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APRIL-JUNE
1995
A SOCIALIST HEALTH REVIEW TRUST PUBLICATION
New Seris
VOLUME
I
UNDERSTANDING MENTAL DISTRESS:
FRANKFURT SCHOOL’S CONTRIBUTIONS
EDUCATING INDIANS IN MEDICINE:
GRANT MEDICAL COLLEGE. 1845-1885
CULTURAL RELATIVISM, ETHICAL
IMPERIALISM AND REPRODUCTIVE
NEW DRUG POLICY MAKES
RIGHTS
WAY FOR PRICE RISE
“REPRODUCTIVE HEALTH: NEED TO BROADEN
THE CONCEPT
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 Iyer, 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
Binayak Sen, Raipur, MP
_—Manisha Gupte, CEHAT, Pune
V R Muraleedharan, /ndian
Dhruv Mankad, VACHAN, Nasik
K Ekbal, Medical College,
Institute of Technology, Madras
Padmini Swaminathan, Madras
Kottayam
Institute of Development
Francois Sironi, Paris
Studies, Madras
ee
Imrana Quadeer, JNU,
C Sathyamala, New Delhi
New Delhi
Thelma Narayan, London
Leena Sevak, London School of |School of Hygiene and
Hygiene and Tropical Medicine, Tropical Medicine, London
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.
Volume
I
(New Series)
Number
2
Letters to Editor
April-June
1995
.
81
Editorials: ‘If You Can’t Have Bread...’
Padma Prakash
Profitable and Now Legal Sandhya Srinivasan
Managing Resources
VR Muraleedharan
83
Understanding Mental Distress: Contributions of
Frankfurt School
Parthasarathi Mondal
89
Indian Practitioners of Western Medicine:
Grant Medical College, 1845-1885
Mridula Ramanna
116
Reproductive Rights and More
Lakshmi Lingam
.
136
Communications
Making Way for Price Rise: New Drug Policy
Wishwas Rane
Reviews
Government Expenditure on Health Care
Brijesh C Purohit
:
145
:
150
Discussion Paper
Cultural Relativism, Ethical Imperialism and
Reproductive Rights
Ruth Macklin
153
Facts and Figures
Status of Indian Women: Production and Reproduction
162
Asha Vadair
Sandeep Khanvilkar
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LETTERS TO EDITOR
Ethics in Health Care
The Medico Friend Circle, an all India group of medical people and those working in
health is holding its annual meet on December 27 to 29 at Sewagram. The theme of the meet
is ‘ethics in health care’. The organising committee invites background papers, articles,
reports , notes, case studies on any of the following or other relevant topics.
Ethical issues in : Health Policy Making and Implementation of Health Policies;
Population Control and Family Planning, Research and Use of Contraceptives; Disaster
Management; Experiments, Innovations etc in Low cost Primary Health Care Delivery by
NGOs; Technology, End Stage Diseases, Transplantation; Mental Health Care; AIDS; Cost
of Health Care and Doctor’s Fee; Any other.
For more information on the meet, write to Amar Jesani, 519 Prabhu Darshan,
31 S S Nagar, Amboli, Andheri(W), Bombay 400058.
Telephone and PCFax:022-6250363; Email:cehat @inbb.gn.apc.org.
Bombay
Ravi Duggal
ICPD Update
A small group of NGOs that met in Ahmedabad in December last had decided to form a
network of like-minded individuals interested in explorin the feasible approaches to move
forward from the programme of action adopted at the International Conference on Population
and Development in Cairo in September that year. We have called it ‘Health Watch’ and it
is visualised as a vehicle to increase the attention paid to women’s health needs and concerns
in public debate and national policy. We also felt that a periodical ‘Update’ could enhance
our interaction.
;
a
For the time being Health Watch will have its office at the Gujarat Institute of Development Research, Gota, 3824, Ahmedabad. (Phone 079-7474809-10; Fax: 079-7474811).
I would like to prepare a mailing list ( of interested people) and seek your help in the form
of addresses of individuals or NGOs who you think share the concerns about women’s health.
Health Watch will be happy to interact.
Ahmedabad
Leela Visaria
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‘If You Can’t Have Bread...’
The compression in the allocations for health in the 1995-96 Budget
together with the deceleration ofdevelopment and employment generation
programmes under structural adjustment will contribute to a worsening of
the health status of the poor.
THE finance minister, Manmohan Singh ended his speech to parliament
before presenting the Budget proposals for 1995-96 with these words: “Let
us strive tirelessly, as the great poet Rabindranath Tagore has said ... ‘to
build an India where the clear stream of reason has not lost its way into the
dreary desert sand of dead habit’.” Nothing could have been more
incongruous or inappropriate. For, if the dream is also of building an India
where its people live in health and security with adequate, even if not
plenty of food, water and shelter, the ‘stream of reason’ has long got lost.
With each new budget itis clear that the welfare of the majority is no longer
a primary concern. The ‘India’ that is being built is both by and for the
middle and upper sections of society, with the labouring masses being
squeezed out of breath little by little.
While health is a state subject, the central allocations do not, of course,
tell the entire story. But they are indicative of the government’s concerns.
Even a superficial glance at the central allocations for health in the last few
budgets show that they have barely kept pace with the inflation rates,
resulting thereby in hardly an increase in terms of the funds available.
There has thus been no real expansion of the programmes. The current
budget has allocated Rs 1,048 crore for ‘medical services and public
health’ giving a meagre 5.5 per cent increase over last year’s revised
estimates.
Health funding has always been haphazard, open as it is to influences
from outside the health sector and its needs. This is best illustrated by
central funding. of public health programmes. While each of these
programmes is supposed to have evaluation units, it is obvious that these
play no part in the allocation of funds. It is not surprising that malaria,
which has shown arecent resurgence, gets the lion’s share of the allocation
for disease programmes. But it hardly needs to be pointed out that the
resurgence is itself probably a result of the neglect of the programme at all
levels, and pumping in funds at crisis pointis not likely to reverse the trend.
Similarly, while the control of tuberculosis has now assumed priority, the
STD control programme continues to suffer.
In asense as an indicator of state’s welfare concerns the health budget
is not half as important as its other components. Take for instance, rural
development. As commentators have pointed out, not only is the increase
meagre, but the targets have been lowered; the number of rural families
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under the poverty line to be assisted has come down from 23.5 lakhs to
19.5 lakhs. Even the government does not claim this is because the
numbers who need the assistance has come down. Similarly, the allocation for rural water supply has gone up by 37 per cent, but on sanitation it
has remained the same. This plus the fact that the budget has been widely
seen to be having the effect of raising the cost of living for the poor and
middle classes is hardly likely to contribute to the betterment of their
health.
It is also important to take note of the fact that under the structural
adjustment programme, there is already evident a greater degree of
unemployment. Even the most vocal advocates of the SAP acknowledge
this, but see it as a temporary measure whose impact can be minimised by
adequate funding to create safety nets. The problem, however is of two
kinds: one, as the operation of the voluntary retirement and such other
schemes have shown, the people who lose jobs are not those who benefit
from the changes in the long run, because retraining programmes are not
generally designed for them although they are supposed to be. This means
that there is a growing number of skilled under-or un-employed who are
finding it increasingly difficult to find the wherewithal for survival.
Second, in no country which has undertaken SAP can it be said that
unemployment levels have gone down. Yet another problem is that the
emphasis on export-oriented industry has had a deleterious affect on the
people’s well being especially of women who are employed in many of
these hazardous industries, and the emphasis on cash crops has reducedfood
availability for the rural poor. What is most distressing is that the government does not seem to be approaching these supposed ‘interim’ problems
of SAP with any degree of seriousness. In a sense one can hear the old
refrain emanating from the corridors of power — ‘if you can’t have bread,
eat cakes’... If you can’t get rice, eat Kellog’s rice cereals; if public
hospitals are ill-equipped, go to the private institutions; if you have no
access to drinking water, drink Pepsi or Coca Cola’.
—Padma Prakash
Profitable, and Now Legal
Legalising organ transplants will not change the fact that these procedures
are exclusively the privilege of the few who can afford their high cost.
_THE Organ Transplant Act, 1994, came into effect on February 4, 1995.
It bans trading in organs and (almost all) transplants from live donors
unrelated to the patient, incorporates a definition of brain death, regulates
those hospitals allowed to remove, store or transplant organs, and makes
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unauthorised removal or trafficking a punishable offence. But it will not
change the fact that kidney transplant is almost exclusively the privilege
of the few who can afford the costs of the operation and drugs.
The organ trade in India is the inevitable result of promoting medical
technology unrelated to a country’s needs. The health problems of the
majority remain neglected — communicable diseases like TB and
malaria, and the consequences of poverty, like malnutrition, which have
a far more devastating effect on their lives. But the bulk of the health
infrastructure is curative, rather than preventive. And curative medicine is
getting more technologically sophisticated, and expensive.
The success of organ transplant surgery depended on a number of
developments—in the pharmaceutical industry, with anti-rejection drugs
like cyclosporin, in medical/technical expertise (microsurgery) and even
the medical instruments industry, whether or not they were directly related
to transplant technology. Organ transplant surgery can be done successfully only by trained personnel at very well-equipped hospitals, and
depends on a battery of tests. And all this is available in India—to those
who can afford to pay. We are not here talking about kidney transplants for
everyone who needs them.
According. to press reports, kidney transplants now constitute a
Rs 400 crore industry, most of which depends on paid donors. It
cannot be acoincidence
that Karnataka, Maharashtra and Tamil Nadu—
the three states where kidney rackets are now being unearthed—also
have the highest concentration of new private hospitals, offering the
latest in diagnostic and therapeutic equipment, some funded with
public issues.
.
India has a market for such sophisticated medicine. It also has a large
and growing population of poor people, unemployed, underemployed,
retrenched from productive work. The majority of Indians sannot hope to
make a decent living; instead, they get used as sources of spare parts, to
treat the very well-off, both in India and abroad. While the kidney
transplant industry has thrived (today in those states which have not passed
the act) there is little serious effortto address the problems faced by the
majority of the population. Not only daes the government decide to hand
over health care to an unregulated private sector; it has also disclaimed
responsibility for other aspects of good health—decently paid employment, good working and living conditions.
In fact, despite the risks of kidney donation {which may be acceptable
to a relative), some doctors have encouraged the poor to sell their
kidneys; they have promoted this as a solution to the problems of poverty.
(Naturally, the donors were rarely if ever informed of the risks of giving
up a kidney; others were reportedly deprived of a kidney without their
knowledge or sanction). The message to donors has been: sell a kidney,
pay off your debts, get your child married, set up a small business. And to
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the government: do not ban the industry, just regulate it: ensure that the
money is locked up in a fixed deposit whose interest will give the donor
a regular income; guarantee free medical treatment for donation-related
illnesses. This way, you can give both desperate patient and povertystricken donor a new lease on life. To put forward its cause, this lobby
describes a scenario of thousands of people on dialysis and whose
salvation rests in the kidney of a poor donor—and of the thousands of
poor, unemployed, whose passport to a life of financial security lies in
donating that kidney. Unemployment, a socio-economic problem, has a
medical solution.
The argument is that people have a right to sell their boaias or any part
thereof. On that basis, one could say that prostitutes have the right to sell
their bodies. But do they do so when they have an option? Kidney
transplant surgery is one of the better refined procedures, which may be
applicable to a relatively large population. According to one estimate,
every year one lakh Indians kidney fail permanently; even the small group
which can afford to pay for the operation represents a sizeable market for
the operation. Then, there are other body parts on sale today—wombs
(surrogate motherhood has started in India, but there is no legislation on
it), ova and, one could argue, blood.(There have even been reports of
people offering an eye for sale—while they are still alive.) In every case,
economic needs guide the vendor to a decision which seems like a choice.
Poor people are being asked to make money selling their body parts.
Throughout, the government has basically turned a blind eye to the
practice.
The act was delayed for years, and passed only due to public pressure.
And it is certainly a crucial piece of legislation, to put an end to the kidney
racket; it will also monitor those hospitals which want to conduct transplants. But how will it be implemented? True, respectable doctors and
hospitals will stop doing unrelated transplants once they are illegal. But
this by itself will not put an end to the trafficking, given the demand,
the profits involved, and: the commercialisation of the medical
profession today. There are also many loopholes: allowing a spouse to
donate, and allowing altruistic unrelated donations—to be regulated by a
high-powered committee—will inevitably be used to disguise paid donation. Finally, until the act becomes effective all over India, the racket will
only move to states whick-do not ban the practice.
But even an ideal law Will not provide enough cadaver kidneys to meet
the demand. For a cadavar transplant programme to succeed in India,
hospitals will have to provide more uniform facilities, and also change
their functioning, patient care practice and inter-hospital coordination.
More important, even a well-run cadaveric programme can hope to help
only a few of those who need it. Rich countries with the best facilities are
not able to supply enough organs in their cadaver transplant programmes—
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which is why they turn to India, where there is no waiting fy for those who
can buy a kidney.
One cannot ignore the plight of those awaiting transplants. But even
before the law, the majority of those needing transplants couldn’t afford
them. The lucky ones survived on regular dialysis. When a medical
technology is expensive and profitable, it gets promoted extensively,
and that can seem. obscene in a country where. people do not get basic
health care.
|
--Sandhya Srinivasan
Managing Resources
We have practically no experience in conducting cost-effectiveness studies in the field of health care.
|
WE often hear people complaining about the meagre amount of resources
spent annually by governments on health care. But rarely do we find
anyone seriously addressing the important question: “Is the nation using
its resources (however small it may be) allocated for ‘health care’ costeffectively?” We do not have even a tentative answer to this seemingly
straightforward question. Nor have Indian planners so far emb arked on
any serious study comparing the contributions of various programmes
(that come under social sector) on the state of health of the people. The
much publicised NSSO (42nd round, 1986) and the NCAER (1992)
studies throw considerable light on health care expenditure and pattern of
use of public and private health care facilities across states in India. They
are useful in many ways to the policy makers, but do not answer even
partially whether the nation is spending its resources efficiently. Till date,
there is not a single well-known published cost-effectiveness study at any
level (micro or macro) in India conducted either by the state or any private
body. It is also true that we have practically no experience in conducting
cost-effectiveness studies in the field of health care. Clearly this is not a
healthy way of managing our health care resources.
According to the 1993 World Development Report, India’s state of
health (measured by life-expectancy in years) is better than what one
would expect given its level of income and average schooling. But India
is also spending more than what it is predicted to, given its income and
education level. Apart from China and Sri Lanka, countries known for
their achievements, there are others with better outcome and lower
expenditure. Morocco is one among them. According to the same World
Bank report, the US is doing much worse, given its level of expenditure on
health care (which is about 15 per cent of its GNP). The logical conclusion
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is that we are more cost-effective in using our resources than the US of
America. The trap in this logic is that we are comparing countries in terms
of gain in life-expectancy years, which is more than 20 years higher in the
US than in India.
The fundamental question remains: are we spending our resources in
the best way possible? There is a general feeling amongst all those
concerned that over a period of time “the gap between what is technically
possible and economically feasible” will widen. A likely consequence of
this trend will be ‘inappropriate’ provision of health care, which has been
widely reported in western countries. A recent Canadian study has found
inappropriate provision to range from 4 to 27 per cent for coronary
angiography, from 2 to 16 per cent for coronary artery bypass surgery,
and from 11 to24 percent for gastrointestinal endoscopy. This means that
the demand for guidance concerning the equity and efficiency implications of alternative health care policies will grow in the future. There is a
definite need to establish units of health economics, both at the central and
- state government levels, which could advice on how funding should be
directed apart from conducting cost-effectiveness studies. These units
should not be allowed to degenerate into mere bureaucratic leviathans.
They should have well trained health officials who have a clear appreciation of medical requirements, economic compulsions and social needs.
They must be aware of the conceptual and measurement problems involved in health care and cost-effectiveness studies. This is because the
concept of ‘cost-effectiveness’ has already been widely used by policy
makers, but itis doubtful if they are all using itin the same and ‘right’ sense.
Ultimately, the use of such studies depends on a crucial assumption.
The CE analysis may result in ‘freeing up’ resources now devoted to more
expensive alternatives. But what assurance is there that these resources
will be diverted to preferable alternatives identified? CE studies that
ignore political constraints cannot predict correctly the outcomes and costs
of policy initiatives. To say an alternative is the most cost-effective is not
enough. How to make the providers and (financiers) accept and implement
it, is equally important. Choices depend as much on values as on analysis.
We must make a beginning in our analysis of future scenarios. We must
analyse the benefits and costs of alternative policies to influence policymakers’ (and our) behaviour for an effective, accessible and acceptable
health care delivery system.
—V R Muraleedharan
KK
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Understanding Mental Distress
Contributions of Frankfurt School
Parthasarathi Mondal
In.the recent past, Marxist ideas have been used to challenge many
of the assumptions and practices of established (biomedical)
psychiatry. This challenge has had a startling impact on the western
world, and there are many institutions, professionals and activists
which are trying to further these ‘Marxist-mental well being’ concepts
and programmes. Unfortunately, however, much
of the theory and
practice of mental distress and mental well-being in India has been
impervious to these hopeful developments in the west. The mainstream
institutional approach in India remains primarily the same as in
western biomedical psychiatry one, and that too, a caricature of it. An
analysis of these Marxist approaches to the study of mental distress
reveals that they have used some conceptual tools which draw inspiration froma corpus of social science works called the Frankfurt School
or Critical Theory. Therefore, it would be interesting and perhaps
useful to study what the Frankfurt School offers for mental distress
analysis.
THE Frankfurt School (hereafter FS) largely denotes the school of thought
which developed out of the Institute for Social Research established in
Frankfurt in February 1923. Its primary objective being to make Marxist
- concepts more relevant to the contemporary West, the FS has concentrated
on interdisciplinary social theory and it has been generally critical of
quantitative research. Out of this school, there has further developed a
large number of studies‘ which have significantly departed from the
original positions of the school. This article is concerned with the rather
strictly defined FS itself.
Over the years, there have been numerous theoretical shifts within the
proper FS itself [Kellner 1985:313]. An attempt has been made to be
~ sensitive to the positions of the older and contemporary theorists but the
focus is on the general scheme of things. Moreover, being of an exploratory nature, the paper covers only some important aspects of the work
of a few critical theorists. The most significant omission perhaps is the
work of Erich Fromm who has dealt directly with the issues of
mental distress and well-being. The idea here is to focus on those
thinkers who have only indirectly studied mental distress and well-being,
and who therefore,
need to be brought more centre-stage
in mental
health studies.
