stressed.
Failure to diagnose and correctly treat psychosocial disorders results in
iatrogenic damage. Thus it is wrong to use potentially toxic drugs when what
is needed is social support, or to rely on institutional care for patients who can
be restored to function while in the community (WHO 1987:6).
Another pharmacological treatment widely in use and implicitly
promoted by the medical model is electro-convulsive therapy (ECT) or
‘shock treatment’, as it is often crudely called. In the West, the inconclu-
siveness of the debate about whether ECT causes cognitive deficits or not
[Shukla, 1992] has resulted in the restricted use of the treatment. Whereas,
in Our Own country this inconclusiveness is taken to be a sanction for its
enthusiastic and continued use. Vahia’s (1974) study of the use of ECT
at KEM Hospital,_Bombay shows that ECT use has increased twenty
times in the last twenty years. Whatever the status of the research debate
about the justifiability of ECT, its practical implementation in our
hospitals and clinics leaves a lot to be desired. In a recent editorial,
Agarwal (1990) noted that surveys in the West showed ‘remarkable
deficiencies’ in the administration of ECT. Agarwal warns that “as a
developing country the situation in India is bound to be more disappointing” (pp 295). The cavalier use of ECT is recognised by professionals:
ECT is often prescribed in series, whereas correct ethical practice demands that treatment outcome is to be monitored after every single dose.
Conditions to be met for the safe administration of ECT, such as brief
pulse current and moderate supra threshold, cannot be satisfied in our
country because of the unavailability of sophisticated machines. Professionals are often not adequately trained for the correct administration of
ECT even at the post graduate level, and the question of patient’s consent
is very rarely looked into.
The professional defense of ECT only complements public demand
for the treatment. The study by Boral, Bagchi and Nandi (1980) showed
that an overwhelming 70 per cent of close relatives of patients favoured
ECT treatment, and an equally large 75 per cent of close relatives
favoured drug treatment; congruently enough, a whopping 76.8 per cent
of relatives were uncertain about the efficacy of psychotherapy.
The overail defense of ECT is built around the cost-benefit aspects of
the treatment, its relative inexpensiveness, simplicity of use and control
of long-term effects as compared to drugs. However, the restricted and
well-defended, but purely pharmacological choices that the professions
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give to afflicted individuals, between drugs and ECT, neatly sidesteps
the vast possibilities of non-invasive treatments like psycho-therapy,
"especially its comparative efficacy in the case of the common mental
disorders.
Doubtless,
there are cultural reasons
for these preferences, which
override professional ethical questions relating to making available noninvasive techniques in the treatment of some forms of mental illnesses.
Among these are the preference for physical cures, especially those that
border on the miraculous. Psycho-therapy is to some extent culture-alien
in our country. We appear to be a people who are less verbal, less
expressive and less emotional than the Westerners [Wig, et al, 1987].
Wig’s study showed that relatives of schizophrenic patients in India were
less hostile, less critical and less over-involved than their western counterparts, but also, they were less warm and less positive, leading to the
overall conclusion that we are on the whole a low EE culture. Psychotherapy demands an openness to inner experiences, capacity to differentiate these experiences, sophistication in self-understanding and capacity
to verbalise. In a country where introspection, especially among women,
has alow premium, and tacit understanding is the primary mode of interpersonal communication, it is understandable that psycho-therapy is
unacceptable.
However,
the professional and cultural defense of ECT and other
psycho-pharmacological treatments of mental illness, and the lack of
non-invasive alternatives such as psycho-therapy, reflected in the NMHP,
leaves the entire foundation of mental health sciences almost without an
ethic. The contradictions in the NMHP are evident, for, while it adopts the
philosophy of community care, it counters its own philosophy by limiting
the scope, priorities and implementation of the programme to the medical
model. If community needs, particularly, if women’s mental health needs
must be met effectively, community mental health care must have an
autonomous programme that gives due consideration to the wide prevalence of the common mental disorders. Community mental health care
must question the priorities of the NMHP, mitigate its contradictions,
debate the medicalisation of mental disorders and evolve ways of addressing the mental health needs of the community.
IV
Mental Health and Law
The current Mental Health Act of 1987 has been criticised for not
departing much from the custodial policy adopted by the Lunacy Act of
1912 [Dhanda 1993; Shah 1990]. Pertinently, it has been pointed out that
legislative changes have not kept pace with recent changes in mental
health practice from traditional custodial care to community care. The
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recent act refers only to hospital settings, where there is a predominance
of psychotic disorders; neurotic and other common mental disorders are
rare. The trend is reverse in the community setting. Again, as in the case
of policy, we see that legislation is not in conformity with community
needs, making us question the intent behind the law. The recent law only
addresses the procedures of commitment and discharge, length of stay,
etc, and attempts to reform hospital conditions for the patients, but
without departing from the custodial philosophy of the earlier law.
Legislative reform has been conservative, retaining much of the older
Victorian philosophy of custodial care.
The custodial philosophy with respect to the mentally ill intends, not
so much to protect the civil rights and liberties of the afflicted individual
but rather the state power in maintaining law and order in its territory.
Those afflicted with psychotic disorders, which the law primarily brings
within its purview, have the potential of being a social threat, of unleash-
ing violence on the community at large. They, more than the somatisers
or the neurotics, commit
more
offences in their ill state, and more
frequently become entangled in criminal cases. They are more often
delusional and paranoid and are often enough seen walking about unclothed and unchaperoned on the streets. It is important for the state to
control the behaviour of these people, just as it is important for the state
to control the behaviour of murderers, burglers, pickpockets, and so on.
The common concern of the earlier law and the present law is not so much
the human rights of the mentally ill roaming the streets or in the hospitals,
but rather the security of the state. Mental illness, under both the laws, is
viewed as a security problem and not as a human problem. Only this
conservative approach of preserving state control over individual
behaviour can explain the excruciatingly limited scope of the present
Mental Health Act.
Where the law relating to the rights of the mentally ill is so narrow and
the intent is state security rather than individual liberty, it is understand-
able that its very existence is being questioned by some professionals
[Channabasavanna 1985]. Channabasavanna urges that we do away with
the law altogether, because of the way it has complicated hospital
procedure. The author is responding to the dangers of external, particularly governmental control over the workings of the hospitals. The
professional resistance to interference and public control is evident
here. What is perhaps required is not that we do away with the act
altogether, but widen its scope and make it address issues pertinent to
current mental health care practice.
Women have been getting a raw deal from legislations relating to
mental health [Dhanda 1987]. The act grants the relatives of patients the
right to apply for commitment and to seek their discharge. In practise,
even if a woman patient has recovered and has been discharged by the
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Board of Visitors, her actual release will not occur unless her relatives come to claim her. It has already been noted in the context of the
discussion relating to chronic patients, that expecting such benevolence
from close relatives is far from realistic. Dhanda writes that the act
“presumes an identity of interest between the lunatics and their relatives.
The possibility of their interests being at cross-purposes with each other
is generally not recognised” (p 414).
Commitment to a mental hospital can be made on the authority of the
guardian, according to the law. Dhanda (1987) recounts cases where this
prerogative given to the family has been used against women. In one case,
a woman was committed by her husband to the mental hospital, because
he wanted to marry again; another unmarried woman was committed by
her siblings, because she was an economic liability to them. There was a
report from Hyderabad (The Hindu 1993) of a woman army official being
illegally lock up within the military premises from where she was secretly
moved to ahospital in Pune to have her committed as a mentally ill person.
The division bench of Andhra High Court directed the military and
hospital authorities to pay compensation to the woman.
Dhanda (1987) also reports other cases where divorce cases filed on
grounds of insanity, sought to establish insanity on the following grounds:
i) wife refused to consummate the marriage on the first night; 11) acted
familiar with strangers despite being warned; iii) did not bathe daily,
despite being a brahmin; iv) put too much salt and pepper in the food; v)
cried in Bowbath ceremony before the guests; and finally vi) did not
properly receive the relatives of the husband. There have also been cases
where medical superintendents of hospitals have colluded witha woman’ s
husband to have her committed. One district judge granted divorce on
grounds of insanity, based solely on the husband’s written affidavit.
Dhanda reflects that given male bias, even psychiatrists’ certification
may only affirm the prevailing gender equations and discredit the woman’s
sanity. She reports two cases where such a bias might have existed in the
professionals’ certification.
Now all these above cases are of women whose legal rights have been
violated using insanity as a ground. But very little can be said about the
civil liberties of mentally ill women, because their rights are not protected
at all by law. Their right to property, to contract or will their property, to
deal with their assets in any way they see fit, and so on, are all complicated
by their mentally ill status. Acts of violence done to themselves and to
others during a depressive fit, for example, would not receive the court’s
sympathy. If cases of bride burning are regularly being reported as cases
of depression related suicide [Flavia 1994], it is because the question of
moral responsibility for the death can no longer be debated within the
purview of law. Under the present social situation of mentally ill women,
the fact that the husband is the legal guardian is not comforting at all, for
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it would be legally uncomplicated for him and his family to take over her
possessions and then desert her, or remarry. Much less can be said about
the human rights of destitute and homeless mentally ill women, and noncriminal mentally ill women who have been illegally and needlessly
imprisoned [Srinivasa Murthy and Dhanda 1993].
This paper concludes with the remark that the area of gender politics
in mental health care raises a number of disturbing issues and questions,
only some of which have been noted here and discussed sketchily. Health
professionals, women’s organisations and professional mental health
institutions need to programmatise the area of women and mental health
with a sense of urgency.
Note
[This study is based on the report I prepared for Anveshi, Research Centre for
Women’s Studies, Hyderabad. I am thankful to Anveshi for the financial
assistance received for the project. I have received great personal support from
Murthy of NIMHANS, Veena, Lalitha, and other friends from Anveshi, for
which I am grateful. The responsibility for the views expressed, however, is
solely mine.]
1 An equally important area to be studied is the class of mentally ill women
abandoned on the streets, and particularly, inside supposedly healing temples,
dharamshalas, chawls and dormitories. I fear that, given the lack of resources
in mental hospitals, the large scale stigma attached to the inmates of these
hospitals, the minimal responsibility required to maintain patients here, and
the greater dependence of women on magico-religious cures would contribute
towards their seeking treatment for illness in these temples. Thus, a singular
focus on long-stay patients in mental hospitals alone will give us only a partial
view of the social victimisation of mentally ill women. To focus only on these
hospitals would be to simply copy the research problems of the West, where
these alternative non-professional institutions are not sought as the final
shelter.