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Here, a tentative conceptual framework has been devised and presented
in the form of certain broad questions of content and questions of method
which are necessary to any process of mental distress, mental well-being
and their societal organisation. It now becomes necessary to see what
information and understanding the FS generates when it is examined in the
context of this framework.
The questions of content are:
(i) what is the FS’s concept of mental distress and mental well-being?
(ii) what notions of and responses to mental distress in the community are
revealed by the FS?
(iii) what is the effect of these notions on the mentally distressed according
to the FS?
(iv) what is the FS’s understanding about the changes in the notions,
responses and effects on the mentally distressed, and how do they come
about?
The questions of method are:
(i) what are the Marxist and non-Marxist tools used by the FS, especially
when dealing with mental distress and mental well-being?
(ii) what questions are enabled to be asked by the tools used?
(iii) how far are the specific questions answered?
(iv) how far do the questions asked by the FS’s use of Marxist and nonMarxist tools cover the required questions of content; in other words, what
are the questions not asked and not answered by the FS’s insights?
The article is divided into three sections. After having made an outline
of the FS’s understanding of capitalism in the first section, an ‘archaeology’ of the FS is conducted in the second section in order to see what light
is thrown on ‘mental distress and well-being’ by the processes and
institutions of rationality, family, personality and intersubjectivity. The
third section ends the paper with some concluding remarks indicative of
future research.
I
Frankfurt School and Capitalism
The FS understanding of society is mainly concerned with the study of
capitalism, and although it has included in its scope some aspects of
socialism, it has mainly concerned itself with human life and societal
evolution of capitalist western industrial societies. The older FS theotists
focused on the economic and social psychological aspects of ‘postmarket’ or state capitalism. °
At the social psychological level of its approach to society, the two
preliminary points which critical theory emphasises are the apathy of the
masses and the co-optation of mass protest. The masses know from their
life-experiences that the various types of capitalism belong to the same
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system of exploitation, and thus they hardly react with such interest when
the mere socialisation of production (i e state capitalism) is paraded as
socialism [see Horkheimer 1987].
A distinction however is drawn — within the older FS — between state
capitalism and fascist (‘national socialist’) capitalism. In the monopolised
and cartellised world of fascism there is a total breakdown of traditional
forms and patterns of social organisation leading to the atomisation of the
individual. Those atomised individuals fall prey to the opportunist and
propagandist ideology of such capitalism leading them to be in a high
degree of anxiety and tension. It is this atomised high- strung mass which
is the breeding ground for the mentally distressed authoritarian personality
(which is examined later):
In terms of modern analytical social psychology one could say tnat National
. Socialism is out to create a uniformly sado-masochistic character, a type of man
lene by his isolation and insignificance, who is driven by this very fact
a collective body where he shares in the power and glory of the medium of
a
ich)he-has become a part [Neumann 1967: 402].
The’ psychological analysis of the later critical theorists focuses on
contemporary advanced capitalism and emphasises the social control
aspects of technology, which results in capitalist domination penetrating
the individual’s innermost psyche, turning him into a non-protesting
object of the capitalist realtiy principle full of ‘false needs’.
This technological control is.further based on the blurring of the
distinction between private and public existence whereby all individuality
is absorbed into the rationality of the repressive capitalist collectivity. The
increasing production and plethora of consumer goods in capitalism has
numbed the critical ability of the individual and ensured his complete civic
obedience. This absolute mobilisation, asserts the FS, is done to achieve
the interests of capital and of the ruling class.
Here, the FS is developing on the thesis of Karl Marx on the nature of .
the commodity as a spectacle, as a fascination:
A commodity is therefore a mysterious thing, simply because in it the seta
character of men’s labour appears to them as an objective character stamped
upon the product of that labour; because the relation of the producers to the sum
total of their own labour is presented to then as a social relation, existing not
between themselves, but between the products of labour become commodities,
social things whose qualities are at the same tine perceptible and imperceptible
by the senses... There it is a definite social relation between men, that assumes,
in their eyes, the fantastic form of a relation between things [Marx 1986:77].
As an expansion and refinement of this psychological analysis, some
contemporary theorists have attempted a more socio-politically integrated
analysis of advanced or late capitalism.
The increasing political nature of advanced capitalism requires newer
and increased forms of legitimisation of its existence. One such form of
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legitimisation is formal democracy which is not the genuine granting of
civil rights; formal democracy, by eliciting diffuse mass loyalty and no
genuine participation, enables state administrative decisions to be made
largely independent of the specific needs of individuals. This sort of ‘civil
privatism’ produces, for the individual, abstentation from real political
commitment and devotion to absolutely selfish desires, a process which is
incorporated by the welfare state, its reward and educational ideology.
This also generates justifications for the ‘naturalness’ of the capitalist
order [Habermas 1989: 36-38]. This sort of politico-economic legitimising
‘capitalism, according to critical theory, is, however, suspect to three
“crisis-tendencies”: economic, political and socio-cultural [ibid: 45-50].
What picture emerges then from the above brief account of the FS’s ©
understanding of capitalism? Against the background of the macro-level
differences between state capitalism and advanced capitalism, the atomisation
of the individual in state capitalism and the psychic domination of the
- individual in advanced capitalism become evident. Theextreme subordination
of the individual in fascist capitalism is also noted. Moreover, under
advanced capitalisrn, the individual is subjected to more stress owing to the ~
several crisis-tendencies, especially motivation crisis.
The most important contribution of the FS’s analysis of capitalism is
perhaps its recognition of the fact that the masses become participants as
much as victims in the process of exploitation:
Enlightenment and manipulation, the conscious and the unconscious, forces of
production and forces of destruction, expressive self-realisation and repressive
desublimation, effects that ensure freedom and those that remove it, truth and
ideology ... now all the movements flow into one another [Habermas 1987:338].
This recognition of mass-based volition, in contrast to its neglect in the
older critical theory, is an important starting point for a fresh look at mental
distress and its organisation, which has so far been studied from either
benevolent or social control angles mainly.
Secondly, the critique of formal democracy is also helpful in understanding societal responses to mental distress. The state supplements its
legitimation by stressing the need for experts and professionals to manage
complex decisions and situations within the vacuum left by the general
public withdrawal or introversion. This general trend could probably
explain the recent turning away from the popular perception of the 1960s
(anti-psychiatry and counter-culture) to the recently growing perception
that mental distress is an area best left to expert professionals, that it is best
tackled within the crucible of biomedicalism (in privatised institutions, if
need be) and that it has little to do with political awareness and movements.
Moreover, there is this whole issue of the link between community
psychiatry and the welfare state, which is supposed to be the product of a
labour-capital compromise. On account of fiscal ‘shortages’ arising out of
the class compromise, the state initiates the closure of big institutions for
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the mentally distressed. This blow to the mentally distressed becomes
more acute when the secondary effects of inflation-management by the
state are distributed amongst the unorganised and the powerless.
In addition, the point made by the economic analysis earlier that the
hegemony of bureaucratised unions, which form the core of resistance in
capitalism, is challenged by splinter groups who themselves have to be
bureaucratised — highlight the difficulty in forming a truly non-bureaucratic challenge and alternative to the present system of psychiatry and
other social institutions. According to Adorno,
..the bureaucratisation of proletarian parties...arise from...the constraint of
asserting oneself within an overwhelming system whose power is realised
through the diffusion of its own organisational fores over the whole. This
constraint infects the opponents of the system and not merely through special
contamination but also in a quasirational manner — so that the organisation is
able, at any time, to represent effectively the interests of its members. Within a
reified society, nothing has a chance to survive which is not in turn reified
[Adorno 1976:7].
The same economic analysis also talks of professionals but its deductive contributions to mental distress can be taken only with a pinch of salt.
It is true that vocational training involves considerable standardisation of
goals, thought-processes and reaction-patterns, and the internalisation of —
only a fragmented view of the world. It is also true that mental health
professionals too are subjected to such a training and world view.
Nevertheless, it is not possible to ignore the fact that-a significant part
of mental health professional work involves spontaneity and is directed
towards helping the mentally distressed to form coherent worldviews.
However, such a deductive inference does not address itself to the question
as to why some people become mental health professionals whilst others
do not.
|
)
The central thrust of the psychological analysis — the individual’s
inability to evaluate social reality rationally — may go a long way in
explaining the basic confusion and ideological view to which the masses
are subjected, leading to the ‘inability-to-explain’ symptom of such of
neurotic disorders. As Marx has said, while discussing the mystification
by a monetary capitalism,
Money as the external, universal medium and faculty (not springing from man
or from human society as society) for using an image into reality and reality into
a mere image, transforms the real essential powers of man and nature into what
are merely abstract notions and therefore imperfections and tormenting
chimeras just as it transforms real imperfections and chimeras... In the light of
this characteristic alone, money is thus the general distorting of individualities
which turns then into their opposite and confers contradictory attributes upon
their attributes... Since money, as the existing and active concept of value,
confounds and confuses all things, it is the general confounding and confusing
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of all things ... the world upside-down ... the confounding and confusing of all
natural and human qualities [Max 1977: 131-32].
But the psychological analysis does not show why only some of those
confused masses respond with mental distress whilst most others do not.
Furthermore, the idea that what was once external domination has now
been internally programmed so that the individual becomes a passive
desiring machine, does not explain the phenomenon of mental distress or
its class implications.
In terms of methodology, critical theory takes up the Marxist tool of
‘crisis formation’ and addresses itself to the issue of crises 1n capitalism.
For Marx, the serious internal contradictions of capitalism — “The real
barrier of capitalist production is capital itself’ [Max 1986:250] — were
to result in a final explosive situation which capitalism cannot avoid.
Butas the FS’ analysis shows, crisis-modeling is amuch more complex
process, and subject to constant revisions with different types of capitalism. The FS’ position shows that not only do the crises of the economy
reverberate in the socio-political fields but also that capitalism postpones
its final explosion by continuously evolving methods to defuse class
conflicts and to survive its in-built contradictions. Moreover, even this
reworking of the tool of crisis-formation falls short of contemporary
developments; it does not take account of ecological and international
crises. It is a lacuna in the FS’ methodology that it does not address itself
to the implications of such a scenario, which has the potentiality of
changing the present consumption-oriented worldview to one which
appreciates the possibilities of human satisfaction in a not completely
abundant world.
Furthermore, the contention that capitalism’s critique must go beyond
the economy enables it to undertake a psychological examination of state
capitalism. In the process it uses the psychoanalytical concepts of the
‘superego’ (which has internalised the ‘surplus repression’ of dominant
exploitation) and ‘eros’ (which has been ‘sublimated’ into ‘vulgar libidinal’ expressions). The FS does not reject the psychoanalytic concept of
‘necessary repression’ (which enables human beings to live in a sane
manner in the real world) but considers such a concept to be historically
insufficient, ignoring societally-induced variations in the degree of repression over time. On the other hand, it contends that repression is heightened
in late capitalism and uses the psychoanalytical concept of ‘sublimation’
to explain the ways — ‘repressive desublimation’ — by which individuals
are led to believe in their autonomy in an actual reality of bondage.
The psychological analysis therefore seeks a synthesis of Marxist and
psychoanalytical tools. It contends that the Marxist position of freedom as
non-alienated work within the community setting is the only way to
individual and collective liberty. It also uses the psychoanalytical tool of
repression to explain the way excessive repression works, but as Marxists,
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believes in the fact that work need not be only repressive. It can be
liberative too, through ‘re-erotisation’ [see Marcuse 1970]. But, as noted
above, such a methodological synthesis leads to a greater emphasis on
psychoanalysis per se than on class analysis, and it is unable to explain the
‘jump from societal discontent to mental distress’.
Many of the infirmities of the above answers by the FS.to the questions
raised in the conceptual framework of this paper are sought to be overcome
inthe FS’ analysis of rationality, personality, intersubjectivity and familial
processes.
II
Frankfurt School and Mental Distress
Mental distress in general usage is mostly expressed in terms of
rationality and irrationality. The FS dwells at length on this issue.
RATIONALITY AND MENTAL DISTRESS
The FS! assumes that one of the most important principles of human
existence — reason — which forms the basis of the other important goals
of life, of truth, freedom and justice, is subject to a rapid process of decay
in contemporary western industrial societies.
ape
This philosophical concept of reason, evident in western societies
before the technological revolution of the 19th and 20th centuries, and
reaching its zenith during the Enlightenment, included the concepts of
critique, freedom
and autonomy,
vision, and will. Such a rationality
established the criteria of rigidity, clarity and distinctness as essential to
any rational cognition. Necessarily therefore, reason set skepticism as a
methodological cheek on itself: to doubt, cross-check and rethink was to
become immanent in the four processes of pre-technological rational
behaviour. Moreover, pre-technological reason was a moral one because
of individual autonomy wherein the individual had not only alternative
action-choices available to him but also a knowledge of the genesis of
these action choices.
Pre-technological rationality was also emancipatory because of vision
and will-power. It willed a better world for human beings, and this force
led it to assume a non-Nature unity and compelled it to become critical by
fighting illusion and dogma.
In other words, such a rationality was,
content-wise and methodologically, a committed rationality. But pretechnological rationality became a ghost of its former self with the coming
of modernity. The cold rationality which so distinctly characterises the
contemporary individual, after having demolished the false worship of
things, allied itself so closely with the newly-forming and rapidly-spreading capitalist system that individuals became, more than ever before,
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dependent on a world of thing and commodities. In other words, what
happens is that “‘...in the service of the present age, enlightenment becomes
wholesale deception of the masses” [Adorno and Horkheimer 1979:42].
This is an advance over Marx’s economistic reading of technological
rationale [Marx 1988: 318-19].
.
The FS strongly asserts that reason in contemporary times can no longer
be called rational metaphysics although the patterns of rationalistic
behaviour have remained. The methodical and regular ordering of ‘facts’,
perception of their interconnections and arrival at the logically correct
conclusions remain. It is the search for a final cause or absolute truth of
Nature and man which has been removed. Therefore, the claim by
technological rationality that it is also anon-ideological critique of illusion
is contradictory because, on one hand, it seeks to project itself as a neutral rationality beyond any subjectivity and so is the most methodical, scientific and logical challenge to the veil of illusion in human society. On the
other hand, existence is geared to technological production and norms of
behaviour and so it illicitly involves a value-choice, which is always a
subjective process.
Technological rationality is aimed at the technological control over the
objectified processes of nature and man, and is therefore instrumental in
character. This instrumental rationality is concerned with survival and
adaptation only. The mass or the collective takes over the personal. Hence,
any individual protest or resistance is considered to be irrational simply
because such protest would overthrow the technological rationality and
constitute a threat to his survival.
|
Critical theory’s analysis of reason and rationality throws up a number
of problems. It seems to have glorified the sanctity of pre-technological
reason and has failed to contextualise it properly. It is not clear, for
instances whether pre-technological reason was interested in the postulate
of human freedom, welfare and justice, or in the welfare and autonomy of
only a specific category of people in each historical period.
Again, the FS handling of the relationship between instincts and reason
leaves such to be desired. What is the nature of an instinct? In what ways
‘ are instincts complementary to and a part of-reflective and committed
reason, and in what ways are they opposed to it? The difficulty arises
because of the usage of the concepts of omitted, reflection and instinctcomplementarity .in pre-technological reason. The innate propensity to
rational acts performed without conscious intention (ie with instinct)
cannot be one and the same thing as a rational process operating with a
particular intent and fully aware of itself and its object (ie committed
reflection). Intentional consciousness exists in the latter whilst the former
is completely unaware of its rational process and intention. It is not very
difficult to contend, then, that one cannot have complete consciousness
and absolute unawareness in one and the same rationality. Moreover, the
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contemporary rationality results in innate, usually fixed, patterns of
behaviour especially in response to certain stimuli and can also be
considered to be instinctual. Hence, what is more important is the goal of
each rationality rather than the absence or presence of instincts. The goal
of reflexive reason was individuality and liberty whereas the goal of
technological reason is the perpetuation of bonded judgment and living.
What appears to be even more illogical is the (older theorists’ )constant
refrain of disappointment at technological rationality’s emphasis on
putting the ‘good’ of the collectivity before the ‘good’ of the individuai.
If it is to be accepted that a vast range of individual human potentialities
exist and that human society is an inescapability (at one and the same time),
then it follows that the full expression of individual will, to various
degrees, trample upon the full expression of collectivity. Hence, a certain
compromise — to which the FS is doggedly opposed in an implicit manner
— between individual aspirations, and societal] imperatives of organisation
and function is the absolute minimum for human civilisation to continue.
As regards the important issue of individual autonomy, it is essential to
be cautious of aromanticisation of the individual’s ability to make choices
consciously in the pre-technological era. What is even more romantic is the
FS contention that technology is fine by itself, and that it is only when it
is misused that an unjust social order based on repressive technology
develops. This neglects the historical-sociological fact that no technological development takes place where the dominant socio-economic and
political factors are not at work: The two are more or less immanent in
each other.
The main problem with the FS (especially of the older theorists) critique
of rationality however could lie somewhere radically different, as made
out by the later theorists:
The critique of instrumental reason, which remains bound to the conditions of the
philosophy of the subject, denounces as a defect something that it cannot explain
in its defectiveness because it lacks a conceptual framework sufficiently flexible
to capture the integrity of what is destroyed through instrumental reason. To be
sure, Horkheimer and Adorno do have a name for it: mimesis... But the rational
core of mimetic achievements can be laid open only if we give up the paradigm
of the philosophy of consciousness namely, a subject that represents objects and
toils with them — in the favour of the paradigm of linguistic philosophy —
namely, that of — intersubjective understanding or communication — and puts
the cognitive-instrumental aspect of reason in its proper place as part of a more
encompassing communicative rationality [Habermas 1988:281-82].
It is because of the potential contributions of a philosophy of communication that mental distress shall be discussed later in connection with the
process of intersubjectivity and language.
Despite these problems, the FS critique of rationality contributes to a
better understanding of mental distress by challenging the dominant
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assumption that human beings can rationally control their destinies
by social techniques and other forces of empirical control, and by asserting that man’s emancipation lies in a reflective, conscious and noble
reason.
This sort of critique seems to suggest some lines of thought for the study
of mental distress. For instanced present-day civilisation and its discontents, it seems, are based substantially on a rationality which technologically represses all instinctual and spontaneous expression of individuals,
and makes it mandatory for a man to master all rebellious tendencies in
order to be called rational or sane. Any protest becomes irrational or
insane. This approach to or an understanding of rationality and irrationality, which was originally imposed, is not internalised as a ‘durable’ attitude
which labels as irrational or insane any behaviour or thought which is
opposed to (and thus disruptive of) the technological process and matterof-fact’ attitude required to survive in it.
But whereas it is true that such a repressive regime is conducive to a
higher level of general discontent and emotional distress, there is no
conclusive proof yet of the implicit assumption that the proportion of
the mentally distressed during pre-technological rationality was lesser
than the proportion of the mentally distressed during contemporary
rationality. In addition, not all those who protest today — and there are
many forms of individual and collective protests — are perceived as or
express themselves through mental distress. In other words, the FS’s
contribution lies more in explaining the general level of discontent than in
expressing the jump from discontent to mental distress, that is, the
phenomenon of mental distress itself.
Another possible area of contribution arises from the contemporary FS
_ derivation of Frederick Sohellina’s conception of reason as controlled
insanity [Habermas 1988: 281-82]. According to this derivation, pretechnological reason tried to make sense of the shapeless phenomena of
the world with the purpose of human liberation. Insanity also aims at
creating a base for the unity and coherence of the world but it is a perverted
process. Yes, but how is insanity perverted? And is this perversion
tolerated by the substantive reason because of the similarity of goals
between reason and insanity or because the perversion process is significantly akin to the rational process?
The theorists go on to add that positivistic empiricism merely abstracts
out. of the shapeless phenomena only that which can be reduced to
manipulable quantifiables. Therefore, this rationality excludes from its
domain the insanity which was a tolerated part of critical reason, but it
never eradicates or vanquishes insanity. Hence, it is precisely because this
technological rationality is a husk of critical reason, a mere reflection of
the parts and not a coherent whole, that it ignores insanity but never really
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mines its very base. In short, this rationality is able to tackle insanity only
to the extent it can reduce the phenomena positivistically.
.
As it turns out, insanity is such more than what positivism can tackle,
so that (for it) the greater part remains ungovernable and meaningless. This
sort of derivation directs attention to the broad link between sepal distress
and rationality but it does not speak much of the nature of mental distress
itself. The intensity of the FS possible contributions to the conceptual
framework of mental distress is further weakened by some problems in
methodology. The FS’s use of the concept of rationality enables it to look
at the psychological constructs of capitalism, a process not sufficiently
explained by Marx.
Max Weber’s work, despite its different methodology, was complementary to Marx’s. Weber expounded on the traditicnal Marxist concept
of ‘socialisation’ of society through his own concepts of ‘rationalisation’
and “demagicisation’. Rationalisation, for Weber, is the historical perme-
ation of the monological formalism of modernisation and industrialisation
into all spheres of life. This is made mainly possible by what Weber calls
“the
rational
ethics
of ascetic
Protestants”
[Weber
1985:
27].
Demagicisation, by extension therefore, is the process of elimination
(from theory and practice) of all unpredictable and ‘irrational’ sensuous
and mysterious elements.
;
Weber’s analysis enables critical theory to adopt critical tools for social
analysis but it fails to distinguish between the two possible scopes of the
Weberian tools, viz (1) aprocess which has permeated all spheres of life but
not necessarily all thought and all action in all the spheres of life, and (ii)
a process which has permeated human society and psyche comprehensively, and hurtling towards its self-fulfillment. Critical theory’s reworking seems to take the latter scope as the entire Weberian usage, and this
uncriticality disables it from explaining the facts of widespread ‘irrational’
behaviour, counter-cultures, resistances and other genuine
‘reflective-
thoughtful’ human processes in contemporary western societies.
Whereas this reworking of a Weberian remoulding of an orthodox
Marxist concept illustrates the FS methodological affinity to orthodox
Marxism, its position on man’s relationship to Nature illustrates its
departure from orthodox Marxism. The conservative use of this concept
states that man has progressively dominated Nature in order to control it
for his own benefit (resulting in civilisation) but that this linear process
gets vitiated in the course of time by certain minority classes forcibly
appropriating the benefits of this process at the cost of the oppressed
masses.
For the FS, on the other hand, this concept means that the original
harmony of man living within Nature gets disturbed as man tries to
dominate Nature more and more through technology and a technical social
organisation. It is this technical social administration of society which
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cruelly and necessarily dampens man’s individuality in order to maintain
social cohesion, and also man’s conquest over Nature. The methodological implication of this departure is that the analysis of rationality becomes
more ps yehological, and less economic and-historical, leading to a weak
emphasis on class issues.
It is against the background of the above tatipaatiey that the FS analyses
the family as a general social unit, with special reference to personality
structure and its implications for mental distress.
FAMILY AND MENTAL DISTRESS?
In the 1930s, critical theorists thought that the-family was the most
important mediator in behaviour modification between the individual and
society.
The family was, however, taken to be an element of domination
which harshly suppressed all instinctual drives of the child towards free
development and creativity in a class society. The central mechanism in such a repressive process was the father-son relationship, whereby the
father strictly oriented the naturalness of the child towards a striving for
economic status and political position. It was such a family regime which
produced a personality type which was oriented towards submission to an
exploitative social structure, and which itself exulted in its perpetuation.
There was a change in the position on the family in the 1950s.
According to this version, the family is not authoritarian when compared
to the authoritarianism of mass society. In this amazing volte face made by
the FS, the
.
i
...father was in large measure a free man ..he became for his child an example
of autonomy, resoluteness, self-command, and breadth of mind. For his own
sake he required of the child truthfulness and diligence, reliability and intellectual awareness, love of freedom and discretion, until these attitudes having been
internally assimilated by the child, became the normative voice of the latter’s
own conscience.. -[Horkheimer 1974:71-72].
In addition to these general accounts of the family, a more psychological
analysis is also attempted. This psychological examination focuses more
on the mass character of society in the west and comes to the conclusion
that although the family structure has loosened, individuals are again
subject to conformity: the individual does not have enough mental space
of his own [Marcuse 1970:88].
It is the lack of the importance of the father, as a result of the fragmented
family, which ensures that individuals will without autonomy in western
societies:
The technological abolition of the individual is reflected in the decline of the
social function of the family. It was formerly the family which, for good or bad,
reared and educated the individual, and the dominant rules and values were
transmitted personally and transformed through personal fate. To be sure, in the
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Oedipus situation, not individuals but generations (units of the genus) faced
each other; but in the passing and inheritance of the Oedipus conflict they
became individuals, and the conflict continued into individual life history.
Through the struggle with father and mother as personal targets of love and
aggressions the younger generation entered societal life with impulses, ideas
and needs which were largely their own. Consequently, the formation of their
superegos the repressive modification of their impulses, their renunciation and
sublimation were very personal experiences. Precisely because of this, their
adjustment left painful scars, and life under the performance principle still
retained a sphere of private non-conformity [ibid:. 86-87].
Other than stating the high level of discontent closed by declining hold .
of the family, the FS is not able to contribute much to an explanation of
mental distress within the specific context of the family. It is doubtful as
to how totalising has been the effect of the capitalist manipulation of the
psyche overriding the family’s influence. Moreover, by altering its 1930s
position on the family, the FS neglects the possibilities of the link
between the real authoritarianism and mental distress. The
greater problem of such a conceptualisation is the neglect of the general
issues as belied by the emphasis on patriarchy; the womenfolk hardly ever
came into the picture.
In methodological terms, the volte face of the FS on the family could
probably be explained by its relinquishing (by the 1980s) of the working
class as the subject of social emancipation, and the consequent emphasis
on individuality and not on class consciousness. This switch, and the
subsequent theoretical preoccupation, enables the FS to perceive the
bourgeois family in aromantic haze. Furthermore, it says precious little on
the phenomenon of mental distress, the family’s role in formations and
changes of perceptions, and the family’s influence on the broadly societal
response to mental distress. These lacunae arise because of an uneasy
synthesis of Marxist and psychological concepts.
AUTHORITARIAN PERSONALITY AND MENTAL DISTRESS?
The central assumption of the FS (mainly the old theorists) in its study
of personality (its preoccupation being the authoritarian/fascist/prejudiced variety) is that the socioeconomic and political convictions of an
individual form a pattern which is acoherent one and which expresses deep
processes in his personality.
_On the basis of this and a few other assumptions, a picturisation of two
broad (non-exclusive) personality types is arrived at: (i) the authoritarian
or fascist type which is featured by conventionality, rigidity, repression,
and sometimes by the break-out of its weakness — fear and dependency
- (this type experiences an authoritarian and exploitative parent-child
relationship), and (ii) the egalitarian type which is featured by egalitarian,
affectionate and permissive interpersonal relationships.
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The authoritarian personality arises from a certain social and psychological background. With the levelling out of the distinction and opposition between critical high culture and social reality in the modern times,
there is aconsiderable constriction of the liberative sublimation offered by
‘high culture’. Desublimation is the rule of the day. It is within such an
environment that the authoritarian personality develops. Herbert Marcuse
explains:
...the technological reality limits the scope of sublimation. It also reduces the need for sublimation. In the mental apparatus, the tension between that which
is desired and that which is permitted seems considerably lowered...The
individual must adapt himself to a world which does not seem to demand the
denial of his innermost needs — a world which is not essentially hostile. The
organism is thus being preconditioned for the spontaneous acceptance of what
is offered. Inasmuch as the greater liberty involves a contraction rather than
extension and development of instinctual needs, it works for rather than against
the status quo of general repression — one might speak of “institutional desublimation”. The latter appears to be a vital factor in the making of the
authoritarian personality of our time [Marcuse 1964: 73-74].
It is against such a context that the FS analyses mental distress.
Mentally distressed persons, it seems, usually display the same levels of
susceptibility to prejudice as normal people. However, the highly prejudicial have lesser awareness of the genesis of configuration of their
mental distress and are less amenable to psychological explanatory frameworks, whereas the lesser prejudiced are more aware of their mental distress and more open to introspection and psychological analysis. In
other words, the correlations between personality and prejudice variables
remain the same for normal and mentally distressed people but in the
mentally distressed they appear in pathological mores and processes.
From this it is deduced that the severely mentally distressed, as
compared to the mildly mentally distressed, display the personality
features of the highly prejudiced individual: rigidity, conventionalised
thought, categorical rejection of impulsive behaviour, narrow and undifferentiated range of ego experiences, and interpersonal relations of
‘dominance-submission’. Hence, whereas the relatively stronger egos and
interpersonal relationships of the less prejudiced are more consistent with
neurosis-formation, the egos in the highly prejudiced become weak owing
to the surfacing into the consciousness of unresolved conflicts. In more
extreme forms, the egos become depersonalised and psychotic manifestations follow.
This analysis of the personality, prejudice and mental distress is the first
concrete step (especially by the older critical theorists) towards an understanding of the phenomenon of‘mental distress itself. Despite the difficulties with such an analysis, the advances at least broadly underline the
possible linkage between prejudiced personalities and mental distress.
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However, whereas it is possible to conceive of a correlation between
highly prejudiced individuals and mental distress in general (i) the ‘jump’
from prejudice to mental distress, from disturbance to pathology, is not
explained, and (ii) the fact that to various degrees normal people too are not
aware of themselves, repress impulses, and have rigidity in defences and
interpersonal relationships is ignored. This means that to the extent a sharp
distinction is not made between lesser prejudiced individuals and normal
people, to that extent it is not possible to explain the correlative propensity
of the lesser prejudiced individuals towards milder forms of mental
distress. In other words, the basic requirement of a clear distinction
between normal and insignificantly prejudiced individuals, and between
abnormal and highly prejudiced individuals is missing.
Furthermore, this analysis of personality and mental distress does not
answer the question as to what happens to the societal notion of mental
distress within the individual after his affliction, and (after exhausting all
the possibilities of the fundamental psychoanalytical processes) as to why
some express mental distress whilst others do not.
And, although the FS’s position advances by using psychoanalysis to
highlight the importance of childhood and familial experiences in the
formation of mental distress, it is the parent-child relationship which is
conceived as the fundamental structure despite the mention of environmental
factors. Moreover, this concept of personality rules out the process of
autonomy and volition, making individuals prisoners of infantile history and
pre-history. Furthermore, it betrays an over-emphasis on the father-child
relationship at the expense of gender issues. All these difficulties reveal the
patriarchal nature of the psychoanalytical analysis. It reveals the political
economy of the family which is based on the aggrandisement of communal
wealth, dominance of the man, and subjugation of the woman:
It (ie the monogamous family) is based on the supremacy of the man; its express
aim is the procreation of children of undisputed paternity, this paternity being
required in order that these children may in due time inherit their father’s wealth
as his natural heirs [Engels 1990].
There seems to be another central problem with the psychoanalytical
processes of the id, ego and superego, which are thought to underlie mental
_ distress. The ego, in being considered as the reality-satisfying and individual-protecting process which compromises the needs of the id and
superego, leads to a mutually exclusive dichotomy between the processes
of the id and superego. In other words, what is normative becomes
naturally opposed to what is instinctual and vice versa. It is a fallacy to
conceive of the normative and the instinctual in such exclusive and transsocietal terms. Although there are some norms and instincts which are
universal, what might only be a norm in one society might be an instinct
as well as a norm in another society. Therefore, it becomes necessary to
specify what exactly constitutes the superego and what the id.
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Additionally, the implicit assumption in the analysis that the expression
of instincts of the lesser prejudiced make them less prone to mental distress
and vice versa for the highly prejudiced, and that the expression of instincts
is desirable, is again a sweeping assertion because it is always normatively
decided in societies that the undifferentiated expression of instincts is not
desirable and subsequently it is always normatively decided which instincts are to be expressed and which not, and these decisions change over
time.
There are two additional issues which require examination. Firstly, the
juxtaposition of prejudice and mental distress can also lead to a study of the
inter-relationships between the prejudiced, the formation of perceptions of
mental distress within them and the changes in these perceptions within the
context of the forces which brings these changes. This analysis which the FS
has not conducted is likely to contribute to the conceptual framework.
Secondly, the FS’s intention to study more how ideologies spread
and get accepted and less how ideologies per se originate, belies the
FS’s implicit model of social movements, viz: ideas originate in a limited
manner within a society and then they gather or do not gather momentum
depending on the levels of readiness in the personality structures of the
majority of the individuals within that society. The socioeconomic factors
are important but personality structure is far more important.
In methodological terms, the FS critique of the personality is based on
an inadequate synthesis of psychoanalysis and Marxism. This leads to a
determinist model which leaves little scope for the role of individual
autonomy or volition.
INTERSUBJECTIVITY AND MENTAL DISTRESS
As mentioned before, the later FS contends that the older FS’s critique
of instrumental rationality is problematic because it remains tied to a
‘philosophy of history’. In order to overcome this difficulty, the later FS
recommends a shift towards the process of language and intersubjectivity.
Marx had already indicated the importance of these two processes:
Language is as old as consciousness, language is practical, real consciousness
that exists for other men as well, and only therefore does it also exist for me;
language, like consciousness, only arises from the need, the necessity, of
intercourse with other men...where there exists a relationship it exists for me...
[Marx and Engels 1976].
FS general framework of normal interaction between individuals and
their personality development through the tool of language is basically a
modification of Noam Chomsky’s model.
Chomsky’s model postulates that every natural language constitutes a
finite number of elements, out of which a person can manufacture an
infinite number of sentences. Such an individual intuitively differentiates
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between correct and deviant formulations, a skill which also enables him
to classify the seemingly senseless sentences according to the degree of
volition of the intuitively learnt rules.
The history of individual exposure and ability in language suggests that
the knowledge acquired is much less than the ability exhibited. Hence,
asserts Chomsky, there is an abstract linguistic system of regulations
which is generative of rules. This system is based on the relationship
between and development of the individual’s stimuli bombardment and
organic saturation. Furthermore, this apparatus consists of language
universals which predetermines the form of all natural languages, and/is
an expression of deeper psychic process.
Chomsky states that
A child who is capable of language learning must have (i) a technique for
representing input signals, (ii) a way of representing structural information
about the signals, (iii) some initial delimitation of a class of possible hypotheses
about language structure, (iv) a method
for determining what each such
._ hypothesis implies with respect to each sentence, (v) a method for selecting one
of the (presumably, infinitely many) hypotheses that are allowed by (iii) and are
compatible with the given primary linguistic data [Allen and Buren 1972:142].
This sort of linguistic capability ... ‘linguistic competence’ ... is based
on the logic of an immediate and clear understanding of the meanings of
the subject and object by each other, because they operate on the same
premises of validity and invalidity.
This sort of intuitive pre-communication knowledge and operation of
language, of human relationships, ignores according to critical theory, the
very substantive and formative social psychological influences. In other
words, in contrast to Chomsky, it is necessary to distinguish between
universal meanings in languages which are peculiar to a person and which
precedes all communication and meanings which are formed out of a
process of human interaction or inter-subjectiveness. Further, these universalities are very much immanent with role-expectations and role-
playing, which are naturally based on the approach to life, and which vary
from culture to culture. The validity or truth of the universal meaning
elements are, therefore, determined by the cultural systems within which
they are located.
These historically-specific world-views
,
...determine the following (a) whether a finite number of independent and not
further analysable meaning components is assumed at all or whether instead a
system of basic, mutually interpreting meaning components is presupposed; (b)
which meaning components are recognised to be the ultimate ones in a given
case or, respectively, which system of meaning components is to be recognised
:
as basic [Habermas 1972:137].
Here, it is noticeable that the lack of normativeness in the examination
of personality is sought to be counterbalanced. The contemporary FS
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central assumption in the linguistic analysis is that conceptualisations
(which are expressed by the meaning elements within languages) of
western industrial societies cannot necessarily be used for societies with
non-techsological approaches to life.
Hence, the FS’s model of language and behaviour is one of ‘communicative competence’, by which an individual not only possesses and
exercises the requirements of linguistic competence but also has the
qualifications of speech and role-behaviour, rooted in an intersubjective
setting. This communicative competence can be completely achieved only
within an ideal speech situation.
An ideal speech situation is one in which there is pure intersubjectivity,
which.exists only where there is complete truthfulness between the partners
in linguistic behaviour. In such a condition, there is complete recognition of
the other’s role in the formation of the self, so that it becomes possible to
demarcate exact degrees of nearness or distance between the self and the
other, leading to a truly individual (because completely self-aware) communication. Moreover, in sucha situation, there exists acomplete understanding
of mental expectations so the formation of universal norms of behaviour takes
place most smoothly. Also, pure intersubjectivity enables the thematisation
of areas of dispute and its criticism, so that a framework for achieving
consensus can be devised.
The important points of differentiation within pure intersubjectivity
are the recognition of a communication on objects and a meta-communication on the level of intersubjectivity; the recognition of the differences
between empirical rules of observable phenomena and valid rules of
intentional actions and; the recognition of the distinction between that part
of the individual constituted by the publicly acknowledged world of
intersubjectivity and that part constituted by personal feelings. Therefore,
itis the condition of pure intersubjectivity which is the embodiment of the
ideals of truth, freedom and justice.