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Bhargavi V Davar
Department of Philosophy
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South Indian Studies
A multi-disciplinary journal
Editor : M.S.S. Pandian
Re-evaluating old themes and problematising received forms of
knowledge is arefreshing aspect ofrecentsocialscience enquiries.
Areas and aspects of social life which have remained outside the
_ domain of academic knowledge, are now being brought under
investigation. While conventional terrains of research show signs
of having been overworked, there are indications of new ones
emerging, provoking fresh insights and keen debates. These
enquiries and debates, dispersed across disciplines, is recasting
our understanding of South Indian society in a new light.
South Indian Studies intends to consolidate the gains of such
enquiries by offering a broad forum to present and discuss current
research on South India. In addition to papers and reviews, the
journal plans to carry resume of major debates taking place in
South Indian languages.
The journal invites papers, research notes, review articles and
reviews for publication. All papers will be refereed before being
accepted for publication.
First issue : January 1996 Size: Demy 1/8 Pages : 150
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Health, Dirt and Images of Organic Food
Rahul Srivastava
The food market in the advanced capitalist economies has recently
had to reckon wih a totally different interpretation of the texture
of food and its relation to health. The source of this critique is
the organic food industry, and its intensity is derived from the growing
popularity of the environment. An examination of this critical edge
of the discourse on organic food and the metaphors it provides
for health, is the purpose of this essay.
BRYAN TURNER, in an essay inspired by the theoretical framework
of Foucault, discusses how the expanding industrial society of late 19th
century Europe demanded state intervention in the field of health in spite
of the valorisation of laissez faire. ‘This was done due to the perceived
necessity of a healthy labour force needed to increase productivity.
Interestingly, it was at this time in the discourse of health that the
metaphor of the body as a machine became popular. According to him
17th and 18th century discourse on the body and health had its origins
in a religious language about self control but in the late 19th and early
20th century the body was no longer informed by “divine sobriety”, but
by calories and proteins, so that discipline and efficiency could be
measured with precision and certainty [Turner; 1982]. This was an
important event with far reaching consequences.
The business of food processing and its tendency of adding on
nutritional qualities through chemical
break-up of nutrients, or con-
versely, subtracting harmful properties (excess sugar or fat) to enhance
the over all nutritional quality of the item, were part of the same discourse
and continued to work on this metaphor of the body as a machine.
Research into food processing extended itself into areas as diverse as
genetic manipulation, fertilisers and insecticides, and today the food
industry is a combined enterprise of all these endeavors. Awareness of
the marketability of health concerns has been a constant presence in
the modern food industry which has responded through the backing of
profit-hungry technology. “With the growing sophistication in manipulating the chemical constituents of food, highly processed food is presented as ‘healthy’ food, manufactured to have low fat, low cholesterol,
and high fibre content, in line with current dietary recommendations”
[Roberts 1991:241].
.
However, the food market in the advanced capitalist economies has
recently had to reckon witha totally different interpretation of the texture
of food and its relation to health. The source of this critique is the organic
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food industry and its intensity is derived from the growing popularity of
the environment movement. An examination of this critical edge of the
discourse of organic food and the metaphors it provides for health, is the
purpose of this essay.
ORGANIC Foop
Organic food is officially understood to be asystem of food production
which aims to work with natural eco-systems as far as possible in order
to optimise the background health of soils, crops and livestock. The
principal goal is sustainability, in terms of maintaining soil structure and
fertility by using renewable natural inputs rather than chemicals [Beharrell
and Crockett 1992].
In Maharashtra, there has been a conscious effort at organic
farming, though on a rather small scale. The Institute of Natural
Organic Agriculture in Pune is one organisation which takes an active
interest in its practice. There also are anumber ofindividuals involved,
largely for personal satisfaction, even though there seems to be a
growing market for organic food the existing supplies for which seem
to be insufficient [Rajendran 1994]. The major buyers come from the
urban upper class sections of society, those who can afford the extra
cost which goes into its production. Even as there is not much data
available on the whole business in India, the fragmented image which
exists, shows remarkable similarity to the organic food industry in
Britain, a nation which is a significant producer and consumer of
organic food in the advanced capitalist markets.
In Britain, even though the organic food movement is marginal in
terms of its structural position in the market (about | per cent of organic
food in the market is grown there and two-thirds of the produce is
exported from abroad [Lisansky Robinson
and Coombs
1991:7]), it
provides important critiques at the level of cultural meanings and images
of food and health. So powerful is the impact of this critique that even the
mainstream food industry has begun borrowing its images and attempts
to market itself appropriately. Food which looks ‘organic’ has been
manipulated in its marketing by food-processing industries. The
phenomenon of ‘green consumerism’ where the industry has marketed its
food as ‘natural’ or ‘healthy’ shows how complex the use of images
around food has become. Eventually labels circulated in the markets have
been legislated in Britain. The organic food industry has legal protection
with the accompanying bodies to enact them against the misuse of the
label ‘organic’, but the term ‘natural’ and the colour green is still being
used quite randomly [Roberts 1991].
The philosophy and the practice of organic food is often traced back
to the teachings of Rudolf Steiner in the 1920s and later to the establish-
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ment of The Soil Association by Lady Eve Balfour in 1946. It is only in
the 1980s, though, that one finds a major increase in the growth of the
organic food industry. Specific food scandals related to the industry such
as the salmonella poisoning in eggs, lysteria in soft cheese or BST in milk
were causes for concern and the mass media which circulated new
research findings on health and food, added its own fuel [James 1993]. For
all these reasons, organic food grew in popularity and what was once seen
as the past time of eccentric farmers, has become a serious entity in the
food market.
TRADITIONAL AND ALTERNATIVE FARMING
When comparing the context of organic food in India and Britain,
the use of the labels traditional and alternative farming takes on an
ironic flavour. These terms are intrinsic to the ‘organic versus
mainstream’ food debate in Britain where traditional agricultural
practices refer to mechanised agriculture which includes inputs from
industry for pest and insect control and increasing productivity. The
‘mainstream’ food industry is entwined in this legacy of farming. As
opposed to this the ‘alternative’ farmers who are involved with the
crganic food movement based on its philosophy of working without
chemical and synthetic inputs have made their presence felt only
recently. In the Indian context the ‘alternative’ farming techniques of
Britain would coincide with the ‘traditional’ practices in India while
the ‘traditional’ techniques of Britain, would coincide with the
government sponsored “alternative” ones which incidentally are as
widespread here as elsewhere.
The environmental critiques of contemporary mainstream farming
have more or less similar arguments in both the countries and the debate
in India is especially focussed on the impact of the ‘green revolution’
techniques. The fact that increased productivity of agriculture has not
lessened the impact of drought or decreased starvation in the world is
another common point of agreement. The reasons for these are now being
located in the production practices of food itself rather than in the
distributive systems of the market which are often seen as hopelessly
manipulated in favour of the privileged.
The accusation that organic food is expensive and therefore an elitist
activity is countered by examining the structural reasons for this expense.
It is often forgotten that mainstream food is hugely subsidised by
governments and that the economy of large scale production are in its
favour. Secondly, the research which has gone into it without the concerns
of environmental impact is largely focussed on increasing productivity
often by transforming the very quality of the food itself. Thus the
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ment and individual health while at the same time ignoring the problem
of unequal distribution of food in spite of its low productive costs.
Organic food is not as intrinsically expensive as made out to be but
certainly requires political will which cannot be easily banked on due to
_ the huge corporate interests which are opposed to it. Recently, because of
economic sanctions against Cuba, farming through traditional means
became a matter of compulsion and the government went all out to
promote organic farming.
Sidney Mintz in his fascinating study on the history of sugar shows
how this food was considered to be a luxury item in 18th century
‘England since its production was heavily restricted. Once colonialism
widened accessibility to raw materials, colonies were forced to grow it .
everywhere and huge profits were made by a few. Of course, sugar
thus became cheap and easily available, in fact it was the main source
of energy for the industrial workforce, but at the cost of destroying
many local farming techniques and even the colonized economies
[Mintz 1985].
The proponents of organic food argue that if political will brought
down the expense of sugar and made it the food for the masses, there is
noreason why the same cannot happen to organic food too. The only hitch
being that the cheapening of sugar coincided with huge profits made by
the related industries and the cheapening of organic food shall only do the
opposite. Thus the question of political will remains problematic in this
regard.
However, our concern in this essay is at another level. One cannot
deny that organic food has made its impact on the food markets in
Britain and its arguments are changing consumption patterns rather
drastically. Notions of health, both of the individual and of the environment
are of primary concern in this regard and it would be pertinent to take a
look at the meanings and images organic food generates. In an economy
saturated by concerns of immediate market forces and large business
interests itis often in the area of consumption that a critique first emerges.
Sometimes this takes place in a trivial manner easily co-opted by market
forces (marketing of eco-friendly products, under the label ‘green’ or
‘natural’) and sometimes in a more persistent and subversive way
(demanding a radical change in production patterns itself, which is the
basis of the organic food industry).
The word health encloses a number of narratives which portray a
movement towards an idealised state of being, its images shared by a wide
spectrum of experiences, ranging from states of individual well-being to
that of the economy (as in the ‘health’ of a nation). However, equally
interesting is the range it posits when seen through a cross-cultural lens.
It is not only different in its images across cultures, it may also indicate
radically opposing images in its constitution. This will become clear if we
rie
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see the concept of health as always being relational, that is to say as tacitly
implying the existence of its perceived opposite, be it disease or a general
‘lack of health’. Both health and disease are accompanied by definite
signs and markers. What makes this process lively is that across cultures
there is a tremendous inter-mingling of these markers and confusions
emerge when the signs of health in one context become its opposite in
another. Since the discussion around organic food is based on such
semiotics it would be necessary to pay attention to. this process. Some of
the important variables in this context are the images of dirt and decay
which take on very important meanings in the food markets of mainstream
food.
THE ANTHROPOLOGY OF DIRT
Social anthropologist Mary Douglas’ theory on ‘dirt’ is fairly well
known. In her view dirt is a relative category, differing from people to
people and even context to context. She defines it as ‘matter out of place’.
Dirt is anything which exists in a place it should not be and is culturally
variant [Douglas 1992].
Using this framework one can understand the semiotics of food in the
market where mainstream and organic food compete with each other by
classifying what constitutes dirt. One sees that in the super-markets of
Britain, mainstream food has to undergo strict regulations before appearing
on the shelves. For purposes as diverse as cost accounting and concerns
of quality, cucumbers and apples only of a specific shape and size are
allowed in. The fruit even have certain uniformity of colour and texture.