It is not, the-contemporary theorists hurry to add, that communicative
competence is completely actualised through pure intersubjectivity. But it
does operate on a paradoxical rush towards such an idealisation.
Intersubjectivity and speech can begin to operate only when the individual
concerned knows the framework of pure intersubjectivity and presupposes
such a base as a necessary precondition before entering into interaction.
However, they also know that the very mix of intersubjectivity and
personal selfhood make that goal merely a distant horizon, very difficult
to actualise.
.
The first level of deviation from intersubjective communicative action
takes place when social action becomes strategic action instead of becoming communicative action. Unlike purposive-rational action or instrumental action, strategic action becomes social by attempting to rationally
influence the decisions of the rational partner.
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The second level of deviation occurs when strategic action becomes
concealed strategic action. This can develop into speech acts which are
either manipulative or consciously deceptive, or are systematically distorted or unconsciously deceptive:
Such communication pathologies can be conceived of as the result of a
confusion between actions oriented to reaching understanding and actions
oriented to success. In situations of concealed strategic action, at least one of the
parties behaves with an orientation to success, but leaves others to believe that
all the presuppositions of communicative action are satisfied... On the other
hand, the kind of unconscious repression of conflicts that the psychoanalyst
explains in terms of defense mechanisms lead to disturbances of communication
on both the intrapsychic and interpersonal levels. In such a case at least one of
the parties is deceiving himself about the fact that he is acting with an attitude
oriented to success and is only keeping up the ieee of communicative
action [Habermas 1984: 332].
The shape and direction of deviation from or disruptions of the
operation of pure intersubjectivity are concretely rooted in the particular
social structure of a particular tine and this deviation can be measured by
the extent of asymmetry in the stages of the ideal speech situation.
In the case of neurotically-oriented people, pathological communication is expressed at three levels. At the level of language, a deviant set of
linguistic rules are used thereby affecting particular meaning elements or
entire semantic fields. At the behavioural level, distorted communication
results in rigid forms and compulsory repetition. In the case of highly
emotional stimuli stereotyped behaviours recur, displaying the gap between the meaning elements and its specific contexts. And, as a whole,
neurotic communication is featured by a total lack of coordination between
language, gestures and actions.
Psychoanalysis is used to explain the isolated content of distorted
communication. The process of condensation, displacement, absence of a
gramatical sense and the opposite use of words explains the deviation at
the linguistic level:
This content expresses an intention which is incomprehensible according to the
rules of public communication; as such it has become private and remains
inaccessible from the author as well.-4o whom it must be ascribed. There is a
communication obstruction in the self between the ego, which is capable of
speech and which participates in the intersubjectively established language
games, and that ‘inner foreign territory’ (Freud) which is represented by privatelinguistic or primary linguistic symbolics [Habermas 1972: 118].
However, although the FS suggests here that psychoanalysis is a powerful
linguistic tool to restore distorted communication and therefore, correct
abnormal behaviour, it does not forget the material base of such a pathology:
In modernised societies disturbances in the material reproduction of the lifeworld
take the form of stubborn systemic disequilibrium; the latter either take effect
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directly as crises or they call forth pathologies in the lifeworld [Habermas
1987:182].
Therefore, the FS’s position on intersubjectivity contributes to an
examination of mental distress thus: generally speaking all motivations or
intentions of individuals are completely and necessarily expressed
through language which is a constant effort towards the achievement of
the condition of pure intersubjectivity. Mental distress, based on the
operations of the id, ego and superego, disputes this equity between
intent and speech and displays itself through pre-linguistic symbol
organisation, which is decidedly not an effort towards absolute normal
communication or pure intersubjectivity. The greater the pre-linguistic
speech forms the lesser the intersubjectivity. These deviations, in turn, are
closely related to the degrees of repression evident in the institutional
structures of specific societies in their specific phases of economic and
political development.
However, some of the contradictions of aes a contribution arise from
its very synthesis of certain philosophical and psychoanalytical concepts.
This analysis uses philosophical premises and arguments only whilst
examining the normal and autonomous behaviour of intersubjectivity; no
mention of the psychoanalytical process is made. It is only when it
examines abnormal behaviour or distorted communication (ie when
conditions of intersubjectivity do not exist at all), that the explanatory
framework adopted is a psychoanalytical one. This implies that the id, ego
and superego exist only in mental distress situations and not in normal
conditions of intersubjectivity: This is a logical absurdity.
There is a further difficulty which arises out of the FS’s inability to
clearly distinguish between normality and mental distress, which is based
on an inadequate understanding of the phenomenon of mental distress.
Pure intersubjectivity is considered to be the pole of absolute mental wellbeing. The other pole of no intersubjectivity will be the condition of
extreme mental distress. Critical theory also tries to define separately the
condition of non-distorted communication but the complete fulfillment of
its conditions would. mean the complete fulfillment of intersubjective
conditions. In other words, normal communication’ s and intersubjectivity’s
premises are much the same.
Now, the critique states that individuals are interactively placed on the
_ axis Sealed by these two poles and that they merely approximate towards
the pole of pure intersubjectivity, not reaching it really. Therefore, using
the critique’s own logic, to the extent individuals fail to satisfy the
conditions of pure intersubjectivity or normal communication, to that
extent they are not normal (mentally distressed). In other words, within the
context of intersubjectivity, there is always latent a degree of abnormal
communication or mental distress. Who, then, are people with mental
well-being and who are mentally distressed?
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Similar difficulties in defining mental distress and mental well being
are evident even if the pre-linguistic, linguistic and pure intersubjectivity
axis is taken. According to this argument, the degree of pre-linguistic
speech forms displays the degree of distortion and the greater the distorted
communication the lesser the intersubjectivity. In other words, with
complete pre-linguistic speech there is the greatest distortion and no
intersubjectivity. Conversely, with no pre-linguistic intrusion, communication is fully linguistic and completely intersubjective. Yet the FS
contends that within linguistic behaviour there is never complete
intersubjectivity, only an approximation towards it. This contradiction
prevents an understanding of the interrelationship between psychoanalysis, language and normal behaviour. A clear picture of mental well-being
and mental distress does not emerge.
The FS gets further entrapped when it seeks to ask the question as to
what happens to the societal notions of mental distress. Again, basing on
the model of intersubjectivity, there is on the one hand, the condition of
absolute normal communication and behaviour wherein, say, person A
knows the extent of person B in him, and B knows the extent his ego is .
formed by A’s; wherein the mutual understanding leads to A and B
agreeing on norms to behave and act; wherein, on the basis of such an
understanding there is a consensus on the strategy adopted to thematise
and resolve conflicts. Pure intersubjectivity is thus completely meaningful, rational and normal behaviour.
!
Now, on the one hand, there is the opposite extreme of no
intersubjectivity. What is there then? A does not understand B’s element
in him and so is less self-assured. This lack of understanding leads to a
failure in the formation of the rules of the game for solving possible
conflicts — there is no consensus, and this void lacks the necessary
universal norms of behaviour. Hence, in this case A does not understand
B nor B understand A. There is chaos: B’s behaviour is totally meaning-
less to A. And so is A’s to B. Both have concrete experiences and needs
of joy and pain, but neither’s linguistic expression is understandable to
the other. Intersubjectivity does not exist and so what stops B from
calling A mad or irrational, and A from perceiving B as insane or
abnormal? The meaninglessness of behaviour is one of the main
reasons why people in the community are labeled as mentally distressed. Besides these extreme poles, A and B might be placed
anywhere on the continuum but the fact remains that the lesser one
understands the other, the greater the chances of the surfacing of the
notion of mental illness.
Of course, it might be said (as the FS implicitly states) that whereas A
experiences intersubjectivity with almost all individuals except B, B
experiences non-intersubjectivity or very little intersubjectivity with
every other person including A. The question, then, is why it is so. If the
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answer has something to do with disability entirely and if the answer is
sought in psychoanalysis (as the FS does), then — as it has been remarked
before — the explanatory framework is insufficient and deterministic in
the last analysis.
Does then the answer have something to do with volition or exercise of
will or opposition and resistance? It could well be so. The grounding or
rationale of the intersubjective framework ... on the basis of which
individual and social truth is supposed to be universally and rationally
constructed ... can be challenged on the grounds that the consensus
brought about by means of reasoning presupposes that the contesting
convictions have been brought about by means of reasoning. This means
that the truth of the intersubjective rationale or consensus depends on an
assessment of the truth of the convictions or arguments. Therefore, it is
necessary to know the pre-intersubjective reason of the convictions before
any content can be made on the consensual process.
Hence, in the above example, as the intersubjective process does not
comprehend this pre-intersubjective process, because A does not understand B’s reasoning prior to entering intersubjective reasoning, all of B
becomes meaningless (condescendingly), irrational (arrogantly) or distressing (sympathetically) to’A.
The very real possibility (derived within the logic of critical theory) of
the existence of meaning, truth and rationality beyond the intersubjective
framework, should lead to the awareness that, contrary to critical theory’s
position of mental distress as alacuna solely within the mentally distressed
themselves, the comprehension, verbalisation and categorisation of mental distress has as much to do with the interpreters and categorisers as with
the mentally distressed themselves.
In terms of action, to state (as the FS does) that the scenic understanding
of psychoanalysis has greater explanatory power than hermeneutic communication, is additionally problematic. In the hermeneutical case, the
rules of the game are implicitly followed and understood, which means
that to a considerably effective extent the ‘what’ and the ‘why’ are
understood by the concerned parties. In the scenic case, the problem arises
precisely because the rules of the game are broken and so the parties do not
understand the ‘what’ and the ‘why’.
Scenic understanding is timed at helping in the relearning and replaying of the rules of the game, a process which progresses to the
extent of the progress in understanding the ‘what’ and ‘why’. In other
words, the attempt in psychoanalysis is to upgrade the operation of
the rules of the game to the ‘stable’ level of hermeneutic communication. The former needs more explanation. Hence, this movement from
attempts at conscious explanation to a level of implicit explanation
cannot lead to the FS’s conclusion that the former is more explanatory
than the latter.
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Concluding Remarks
Capitalism, which defines all western nations to differing extents, is the
archetype of an entire society which is mentally distressed in the most
thoroughgoing manner. Marx’s description of the England of his tines in
which he calls capitalism a ‘living absurdity’ is pertinent today [Max
1977:182].
In addition to having identified the: economic, political, social and
psychological features of the ‘madness’ in its main forms in contemporary
western industrial societies, the FS’s critique of capitalism contributes to
this paper’s conceptual framework on mental distress, especially with
regard to the societal response to mental distress.
It shows how fiscal crises determine the institutional response of the
state to the need for mental health services. The state overcomes its many
crises but distributes its side-effects on the unorganised mentally distressed sector (to this sector’s disadvantage naturally). The organised
opposition tacitly plays a role in this unfair game within the overall
context. Further, the FS’s critique portrays how a general public withdrawal from politics adversely effects the societal awareness of mental distress
and spurs on the turn towards biomedicalism. Moreover, the FS is aware
of how difficult it is to form a truly non-bureaucratised resistance (within
the field of mental distress) to capitalist policies of exploitation.
The critique does not explain the fact that community psychiatry
developed in some western societies which were not undergoing fiscal
crises. Further, the link between manifestations of formal democracy and
configurations of mental health services are not detailed. Again, the
critique does not show how at the community level responses form to the
surfacing (within the community) of mentally distressed individuals. The
psychological thread in the critique of capitalism goes a long way in
explaining the genesis and shapes of discontent in advanced capitalism,
and the basic confusion and ideological veil to which the masses are
subjected, but the FS’s efforts do not explain the phenomenon of mental
distress itself; why only some of the confused masses respond with mental
distress whilst other do not.
Critical theory’s critique of reason and rationality shows Hoe a technological rationality, in contrast to the reflexive and committed reason of the
pre-technological west, has permeated all layers of contemporary western
industrial society, and has moulded human thought processes into one of
instrumental reasoning geared towards the optimal co-ordination of means
and ends, for the benefit of an exploitative capitalist technological system.
This critique shows, at least, the very tight leash on instincts required
by such rationality and of the chances of instinctual expression being
labeled as irrational or insane behaviour or protest. Moreover, it reveals
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that the positivistic empirical rationality fails to comprehend the philosophical content of mental distress. However, this approach does not itself
explain the philosophical content or nature of mental distress in detail, and
it is also unable to explain the existence of critical democratic resistances
at'all levels in western societies which is seemingly swamped by the
numbing technological rationality. Also, it does not explain as to why only
some forms of resistance or protest are perceived as irrational or mentally
distressed whilst most others are not.
As regards one of the main sites of mental distress ... the family ... the
FS’s critique is disrupted by its volte-face. If the family in the 1930s was
the site of the harshest repression, in more contemporary times it becomes
the site for liberation. However, even this liberative family is fast disintegrating under the onslaught of formalised and institutionalised psychological manipulation of late capitalism. On the whole, the FS’s critique
remains unsure of its position and does not explain the still considerable
spontaneity and privacy attached to the family. Moreover,
the specific link
between the family and mental distress remains unexplored.
The FS, however, does attempt mental distress analysis in its examination of the personality. It shows how highly prejudiced and authoritarian
personalities are more likely. to become mentally distressed, and how
behaviour cannot be equated with personality because whereas certain
personality forces determine the susceptibility of personalities towards the
acceptance or rejection of ideologies, actual action depends on the broader
socio-economic and political factors. Again, that repressive childhood
experiences of individuals can lead tc high levels of prejudice ... increasing the likelihood of mental distress is.shown.
The FS does not explain its concepts of. mental well-being and
mental distress so that the attempted distinction and relationship
between types of prejudice and types of mental distress get jeopardised. In
addition, it does not explain the formative role of the environment and of
adult autonomy because it conceives the personality as a fundamental
structure built during childhood. Further, what happens to the societal
notion of mental distress within the prejudiced individual after he gets
afflicted with mental distress is not explained. Again, whilst the social
forces of prejudice are identified, the societal responses (especially at the
community level) to mental distress are not addressed at all.
This critique of personality nevertheless does pave the ground for
critical theory’s critique of intersubjectivity, which shows how language
is an important tool or, in fact, is the very basis of understanding human
behaviour. Greater conditions of intersubjectivity expressed through language lead to a greater approximation of truth, freedom and justice. The
operation of intersubjectivity ....of the ‘I’, ‘You’ and ‘We’ ... are
formative of societal perceptions and societal responses. This position
does not explain how the forces of id, ego and super-ego operate in mental
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well-being. This link between psychoanalysis, linguistic behaviour and
intersubjectivity is not clearly explained, thereby invalidating much of its
reduction of Freudian metapsychology to language.
Again, such acritique does not offer a clear conceptualisation of mental
well-being and mental distress through linguistic and psychoanalytical
tools. Italso does not explain the possibilities of volition in mental distress.
Furthermore, although it shows why it is necessary to locate language,
meaning and behaviour within specific cultures and societies in order to
gauge their truths, it does not explain how societal responses (in recognition of the existence or sudden surfacing of mental distress) form, at the
community level, in contemporary western societies.
These advances and lacunae in the FS’s total critique is closely linked
to its contradictory and uneasy combinations of methodological tools,
mainly Marxist, psychoanalytical and other philosophical ones. The
departures from and affinities towards each of these tools created by the FS
leads ... to the FS’s credit ... to some unusual or neglected areas of human
‘ life and society being subjected to the critical gaze, which contributes to
an understanding of mental distress and its organisation. It also leads ... to
the FS’s discredit ... to an awareness that an integrated or holistic social
methodology has not yet been attained, leading to all the illogicalities
which have been so far identified.
Along with these methodological complexities what further weakens
the advances of theory vis-a-vis mental distress is the FS’s neglect of a
philosophy of praxis, a programme for action and change. As a matter of
fact, one critical theorist has himself called the efforts of his predecessors
as being limited by “the politics of hibernation” [Habermas in McCaan
1989]. One of the important purposes of throwing light on mental distress
is to evolve some programme for chanZe, out of the critical knowledge
gained. Some of the all too rare suggestions (such as ‘fantasy play’ or
‘identification and organisation of intersubjective collectivities’) remain
undeveloped.
)
|
Atthe micro level, therefore, the FS is plagued by the constant inability
to explain how and why some people express mental distress whilst others
do not, even under similar conditions. The reason for this lacuna is perhaps
the FS’s inadequate attention to personal differences. Similar conditions
can and do acquire different meanings for individuals through the different
interpretative or meaning systems embedded in different personality
structures. Hence, the FS’s future attempts at forging a better link between
personality, linguistic behaviour and intersubjectivity has to pay more
attention to the hermeneutical aspects of the structure of personality.
However, it needs to be ensured — at the macro level — that mental
health care alternatives based on complex hermeneutics do not reinforce,
in any sophisticated way, the limiting encrustations of the individual
which are done by traditional meaning systems. One of the foremost such
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meaning systems is the Oedipus complex, whose terrain is the institution
of the family or household in its relationship to the economy. A fresh look
at the family and its constitutive relationship to intersubjectivity and the
economy is thus required.
One way out could be the development of ‘radical group therapy’ for
the mentally distressed. These groups shall not be formed and guided by
outsiders/experts, which make the mentally distressed dependent (as
happens in traditional psychotherapy). Instead, the radical groups would
conduct an examination of the innermost recesses of their psyche only
whilst pursuing (in conjunction) an analysis of the socio-political and
economic nature of capitalism, and their own location in it. This analysis
is likely to become sharper if such groups are encouraged to participate as
activists (according to their abilities) in collective interventionary
programmes designed to overcome capitalism. Therefore, the intertwining of an emphasis on the personal hermeneutical experience with interventions (radical therapeutic groups) aimed at the collective defeat of
capitalism can advance critical theory’s achievement of indicating the
madness of capitalism and its penetration into the human psyche through
personality structure and familial processes.
Notes
{I am grateful to Shulamit Ramon (London School of Economics) and Imrana
Qadeer (Jawaharlal Nehru University) for their comments on this paper].
1 A good account of the pre-technological and modern rationalities is to be found
in Horkheimer (1987) “The End of Reason’ in Arato and Gebhardt (1987). Also
see Horkheimer (1993) ‘The Rationalism Debate in Contemporary Philosophy’
in Horkheimer ‘Max, Between Philosophy and Social Science: Selected Early
Writings, Cambridge, MA: The MIT and Social Science: Selected Early
Writings, Cambridge, MA: The MIT Press, pp 217-64.
2 A comprehensive critical account of the FS’s positions on the family is to be
found in Mark Poster (1978) Critical Theory of the Family, London: Pluto.
3 The best orthodox exposition of the authoritarian personality is to be found in
Theodor W Adorno et al (eds) (1969) The Authoritarian Personality, New York:
W W Norton.