Blemishes and the presence of soil on the food item, or even a small
decaying part of a fruit which in India would simply be consumed after
cutting off the offensive portion, would be disqualified. This process,
valid on the grounds that they are safeguarding the health of their patrons,
also ends up by establishing the rules of what is healthy and unhealthy
food. So much is dependent on visual appeal that the concerns of health
often merge with those of good looks and what emerges is a highly
complex semiotics around mainstream food, which classifies all outside
its domain as unhealthy, dirty and dangerous.
How exactly does this happen? To be marketable, food must evoke
images which are specific to the product in question. Food itself
must have some perceived qualities which are seen as essential to it.
Nutrition and taste are two of them. Mainstream as well as organic
foods make claims for these two qualities, though in rather different
ways.
In addition to these, there are other processes
involved.
The
process of decay is also intrinsic to fruit, vegetables, cereals, meat, etc.
and it is the signs of decay which become the indicators of healthy or
unhealthy food.
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AM
Mainstream food uses this to its advantage and creates a huge variety
of processed and preserved items in its repertoire, by the techniques of
artificial preservation and colouring. Perishability, along with its associated
symbols (decay and rotting) are disguised by it which can thus look like
other attractive products in the market and through processing can lay
claim to improved nutritional qualities.
Organic food is limited on this front. But its attempted strategy 1s
to convert these symbols to its own advantage. This is done by
claiming that mainstream food is distorting the essential quality of
food, by disguising the perishability and erasing its symbols, like
decay. blemishes, uneven colouring etc.. Consequently it not only
looses its nutrition and taste,
consumption, environmentally
but is also in its production and
destructive. Thus, the very same
symbols of perishability come to signify the opposite within the
discourse of organic food.
Organic food demands a reorientation of notions of dirt and the
properties of that dirt. Thus the artificial colouring agent, the synthetic
preservatives, pesticides and the chemical fertilisers are all seen as
dangerous presences. The function of each, visual appeal, postponing
decay, avoiding wastage and increasing quantity, are all rendered
unimportant as compared to their harmful effects. And each can be
seen as misplaced matter from the perspective of organic food.
~ ORGANIC MATTER AS DiRT
Mainstream food can be seen as emphasising the negative aspects of
the ‘organic’ nature of food and the benefits of human intervention to
transform it. On the other hand, it is precisely the very same ‘organicness’ which is emphasised by organic food as being its virtue. By being
critical of treating food like other items in the market it thus distinguishes
the properties of food from them and claims that the signs of decay which
mainstream food seeks to disguise are actually indicators of the edibility
of the item.
This distinction rests on the perception that the composition of food
should be as continuous as possible with that of the human body and
with the natural environment. Without this perception the meaning of
the word ‘organic’ would not have the same impact amongst its
producers and consumers. And without the acceptance of environmental
concerns as indicating serious dangers to the body and the larger
environment, this perception would not have been possible. This
exchange of meanings and»metaphors is significant. In pamphlets
espousing environmental concerns one often comes across the metaphor
of the earth as a sick body and images of the human body as being
composed of leaves and vegetables.
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‘This attempt ata reclassification of notions of dirtreflects the framework
of Mary Douglas. By claiming that dirt essentially represents disorder,
wherein the response of doing away with it consists of a reordering of the
universe, she allows us to perceive the competing discourses as working
within certain patterns. Yet the specificity of this topic creates its own
peculiarity. While Douglas uses dirt metaphorically, as a starting point for
other conceptualisations, we find that here the category has more literal
implications. And even though the notions of dirt are a site of conflict
between mainstream and organic foods, eventually the latter attempts to
transform the notion of dirt itself into a more subtle category, where the
word ‘organic’ develops interesting meanings.
The distinction between the images of ‘nature’ and ‘organic matter’
must be noted. While there is an exchange between them, they are not
synonymous. Unlike the word ‘nature’ which may suggest a variety of
images, from landscapes to human behavior, organic matter refers to
specific biological processes. Food is a more specific aspect of
‘nature’ with its own autonomous imagery which is derived from such
processes. For example, in discussions with informants one often
found them
linking the word
‘organic’
to manure,
soil, decaying
leaves, garden smells etc. All these of course represent facets of
‘nature’ itself but are more specific. It is around these images that
mainstream food justifies human intervention, and itis by appropriating
them differently that organic food markets itself.
The fact that organic food has managed to create a positive impact with
the label is indicative of the popularity of environmental concerns among
the relevant population which allow for the word ‘organic’ along with its
accompanying imagery, to mean something positive.
Lady Eve Balfour, an important figure in the organic food movement,
refers to this imagery of ‘organic matter’ in her work The Living Soil
published in 1943. The images of decay and reproduction are evoked
throughout the book and identified more specifically with the
composition of the soil which is the medium through which food is
produced. Soil in its ideal healthy state represents the balance between
reproduction and decay and its quality is the main source of the
eventual health of the produce. “It is still organic matter, in the
transition stage between one form of life and another” [Balfour
1974:25].The main focus of the book is relating the quality of soil to
the health of individuals. We find her quoting from Adrian Bell’s Men
and the Fields, where the “true peasant” states that; “If people ate
more of what’s grown with muck, ther’d not be half the illness about.
People say that what’s grown with artificial manure does you as
much as good as what’s grown with muck. But I know that’s wrong.
What’s grown with chemicals may look all right, but it ain’t got the
stay in it” [ibid:57].
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pA ce)
The linking up of the images of health to the quality of soil, which in
turn is related to images of rich manure, ‘muck’ with healthy properties,
is significant. In most readings of contemporary literature on organic food
as well as the statements received through field inter-action one can come
across similar images.
Today organic vegetables and fruit in the shops often have soil
stuck on it and this has come to be seen as representing its ‘natural’
origins signifying good health. ‘Whole meal’, ‘coarse’, “stone ground’
are other words which can be seen as part of the same discourse
attempting to signify “closer to natural” and therefore more healthy
states. The jagged edges, rough looks have all become marketable due to
such linking of images. So much so, that mainstream food often simulates
these images even though the product may not have been organically
produced.
This linking and de-linking of images, where a distinction is made
between organic matter and dirt, and the signs of decay are actually
infused with the meaning of health, is a significant happening in the
cultural perception of health. The vision itself is indebted to the
environmental movement which provided the necessary scientific
backing to the holistic image of the environment allowing for a sense
of continuity between the substances constituting the natural world
and the biological individual, especially through the images of decay
and reproduction. This is particularly radical in modern cultures where
notions of health and hygiene have created a semiotics of dirt which
unjustifiably includes a number of random images.
It also sensitises one to the fact that the environmental movement itself
needs to create nuances in the concept of ‘nature’. Besides the well known
images of landscapes of geography and scenic beauty it also has an
autonomous sub-set of images which portrays its other side, that of decay
and rot. The modern sensibility towards hygiene which exaggerates these
negative images into having a special significance, has been contested by
organic food.
NATURE AND ORGANIC MATTER
What thinking and experience gives rise to these different visions of
‘nature’, in the first place? Thomas Keith.shows us how ‘nature’ has
had varying connotations in different periods of English history
[Macfarlane 1987]. Before agriculture became rational and intensive,
nature, synonymous with wilderness, had negative implications. This
was linked to the distinction between the city as representing civility
and the country, rusticity’[ibid:81]. Increasing control of the natural
world, especially through rationalisation of agriculture, lead to the word
‘nature’ as representing values of simplicity and traditional life. Thus
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increasing urbanisation lead to more nostalgia and is perhaps one of
the major reasons for its connotations today.
The forms which agriculture took, via rationalisation of its techniques, transformed the rural countryside, making it into an area of
consumption (for recreation) which had to be protected [Goodman 1991].
The industrialisation of society lead to an increasing drive to conserve
“wilderness” areas which came to signify a true embodiment or
representation of ‘nature’ [Goodman and Redclift 1991:250].
The separation of spheres of ‘nature’ from the main human habitats
allows for myths to generate which infuse the word with positive
meanings. Yet the every-day world of industrialised society lives at a
distance from these niches which have become merely areas of
recreation, as exemplified in the wildlife preserves and sanctuaries. At
the same time this distance allows for other, negative images of
“nature” to prevail, thus the processes of decay and rot, also part of the
natural world, become signs of something negative. These processes
are very much alive in the modern imagination as images of disease,
dirt and evil.
Horror films often show ‘evil’ as represented by filth, decay and rot
and these connections can be seen to have an older genealogy in Euroamerican culture. Martha Duncan in her article ‘In Slime and Darkness;
The Metaphor of Filth in Criminal Justice’ [Duncan 1994] shows the
historical presence of such connections in literature and art which
continue to influence the portrayal of evil in contemporary horror films.
These images, in her opinion, draw from those processes in ‘nature’
which are linked to bodily emissions, rot and decay of organic matter. She
refers to Mary Douglas’s analysis of dirt which places the ‘ambiguous’ at
the centre of notions of danger, and examines how these processes came
to signify evil. Thus substances which are neither liquid or solid in their
composition and texture have a greater chance of becoming signs of
danger.
What this shows us is that ‘nature’, with its positive images, and decay
of ‘organic matter’, with negative ones, exist in the popular imagination
which connects images from different spheres of life. Images of decay can
be magnified and linked with certain processes of the perishability of food
thus exaggerating its meaning to include an aversion of associated
symbols. This takes place in the context of marketing, leading to the
whole process whereby organic food has to resist and transform this
association for it to be more acceptable.
At a more fundamental level we see the discourse of organic food,
through its complex use of the semiotics of ‘dirt’, creation of nuances
in the image of “organic matter” and bringing in a sense of continuity
between the health of the environment and of the human body, as
contesting the use of the metaphor of machine for the human body.
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The integration of markets across the middle-class sections of
societies around the world reveals a standardisation of consumption
patterns. Even in the advanced capitalist economies critiques like that
of the organic food industry are only just making their presence. By
and large the mainstream food industry, true to its label continues to
dominate the markets. Its philosophy influences the specific cultural
logic of different people by its own peculiar aesthetics. Thus in India
we come across advertisements which promise us that the salt or papad
being sold is ‘untouched by human hands’ and processed only through
the finest and most hygienic technologies. A food processing unit
from Madras claims to cook and seal the most ‘authentic’ idlis and fly
them to other cities even as the same product is made locally and sold
quite regularly there.
The coming of supermarkets with their stringent quality control also
marks the beginning of large wastage of food as is evident in the
experience of markets abroad. Most multinationals which made their
entry into the consumer markets in India did so in the food processing
sector. The mono-cultivation which inevitably results through such an
integration of the food-processing unit with farming has its own
consequences on rural political relations as well as the environment.
Simultaneously, the urban middle-class consumer gets less nutritious and
more expensive food while the level of hunger and starvation deaths
among the under-privileged become an unpleasant reality.
Interestingly, concerns of hygiene play a major role in the marketing
of the products and work well with the fears of the middle-class. While
many of the concerns may have valid reasons considering that even clean
drinkable water is a luxury and that many contagious diseases in India are
widespread due to basic unsanitary habits, these fears are immediately
rationalised for the use of the latest technology to see that all food is
“untouched by hand”. Obviously, under the concerns of hygiene the
demand for providing clean water which would bring down the level of
disease gets a back seat while bottled mineral water gets a secured place
in the market.
As far as the discussion on the images of organic matter and dirt go
in the Indian context, one can only make generalised observations.
Like urban environments everywhere, one sees a distance from the
“negative” images of nature. The thought that cowdung can actually
be a cleansing agent becomes quite unthinkable in an urban context.
Of course, our tolerance of the presence of organic matter and other
forms of dirt even in cities is still much higher than our counterparts
elsewhere and the line between healthy organic substances and pure
dirt is rather thin. But before passing judgements, the discourse of
organic food cautions us from glossing over these differences as
trivial and demands that notions of health and hygiene include the
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complexity discussed earlier . Lest we lose something important in the
obsession for cleanliness.
CONCLUSION
The sentiment voiced by the farmer in Adrian Bell’s book Men and the
Fields that “what’s grown with chemicals may look all right, but it aint’
got the stay in it” has its own versions in India. One comes across people,
especially of an earlier generation, claiming that the quality of food they
ate had more ‘stay’ in it. Or that their grandmothers lived longer because
of the pure ghee they ate as compared to the refined oil used today.
Farmers from all over complain that the use of fertilisers does to their soil
and occasionally a newsmagazine reports the presence of pesticide
residues in food. There are also generalised and vague complaints that the
taste of food has declined. One wonders whether all this will add up to an
awareness of the politics behind eating and acritical inquiry into production
practices of food and not simply reflect a nostalgia which comes as part
of every shift in generation. One safeguard against this possibility is
the experience of the environmental movement which has provided the
necessary scientific backing to give a special political resonance to these
random utterances.
Food has been an interesting source for providing metaphors for
different aspects of cultural existence. To end this discussion it would be
useful to listen to an evocative phrase used by an informant in Bombay
(a hawker owning a ‘wada-pao’ stall) when asked why he felt that the
quality of life, politicians and values (among a list of other variables of
his choice) had declined. His response; “Arre bhai, woh toh desi-ghee ka
zamana tha... yeh toh dalda ka zamana hai!”
References
Atkinson, P (1983) Eating Virtue, Murcott, A. (ed), The Sociology of Food and
Eating, Gower, England.
Balfour, E B (1975) The Living Soil and The Haughley Experiment, Faber and
Faber, London.
Barry, W (1987) Rushall. The Story of an Organic Farm, Basil Blackwell,
England.
Beharrell, B and A Crockett (1992) ‘New Age Food! New Age Consumers!’,
British Food Journal, Vol.94, No.7, 5-13.
Douglas, M (1992) Purity and Danger. An Analysis of the concepts of Pollution
and Taboo, Routledge, London.
—(1975) Implicit Meanings. Essays in Anthropology, Routledge and Kegan
Paul, London.
Duncan, M G (1994) ‘In Slime and Darkness : The Metaphor of Filth in Criminal
Justice’, Tulane Law Review, Vol.68, No.4, (725-802).
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Goodman, D and M Redclift (1991) Refashioning Nature, Food, Ecology and
Culture, Routledge, London.
Goody, J (1982) Cooking,
Cuisine and Class, erga
rake University Press,
Cambridge.
James, A (1993) ‘Eating Greens: Discourses of Organic Food’ in Milton, K. (ed),
Environmentalism, The View from Anthropology, ASA Monographs 32,
Routledge, London.
Lean, G (1994) Organic Veg. in the Independent on Sunday, May 8.
Lisansky, S, A Robinson and J Coombs (eds) (1991) The UK Green Growers
Guide, CPL Scientific Ltd, England.
Macfarlane, A (1987) The Culture of Capitalism, Basil Blackwell, UK.
___ (1985) ‘The Nature of Evil’ in Parkin, D (ed), The Anthropology of Evil, Basil
Blackwell, USA.
Mintz, S (1985) Sweetness and Power. The Place of Sugar in Modern History,
Viking.
Murphy, M C (1992) Organic Farming as a Business in Great Britain, Agricultural Economics Unit, Cambridge.
Rajendran, S (1994), Organic Farming, Exploiting Earthworms for Fertilisers,
Down to Earth, March 31 1994.
Roberts, D (1991) Natural: A Trading Standards Viewpoint, British Food
Journal, Vol.93, No.1, 17-19.
Strathern, M (1992) Reproducing the Future, Anthropology, Kinship and the
New Reproductive Technologies, Manchester University Press, England.
Turner, B. (1982), The Discourse of Diet, Theory, Culture and Society.
Rahul Srivastava
Research Fellow
Social Science Centre
St Xavier’s College
Bombay
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COMMUNICATIONS
Plague: The Subaltern Experience
In colonial accounts of plague the subaltern experience has been
largely ignored. One such response is to be found in a Tamil ballad
published in 1906 in Tiruvannamalai.
THE plague in India has its origins in the colonial period. From 1986,
when it first appeared on the Indian scene at Bombay, until the late
1920s, it had claimed no less than 10 million lives. The geographical
spread and pestilential virulence which marked the plague, seemed
to confirm, from the British perspective, many
of their Orientalist
stereotypes and prejudices about India. Poverty, squalor, bad sanitation and superstition were seen to, not only cause the plague, but
also to make it take on epidemic proportions. The reaction of many
European countries— banning of Indian imports, restrictions on
Air India flights and the monitoring of passengers who had flown
via India — is a reminder of how such Orientalist biases continue
to persist.
If this was the British response, the Indian elite laid the blame
squarely on the British. Their reaction to plague control, jas to put it
mildly, often hostile. Tilak’s condemnation of plague control-methods, and the subsequent murder of W C Rand, the Plague Commissioner of Pune, by the Chapekar brothers is too well-known to students
of Indian history to need recounting. Similarly, a ‘seditious’ pamphlet
supposedly printed at the Feringhee Destroyer Press, Madurai and
circulated by a group of terrorist in the southern districts of Tamil
Nadu in 1911, pointed to the visitation of plague as a consequence of
British rule.
Plague has become an integral part of our country. In the past week alone,
it is said that 42,700 people have died of plague. Oh! In just seven days how
many people — how many aryans — have died of plague! This has not
happened in this week alone. Every week, no less than 40,000 Indians are
dying of this disease[1].
Subramania Bharati, the nationalist poet, published a cartoon in his
weekly India (1907), in which a stream of rats (‘plague’) is emanating
from the mouth of a demon (‘poverty’) and the colonial officials are
_ depicted as attacking the rats instead of the demon[2].
What gets crucially left out in such polemics, of both folk, or so to
speak, the subaltern experience. The common people in colonial
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accounts, emerge as little more than rumour mongers or superstitious oafs, who cannot see the benefits of a superior medical
system, while in nationalist polemics, they are so much fodder for the
propaganda cannon. How then to retrieve the lived experience of the
common folk?
Luckily, we have at least one subaltern account of a plague, in a
temple-town of Tamil Nadu, in the early years of this century. It is a
chapbook ballad in Tamil, barely seven pages long, published in 1906.
about the epidemic in Thiruvannamalai. Such songbooks written by
professional songsters who made a living through selling them were
quite common in the late 19th and early 20th centuries. Printed on
cheap and flimsy paper, badly typeset and swarming with errors,
such chapbooks were hawked
at crossroads
and marketplaces,
and
sold at about half an anna or even less. Looked down upon by the
emerging middle classes, this chapbook tradition was part of a vibrant
culture, which was marginalised by the onslaught of the mass media
in the middle of this century. Murders, scandals and other matters of
topical interest were the staple of such chapbooks. In such a context,
that the Plague Chindu (The Plague Song), for that is the title of our
sonbook, has survived is what is surprising and not that it was ever
written. The Plague Chindu is set in Thiruvannamalai, a small town,
over a hundred km south west of Madras and well-known for its
towering temple and the annual ‘karthigai deepam’ festival, when a
massive lamp, visible for several km around, is lit. The song has been
written by one Choolai Muniswamy Mudaliar, of whom very little
is known.
The Chindu starts with a conventional invocation to god Vinayakar,
and immediately gets to the crux of the matter without much ado.
“Look at the plight of Thiruvannamalai. Listen to its tragic tale’, is the
refrain of the song. Briefly, it refers to the origins of the plague in
Europe and how, much nearer home, it spread to Bangalore, Coimbatore
and Vellore. Plague is personified as a deity, though malevolent — the
very antithesis of Lakshmi (Moodevi), whose very look causes
disaster[3].
Thiruvannamalai
too succumbs
to its influence.
Once
reputed to be the Kailash on earth, where numerous pilgrims flock,
now all festivities cease. No prayers are offered. The annual festival
is called off.
Is there no god?
Alas, has he lost his eyes?
Can he not see?
the songster cries in exasperation. The malignant influence of ‘saniyan
(Saturn) is also obvious. Even crows and sparrows have left. If dogs
and cats perish on the streets, the fate of people is little better. The
young and the old, school-going boys and virgin young girls, strong
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youths and the only sons of their mothers — all die like rats! In fact,
“Yama, his arms tired (of taking lives) looks away wearily.” People
mortally scared, troop outof the town like a line of ants. Many flee.
the town much ahead of Pongal (the annual harvest festival). Some
men even leave behind their families wives and children. They take
a way all the possessions they can manage to carry. All shops, the
grain mandy, vessel shops, textile outlets and the grocers close down
their business. Teeming with people, the railway station presents a
picture of frenetic activity. The towns of Villupuram, Dindivanam,
Cuddalore, Thirukolur and Chetpet seem to be their destination: The
entire taluk of Thiruvannamalai seems to be milling with plague
refugees.
And then the municipal authorities and colonial officials take over.
Our songster is all praise for them. The army is brought in to clear up
the town and the police provide bundobast. The colonial officials
watch all this benevolently. The name of the district collector Cumming,
is expressly mentioned. He is seized of the problem and declares the
town to be plague-hit. He reassures the people that adequate steps are
being taken. Every house, every shop is thoroughly cleansed. Only the
temple is spared! Men are paid to remove the corpses and bury them.