-References
Adorno, Theodor W (1976):’ Introduction’ in Theodor W Adorno et al (eds) The
Positivist Dispute in German Sociology, Heinemann, London.
Adorno, Theodor W and Max Horkheimer (1979): Dialectic of Enlightenment,
Verso, London.
Allen, JP B and Paul van Buren (eds) (1972): Chomsky Selected Readings, Oxford
University Press, London.
Engels, Frederick (1990); “The Origin of the Family, Private Property and the
State: In the Light of the Rsearchers byn Lewis H Morgan’ in Karl Marx and
114
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Frederick Engels Collected Works, Vol 5, Progress Publishers, Moscow.
—(1972): ‘Toward a Theory of Communicative Competence’ in H P Dreitzel (ed)
Recent Sociology No 2: Patterns of Communicative Behaviour.
—(1987): The Theory of Communicative Action, Vol2 ; Lifeworld and System: A
Critique of Functionalist Reason, Polity Press, Cambridge.
—(1987a): The Philosophical Discourse of Modernity: Twelve Lectures, Polity
Press, Cambridge.
—(1989): Legitimation Crisis,Polity Press,Cambridge.
—(1989a): cited in Graham McCaan : ‘Perspective:Message in a Broken Bottle’,
The Times Higher Educational Supplement, London.
Horkheimer; Max (1974): Critique of Instrumental Reason, Seabury, New York.
— (1987): ‘The Authoritarian State’ in Andrew Arato and Eike Gebhardt (eds) The
Essential Frankfurt School Reader,Continuum, New York.
Kellner, Douglas (1985) ‘Frankfurt School’ in Adam Kuper and Jessica Kuper
;
(eds) The Social Science Encyclopedia,
London.Marcuse,
Routledge and Kegan Paul,
Herbert (1964): One Dimensional Man:
Studies in the
Ideology of Advanced Industrial Society, Beacon Press, Boston.
— (1970): Eros and Civilisation: A Philosophical Inquiry into Freud, Allen Lane,
The Penguin Press, London.
Marx, Karl (1977): Economic and Philosophic Manuscripts of 1844, Progress
Publishers, Moscow.
—(1986): Capital: a Critique of Political Economy, Vol 3, Progress Publishers,
Moscow.
—(1988):’Economic Manuscripts of 1861-63: A Contribution to the Critique of
Political Econmy’ in Karl Marx and Frederick Engels Collected Works, Vol 30,
Progress Publishers, Moscow.
, Unwin, London.
Marx, Karl and Frederick Engels (1976): “The German iésolozy? in Karl Marx and
Federick Engels Collected Works, Vol 5. Progress Publishers, Moscow. Weber,
Max (1985): The Protestant Ethic and the Sprit of Capitalism
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.
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Indian Practitioners of Western Medicine
Grant Medical College, 1845-1885
Mridula Ramanna
Colonial medical history has been extensively researched in recent
years. This review focuses on the first four decades of medical
education in Bombay city. British policy towards professional education was motivated primarily by the need to train subordinate personnel for the medical and engineering services, and thus to reduce the
expenditure of recruiting Europeans for these jobs.
BY the early 19th century, it was no longer considered ‘safe’ to leave the
healthof the Company’s servants in the hands of Indian medical
practitioners, who had no knowledge of western medicine[1]. A school for
‘native doctors’ was established in 1826 in Bombay, on the lines of the
Native Medical Institution, Calcutta, instruction being provided through
the vernaculars. Both western and Sanskrit works were translated into
Marathi[2]. However, as a consequence of the new policy in the 1830s to
Support western medical knowledge, imparted through English, this
school closed in 1832.
Mountstuart Elphinstone had earlier advocated’ the spread of such
knowledge in this Minute on Education[3]. Indians, too, were urged to
study western medicine by the paper, Bombay Durpun, which was
representative of educated Indian opinion. Edited by Bal Shastri
Jambhekar, the paper pointed out that few could afford the fees of
European doctors[4]. The Bombay Medical and Physical Society, an
association of British medical men established “to encourage a spirit of
scientific enquiry and the cultivation of medical sciences and its collateral branches by discussion”, prepared a report on the state’of Indian
medical practitioners[5]. On the basis of this report, a scheme was drawn
up for the establishment of a medical college, by Robert Grant, Governor
of Bombay. A generous donation by Jamsetji Jejeebhoy led to the
subsequent establishment of Grant Medical College, and the adjacent
J J Hospital, in 1845.
Indian response to medical education, as apparent in the social
composition of the students, shows the dominance of the westernised
Parsis and Christians, who had fewer reservations about dissection than
the Hindus. A steady increase in the number of Hindus is to be found,
while Muslims constituted a small section. Significantly, there were a few
from families, where the Indian system of medicine was a hereditary
profession. The syllabi taught at Grant Medical College reflects the
conviction of the framers regarding the superiority of western over Indian
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systems of medicine. While the government’s intention was to train Indian
doctors for government service, the low salaries and middle level positions
offered to them led many to quit and to take up lucrative private practice.
These practitioners combined their knowledge with an understanding of
Indian customs and beliefs, in promoting western medicine and immunising
methods. But some of these doctors did not accept the exclusive efficacy
of western medicine and prescribed well-known Indian drugs, as well.
Information on /ndian Materia Medica was compiled and presented in
comparison to western materia medica. In the meetings of the Grant
College Medical Society, these medical men exchanged their experiences
in treating different diseases.
In the 1880s, they supported a move to register medical practitioners
in order to obstruct the practice of ‘quacks’. At the same time, they
cautioned that this should not interfere with the rights of hakims and
vaids. A number of British health officials from other parts of the country
were also of this view. The indigenous practitioners provided medicalcare to the majority of the population, while the western educated doctors
were too few to cater to the needs of all. The proposal was consequently |
not approved. By the end of the century, there was the same kind of
‘uneasy co-existence’ between western and Indian systems of medicine
in Bombay as happened in Bengal[6].
The Medical Board founded the school for native doctors (1826) with
McLennan as superintendent, with three ‘munshis’ to help him with the
translations. The London Pharmacopoeia, Essays on Dysentery,
Rhematism Fevers and Other Diseases, Treatises on Anatomy and
Physiology were translated into Marathi. Sanskrit works translated
included Susruta’s text. The substances of materia medica arranged into
classes by John Murray, who served in Agra and Meerut, was translated
into Hindustani and a Marathi dispensatory was prepared. These works
were circulated through the lithographic press. McLennan’s report
referred to the students’ knowledge of materia medica, but observed that
they had difficulty in understanding anatomy. The lack of practical
training was a drawback. The products of this school were posted as
apprentices to European corps and Indian regiments[7]. As noted earlier,
the school closed six years later.
With the opening of Grant Medical College in 1845, the system of
western medical education was establised. Jejeebhoy had specified that
the sum of one lakh of rupees was to be paid to the government treasury,
provided that the government paid an equal sum, and granted an interest
of 6 per cent to maintain a hospital for the relief of the “sick and native
poor” of all denominations. The J J Hospital took over the patients of the
Native General Hospital, founded in 1809, and the Bombay Native
Dispensary, set up in 1834. Practical training to medical students was to
be provided at the hospital[8].
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hi]
_
The first principal of the College was Charles Morehead, MD, FRCP.
Morehead had served_.at European General Hospital, an ‘Europeans Only’
~ institution and had conducted clinical research, compiling statistics on
_ the incidence of death, and diseases, like small pox, measles and
cholera[9]. Morehead served as professor of medicine at the college,
while John Peet, MD, FRCP, who was also superintendent of vaccination
in the 1850s, was professor of anatomy and surgery; and Herbert Giraud
MD was professor of chemistry and materia medica. Both Peet (1860) and
Giraud (1865) served as principals. William Hunter MD, FRCP (18661876) and Henry Cook MD, FRCP, FRCS (1876-1886) were their
successors. Most of the teaching faculty, in the early years, were
graduates from Scottish universities, like their counterparts at Elphinstone
College. They were also required to serve at the J J Hospital, reportedly
on salaries lower than their counterparts were paid at the Bengal and
Madras Medical Colleges[10]. Instruction was provided both to undergraduates, who would qualify as doctors, and to trainees for the subordinate medical services of government.
SOCIAL COMPOSITION OF STUDENTS
In the early years, medical education was free and stipends were
provided to attract students. The social background of the students
admitted to the college from 1846-1866, depicted in Charts | and 2,
indicate the number on the rolls during these years. It was considered ‘a
sign of the times’ that the ‘gentle Hindu’ and ‘scrupulous Parsee’ united
with the ‘bold European’ in opening up and examining all the “awful
mysteries of the human frame’”[11]. Not all the students completed the
course. The Parsis constituted half the total strength, so much so that, in
1855, Peet complained, that they monopolised the stipends, to the
exclusion of Hindus who, he said, needed them more[ 12]. However, there
was a fallin their numbers in the 1860s; this was attributed to the
discontinuance of the stipends, three Parsis being rejected for government
posts, and the commercial boom making careers in commerce more
attractive[ 13]. The Christians were next and included East Indians, Goans
categorised as Portuguese, brahmin and mahar converts. Among the
Hindus, the shenvis and the pulsias/palsikar brahmins, about whom it was
noted, that the profession of medicine was probably hereditary, were
greater in number than the prabhus, who figured so prominently among
students pursuing contemporary arts and science courses at Elphinstone
College[14]. The other Hindu castes included brahmins, kayasthas,
_sonars, khatris and vaisyas. In the mid-1850s appear banias and one
Kansara, while a bhandari student is listed in the 1860s. Muslims attended
in small numbers and included Bohras, Khojas, and Mohammedans. It is
significant that, in the same period, Muslim males constituted one-third,
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FiGuRE 1: COMMUNITY-WISE BREAKUPUP OF STUDEN TS OF GRAMT MEDICAL
COLLEGE, (1846-66)
Muslim (3.5%)
Paris (43.5%)
Jews (0.2%)
Hindu (30.2%)
/
Source: Reports of the Board of Education (relevant years)
Reports of the Director of public Instruction (relevant years)
and females one-fourth of all patients treated at J JHospital, indicating that
though the number of medical students among them was small, Muslims
did avail of medical facilities[15].
The table reflects the communities of all students of the college, from
1873-1886 including matriculates, (which was the required standard of
admission) and hospital apprentices and women, attending the certificate
practitioners class. In 1886, Parsis formed 42 per cent, Hindus 29 per cent,
Christians including Eurasians, 26 per cent, Muslims 2 per cent and others
1 per cent.
Scholarships endowed by Indian and British donors replaced the
stipends. The gradual acceptance of medical education is apparent,
especially when the numerical strength of the college was not affected
even when fees were introduced from 1870[16]. But contrary to British
intentions of attracting the upper classes to this course, it was the middle
and the poorer class of students, who constituted the student community.
In 1884 out of a total strength of 378, 54 were sons of merchants, 50
government servants, 25 pensioners, 25 priests, and 12 ‘propertied’[17].
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FIGURE 2: CASTE-WISE BREAK UP OF HINDU STUDENTS
(1846-1866)
Yn
O
W
ADAAAAAARAne
The admission of women as medical undergraduates was due to the
initiative and efforts of Sorabji Shapurji Bengalee, reformer and educationist, and George Kitterdge and American business man who set up the
Medical Women for India Fund in 1882. The university granted recognition for a five-year course to matriculates and the college offered a
three-year certificate course to non-matriculates[18]. Classes for women
began in 1887.
|
Students seeking admission to medical courses in the early years were
required to possess a knowledge of English, the vernaculars and simple
Arithmetic. This was expanded to include an extensive knowledge of
Algebra, Geometry, ordinary natural phenomena, Geography and Histo-
ry. The students were mainly from local school — Elphinstone Institution,
John Wilson’s General Assembly Institution, Robert Money School — or
from Goa, Poona, Ratnagiri, Broach and Surat. When the college was
affiliated to the University of Bombay, matriculation was made a
requirement for admission[19]. A short-lived attempt was also made to
award the medical degree as a post-graduate degree, but there were few
applicants and the entry qualifications had to be reduced to matriculation
again[20] The periodic poor performance of students was attributed to
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difficulties with the English language[21]. Not only had the average
student to learn unfamiliar medical terms and methods, but had to express
himself in one language, while thinking in another. The early batches of
graduates served a year or two under their teachers, but by the 1870s they
went into practice directly after graduation, allegedly gaining experience
at public expense[22].
In 1885 the standards were raised, requiring
candidates for admission to pass a previous examination, testing their
knowledge in advanced Mathematics, Homer and Virgil. While this
reflected the contemporary accent on humanities over sciences in the
- syllabi, the local press regarded it as of little use to medical students and
ascribed the decision to the ‘selfishness’ of government[23].
The courses. were modelled on those taught in medica! schools in
England. Both medical men like Morehead and educationists like Erskine
Perry (president of the Board of Education, Bombay) were firmly of the
opinion that the Indian system of medicine was defective[2‘]. Initially,
medical studies constituted Anatomy, Chemistry, Institutes of Medicine,
including Physiology, Pathology and Therapeutics, Materia Medica,
including Pharmacy and Elements of Botany, practice of Medicine,
Clinical Medicine and Clinical Surgery[25]. When courses in Midwifery
and Medical Jurisprudence were proposed, the Court of Directors of the
East India Company refused to sanction the professiorships. The Bombay
Government had to point out that postponement in the instruction of these
subjects would shake public confidence in the institution, in view of high
mortality rates during child birth. Jagannath Shankar Shet a patron of
western education and a member of the Board of Education contended that
a class of Indian medical practitioners would go a long way to remove
those prejudices of caste or.ignorance causing opposition to the Coroner’s
investigations[26]. Morehead emphasised constant study and observation as attributes of medical men and guided the first groups of students
accordingly[27]. Later courses on Dental Surgery, Hygiene, Practical
TABLE: COMMUNITY OF STUDENTS OF GRANT MEDICAL COLLEGE (1873 To 1886)
Years
Hindu
Parsi
Muslim
Christian
Jews
Others
Total
73-74
74-75
78-79
79-80
80-81:
81-82
84-85
85-86
97
89
47
49
65
heh
WOT
86
71
97
105
107
128
114
143
Lis
re
4
l
l
3
3
5
5
119
85
78
81
86
88
112
78
10
Z|
0
0
0
0
3
0
0
0
0
0
0
l
0
4
309
282
231
238
282
283
370
296
ic
Note: Reports of the Director of Public Instruction (relevant years) figures
include all matriculated students, hospital apprentices and women.
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|
5
!
Toxicology, Diseases of the hi and of Wonier and iceman were
introduced[28].
To illustrate the Anatomy course, amuseum was set up, with specimens
in human and comparative osteology, wax models, plates and pathological
preparations, showing changes wrought by disease on the human body.
For the study of materia medica, specimens of drugs and pharamceutical
preparations, including articles used in Indian medicine were procured.
Specimens illustrating the adulteration of imported drugs, offered for sale
as genuine in the Bombay market, were also acquired. Grant Medical
College students gained practical experience at J J Hospital, the male and
female outpatients dispensary, The Eye Dispensary and Ophthalmic
Hospital, the Obstetrics Institution and the Incurables Ward. Mental
disorders were studied at the Mental Asylum, Colaba.
_ The first group of eight students graduated in 1851 with the Pte of
Graduates of Grant Medical College (GGMC). This degree qualified them
to be civil sub-assistant surgeons (redesignated assistant surgeons after
1873): They were in order to merit: Sebastian Carvalho, Anatna Chandroba
J CLisboa, Bhau Daji, Atmaram Pandurang, Paul Francis Gomes, Merwanji
Sorabji and Burjorji Dorabji. The first Muslim graduates was Abdul
Karim[29]. The University of Bombay awarded the Licentiate of Medicine (LM) degree for the first time in 1862 to Lamna Nasarwanji Jamsetiji,
Sanzgiri Shantaram Vithal, Vicaji Kaikhosru Hormusji and Berojorji
Behramji. This degree was redesignated Licentiate of Medicine and
Surgery (LM and S) in 1877. By 1885, there were 264 LMS and 63
GGMCs, and two MDs[30]. The first MD was Anna Moreswar Kunte BA
in 1876 who served as Demonstrator in Physiology at the College, Gopal
Moreswar Deshmukh BSc, BA passed his MD in 1885[31].
TRAINING OF SUBORDINATE MEDICAL PERSONNEL
_ The college provided training to the military sub-medical department:
student apprentices and warrant medical officers, the majority of whom
were European, or Angb Indians. They had a shorter curriculum. On
completion of the course, student apprentices qualified as assistant apothecaries and warrant medical officers as apothecaries. In 1868, the military
sub-medical department was divided into two classes viz. apothecaries
and hospital assistance[32].
|
_The government also established, in 1861, a vernacular class, to train
Indian Hospital assistance. The class, taught in Marathi, was so popular
that there were 175 applicants for 22 vacancies. More than two-thirds of
the students were brahmins and the rest were marathas, shenvis and sonars.
The majority were from local anglo-vernacular schools and a few from the
medical department. Initially a two-year course, it was increased to three
years and included the study of Anatomy, Physiology, Chemistry, materia
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medica, Clinical Medicine and Clinical Surgery. The class was taught
through conversation-by-the-bedside methods, by Narayan Daji and Bhikaji
Amrit Chobe both graduates of the College. They prepared text books on
Materia Medica and Physiology[33]. In 1872 Chobe exchanged his
appointment with Narayan Ananta Dandekar of Pandharpur Dispensary.
Sakharam Arjun, Gopal Shivram Vaidya and Shantaram Vithal Sanzgiri
were the other teachers. Sakharam Arjun and Gopal Vaidya prepared a
work on Midwifery and Medical Jurisprudence. The Government provided stipends to students and scholarships were endowed by Jagannath
Shankar Sheth. Donations for the purchase of books were made by ©
Cowasji Jehangir and John Willoughby, member of the Bombay Council
and an advocate of vernacular education[34].
Cowasji Jehangir, Mangaldas Nathubai, Byramji Jzj;eebhoy, Keshavji
Naik, Dinsha Manekji Petit and Gaekwar of Baroda financed the class
providing instruction in Gujarati, which attracted 158 applications for the
15 seats. This class was taught by Dhirajram Dalpatram and Rustomji
Nasserwanji Khori[35]. However, there were many early dropouts because, according to the paper Swadeshi Hitechu the students could not
afford expensive books[36].
Students of these classes were appointed as Grade III, hospital Assistants on a salary of Rs 25 pm with an extra allowance of Rs 30 p.m. if
placed in charge of a dispensary[37]. successive principals of Grant
Medical College regarded these classes as unimportant, because they saw
the institution as an educational centre rather than a training college. On
the other hand, Native Opinion perceived the work of these ‘native
doctors’ in the mofussil as useful, though they might not have the scientific
knowledge or professional skill of medical graduates[38]. The classes
were wound up in 1878 and the training of hospital assistants was
thenceforth provided at the Byramjee Jejeebhoy School, Poona (1878),
Byramjee Jejeebhoy School, Ahmedabad (1879) and the Hyderabad
School (1881). These trainees were also placed in the Vaccination and
Sanitation departments as inspectors. Even though salaries were sub8e. quently raised, there was a glaring disparity between assistants, paid Rs 85
pm and apothecaries, paid Rs 750 pm in 1886, Indians having been
excluded from the latter positions in 1884. This move was attributed to the
racism of British soldiers, who could nto ‘bear’ to be treated by Indians[39]. |
The training of midwives, funded by Peroj Bai, sister of Rustamji
Jamsetji, was begun in 1870. Sakharam Arjun instructed the class in
Marathi. The Bombay Chabuk a Gujarati paper, regarded this one more
instance of Government’s preference for Marathi over Gujarati[40].
Subsequently a Gujarati class was started, in 1872, with the financial
support of Ardesir Hormasji Wadia, while Cowasji Pestonji Naigaumwala
was appointed teacher. However, only one Parsi responded initially; this
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was considered a reflection of Parsi prejudice against lying-in. The
number soon increased and 25 women from both classes were certified as
trained. But with no encouragement from government, this training
programe was wound up shortly thereafter[41].
CARRERS OF INDIAN MEDICAL MEN
While the British claimed that medical education was imparted not
merely with reference to ‘excutive wants’ but to provide for India’s own
need, the Bombay
government,
in contrast to Bengal, did not make
adequate provision for the employment of Indian graduates[42]. Under
the 1849 regulations, diploma holders of medical colleges were considered qualified for the post civil sub-assistant surgeon. This position was
graded, the appointee beginning in the III Class on a salary of Rs 100 pm.
After seven years in this grade, he qualified for the II class on a pay of Rs
150 pm, and after 14 years for the I Class, on Rs 200 pm. Each promotion
was granted after a committee had examined the candidate in Medicine
Surgery, Midwifery, and tested his acquintance with medical literature and
later improvements. Most of the early graduates began in government
service but moved soon to more lucrative private practice, where they
earned between Rs 200 nd Rs 1000 pm. Out of 28 graduates in Government
Service, up to 1858, only 11 found it worthwhile to stay on[43]. One such
was Anant Chandroba Dukhle who served with a Bhil Corps at Bhopawar
in Centtal India and subsequently at Indore and Bhopal. Between 1854 and
1859 he worked for the Karachi Municipality, where he earned the praise
of the then commissioner, Bartle Frere. He was consegently promoted out
of turn and returned to Bombay as vaccination superintendent, which post
he held for over 25 years[44].
Among those who moved from government service to private practice
was Chandroba’s classmate Bhau Daji, who enjoyed “an amount of
practice, which notwithstanding the novelty of regular professional men
among the natives and their aversion to pay for anything intellectual, a
medical man of his age in England would be proud of’[45]. Assisted by his
brother, Narayan Daji, Bhau Daji provided free medical attention at the
Nagdevi Charitable Dispensary. Between 1853 and 1861, they treated
more than 81,000 patients, some of whom came from Sind, Kutch,
Kathiawar, Khandesh, Nasik and Hyderabad (Deccan). The number of
lithotomy, cataract and obstetrical operations performed at the dispensary,
exceeded the operations performed by European private practitioners[46].
-Atmaram Pandurang practised in Bhiwandi, where he was initially discouraged from going in view of the bad climate and the opposition to
vaccination. He was successful here, though his practice was not as
lucrative as Bhau Daji’s[47]. Sadashiv Hemraj, who was in charge of the
dispensary at Bhuj, was so popular that not only did patients “swarm” to
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&
him, but he was induced to leave government service for employment with
the ruler. Carvalho and Lisboa, both attached to the college initially, later
set up practice in Bombay city. Burjorji Dorabji gave up medicine for a
while to conduct an import-export enterprise in England and on his return
practised in the Fort Area[48].
The Rast Goftar and Satya Prakash
observed that there was scarcely a rich Indian family in Bombay that was
not glad to employ these graduates, either by annual payment or as
occasion required, and maintained that they had nearly driven out European practitioners, who were confined to the European sections of the
city[49]. Motivated by public spiritedness these doctors also worked in
charitable dispensaries. Burjorjt Dorabji and Ardesir Jamsetji attended the
Fort Charitable Dispensary while Paul Gomes was in charge of a dispensary at “Bandora’, which was financially supported by Indians. However,
the pursuit of medical careers was not easy for all. Of the 50 graduates who
left the college between 1856 and 1860, 23 were in non-medical occupations, most being clerks. A photographer, a teacher, a merchant and two
unemployed persons were the others[50].
Indians were made eligible for the convenanted medical service in
1855, when S C G Chukerbutty of Bengal headed the list of successful
candidates[51]. Rustamji Byramji of Grant Medical College, after obtaining the Diploma of the Royal College of Surgeons, London, and
Doctor of Medicine, University of St Andrews, competed successfully for
the IMS[52]. Later, Atmaram Sadashiv Jayakar went to England
on the
Mangaldas Nathubai Travelling Fellowship, passed the examination of
the Royal College of Surgeons and Physicians and then entered the
service[53].
When the assistant surgeon’s post in the IMS was abolished in 1873,
that designation was given to sub-assistant surgeons. The number of these
posts was fixed at 35 and included the charge of dispensaries in Bombay
city (Mahim and Kurla for example), Kalyan, Poona, Bulsar, Navsari,
Baroda, and the Persian Gulf[54]. These doctors were paid Rs 100-Rs 150
pm as salaries. This glaring contrast with the emoluments of their Euro- .
pean counterpart evoked critical comments in the Indian Press[55]. At the
turn of the century Dabadhai Naoroji pointed out, that the maximum salary
Indians in government medical service could draw was Rs 350 per pm,
while hospital apprentices and warrant medical officers, (who were
Anglo-Indians or Europeans) who faced less exacting qualifying examinations, were paid Rs 700 pm[56]. In 1885, 32 graduates of the college
were with princely states, eight in railway companies and seven were
attached to the college[57].
The medical officers in the civil department of Bombay Presidency,
in 1883, included surgeons major Jayakar, civil surgeon, Muscat; Salaman,
superintendent, Yervada Jail;DN Parakh, assistant civil surgeon Tanna,
later acting professor at the Grant Medical College; and K S Nariman,
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civil surgeon, Panch Mahal and Dohad. Lt Col Rustom Hormusji Cama,
who pursued higher studies in England, passed the IM S in 1880 and
served in the Punjab and Madras Presidency[58]. There were two GGMCs
and 19 LMS in the IMS by 1885. Service in the IMS, however, was attendd
by problems. The racist objections of wives of Europeans, with “scarcely
an exception”’, declining to be treated by Indians is noted in a confidential
note by Surgeon General Hunter in 1879. It was further pointed out that
a number of officers “shrank” from seeking their advice. British resentment was motivated by two factors, viz Indians qualifying through an
Indian university education, which was less expensive than in Europe and
their availing of all advantages and emoluments allowed to Europeans,
who served in a “foreign country and unhealthy climate”[59].
GRANT COLLEGE MEDICAL SOCIETY
Grant Medical College graduates developed a spirit of association and
engaged in meaningful exchanges through the Grant College Medical
Society founded in 1852. Professor Peet, the first president, emphasised
that the Society should be a deliberative body, with a scrupulous regard
for facts, rather than a debating forum. He further suggested that, in view
of the understanding of the previous 50 years of the injurious influences
of impure air and unwholesome food on diseases and deaths, inquiries
into the meteorology, types of dwellings, quantity and quality of food,
habits of people, diseases of pregnant women and children and attitudes
towards smallpox vaccination could be conducted. Consequently, Paul
Gomes read a paper on the ‘Medical Topography of the Salsette’, Bhau
Daji on the ‘Diet of Western India’, Rustamji Merwanji presented a
topographical account of Panvel, Ananta Chandroba sent a paper on
Bhopawar, Ruttonjee Hormusjee on Aden and Sadashiv Hemraj on
Bhuj[60].
3
On the question of vaccination, Atmaram Pandurang outlined the
obstacles in a paper, where he referred to the ignorance of even the
“intelligent” classes about the difference between inoculation (variolation)
and vaccination. He objected to the “secondary causes of neglect”,
particularly among middle-class Hindus, who carried a child saved from
small-pox or even after vaccination to the:Sitala Devi temple. Bhau Daji
also gave an account of the process from its origin and appealed to Indians
to extend its practice. The members of the Society resident in Bombay
offered their services, free, to propagate the method and a circular was
prepared in the vernaculars explaining its efficacy. Nineteen yaccination
‘stations’, as they were called, were set up at the local dispensaries and in
other parts of the city. These efforts had limited success owing to the
paucity of lymph and the reluctance of parents to let their children be
lymph donors in arm-to-arm vaccination[61].
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The Society also served as a forum for the exchange of notes on the
treatment of cures. Lisboa made his observations on leprosy while the
Statistics of tetanus cases at the J J Hospital from 1845 to 1851 were
compiled and presented. Moreswar Janardhan provided data on his treatment of measles. Details from various dispensaries with classes of diseases, a list of surgical operations and daily average attendance were also
placed before the Society. These doctors used Indian medicines as can be
seen in two papers presented by Bhau Daji. ‘Notes on Some of the Native
Medical Drugs Used in the (Nagdevi) Dispensary’ and ‘On the Native
Remedies Used in the Treatment of Poisons by Venomous Serpents’ [62].
The remedies listed by him include ‘rooi’, ‘kooda’, ‘gool’ ‘wail’, ‘neem’,
‘sagurgota’, ‘pandhara chap’. These are also mentioned by Sakharam
Arjun in his Catalogue ofBombay Drugs, which gives an account of drugs
available in the bazar and grown near Bombay[63]. Rustomjee
Nasserwanjee Khory and N N Katrak published Materia Medica of India
and their Therapeutics, in which Indian drugs were listed along with
western drugs so that their comparative merits could be judged. The drugs
were arranged according to chemical, botanical and zoological order and
provided a brief account of the antidotes, incompatibles and antagonists of
the drugs. In the preface, Khory pointed out that since Jndian Materia
Medica, neglected, to mention the doses, vaids and hakims had been
consulted to give doses. He further stated that the aim of the work was to
stimulate research into indigenous Indian drugs[64].
Reports from other parts of India were also received by the Society.
Mooteswamy Moodely (Mudaliar) of Madras Presidency, who was made
a member of the Society, reported, on the treatment of three surgical cases
in the Civil Hospital Kumbakonam. M A Misquita compared his treatment of worms with that reported by sub-assistant surgeon Taruck
Chander of Aligarh, described in the Indian Annals of Medical Science[65]. The Society also subscribed to the medical journals, Lancet and
Indian Medical Gazette.
;
These medical men disseminated their knowledge through the vernaculars. Thus papers were presented in the vernacular societies of the
Students Literary and Scientific Society. Dosabhai Bozunji discussed the
treatment of children at the Gujarati Dnyan Prasarak Mandali, Ambaram
Kevalram read a paper ‘On Medicine’ to the Gujarati Hindu Buddhi
Vardhak Sabha. Atmaram Pandurang lectured on ‘Rules for the Preservation of Health’ and Dhirajram Dalpatram on ‘Hindu Medical Science’
to the Marathi Dnyan Prasarak Sabha. Sakharam Arjun prepared a tract
in Marathi explaining the benefits of smallpox vaccination[66].
Bhau Daji and Narayan Daji pursued botanical studies. Bhau Daji edited
a Gujarati work on Indian plants, written by Kata Bhat of Kathiawar, to
which he contributed Latin and English synonyms. He also researched on
a cure for leprosy. While those who benefited from the treatment, including
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the son of the superintendent of police, claimed its effectiveness, sceptics
doubted its efficacy. Bhau Daji’s request for beds in the Incurables ward of
J J Hospital to be placed under his care, for leprosy treatment, was initially
turned down; but, in 1868, a few cases were treated and showed improvement. Principal Hunter of Grant Medical College, who had permitted this,
investigated the cases with the help of Sakharam Arjun and concluded that
chaulamogra oil and a controlled diet comprised the treatment. Bhau Daji’s
death prevented the completion of this work[67]. Atmaram Pandurang and
Sakharam Arjun were among the eight founders of the Bombay Natural
History Society, established to exchange notes on zoology and to exhibit
specimens of animal life[68].
J C Lisboa did a study of the ‘Grasses of Bombay’, and was such an
expert botanist that the paper, Native Opinion contended that he was fit |
to be professor of botany at Grant Medical College, Col Kirtikar authored
Indian Medicinal Plants(69}.
Most Indian doctors promoted western medicine by using their knowledge with sensitivity. Atmaram Pandurang advised his patients to follow his
instructions exactly, report their reactions to his treatment and not resort to
self diagnosis or medication. Sadashiv Hemraj’s cure of three powerful
‘maharajs’, Gujarati religious leaders, won over their numerous followers.
State intervention in publichealth was done more cautiously after 1857, and
by relying on Indian intermediaries, as David Arnold has established[70].
Thus in promoting smallpox vaccination in Bombay city the effort of
Ananta Chandroba Dukhle is significant. He successfully tried animal
vaccination from 1869, whereby calves were inoculated and the lymph
collected from them was used. This method was more generally accepted
than the arm-to-arm method, which was regarded as ritually polluting since
lower caste children were used as vaccinifiers. It was due to his perseverance
and tact that the Vaccination Act 1877 could be enforced. He worked in the
face of opposition, which occasionally took the form of assaults on his
assistants, the powerful belief in Sitala Devi and on his own low salary[71].
His work was carried on by Sakharam Arjun and Shantaram Kantak in the
1890s, when the staff of the sanitary department were trained and data was
compiled on the incidence of the disease among migrant mill workers. By the
end of the century the number of deaths from small-pox declined and
epidemics when they did occur, became controllable. In other parts of the
Presidency, vaccination was promoted by Muncherji Beramji Colah in
eastern Gujarat, Dorabji Hormusji in Ahmedabad and Balkrishna Chintoba
in Poona[72]. Nanabhai Naoroji Katrak was lies geen special medical
officer during the cholera epidemic of 1883.
The establishment of medical facilities for Parsis was the achievement of
Parsi doctors. Kaikhosru Nusserwanji Bahadurji, MB, MRCS and MD, from
England, served for a while, as professor of clinical medicine at the College
and subsequently founded the Parsi Fever Hospital. Tehmulji Bhicaji Nariman
ia 3.
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established the Parsi Lying-In Hospital, while Sorabji Kharshedji Nariman
drew up the scheme for the Parsi General Hospital. It appears that most of
these practitioners served in cities — Nasserwanji Nouroji Khambatta in
Surat, Muncherji Sorabji Postwala in Broach, Jehangir Manekji Penti in
Hyderabad, while Dosabhai Kawasji Patel and his classmate, Ismail Jan
Mohammed opened a dispensary at Khoja Jamat Khana, Mandvi[73].
INDIAN MEDICINE AND ‘NATIVE Doctors’
While western medicine may have been a ‘tool’ of the empire, as
Headrick has suggested, and the colonial policy was to promote it with
the assistance of Indian doctors, the mass of the population used Indian
medicine[74]. Early in the 19th century, a suggestion had been made that
vaids be trained in the western system but nothing came of it, except that
a few students of the College were from families which had practised the
Indian system for generations. Burjorji Beramji, the son of a famous
Unani hakim did his L M and practised western medicine, laying the
foundation of the Bhavnagar Medical Department[75].
Most Indians peresisted in going to Indian practitioners. This persistence and the conviction of most British medical men of the superiority
of western medicine led to proposals for ‘suppression’ of their practice,
particularly in Bombay city. Principal Sylvester called for the “speculative doctrines” of Charaka and Susruta to be supplanted by those founded
on what he termed “an assured and exact basis”[76]. The preference for
Indian medicine seems to have been based on it being more readily
available and cheaper[77]. At the same time there were a number of
quacks practising. Motivated by what he called the ‘unscrupulous use’ of
medical titles and degrees, a proposal for registration was initiated by
Principal H Cook in 1881. He contended that graduates of the College and
University could take care of the needs of the Presidency, the Legal
Practitioners Act XVIII 1879, imposing restrictions on the practitioners
of law serving as the precedent[78].
The Grant College Medical Society discussed the issue at the instance of
Lisboa, the then president of the Society, and appointed a committee to study
the act in force in England and prepare a draft bill. The Indian members of the
committee were Lisboa, Atmaram Pandurang, Dossabhai Bazunji, Edalji
Nasservanji, Cowasji Hormusji, J A da Gama, Sakharam Arjun, Tehmulji
Bhicaji and C F Khory. The proposed act to be called The Bombay Medical
Act, provided for a Council of Medical Education and a Registrar to register
qualified persons. Those regarded qualified, were GGMCs, LMS, products
of other Indian universities, medical colleges or schools, and members,
licentiates and doctors of institutions in Britain and Ireland. In other words,
the prescribed qualifications were mostly in western medicine. The act was
to give registered medical practitioners the right to give medical evidence in
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a court of law, to be exempted from legal responsibility in the case of injury
done to the patient, and registration had to be a requirement for employment
in a hospital, dispensary, infirmary jail or on ships[79].
The proposal was circulated among Bombay officials for their reactions. Those who supported it included Sidney Smith, the police surgeon,
who maintained that incalculable mischief had been done by hakims and
vaids to the “eyes and ears of the poor”. Indian practitioners of western
medicine like Sakharam Arjun advocated the scheme. Philip deSouza
wanted apothecaries and hospital assistants to be included within the
purview
of the act, but, like Blanc,
vaccination
superintendent,
he
excluded hakims and vaids, with whose “right and title”, it was neither
politic nor wise to interfere[80].
|
On the other hand, Hewlett, the deputy surgeon general, observed that
the agitation for the act had emanated from medical professionals and not
from the public, who, by their silence, had shown their satisfaction with
hakims, vaids, herbalists, midwives and bonesetters. Though not educat-
ed, these persons did possess useful empirical knowledge[81]. Medical
aid was also provided by retired members of the subordinate medical
services. Both the surgeon general and the consulting surgeon, BB and CI
Railway, held that the time was still not ripe for registration[82]. The
deputy surgeon general, Moore, pointed out that while a more correct
registration of deaths could be expected from such a measure, the number
of coorners would increase, entailing additional expenditure. Brigadier
Surgeon Pinkerton, on the basis of his experience as superintendent of
vaccination, cautioned that public opinion should be assessed before the
introduction of such a measure[83].