Survivors are ‘segregated’ (the song uses the ‘English word in transliterated form).
And then the Plague Chindu also proffers some advice. Put on footwear. Drink boiled water. Keep the home and hearth clean. Keep foodstuff
covered. Kill the scampering rats.
Finally, Choolai Muniswamy Mudaliar rounds of his song with the
words, “Will a book be enough to set out the travails caused by the
visitation of the damned plague” and signs off with his name in the last
line, in keeping with the convention of popular balladeers.
[I am grateful to
V R Muraleedharan for comments on an earlier draft.]
References
[1] ‘Ariyargalukku Or Aptha Vakkiyam’ (A Word of Advice to the Aryans)
reprinted in A Sivasburamanian, Ashe Kolaiyum India Puratchi
Iyakkamum, Madras, 1986, appendix 5, p. 96.
[2] A R Venkatachalapathy (ed.), Bharatiyin Karuthuppadangal: ‘India’
1906-1910, Madras, 1994, p. 203.
[3] Incidentally, in the Coimbatore district of Tamil Nadu there is a deity of
‘Plague-Amman’ (literally, plague-mother).
A R Venkatachalapathy
Madras Institute of Development Studies
Madras
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Market, Health and Ideology
Rhoteric and Reality
The currently popular opinion that capitalism has been more
effective than socialism in meeting human needs is belied bya
recent analysis of health performances under the two systems.
_
AFTER the release of the World Development Report 1993 much has
been written on health and development and on the ideas advocated in
the report. Most critiques of the Report in the media tend to do so from
a liberal perspective. The ideological assumptions of the Report or of
the World Bank’s prescriptions is hardly discussed in detail. With
socialism being out of fashion and ‘end of ideology’ being celebrated
as the ultimate turning point, few of the critiques implicitly or explicitly
do not challenge the ideological orientations of the Report. The failure
of socialism is taken as an axiom and it is presumed that there is no ‘
hope for revival of socialism. So minor differences apart, there seems
to be aconsensus in favour of market-oriented medicine with the private
sector playing a major role in providing health care, enjoying monopoly
in some sectors. Of course the need for regulation is mentioned, but
more as an afterthought than as a necessary condition. This is because
of the widely held opinion that capitalism has been more effective
than socialism in meeting human needs and it has survived while the
socialist empire has collapsed. The ‘moral’ victory of capitalism is thus
assumed as a proof.
In this context, an important article ‘Has Socialism Failed? An
Analysis of Health Indicators Under Capitalism And Socialism’ by
Vincente Navarro (Science and Society, Vol 57:1) deserves wider attention and discussion. Navarro who teaches at Johns Hopkins University
and is well-known as editor of /nternational Journal Of Health Services,
has written a book on Social Security And Medicine in USSR. Navarro
shows that it is possible to compare the two systems and their performances in terms of health indicators. According to him there is no
correlation between level of medical expenditure and level of health.
Nor is there a correlation between level of medical consumption and
level of health. In fact the health of the population is “the outcome of a
whole set of social, economic and political interventions, among which
medical care plays a minor role”. For example, Baltimore has an above
average utilisation rate of prenatal care services for all sections of the
population but has one of the highest infant mortality rates in the US. This
is due to the extensive poverty prevailing in the city. Health indicators
thus do tell us about social and economic development.
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Navarro does not consider the countries in East Europe, Afghanistan
and Ethiopia as socialist countries for the changes were brought in by
forces outside or by military coup. According to him only when a system
is the outcome of an autonomous revolutionary process, with large
sections of working class or peasantry participating in it the system could
be considered as a socialist system. He contends that superiority of one
system (socialism) over another one can be shown by not only looking at
comparable countries with different regimes but also by analysing comparable capitalist countries with different correlations of forces between procapitalist and pro-socialist’ elements. He points out that since 1958, health
indicators have improved more rapidly than the rest of Latin America. In
1955, the life expectancy in Cuba (62 years) was shorter than that in
Argentina (66 years), Paraguay (62 years). But in 1985 the life expentancy
in Cuba had increased to 75 years, the highest in the whole continent. In
terms of other indicators also Cuba had done exceedingly well. Infant
mortality rate was 81 deaths per thousand in 1955, higher than the infant
mortality rate in many Latin American countrie. Within three decades this
was reversed and by 1985 Cuba had the lowest infant mortality rate (13
per thousand) in Latin America. Similarly when measured in terms of
indicators like under-five mortality rate per thousand, malnutrition, percentage of infants with low birth weight, percentage of children under five
years suffering from malnutrition (from moderate to severe), with best per
capita calorie in take as percentage of requirements.
The progress made by Cuba in providing basic sanitation facilities to its
people is also remarkable. In 1956 only 35 per cent of the population had
water supply systems connected to their houses, compared to 80 per cent
in Honduras, 44 per cent in Argentina and 63 per cent in Dominican
Republic. By 1980 Cuba had one of the best records in providing
environmental services in the whole of Latin America 74 per cent of the
population had water supply systems connected to their houses, 91 percent
of people had access to flush toilets. The age-adjusted death rate for
diarrhoeal diseases was 2.8 per one lakh population in 1988. According to
the Pan American Health Organisation (PAHO), this was one of two
lowest in Latin America. The literacy rates in 1950s were ranging from 30
- per cent to 40 per cent, but now Cuba has the highest literacy rate in Latin
America 1 e, 96 per cent of the adult population.
After analysing the health of the nations in terms of such indicators
Navarro points out
Given this information, one could conclude that Pope John Paul’s statement in
Centesimus Annus defining capitalism as the best system to respond to human
needs in the third world, at least for Latin America may not be fully justified.
The great majority of peasants and workers — most of the population of Latin
America — would have a higher quality of life with more substantial socioeconomic human rights under socialism, than they are having under capital-
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ism. If the rest of Latin America had the same infant mortality rate as Cuba,
over two million children’s lives would be saved each year. Cuba is currently
facing major economic problems, due primarily to the discontinuity of international network of support resulting from changes in the Soviet Union and
Eastern Europe. But these difficulties are no larger than in most Latin
American countries, which are facing one of the greatest depressions in this
century. Malnutrition and hunger are reappearing in countries such as Argentina and Uruguay where these mass phenomena have not existed in the last 40
years. The appearance of cholera at the continental level is yet another
symptom of this socio economic deterioration.
Comparing China and India in Asia, he points out that since the revolution,
China has fared better than India in terms of health indicators. At similar
percapita income China has much better health indicators than India. In
terms of calorie supply per capita also China has made much progress
when compared to India. Rates of increase in height per decade for children
five to seven years of age in China over the last two decades has been
equal to or higher than increases per decade in European countries having
rapidly increasing high per capita income. Since the introduction of
capitalism in China in the early 1980s the dramatic rate of improvement
in infant mortality in the period 1949 to 1980 has slowed down.
Inevitably the Kerala example is being cited as a model in India, despite
recent controversies. Often factors like women’s literacy, government
intervention and investments are cited as major reasons for the outstanding
performance of Kerala in terms of many health indicators, although per
capita income-wise Kerala has done as well as other states like Punjab,
Haryana and Maharashtra. Navarro points out that the dramatic improvement in health took place from 1970’s onwards, the period with highest
socialist participation in Kerala’s government. This is clearly evident in
reductions in infant mortality rates from 1970s onwards. Prior to the
election of socialist forces (in the 1950s) the health record of Kerala was
like any other state. But three decades of predominantly socialist policies
have made their impact. Between 1951-81 the decrease in infant mortality
rates was 26 per cent for all India, while for Kerala it was 73 per cent, much
of the decrease was after 1970. This was achieved at per capita incomes,
similar to those of all India.
Similarly by analysing the health indicators ofAsiatic republics of
erstwhile USSR with those of comparable countries, bordering the republics, he shows that in terms of such indicators they were far ahead of their
neighbours. According to him “in Africa socialist experience is too new to
be able to detect significant changes”. He also states that European
republics of erstwhile Soviet Union do not fare better than the majority of
capitalist countries in western Europe. But the criticism that health peers
of Soviet Union were to be seen in underdeveloped countries is not
supported by data.
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After analysing the socialism in developed capitalist countries he
points out that social democratic and socialist forces had played a significant part in creating a welfare state in these countries. Wherever socialists
haveparticipated in the government, despite constraints public welfare
and health were given enough attention. In terms of health indicators
Sweden, Norway and Denmark are ahead of the US. He concludes
Based on this information one could hardly conclude that socialism is less
effective than capitalism in responding to the health needs of population. I do
not deny that capitalism has been effective in some parts of the world, and that
in some limited instances — limited in both space and time — capitalism may
have been even more effective than socialism. But the empirical evidence
presented in this article shows that, contrary to what is widely claimed today,
the socialist experience (both in its Leninist and its social democratic traditions) has been more frequently not more efficient in responding to human
needs than the capitalist experience.
Unfortunately, the socialist experience has also included very negative developments that have negated important components of the socialist project and
forced a much needed reevaluation of the socialist project and best road to
reach it. The distance between socialist theory and practice has too frequently
resembled the distance between the Sermon on the Mount and Christianity in
the 2,000 years of its existence. Still, the historical experience of socialism is
quite short. Capitalism has existed for over three centuries. Socialism, on the
other hand has just begun.
K Ravi Srinivasan
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REVIEWS
Demographers and Population Policies
|
Malini Karkal
Regulating Reproduction in India’s Population — Efforts, Results
and Recommendations by K Srinivasan, Sage Publications, New Delhi,
pp 329, Rs 350 (cloth).
INDIA was the first country, in the world, to accept a national family
planning programme. The programme was launched with a clear objective of improving the life of Indian people. The Health Survey and
Development Committee’s (Bhore Committee) 1946, report identified
India’s major health problems and recommended various measures to
improve public health, environmental sanitation, nutrition, and prevention of communicable diseases. It also suggested the organisational
structure appropriate for implementing these programmes. The report
devoted an entire chapter to population, strongly recommending the
adoption of a national family planning programme as an essential public
health measure. The specific recommendations contained in the reports
of the Bengal Famine Inquiry Commission and Bhore Committee were
instrumental in the family planning programme becoming a constituent
part of India’s developmental strategy, starting with the First Five Year
Plan in 1951 (p23).