The act had a number of opponents in the Indian press viz Lok Mitra,
Wepar Vartaman, Gujarat Mitra, Arya Mitra, Nyaya Prakash and
Hitechhu. The Bombay Chronicle noted that the knowledge which some
hakims and vaids possessed was not known to Eurpoean materia medica.
The Native Opinion, held that the act had originated with European
doctors, who feared competition from practitioners of Indian medicine.
Both the Indian Spectator.and Indu Prakash referred to the expense of
western medicines while the poor and even trading classes preferred
cheaper Indian drugs. The Arunodaya, however, criticised educated
Indians, who believed that India was “barbaric” and recounted two
successful cases treated by vaids[84].
,
~The Bombay government forwarded the proposal to the Government of
India with the suggestion that it should be applied throughout the country.
Consequently, opinions were gathered regarding its feasibility. The critics
outnumbered the supporters and their arguments throw light on existing
public health facilities. The chief commissioner of Coorg held that such an
act was not required for his area. His counterpart at Amritsar opposed the
measure. The officials at Assam and British Burma pointed out that there
130
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were no medical colleges in their regions[85]. The Government of Bengal
held that medical titles had little or no influence on the selection of doctors,
who were usually relatives, friends or retainers, while surgeon Major Kees
of Madras Medical College objected to apothecaries and hospital assis- °
tants being disqualified, for they provided cheap medical assistance and
manned emigration ships. Major Rutledge, civil surgeon, Jaunpur, referred to the impossibility of registering unani and misrani practitioners,
while the deputy commissioner, Barabanki mentioned the difficulties in
testing their qualifications. A pertinent point made was that conditions in
the interior were different from Presidency towns and such a measure
would have a baneful influence in small towns, where Indians had been
going to these doctors from infancy[86].
The causes for the unpopularity of western medicine were outlined by
Pandit Kali Sahi, extra assistant commissioner, Barabanki as (a) The Indian
belief that western medical practitioners could not treat fevers but only
perform surgeries, (b) Hindu and Muslim ‘religious prejudices’, and (c)blind
obedience to the authority of others. On the other hand, hakims and vaids
took an interest in their patients, were within call, did not take fees, or if
they did, did so on a moderate scale, and most important their treatment did
not interfere with local habits. Sahi listed the types of practitioners in
British India, which included compounders,
failed students of medical
colleges, midwives (European, American and Indian), retired medical
personnel of the subordinate services, and’even salotries or horse doctors.
He strongly urged the passing of the act, exempting hakims, vaids and
jarrahs, or surgeons, in view of the inadequate number of western medical
graduates. The Government of Punjab was of the same opinion but cautioned that such a move should not lead to opposition to the vaccination
campaign. Adulteration of drugs was a serious problem in the Punjab and
Delhi. The Jullunder division reported that calomel ‘ras kapur’ was mixed
with a corrosive sublimate, resulting in poisoning, while in Ferozepur
district, medicines were tied up in cloth or earthen pots destroying their
potency. Those selling western drugs in Delhi included “uneducated
merchants” anddismissed government employees, hence control over drug|
gists was urged.
Babu Bhagwan Das, civil surgeon, Gurdaspur, while stating his support
for the act gave examples of the damage to eyes caused by vanjaras
operating for catracts, nais and carpenters treating fractures, and banias
being tapped for hydrocele. He held that few vaids were knowledgeable,
and were mere ‘attairs’ (druggists), but this did not prevent them from
demanding high fees. Consequently the common quacks, some of whom
were sanyasis, provided medical advice. The Anjuman-i-Islam, Amritsar
the Peshawar Anjuman and Delhi Literary Society expressed their opinions in favour of the measure, though the Senate and Medical Faculty of
Punjab University regarded it impracticable[87].
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After taking into account these views, the Government of India did not
“consider it expedient” to undertake any legislation on the subject[88].
Another proposal made, in 1887, for an act, confined to Bombay city, was
also not approved. Only in 1912 was the Bombay Medical Registration Act
passed.
CONCLUSION
The above analysis has attempted to assess the response to western
medicine through the careers of medical graduates. Initially, it was the
local elite who used their services and, in the 1860s, some of these medical
men had even to pursue non-medical careers, reflective of the in adequate
response. By the 1880s, more than 300 doctors and qualified from the
College, and under-graduate courses were opened to women. The
profession seems to have been established by then and doubtless it was
the practice of western medicine by Indians that contributed to its gradual
acceptance. It was their tact and persuasion, as the British acknowledged,
that made Indians receptive to smallpox vaccination. However, while
more Indians used hospitals and dispensaries providing western medicine
by the end of the century, the majority still went to hakims and vaids.
Moore, deputy surgeon general, noted in 1882, that only one-tenths of the
population of 7,73,196 in Bombay city were treatedby western educated
doctors[89]. R N Khory observed that despite the efforts of medical
pioneers in the 50 years, the greater percentage of the population either
did not like or could not afford to avail of western medicine[90]. Even
intellectuals had not overcome their reservations, as K N Pannikar has
shown, with reference to K T Telang, who refused to undergo surgery,
though it might have saved his life[91].
The scientific training of Indian doctors was an important modernising
force, yet they faced dilemmas of the kind Bhau Daji did, when he had
to undergo ‘prayaschhita’, for dining with Govind Karkare, who had
crossed the kala pani[92]. Like other intellectuals of the time, medical men
wre connected with the public life of the city, social reform activiteis in
their castes and communities and political associations. While some made
western medical knowledge accessible through the vernaculars, others
provided facilities for their community and for women and children.
Indeed, it is significant that the first few medical women came from the
families of male doctors.
Notes
1 David Arnold, Colonising the Body, Berkeley, 1993, p 54.
2 Appendix to The Report from the Select Committee of the House of Commons
on Affairs of the East India Company, London, 1832, pp 312-314.
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3 G W Forrest, Selections from the Minutes and Other Official Writings of the
Honourable Mount Stuart Elphinstone, London, 1884, p 92.
ms G G Jambhekar
(ed) Memoirs and Writings of Acharya Bal Gangadhar Shastri
Jambhekar (1812-1846), Poona, 1950, II, p 119.
Nn Transactions
of the Bombay Medical and Physical Society, Berka
1851-52, p 351.
Poonam Bala, /mperialism and Medicine in Bengal, New Delhi, 1991, p 69.
Appendix to House of Commons Report, pp 312-314.
Reports of the Board of Education (RBE) 1845-48, Bombay, Reports of The
Grant Medical College, (RGMC) 1845-48, pp 1-5.
Charles Morehead,
Clinical Research on Disease in India, London,
1860,
pp 190-199.
Oriental Christian Spectator, 1847, p 171.
General
Department
Volumes,
(GD
Vol), Government
of Maharashtra
Archives 28, 1850, p 271.
1 N Reports of the Director of Public instuction (RDPT), Bombay 1855-56,
RGMC, p 2.
13 RDPI, 1863-64, pp 143-144.
14 RBE, 1850-51, RGMC, 1849-50, p 24. Mridula Ramanna, ‘Sagra Background of the Educated in Bombay City, 1824-58’, in Economic and Political
Weekly, XXIV, No 4, 28 Jan 1989, p 203.
15 RDPi, 1856-57, p:xli, ibid, 1857-58, p 33; ibid, 1858-59, p27.
16 RDPI, 1872-73, App B4, p 42.
17 Ibid, pp 293-294; RDPI, 1884-85, p 36.
18 George Kittredge, A Short History of The Medical Women for India Fund,
Bombay, 1889, p 27.
19 RDPI, 1856-57, Appn p xvi.
20 S R Dongerkey, A History of The University of Bombay 1857-1957, Bombay,
1957,,p218.
21 RDPI, 1857-58, p 70.
Ze RDPI 1867-68, p 182. Report on Native Newspapers, Bombay Presidency
(RNN) Rast.Goftar, October 26, 1873.
58 RNN, Bombay Samachar, November 24, 1885; Rast Goftar, November 29,
1885.
24 RBE, 1850-51, RGMC, 1849-50, pp 208, 213.
25 Ibid, pp 2-8.
26 Ibid, p 11.
27 Ibid, pp 210-11.
28 Bombay University Calendar (BUC), 1890-91, pp 84-88.
Ja RBE, 1850-51, RGMC, 1849-50, p 200; RDPI, 1860-61, pp 41-43.
30 RDPI, 1885-86, App F, p viii; BUC 1898-99, p 195.
31 BUC, 1890-91, p. 225.
32 DG Crawford, A History of The Indian Medical Service, Laine 1939,
p 110. Among the very few Indians in 1851-52 was Shripat Sheshadri who had
earlier been.a Cause celebre when he had sheltered at the Scottish Mission and
had subsequently been readmitted to Hindusm due to the efforts of Bal Shastri
Jambhekar, Memoirs of Jambhekar, Il, pp 545-72.
33 RDPI, 1863-64, RGMC, pp 156, 160-1, Ibid, 1863-64, pp 149-150. Narayan
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Daji, Treatise on Materia Medica and Therapeutics, Bombay 1865.
34 RDPI, 1872-73, App B4, p 291; Ibid 1874-75, p 45.
35 Ibid, 1872-73, App B4, P 291; ibid 1874-75, p 45.
36 RNN, Swadeshi Hitechu, May 19, 1872.
37 RDPI, 1870-71, App B 3, p 486.
38 RNN, Native Opinion, January 19, 1873.
39 RNN, /ndu Prakash, July 14, 1884.
40
41
42
43
44
45
RNN, Bombay Chabuk, November 9, 1870.
RDPI, 1879-80, App X, p 89.
RBE, 1850-51, RGMC, 1849-50, p 200.
RDPI, 1857-58, RGMC, 1857-58, p 8.
GD Vol 82, 1858; p 103; GD Vol, 154, 1883, pp 5-7.
Lancet, Quoted by Srinivas Narayan Karnataki, Dr Bhau Daji Lad Yanche
Charitra, Bombay, 1931, p 14. Pherozeshah Mehta was treated by Bhau Daji
as a child, ibid, p 15.
46 Rast Goftar and Satya Prakash, October 13, 1861.
47 D V Vaid, Prarthana Samajacha Itihas, Bombay, 1926, p 8.
48 H D Darukhanawala, Parsi Lustre on Indian Soil, Bombay, 1939, II, pp 225, 240.
49 Rast Goftar, and Satya Prakash, October 13, 1861.
50 RDPI, 1860-61, pp 40-42.
51 Lt Col W J Buchanan, ‘The Introduction and Spread of Western Medical
Science in India’, in Calcutta Review N S, 1914, p 433.
52 RDPI, 1856-57, RGMC, 1856-57, p vi.
53 RDPI, 1867-68, App B 3, pp 190-191.
54 Annual Administration and Progress Report of Hospitals in The Bombay
Presidency, 1874-76, Bombay, 1876, pp 12-38. The Assistant Surgeons, in
1876, were Dosabhoy Pestonji, Cooverji Dorabji, Pestonji Bomanji,
Nasserwanji Dhunjibhoy, Jamsetji Byramji, Nasserwanji Jehangir, Ganesh
Ramchander Desai, Bhalchandra Krishna, Balkrishna Sadumji, Tribhovandas
Motichand Shah, A R Hakim, V R Gholay, Narayan Anant, Sheikh Sultan,
Trimback Sakharam and R P Bharucha.
55 RNN, Akbhar-i-Samachar, April 30, 1870; Bombay Samachar, may 3, 1870.
The Superintendent of the Lock Hospital, Dr Knapp was paid Rs 1200 pm.
56 Dadabhai Naoroji, Poverty and UnBritish Rule in India, London, 1901, pp 102-4.
57 RDPI, 1885-86, App F, p viii.
58 G D Confidential, vol 9, 1883, pp 150-302.
59 Ibid, 5, 1879, pp 111-118.
60 RBE, 1851-52, RGMC, App W, pp clvi-clxiv, Ibid, 1852-53, p Cxxxili;
RDPI, 1856-57, RGMC, p cxx; ibid, 1857-58, RGMC, p 89.
61 GD Vol 88, 1857, pp 111-173.
62 RDPI, 1855-56; RGMC, p 105. The medical drugs were ‘Kooda’, antidysentric; ‘Sagurgota’ whose leaves were given for fevers, gool-wail, which
had tonic and diuretic properties, ‘kudoo koolkee’ and ‘kala dana’ used as
purgatives, neemb, used for ulcers, as a poultice for open sores and in
rheumatism. The snake remedies included rooi, also used in syphilis, nagul
cooda and pandhara chapa, all of which produced vomiting and purging.
Masselos has shown that Bhau Daji used Western methods of proof to justify
the use of Indian remedies. Jim Masselos, The Discourse from the other side:
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Perceptions of Science and Technology in Western India in the nineteenth.
century, p 14.
63 Sakharam Arjun, Catalogue of Bombay Drugs, Bombay 1879.
64 Rustomjee Nasserwanjee Khory, Materia Medica of India and their Therapeutics, Bombay, 1903, pp v-vii.
65 RDPI, 1856-57, RGMC, p cxiv, RDPI, 1857-58, RGMC, p 86.
66 Proceedings of the Students Literary and Scientific Society, 1854-56, p 36;
1856-59, p 14; 1862-63, p 75. Mohini Varde, Dr Rakhmabai Ek Aaarta,
Bombay 1982, pp 188-89.
- 67 AK Priolkar, Dr Bhau Daji, Bombay, 1971, pp 353- 388.
68 The Bombay Natural History Society, 1883-1933, Bombay, 1933, p 1.
69 J C Lisboa, List of Bombay Grasses and their Uses, Bombay 1896. RNN,
Native Opinion, May 3, 1885, Bombay Natural History Society, p 38.
70 David Arnold, ‘Small-pox and Colonial Medicine’ in Arnold (ed) Imperial
Medicine and Indigenous Societies, Deihi, 1989, p 62.
71 Vaccination’ Reports, Bombay Presidency 1877-78, p 195.
72 Ibid, 1870-71, pp xxiii, xxx: Annual Report of the Sanitary Commissioner ‘ee
the Government of Bombay, 1878, p 44, and 1880, p 67. Mridula Ramanna,
‘Indian Response to Western Medicine: Small-pox Vaccination in the City
of Bombay in the Nineteenth Century’, in Ashan Jan Qaisar and S P Verma
(eds), Art and Culture, II (Abhinav, forthcoming).
73 Darukhanawala, Parsi Lustre, I, pp 160-1, 164-5, 177, II, pp 258, 288.
74 Daniel R Headrick, The Tools of Empire, New York, 1981, p 72.
75 GD Vol, 22/25, 1821-23, pp 69-70; Darukhanawala, Parsi Lustre, Il, p 355.
76 RDPI 1872-73, pp 293-4.
77 RNN, 1973, Bombay Samachar, January 13, 1873.
78 GD Vol, 76, 1882, pp 3-8, pp 81-3.
79 Ibid, pp 24-29.
80 Ibid, pp 56-57, 63-66, RNN, 1880, Indu Prakash, May 24, 1880.
81 GD Vol, 76, 1882, p 32.
82 Ibid,’pp 59-62.
83 Ibid, pp 47-48.
84 RNN, 1880.
85 GD Vol, 138, 1883, pp 2-4.
86 Ibid, no page nos.
87 Ibid, p 6.
88 Ibid, No page nos.
89 GD Vol, 76, 1882, pp 35-38.
90 Khory, Materia Medica, op cit, pv.
91 KN Panikkar, ‘Indi genous Medicine and Cultural Hegemony: A Study of the
revitalisation movement in Keralam’ in Studies in History, VIII, No 2, 1992,
pp 285-6.
92 Priolkar, Bhau Daji, p 216.
Dr Mridula Ramanna
Department of History
SIES College
Sion, Bombay 400 022
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{35
*
Reproductive Rights and More
Lakshmi Lingam
The demand for reproductive rights can be effective only in the
context of political, social and economic rights. The current debates
on reproductive rights should be seen in the context of western
consumerism, the unequal power relations between countries, the structural adjustment programme,
international debt bondage and other
elements of change affecting the world.
DURING the Earth Summit; 1992 held at Rio de Janeiro, Brazil the attempt
by the countries of the north to blame population as the main culprit of
environmental degradation was not successful. This unresolved issue was
reopened at the 1994 International Conference on Population and Development (ICPD), Cairo with added focus on women’s reproductive rights.
A concern for women, environment and sustainable development were the
three themes among the six priority themes in the ICPD, 1994. The
forthcoming Fourth UN World Conference. on Women to be. held at
Beijing will review and appraise the advancement of women since 1985
in the lightof the Nairobi Forward Looking Strategies. A Platform for
Action will be adopted with: a focus on removing the obstacles to the
advancement of women. Some of the issue that will be taken up are:
Awareness-building, decision-making, literacy, poverty, health, violence,
refugees and technology.
This article critically examines ‘reproductive rights’ as a demand and
highlights the need to contextualise the demand within struggles for basic
rights and rights to equality.
Population ‘boom’, ‘explosion’ or bloat are the terms often used
when reference is made to the growth of population in the countries of the
south. Global environmental problems like the degradation of land,
deforestation, climate changes, global warming and the decline in the
natural resource base, increase in poverty and acceleration of social
inequalities are largely attributed to population growth. This perspective,
which prescribes population control as a solution, is critiqued by the
women’s movement. The women’s movement attributes the present
model of development, unequal distribution of resources, energy intensive
technologies, the affluent life style and consumption patterns of the rich in
the north and the south as the major causes behind the poverty of people
and nature. The opposition to population control policies from the
women’s perspective emerged from: (a) the examination of the detrimental effects of the development process on women and environment during
the ‘integration of women in development’ phase of the Women’s Devel-
136
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opment Decade 1975-84, and (b) the clear connections that were observed
between ecological crisis, colonialism, capitalism, and patriarchy.
The detrimental effects of the development experiences on people in
general and women in particular has been well documented. 'It has been
observed that, growing poverty is linked to processes like reduced access
to arable land, lack of grazing rights for cattle, privatisation of common
property resources, commercialisation of agriculture, faulty water management systems, increasing’ salinity of soils due to use and overuse
of fertilisers and pesticides, loss of traditional skills and displacement of
large populations due to modern large ‘development’: projects: These
processes in turn create conditions for the increase in birth rate, as also
increase in child: labour, decrease in school enrolment, increase inschool
dropout rates, increase in rural-urban migration, and consequently a
change inthe relationship between people withnature. Within this context,
women. who are the repositories of knowledge on environment have
become victims in the environment and development ‘crises with an
increase in their overall work burden, decline in their incomes, nutritional
status, increase in headship of households and'so on. The critical
relationship of women’s work and procreation to the development and
environmental crises has come into focus in preparation for the ICPD,
1994.