In the words of Indira Gandhi (1968), “In fact the very significance of
calling our movement family planning and not population control, is that
our aim is to secure the welfare of our people.” The programme outlined
for the welfare of the people became a programme of population control
under the influence of western countries and the main among them was
the US. Davis (1968) argued that large countries such as India and China
could pose a threat to the western countries as “It seems, that power results
from sheer numbers, the importance of non-western and less developed
areas will increase” Dorn (1968) supported Davis when he said “Millions
of persons in Asia, Africa and Latin America are now aware of the
standard of living enjoyed by European and North Americans. They are
demanding the opportunity to attain the same standard, they resist the idea
that they must permanantely be content with less.” Dorn added. “The
results of human reproduction no longer are solely the concern of two
persons immediately involved, nor of their families, nor even of the
nations of which they are citizens.” Malthusian theory of population had
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already stated that effects of growing population and shortages of resources were disease, famine or other disasters, widespread poverty and
degradation. In other words Malthus provided an explanation of underdevelopment.
Taking acue from the studies of Coale and Hoover (1958) based on the
data from India and Mexico, it was argued that rapid reductions of fertility
could contribute to better economic progress (p 34). “In 1959, the Ford
Foundation made to India its first international population control grant.
In various countries the voluntary family planning associations were
gaining strength and making a beginning in international collaboration
which blossomed as the International Planned Parenthood Federation”
[Loarell 1968].
Under these influences the objectives in the Indian plan underwent
changes. In the Third Five Year Plan “The family planning programme
was viewed not simply as a social welfare measure for improving
women’s health and status, or in helping couples to space and limit their
children according to their desires, but as a positive policy instrument for
achieving the country’s demographic goal” (p 34).
D R Gadgil (1972) the eminent economist who played an important
role in Indian planning said, “For about 200 years the European people
have been used to thinking themselves as the natural ruling powers. It has
been with great reluctance and strenuous opposition at each stage, that
they have admitted nations or other races to a position of even theoretical
equality. If now those countries, some of whom are extremely populous
attain a status of something like real equality the mental adjustment
required of European people in accepting this fact would undoubtedly put
them under great strain. There is no doubt that this is partly the explanation of the great attention paid by the Anglo-Americans to the population
problem of the Asian countries.”
|
Promoters of population control programmes, those who encouraged the setting of demographic goals to the population policies,
rather than human welfare, had their own vested interests. “For the
rich countries of the west the commitment to the concept of international equality involves the obligation to make substantial contribution to the programmes for reduction of international disparities in
levels of living by helping to raise incomes in poorer countries. The
view that the responsibility for the prevalence of poverty in the
underdeveloped world rests on its continuing attatchment to archaic
social institutions and overpopulation, serves to divert attention away
from this moral problem” [Joshi 1974].
Access to information as well as services for family planning is an
urgent need of couples and also their right. However to blame human
reproduction for prevailing poverty, resource crunch, environmental
problems, and many of the social problems and reduction in birth rate as
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229
the solution, as Srinivasan, the author of the book under review, assumes
is completely missing the point.
Promoters of population control policies concentrate on reduction of
birth rates and at any cost. Srinivasan has no hesitation in saying “family
planning programme performance during 1976-77 (in India) was the best
ever realised in the history of any country, with a total of 8.26 million
sterilisations — more than the total number done in the previous four
years. Had this tempo continued, even ona slightly more modest scale, for
a few more years, India’s birth rate would definitely, have plunged as
dramatically as it did in China” (p 39). He believes, “it seems that India
made a sacrifice in terms of delayed demographic transition, and possibly
socioeconomic development to safeguard people’s democratic rights”
(p 41). Srinivasan must sure have had access to the detailed descriptions
of series violations of human rights that were the mainstay of the 1976-78
campaign or for that matter are a part of all implementation of the Indian
family planning programme. One wonders what the definition is of
democratic rights that Srinivasan believes in. Incidently, Srinivasan
surely knows about the forced abortions — even during late gestations —
and forced and sterilised IUD insertions that are widely practiced to
implement one child policy in China. The widespread practice of female
infanticide in China is also well documented. Srinivasan’s praise of
China’s achievements in demographic goals therefore raises several
questions.
It is easy to understand that a national government should plan for
improving the life of its people. It is therefore natural that soon after
gaining independence the government of India accepted family planning
as a national programme as a part of initiation of “a process of development to raise living standards and to open new opportunities for a richer,
more varied life” (p 27).
If is difficult to understand how a programme that was initiated as a
programme to improve the health of the people was converted into a
programme of population control with a sole objective of reducing birth
rate. Demographers and biomedical professionals have contributed significantly to this transformotion. The book under review presents a good
example of how a demographer looks at the population situation from
different angles and comes to the pet conclusion that there is an urgent
need to control populationand that will solve all national problems. And
this is being done inspite of repeated evidence of absence of relationship
between population size and economic development. Asearly as the
1960s, data from developing countries gave a clear evidence of this. The
World Bank in the 1970s and 1980s showed that the populations of the
developing countries increased, and yet with the exception ofa few, there
was an improvement in income per capita, in literacy, in level of nutrition
as well as in life expectances. Many economists including Simon Kuznets
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and Richard Easterlin have cautioned that the actual effect of population
growth on economic development was complex and could not be easily
used in argument as a basis for promotion of population control policies.
According to Srinivasan “The effective couple protection rate from
within the program also seems to be influenced significantly by female
literacy and infant mortality indicating that the extent of contraceptive
protection the program offers is influenced by women’s status and child
survival” (p 211). The three case studies as given by Srinivasan of the
states that have undergone fertility transition also show that social
indicators brought about the change (chapter 7). Tinmothy Wirth, US
representative to the ICPD at Cairo accepts that donor-funded population
programmes had a narrow focus on reducing birth raes and in attention to
human rights, women’s health and cultural differences. He points out that
the developing countries resent the emphasis given to population growth
as a cause of environmental problem in he absence of a parallel focus on
the consumption in the North [Wirth 1994]. Debates in the past few years
have led the population lobby to admit that “numbers tell only part of the
story” [Mazur 1994]. World Bank (1990) says that it is not population
growth that leads to poverty, but it is the poverty that leads to population
growth. There is greater awareness and acceptance that it is the social
prosperity that brings slower population increase. As seen from the
presentation in the book under review, Srinivasan
seems
to be fully
unaware of the national and international debates that have been widely
reported. If one looks at the 196 references at the end of the book only 26
refer to period between
1990 and 1992, and none beyond 1992. Even
among these 26 mostly deal with available data on births, contraceptive
use. etc. None is on the discussion the policy issues. Srinivasan blames
Gandhiji for unpopularity of the ‘artificial methods of contraception’.
There is not even a mention, since Gandhiji’s name is brought in, about
Gandian philosophy. Interestingly, an academician, Srinivasan makes his
comments on this ‘man of the century by referring to another writing.
Similarly a whole chapter devoted to population policies and programme
since independence also depends on what Col Raina, first person appointed as acommissioner of family planning, a post created after family
planning programme became a population control programme, wrote in
1988. All the presentations in the policy statements and the ‘readings
between the lines’ present Indian policy as apolicy for population control.
It must be repeated here that even Indira Gandhi was convinced that
Indian family planning programme was not a programme for population
control (see reference above).
The demographer Samuel Preston [quoted by Aird 1993] who was an
important participants in a study on population, conducted in 1986, said
that the relationship between population growth and income per capita
does not provide a basis for a ‘doomsday scenario’ used by, family
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Zu
planning advocated to promote their cause. In. his opinion, it however gets
public attention and brings in money. Further, “he warned that those who
use it may crash with it when it is finally shot down”.
One is not sure whether the book is a “must for students and researchers
in population studies” but it is surely helpful in pointing to the role of
demographers in the promotion of population control policies.
References
Aird, John S (1993): ‘Family Planning, Human Rights and the Population
Establishment’, Population Research Institute Review, Vol 3, No 5, p 2.
Davis, Kigslex (1968): ‘Population and Power in the Free World’, in Population
and World Politics, ed Hauser Philip M, Jaico Publishing House, Bombay.
Dorn, Harold F (1968): ‘World Population Growth in The American Assembly’,
The Population Dilemma, ed Hauser Philip M Jaico Publishing House.
Gadgil D R (1972): Planning and Economic Policy in India, Gokhale Institute of
Politics and Economics, Pune.
Gandhi, Indira (1968): Inaugural Address to Sixth All India Conference
on
Family Planning November 30 -December5, 1968. Reportof the proceedings
published by Family Planning Association India, p 14.
Joshi P C (1974): Population and Poverty: The Discord in Population in India’s
Development 1974-2000 ed by Bose A, Desai P B, Mitra Asok and Sarma J
N, Vikas Publishing House.
Leavell Hugh R (1968): The Role of UN and Other International Agencies in
- World Population Control,Sixth All India Conference on Family Planning,
30
November to 5 December, Chandigarh. Report published by FPAI,
p 268.
Mazur Laurie Ann (1994): Beyond the Numbers: An Introduction and
Overview, in Wirth (below).
Wirth Timothy E (1994) Foreword to Beyond the Numbers — A Reader on
Population, Consumption and the Environment ed Laurie Ann Mazur, Island
Press, Washington DC, p XIV.
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.
2%
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Health Research: Strengths and
Weaknesses
Ramila Bisht
Nilambari Gokhale
Health
Research
in India:
A Review
and
Annotated
Biblio-
graphy compiled by Foundation for Research in Community Health,
Bombay, 1995.
THIS bibliography tries to examine the available literature on health
research conducted by social science research organisations, academic institutions and market research organisations in both governmental and non governmental sector. This review is particularly
important as health research in India is of recent origin. The team
has not only documented the available research carried out between
1985 and 1992 but has also critically examined it, pointing out the
gaps in knowledge as well as the methodology of the research. The
book covers 102 institutions/organisations. Out of 400 documents
gathered, 250 studies covering five broad topics were selected for
review.
This is the largest section of the book.
It covers studies on
provision, access and utilisation of health care services along with the
evaluation of national health programs,and health facilities in the
public and private sector. The FRCH team in its review discovered
that studies have concentrated mainly in public sector instead of
predominantly prevailing private sector. Even in the public sector
focus is more onrural public health services, concentrating on primary
health care services and below, with only occasional focus on hospital
and other referral facilities. Similar trend is evident in studies on
humanpower. Unfortunately the approach here is from an operational
perspective rather than social.
The review clearly points out the inadequacy of public health services
to handle the expected range of health care responsibilities, the focus
being largely on family planning programs. The growing private sector
is no better.
Despite increase in number,
it fails to maintain
even
minimum standards. The bibliography reveals that very few research
studies have been undertaken is the area of finance. In shortlisted research
studies, the main coverage is on non-governmental sector. The document
correctly points out that probably the non-availability of recorded information and reluctance on the part of private and non-governmental sector
to share this information must be barrier to undertaking studies on aspects
related to finance.
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Under organisational dynamics the review focuses on management
information systems in public health care model. The studies report
duplication of reports and absence of standard formats.
Lot of
information is generated, but its not very relevant or reliable and
hence cannot be used for decision making or planning. The FRCH
research team found very few studies focussing exclusively on access
and utilisation of health services. The bibliography reveals that even
in rural areas there is predominant preference for the private sector.
But the studies fail to elicit the magnitude of utilisation of the private
practitioners and services among various classes of society or their
distribution in rural areas. The review team in its study reached the
conclusion that the emphasis has been more on vertical programmes,
stress being on family planning activities, leading to neglect of other
important programmes. The evaluations point to the diversity of
health circumstances present, which speak of importance of priority
setting. Given limited resources and the immensity of health problems facing our country, it is imperative that priorities be set and
resources be allocated efficiently, if we want to have any impact on the
health situation of the country. Several health problem are receiving
attention,
but other equally important ones appear relatively neglected.
The review makes no reference to the recent explosion of funding for
research on AIDS. There is no doubt of the enormous health significance of AIDS, but it is critically important that research investments
on AIDS do not take funds from research urgently needed on other
health problems causing greater mortality and morbidity. Research on
fertility and reproductive health claims high priority because of
unwanted fertility and its relationship to population control. The need
is to undertake research on issues related to women’s health rather
than just fertility or reproductive health.
Throughout the book, the reviewers point to the paucity of information
on private health sector. No wonder this has resulted in hardly any data
being available regarding their growth, distribution in rural and urban
areas, standard of medical cure provided or patterns for regulating or
monitoring them. This is a significant omission pointed out by the review
team as private health sector is an enormous area rapidly growing under
the umbrella of liberalisation. The documents stress on research attention
in areas such as financing of health services and development of health
system. A visible gap in this book is a review of research studies in
traditional medicines or indigenous system of medicine and practices.
Health research in ayurveda, siddha and unani needs to be documented.
One expected the FRCH team to at least attempt to include it in their
review of health research. Similarly no attention is paid to research in
field of mental health and behavioral health which is a major cause of
morbidity.
234
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EPIDEMIOLOGICAL PATTERNS
The review team undertook studies in this area with the objective of
assessing the available evidence on prevalence and incidence of communicable diseases and their morbidity and mortality rates. Bibliography
reveals most epidemiological studies are hospital-based though there is a
. trend towards doing smaller surveys which generate health and morbidity
patterns in selected geographical areas. They also discovered that the
most commonly researched diseases are ARI and diarrhoea. Pointing to
the gaps in research, the team rightly indicates the need to do cultural epidemiological studies. It points out, though not very explicitly, the
urgent need for epidemiological data to be desegregated from national
averages. These average often hide differentials and variabilities in terms
of geographical area, income, social stratification, various social groups
— minorities, tribals, immigrants and those disadvantaged due to the
orocess of industrialisation and modernisation.
Critically analyzing this area of research the team intelligently suggests prioritising diseases into various categories. This will help in
identifying those diseases far which an understanding of the disease load
is useful. It also points out the needto utilise available data to gauge the
current disease load which they erroneously feel is sufficient. This is a
contradiction in the analysis of the reviewers, as they have already
questioned the quality, reliability and. validity of the available data.
Despite accepting the ‘unregulated’ nature of private sector, the team
hopes that better imposition of ‘compulsory notification act’ is possible
and would help in collecting reliable epidemiological information in this —
sector. This stand taken by the review team seems rather far-fetched to
this commentator,as such laws and acts have existed for long — with
negligible impact. The review-team seems to be unduly hopeful.
Though health education is a universally accepted component of all
health programs, the FRCH team throws light on only nine studies
indicating need for more research in the area. The ajority of studies
reviewed are evaluations of effectiveness of methods, materials and
medium used in health education activity. Imparting information is only
one part of health education. The other objective is to bring about change
in health-related attitudes and behaviour in directions more conducive to
good health. Studies examining the second objective of health education
are scarcely reported. The team, for some reasons has also not delved into
the methodology adopted by the studies in this sections, which are of
relevance and should have found a place in a study like this.
The studies reviewed under this category cover studies on sociocultural factors influencing use of, and access to public health services
and evaluation of community participation in health care delivery. Large
number of studies reviewed are KAP/KABP studies which the team
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piebe
reports are accompanied by in-depth interviews, focal group discussions,
etc in order to enhance the quality of data gathered on people’s belief,
attitudes, perceptions and behaviour.
As we all know community participation is of utmost importance, and
is a desired goal of all community-based health programmes both in
government and non-government sector. But a look at the studies indicates that it is still an elusive goal. Unfortunately none of the studies have
analysed the success or failure of efforts in increasing community
participation by any agency. Various tenets of community participation
had not been spelt out in these studies, therefore as correctly pointed out
by the FRCH team further action research needs to be encouraged and
promoted.
The annotated bibliography ends by reviewing studies that evaluate alternative approaches to health care delivery in public, private
and nongovernment sectors, especially with regards to cost- effectiveness are few and far between. Another important finding is that despite
trying to make delivery patterns of these nongovernmental
organisations through their activities are able to bring about improvements in levels of awareness, it is seldom seen translated into indi-
vidual or collective efforts at self-care. The team though points out to
the overall vulnerable financial position of nongovernment sector
because of dependence on time bound external funding, it does not
explicitly indicates need to study this whole issue of ‘sustainability’
of these experiments. In the field of alternative strategies, the current
focus is on greater participation of private sector and alternative
sources of health care financing (Reflected in WDR, 1993). The
review clearly points out that research in this area is still marginal.
Studies reviewed present a rather hazy picture of the role of private
sector in insurance-based health delivery.
The team also reviewed a few modification in health care delivery
within the prevailing public health system. In the rural sector, the team
reviewed the area development projects — an effort towards socially
integrated approach of the bio-environmental sector control programs.
While in the urban areas, the team reviewed the studies on establishment
of health posts with the aim of covering the needs of primary health care
in urban population. The FRCH team concludes by emphasising that no
clear understanding of alternative strategies seems to be emerging from
the literature under review. There is need to look at health sector in a
holistic manner, recognizing the role of the private sector. It appropriately cautions that better regulation of private services and well-designed
research of comprehensive financing systems needs to be undertaken.
This will bring the private practitioners into an integrated referral systems
and enhance coverage rather than burdening the people with increased
user charges.
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DISCUSSION
TB: Unrealistic Prescriptions
Sunil Kaul
LAST month I lost two more patients, Hardan and Nanu. They were
under my treatment for tuberculosis and lost their battle without a good
fight. The WHO has declared an epidemic of TB but in the cacophony
of AIDS, no one has heard the clarion call to fight it. To be fair, even
the WHO has tried to focus on the twin epidemics of HIV and TB and
not on TB alone. Neither Hardan nor Nanu had heard of this epidemic.
To them TB was a motodi bimari or a big disease. They had come to
us for treatment because they knew that it cost a lot to fight TB and
that we provided free treatment at our monthly camp at Lukaransar.
Hardan and his brother Devidan had come to us within a month of each
other and neither had responded to the latest WHO prescribed regimen.
While Devidan had a relapse, the second time in four years, after having
been declared cured, his elder brother had been picked out by our village
level workers after they found out that he was buying medicines from the
market but was unable to afford them. Since neither responded to the
treatment, they had been sent to the specialists at Bikaner, 70 km away,
but the second line, Rs 1,500-a-month treatment did precious little to the
TB bacteria.
In our quest to provide the latest and the best to our patients, I sought
the TB people at Delhi to get a tab on the antibiotic sensitivity of the
bacteria that was playing truant with us. Although Bikaner has a medical
college, we have only the facilities to grow the organism but no way to
find out how to kill them. Even worse the microbiology professor
confessed that she had an unreliable and overworked staff and that she
could not rely on the results — which take six weeks because of the slow
growing TB organism — and this led me to Delhi, where politely but
plainly I was told that I was practising quackery by shifting to the second
line drugs without drug sensitivity tests. Acting on their advice I sent
Hardan’s sputum for culture and antibiotic sensitivity and after a lot of
patient explaining, convinced him to go on to the minimum possible
medicine. “After all, you’ll get results in 10 weeks and then we can give
you the right treatment.” I was still smarting from having been called a
quack and would go by the book, I decided. I got Hardan’s treatment
endorsed by the doctors of arural hospital which specialises in TB and felt
that I had salvaged my conscience.
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Lon
Less than a month later, Hardan was brought to us with a severe bout
of haemorrhage from his lungs, and after his last valiant fight with the
disease at the Bikaner hospital with the help of all the drugs in the TB
armoury, he was sent back home where he succumbed the following
morning.
Nanu had been on TB drugs ever since our village level worker could
recall. Incoherent in her speech when I first saw her, I’d got herexamined —
at way-off Jaiur, and she had been put on as many drugs that I had heard
of in TB, anc continued to take the same for some months. She didn’t
collect her drugs for the second consecutive month and I paid her a visit.
“No way I will take these drugs. I’ve had enough of them. I threw them
away the last time and I’1l do the same this time too. For 10 years I’ve
taken these drugs and enough is enough.” I didn’t try too hard to persuade
her and came away after telling the family that they could contact us in
case she changed her mind. She never got a chance to do so as she
succumbed to TB the following day.
Devidan and six others are facing death which seems inevitable to me
and to them. Multidrug resistant TB is increasingly seen nowadays, I’m
told. WHO would like me to put them on the last priority and not to waste
money
on them. “For chronic tuberculosis, put them on the minimal
possible medicine and try to keep their infectious nuisance to the society
to the minimum.” Is that all to it?
As a public health measure it may sound logical to allow some people
to die to prevent wastage of drugs, but how does one take this decision?
Like in Hardan’s case, we might be hastening death by this decision. In
real time OPDs and with the real time patients from your own villages you
can’t appear to have given up. Besides, one death means one less regular
patient in the OPD, a fact which every other patient takes note of and gets
demoralised by. ,
“After all, some of the patients have to die — don’t feel so upset”
consoled an expert that I called on. I agree one shouldn’t feel upset about
someone dying of TB inacountry which loses five lakh people every year
to this disease. But is it fair? In a world which loses more people above
the age of five to TB than all the other infections put together, why should
this scourage of centuries ago get the second least funding of all infectious
disease programmes? Who decides that AIDS should get the maximum
funds when all that HIV can do is to make it easier for one infected by it
to die of the other infections including TB?
It is well known that TB bacteria — any organism for that matter —
get resistant to the drugs if they are exposed to improper dosages or
intermittent and inadequate treatment. Patients give up midway through
the long haul of treatment for TB; some due to lack of adequate funds,
some because they feel better early in the course of therapy, and many
others simply because they were never informed about the nature of their
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ailment or its treatment. But a much bigger cause is the easy availability
of anti-tubercular drugs with quacks and other practitioners who have no
business to be dealing with them. If Ihave seen Ethambutol — a TB drug
— béing prescribed to a colleague’s father for his cough, or the whole lot
of drugs to a patient on the basis of her X-ray which was fit enough only
to see the eclipsed sun, some
of my friends have seen Rifampicin,
available over the counter, as a cure for gonorrhoea, a common sexually
transmitted disease.
Many such ‘quacks’ who prescribe these have proper MBBS and MD
degrees. Such thoughtless dosing not alone suppresses TB symptoms for
sometime or spoils sputum examination results, but it also exposes the
silent TB bacteria (available inside half of the Indian population) to the
drugs and allows them to develop their resistance against these drugs. The
strains that we talk of as multidrug resistant have precisely developed like
this. And then spread from one to another.
Ciprofloxacin, the most commonly prescribed antibiotic in the market
since the past few years was found to be effective against TB as a second
line drug, and could have been preserved for this deadly disease for those
who were resistant to the other drugs. But what one gets it for are colds,
coughs, boils, typhoid, dysentry and urinary tract infections. How then
does one expect it to be of any use now for TB? Where does one go from
here — to third line drugs which would be doubly toxic and trebly costly?
The TB epidemic which has been announced by the WHO has come
about.because of many reasons, only one of which is the recent spread of
the HIV. To me and many of my ilk, it is only a symptom of the larger
disease that afflicts us. It is an indicator of the insensitivity of the world
which would care to spend more on what it may get in the future than on
what people are dying of today. It tells us about the state of affairs of a
nation where there is a total lack of administration and a break down of
drug enforcement agencies. It shows us that we still do not provide
enough for our people to allow themselves to be able to take the complete
course of medicines and that the right to live provided for in our
Constitution is of no avail. Last but not the least, it tells us that we have
miles to go in educating people so that they can avoid quacks and
participate better in treatment.
TB, like other health problems, is too serious a problem to be left to the
medical practitioners to handle especially when the majority of that
fraternity sees little but commerce in their practice. The way it is going,
it needs the collective attention of sociologists, administrators, drug
industrialists, medical scientists, and that of doctors and the community
also. The time to act is now. Or else we’ll have only ourselves to blame.
Sunil Kaul
URMUL,
RJH
Rajasthan
(New Series)
Vol 1:3
1995
239
————————
oo
FACTS AND FIGURES
TABLE 1: STATUS OF CHILDREN IN SELECTED COUNTRIES
Annual No of
Under-5
Under-5 Deaths Mortality
Eate
(thousands)
1993
1993
Per Cent
Per Cent
GNP
Per Capita of Under-5 of Children
($)
Children
Reaching
1993
Under-weight Grade 5
S
ne SEUEEEIEtSIyEEIS SSUES SES
nnn
Sub-Saharan Africa
Angola
|
154
Burundi
Eritrea
Ethiopia
Ghana
49
29
514
116
Kenya
105
Mauritius
1
Mozambique
194
Rwanda
Somalia
South Africa
Tanzania
47
96
85
202
Uganda
19]
292
178
204
204
170
90
22
282
141
700
180
110
100
430
270
2980
80
200
38
_
48
27
22
24
29
34
53
_
9
72
i
if
95
23
60
211
150
~
3
69
167
185
2900
100
190
29
23
71
24
37
122
12
128
137
19
220
290
160
430
600
66
69
70
40
38
47
62
52
37
92
43
17
59
6
48
490
3160
830
19310
170
17
23
34
14
52
88
92
75
100
58
South Asia
Bangladesh
500
India
3166
Nepal
105
Pakistan
740
Sri Lanka
a
East Asia and Pacific
China
Malaysia
Philippines
Singapore
Vietnam
925
9
| te
0
104
TABLE 2: PREVALENCE OF DISEASES PER 1000 PopPuULATION 1992-93, MAHARASHTRA
Total
All ages
0-14 years
Rural
All ages
0-14 years
Urban
All ages
0-14 years
240
Malaria Sample
Limbs
(Last
Size
Impairment 3 months)
TB
Leprosy
=P
iB
2.9
1.5
0.7
0.4
5.7
a
37.4
31.7
22183
7957
36.5
4.2
4
2
3
0
1.0
0.4
6.1
6.0
a3
44.0
12806
4817
26.1
3.2
lo
0.6
5
-
0.3
0.3
ne
4.8
18.4
12.7
9377
3140
RJH_
(New Series)
Blindness
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175
1995
TABLE 3: PREVALENCE AND TREATMENT OF CHILDHOOD PROBLEMS,
MAHARASHTRA, 1992-1993
I
Male
Female
Rural
Urban
Total
1 By fast breathing
57
TED
15
3.5
5.9
2 Fever
3 Diarrhoea—any
— with blood
22.6
10.8
1.3
20.7
8.5
0.7
p Pigs
10.2
3
20.8
8.8
0.6
21.7
9.7
1.0
5.8
4a
a2
5.0
5.1
84.5
61.0
Powe
te ie
72.6
—Injection
39.7
27.6
Dab 4
Zou
35.6
26.7
37.0*
PORE &g
35.9
25.6
—Cough syrup
24.1
18.6
Dae
1H i
21.4
health facility
78.1
12a
70.9
82.8
75.4
(b) Per cent treated with
—Anti Malarial
9.2
6.4
8.6
6.7
7.9
—Antibiotics
29.8
30.5
517
27.6
30.2
—Injection
26.8
Lik
31.0
20.9
pg
59.6
62.7
57.7
66.7
60.9
19.3
31.2
21.1
11.5
16.9
513
20.5
22.9
21.1
31.7
22.0
24.4
13.0
ne pal
18.8
10.1
18.2
33.9
20.8
19.3
Prevalence of:
(per cent children
0-4 years in last
2 weeks)
4 Diarrhoea in
past 24 hours
II Treatment
1 Acute Respiratory
Infection
(a) Per cent taken to
health facility
(b) Per cent treated with
—Antibiotics
2 Feverg
(a) Per cent taken to
3 Diarrhoea
(a) Per cent taken to
health facility
(b) Per cent treated with
—ORS packets
—RHS at home
—Antibiotics
—Injections
RJH
(New Series)
Vol1l:3
1995
241
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243
HEALTH STATUS OF CHILDREN
The health status of children reflects the progress made in achieving
social development targets and is a measure of the improvement in
the human condition. While it is true that economic performance is
not everything and that some poor nations have been able to achieve
levels of health and nutrition surpassing those of richer nations, the
crucial factor is the removal of unjust and exploitative economic
relationships between and within nations. As Table 1 compiled from
UNICEP’s Progress of Nations shows, the neglect of children is seen
both in the under- five mortality rate as well as in the number of
children who reach grade 5 in schools.
The level of child mortality is a basic indicator of the quality of life
in a society. In India the National Family Health Survey (NFHS)
provides national-level and state-level data on fertility, nuptiality, etc,
family size preferences, as well as on child health indicators such as
utilisation of antenatal care services, breastfeeding, food supplementation practices, child health and infant and child mortality.
The NFHS covers 99 per cent of the population in 24 states and Delhi.
In all 89,777 ever-married women in the age group 13-49 and 88,562
households were covered using uniform questionnaires, sample
designs and field procedures.
The survey records the following rates of mortality:
neonatal mortality:the probabilityof dying within the first month of
life; postneonatal mortality: the difference beween infant and neonatal mortality; infant mortality: the probability of dying before the
exact age of one; child mortality: the probability of dying between
the first and fifth birthday; under-five mortality: the probability of
dying between birth and exact age 5.
Similarly infant feeding practices and child nutrition have
significant effects on child survival. These are. recorded in
Table 4.Childhood diarrhoea is one of the major killer diseases in
India affecting particularly children under age 5. One of the priority
government programmes for child survival is the oral rehydration
therapy programme one component of which is an awareness education programme for mothers in the community. Table 4 compiled
from several tables of the NFHS shows the proportion of children
with diarrhoea, children who received treatment with ORS or home
eae indicators of breastfeeding practices as per WHO guideines.
Table 2 shows the prevalence of childhood diseases and other
problems which affect child mortality rates as well as the health of
the child, for Maharashtra. Table 3 records how these diseases are
treated.
244
RJH
(New Series) Vol 1:3
1995
+e.
si
oe+z
Medico
Friend Circle
Publications
_In Search of Diagnosis edited by Ashwin Patel, pp 175,1977
- (reprinted 1985). Rs 12. (Currently out of stock)
~ Health Care: Which Way to Go? Examination of Issues
‘and Alternatives edited by Abhay Bang and Ashwin Patel,
pp 256, 1982 (reprinted 1985), Rs 15. (Currently out of
stock)
Under the Lens: Health and Medicine edited by
Kamala Jayarao and Ashwin Patel, pp 326, 1986, Rs 15
(Currently out of stock)
Medical Education Re-Examined edited by Dhruv Mankad,
pp 214, paperback Rs 35, hardcover Rs 100.
Bhopal Disaster Aftermath: An Epidemiological and Sociomedical Study, pp 76, 1985.
Distorted Lives: Women’s Reproductive Health and Bhopal
Disaster, October 1990,‘Rs 10.
Medico Friend Circle Bulletin. Bi-monthly, Individual
subscription: Rs 30.
For enquiries
Ravi Duggal, Convenor, Medico Friend Circle,
Building 4, Flat 408, Wahatuk Nagar, Amboli, Andheri(W),
Bombay 400 058. Phone/Fax: 621 0145.
The growth of movements that can
challenge both environmental pollution and
women’s oppression requires all groups to
re-examine how they define issues and
choose allies. Feminists will have to look
for ways to connect reproductive rights
struggles with the fight against toxic
chemicals. Environmentalists will have to
understand that access to safe abortions
and easily available child care are
necessary conditions for women’s active
political participation. Labour activists will
need to find ways to include women
and
community groups in campaigns for safe
working conditions and against plant
shutdowns.
Nicholas Freudenberg
and Ellen Zaltzberg
in Double Exposure: Women’s Health
Hazards—On the Job and At Home,
edited by Wendy Chavkin,
Monthly Review Press, 1984
zy
4
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