WOMEN’S STATUS: MEANS OR END?
The crucial position of women in the population, environment and
development (PED) triangle has been identified by international agencies
concerned with population growth and its control. According to UNFPA,
the role and status of women affect at each point of the triangle and are in
turn affected by them. By performing their daily tasks of fetching water,
fodder, firewood collection, etc, and managing their family resources,
women influence the environment. Women’s reproductive behaviour
affects the population growth. Women affect development through their
economic roles in the family and society. Thus, according to UNFPA,
improving women’s status speeds fertility decline, thus reducing considerably ‘the overall negative impact’ of population on environment and
development [UNFPA1992a]. Elsewhere, in another report, UNFPA
observes: “Women’s access to labour market brings multiple benefits. It
works to lower fertility bydelaying the age of marriage. After marriage
it provides women with an independent income which will improve their
power and status in the family” [UNFPA 1992b}. In addition to enabling
women to regulate their fertility, the UNFPA believes that the other way
to incorporate them in PED programmes is to improve and enhance
women’s role as ‘resource managers’ [UNFPA 1992a]. The positioning of
women at the centre of planning and policy-making has been a long
RJH
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standing demand of the women’s movement. However, in the present
context women are being positioned in the centre of the PED concerns with
a focus on their fertility; since elevating the status of women is seen as a
precondition for reducing the fertility rates.
Various socio-economic, ecological and religious variables received
differential focus as key indicators in fertility behaviour research. A recent
line of observation is the recognition of the relationship between women’s
autonomy over their lives and fertility control. However, there is still no
clarity in official planning as tohow women’s autonomy or empowerment
could be achieved in order to influence fertility control. On the one hand,
piecemeal efforts to generate employment for women through povertyalleviation programmes and mass employment programmes, reservation
of seats in political bodies,etc are underway. On the other, economic crisis
emerging out of the structural adjustment programme is likely to decrease
the chances of employment, increase the cost of food, directly affect the
infant nutritional status and survival among poor households. To cope
with the weakening child survival prospects and the need for additional
hands to bring in meagre income, poor women might face further constraints in limiting their family size. However, governments and aid
agencies continue to view the economic and fertility aspects in isolation.
Limiting population growth especially of the south countries, has
become a major international activity since the 50s. India was one of the
first countries to accept family planning as a national policy. The policies
have been incorporated in the Five Year Plans along with commitments to
‘progress’ and ‘development’. Incontrast to the earlier plan documents the
Fourth Five Year Plan document viewed women as ‘partners in development’. The major impetus was due to the global focus during International
Women’s Decade on the deteriorating status of women. Simultaneously
on the population issue front, the Bucharest Population Conference 1974,
felt the need to move away from narrow, technology-oriented family
planning programmes (FPP) to strategies that located these programmes
within a broader perspective of improving health and education.
In the 70s, the FPP was renamed the family welfare programme (FWP).
It was felt that this would generally call for an improvement in the overall
welfare of the people. Family welfare activities were to include programmes
for the improvement of health, such as income-generation or economic
programmes, educational programmes, community development
programmes, etc. The maternal and child health (MCH) programmewas
merged with FPP. Experience shows that the high priority given to
reducing birth rates has overshadowed the provision of MCH services.
The issues of informed choice and safety of the contraceptive have been
neglected in the FWP in India. There is limited choice of methods available
for women, much less formen. The circumscribed contraceptive choices that
women are given, the secrecy maintained in informing women about the side
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effects of each method, the lack of check-ups or counselling before and after
the method has been accepted, the undermining of complaints of women
contraindicated for each method and the adoption of unethical medical
practices to achieve ‘targets’, together have made it the least credible and
most distrusted of all the health services.
Further, the onus of burden of
contraception and sterilisation is on women which disregards male responsibility and the lack of decision-making power of women in sexual matters.
The women’s movement in India is actively involved in campaigning
against coercive contraceptive technologies and population control policies of the state. Simultaneously, it has drawn attention to the need to
understand women’s health in a holistic context. It is against this background that the incorporation of women’s reproductive rights in the ICPD
and the renewed interest in a population policy by the government of India
has thrown fresh challenges to the movement.
REPRODUCTIVE RIGHTS: A LIMITED DEMAND?
The first Global Women’s Health and Reproductive Rights Meeting in
‘Amsterdam marked the birth of the international reproductive rights
movement which promoted the belief that “women should be subjects and
not objects of population policies”. Reproductive rights as a concept and
slogan gained currency in the 1980s as representing women’s needs and
interest. Various terms like ‘reproductive health’, ‘reproductive selfdetermination’ etc, have gained currency during this period. By far the
most comprehensive definition is given by the Women’s Global Network
for Reproductive Rights (WGNRR) Amsterdam:
Women’s right to decide whether, when and how to have children—
regardless of nationality, class, age, religion, disability, sexuality or
marital status — in the social, economic and political conditions that make
such decisions possible. These rights include, “access to safe, effective
contraception and sterilisation; safe legal abortion, safe woman-controlled
pregnancy and childbirth; safe effective treatment for the causes of
infertility; full information about sexuality and reproduction, about reproductive health and health problems, and about the benefits and risks of
drugs, devices, medical treatment and interventions...; and good quality,
comprehensive reproductive health services that meet women’s need and
are accessible to all women”. Quoted in /ssues in Gender and Development, No 6, p 6, November 1993).
The exercise of ‘choices’ or ‘reproductive rights’ cannot be seen in
isolation of socio-economic, political, cultural and ideological structures.
The Indian scenario regarding contraceptive use, health service utilisation
and abortion services is as follows:
(a) Fertility regulation and birth control measures are acknowledged by
women as a requirement. However, the low contraceptive prevalence
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rates, high fertility rates, and the acceptance of terminal methods in the
place of spacing methods, highlights the circumstances within which
fertility decisions are made (or not made). It has been observed that
women’s low decision-making power in the early ages of marriage , their
poor health and pregnancy wastage , social pressures against contraception before completion of the desired family size, general son preference,
secondary infertility because of reproductive tract infections, etc, are
barriers to women’s utilisation of contraception [Ravindran 1993]. Moreover, the safety and efficacy of the various methods of contraception, the
- quality of delivery and follow-up care are other major issues that are linked
to the utilisation of family planning services.
(b) Though the proportion of trained attendants at birth is increasing,
the majority of the domiciliary births are still attended by the traditional
birth attendants and others, especially in the rural areas. ‘While women
report non-availability of facilities as the reason for not going for hospital
births, researchers have pointed out that there is also a strong preference
for deliveries at home . Along with the cultural reasons for this ‘preference’, the service—provider factors like the gender and attitude of health
personnel emerge as important determinants of utilisation of maternal care
services.
(c) The competing demands made on women’s time by domestic work,
child care and income-earning work also have implications on women’s
utilisation of health care services. The key~factors that emerge as constraints in the utilisation of health services by women are the loss of daily
wage, high cost of transportation, considerable stress, complicated hospital procedures, long waiting time, and poor interpersonal skills of the
health providers .
(d) The liberalisation of abortion services with the Medical Termination of Pregnancy Act, 1972, has not been followed up with the provision
of safe abortion services at the level of the primary health centre (PHC).
The majority of PHCs do not have trained medical officers or MTP
apparatus to conduct abortions. Therefore, liberalisation has not significantly increased the rate of legal and induced abortions or decreased the
abortion related mortality. It has been observed that health personnel
insist On sterilisation as a condition for abortion. Dissatisfied with the
available ‘choice’ of contraceptives, women take recourse to abortions
outside the health facility. [Gupta 1993; Ravindran 1993].
Women not only wantto make an informed ‘choice’ aboutcontraceptives,
child care facilities, a better future for their children and an appropriate
constellation of health services, but also want control over their life
situation, sustenance, safe work place, clean drinking water, sanitation,
secure living space, harmonious gender relations, no violence, no abuse
and no wars. Which means, women not only need control over their
fertility but also over their sexuality and life situation. All these are
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inseperable preconditions for the exercise of any choice. In which case,
isn’t the claim for ‘reproductive rights’ a limited demand? A demand
which has its own dangers of reinforcing the view of all reproductive
activity as the special, biologically destined province of women.
There are also proposals to include sexual and reproductive rights in the
frameworkof human rights in order to update the Universal Declaration
of Human Rights, giving it greater integrity.
Rosalind Petchesky notes: “(R)ights are by definition claims staked
within a given order of things. They are demands for access for oneself, or
for “no admittance” to others: but they do not challenge the social structure,
the social relations of production and reproduction “. [Petchesky 1990, p 7].
Farida Akhter, a feminist from Bangladesh raises these questions:
If our concept of right only includes reproductive sphere, remaining insensitive
to the right to be realized in the sphere of politics and economy, we are then
operating within a narrow horizon, a horizon determined by the capitalistpatriarchal culture. As women we are limiting our demand only in the sphere
of reproduction, while men should lead the sphere of politics and economy. Isn’t
that why patriarchy has kept us reduced to reproductive function over the years
of history? ... the demand has a sharp bourgeois imprint as well. Notice that we.
are demanding for the individual right of women over her own body. It is a
ownership concept we are imparting. Implicitly we are demanding that women
should own individually the reproductive factory she is carrying within her own
body. We are not saying that production of the human species is a social
function. Bourgeois individualism blinds our vision so much that we fail to
recognise our social being. It is important that we start to see that the reproduction of the human species is primarily a social activity which is realised through
individuals, but it is never an individual affair”. [Akhter,undated, p 9].
Consciously aware of the limitations of the slogan ‘reproductive
rights’, Sonia Correa, a Brazilian feminist and. research coordinator at
Development Alternatives with Women fora New Era(DAWN))clarifies:
Though the framework for the concept of reproductive rights requires
revisions, some basic notions do exist. The first is the principle of bodily
inviolability, which corresponds to the first generation of human rights.
Second, the reproductive agenda cannot be disconnected froma broader
political rights charter. Third, the exercise of reproductive rights requires
the accomplishment of the second generation human rights dealing with
social, economic and cultural dimensions. Finally, as many issues on the
agenda are still subject to controversy, they may be seen as ‘potential rights’.
[Correa 1993, p 36].
The notion of rights has tremendous polemical power, with which
terms. like ‘choice’, ‘control over our bodies’, “women’s body is women’s
right’, can be perverted to suit extreme individualism to the detriment of
women’s collective struggles, strategies and slogans. Most technological
options in the area of reproduction (pills, IUDs, injectables, in-vitro
fertilisation (IVF) and so on) are heralded as adding to the range of
‘choices’ to women.
For example (a) Sex-determination tests are seen as
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providing a ‘reproductive choice’—a choice to decide to have a boy or a
girl! This is in line with the choice of commodities, consumer products and
now the choice of the ‘right’ baby [Lingam 1991]. (b) The slogans ‘choice’
and ‘control over our bodies’ used in the western feminist movement (to
denote access to safe contraception, the right to say ‘yes’ or ‘no’ to sex etc,)
are also used by agencies hiring fertile women’s wombs. These slogans
are interpreted as the control of body as a piece of property, the parts of
which can be hired, leased, sold, donated and so on.
The demand for reproductive rights also needs to address the ethics
involved in the increasing medicalisation of reproduction through technological interventions in pregnancy, conception, childbirth, contraception
and menopause. The value-neutrality of ‘new reproductive technologies’
(NRTs) such as IVF, foetal surgeries, sex detection, sex preselection,
Caesarean sections, hormonal implants, injectables, vaccines, hysterecto-
mies etc, should be questioned. The demand for reproductive rights has
tocounter the ‘appropriation of language’ and the increasing ‘medicalisation
of women’s bodies’ by placing the issues of ‘safety’, ‘informed choice’
and ‘ethics’ in context.
PRO-NATALISM AND ANTI-NATALISM
The issues of population ‘implosion’ of the north and population
‘explosion’ of the south places women as central to pro-natalist and antinatalist population policies. Pro-natalism encourages women to have more
rather than fewer children for various reasons, e g, to replace the dead
during wars, to increase the numbers of one population for racist, nationalist and ethnic reasons and so on. On the other hand, anti-natalism
involves the emphasis on fewer children and the controlling of births of
some population over the others. It is not surprising to observe that
developed countries practise pro-natalist policies domestically and advocate anti-natalist policies for the developing countries. Women from the
north are expected to procreate, develop ‘pro-natal behaviours’ whereas
the women of the south are targets of an international war against the
population problem. Therefore, pro-natalist technologies (like IVF etc)
are developed for the white middle class women of the north to achieve
‘motherhood’ and anti-natalist technologies (injectables, implants,
vaccines) are developed to control the fertility of poor women from the
south. The manipulation of women’s fertility for one or the other purpose
needs to be critiqued.
At the Latin American and Carribbean Health Network meeting in
Mexico, the issues of women having fewer children and postponing
childbearing in the north, and women having many children at
short intervals in the south, were discussed. The Conference report
mentions:
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Inthe North, men must play arolein child rearing so that women are not faced with —
the choice of work or children; in the south, men must commit themselves to
responsible parenthood and the use of male contraceptive methods (p21). In short,
this decade places great responsibilities on men, both in birth promotion in rich
countries and birth control in the poorer countries [Berquo 1993 p 48].
Though the issues of male responsibility in parenting, childcare, etc, and
the patriarchal context within which reproduction takes place cannot be
undermined, the political ideology behind birth ‘promotion’ and birth
‘control’ should be questioned . If population growth per se is posed as a
burden on the environment, then why are allowances made for birth ‘promotion’ in some parts of the planet? Further, the ‘explosion-implosion’
approach misses out on the issue of unsustainable consumption patterns,
resource use and wastage of the northern countries which have greater
implications to the environment than the population of the poor in the
southern countries.
Along with this, the unethical ways by which (a) multinational pharmaceutical companies carry out test trials on innocent women from the south;
(b) governments of the north permit the export of banned drugs/contraceptives to the poor countries and (c) also tie up coercive population policies
to development aid/structural adjustment programmes, need to be addressed in order to converge the demands, struggles and concerns of the
women of the south with those of the north.
This article has attempted to situate the discussion on reproductive
rights at the global and local level. It identifies the limitations in the
demand for reproductive rights from the vantage point of the south,
especially India, and identifies the issues that require attention. The article
points out that the discussion on the issue of reproductive rights within the
population, development and environment debate should be seen in the
context of western consumerism, the unequal power relations between
countries, the structural adjustment programmes, international debt bondages, etc. The notion of reproductive rights will have concrete meaning for
’ women only when political, social and economic rights aré ensured and
exercised effectively.
References
Akhter, Farida(undated): “Issues of poms, s Health and Reproductive Rights*.
Draft paper (undated).
Antigena (1993): ‘A Critical Appraisal of the Women’s Declaration on Population
Policies’. Women’s Global Network for Reproductive Rights, January-March,
42, p 28.
Berquo, Elza (1993): ‘North-South Face off: Demographic Explosion Vs Implosion’. Paper presented at the Latin American and Carribbean Women’s Health
Network meeting, Mexico, July, pp 43-52.
Correa, Sonia (1993): Shaping a Better Future: Perspectives on Alternative
RJH
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143
Economic Framework and Population and Reproductive Rights. Report of the
Regional Meeting on Population, Gender and Sustainable Development, April,
Singapore..
Gupta, Jyotsna A (1993): ‘ ‘People Like You Never Agree To Get It’: An Indian
Family Planning Clinic’, Reproductive Health Matters, No 1, pp 39-43, May.
Karkal, Malini (1991): ‘Abortion Laws and the Abortion Situation in India’, /ssues
in Reproductive and Genetic Engineering, Vol 4, No3, pp 223-30.
Lingam, Lakshmi (1991): ‘Sex Detection Tests and Female Foeticide—Discrimi-
nation Before Birth’, Indian Journal of Social Work, Vol LII, No 1, January,
pp 13-19.
Petchesky, Rosalind Pollack (1990): Abortion and Women’s Choice.
The State,
Sexuality, and Reproductive Freedom. The North-eastern Series in Feminist
Theory, Northeastern University Press, Boston.
Ravindran, Sundari,
T K (1993): ‘Women and the Politics of Population and
Development in India.’ ReproductiveHealth Matters, No 1, pp 26-38, May.
Dr Lakshmi Lingam
Tata Institute of Social Sciences
Deonar, Bombay 400 077
STATEMENT about ownership and other particular of about newspaper Radical
Journal of Health to be published in the first issue of every year after the last day
of February.
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Quarterly
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Address:
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Dated March 1, 1995
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1995
COMMUNICATIONS
Making Way for Price Rise
New Drug Policy
The Drugs Price Control Order 1995 makes a mockery of the efforts
of the drug consumer lobby to bring a semblance of rationality in the
drug market in the country.
IN January this year the Government of India passed the Drugs (Price
Control) Order, 1995 (DPCO 95)which is supposed to came into force on
the date of its publication in the official gazette.
The New Drug Policy 1994 had radically modified the earlier policy
of 1986. Industrial licensing for all bulk drugs excepting vitamin B}
(Thiamin), (and its salts and derivaties), vitamin B2 (Riboflavin) (and its
salts and derivatives), folic acid, tetracycline and its salts, and
oxytetracycline and its salts have been abolished. These five identified
bulk drugs are exclusively reserved for the public sector. Other exceptions
are bulk drugs produced by the use of recombitant DNA techonology, and
those requiring in-vitro use of nucleic acid as an active principle.
DPCO 1995 has specified 76 bulk drugs under the first schedule and
these are price controlled. The government has power to fix the maximum
sale prices of these bulk drugs. In fixing the maximum sale price, a posttax return of 14 per cent on net worth (paid-up share capital plus free
reserves) or areturn of 22 per cent on capital employed will be considered.
In case of a product from a basic stage, post-tax return of 18 per cent on net
worth or a return of 26 per cent on capital employed will be considered.
These margins seem to be satisfactory, provided the imported material
does not compete in reduced rates. |
The government has empowered itself to recover overcharged amount
accrued due to charging prices higher than those fixed or notified by the
DPCO 1987 and DPCO 1995. But the big firms are still to deposit over
Rs 300 crore in price equalisation on account and that too after the
Supreme Court decision. This measure will be effective only if the
government takes bold steps in recovering the past dues.
The order says that no dealer shall withhold from sale or refuse to sell
any drug available with him to acustomer intending to purchase such drug.
But what action has the government regarding dealers who have refused
to stock and sell an essential drug like phenobarbitone?
The margins allowed to the dealers are 16 per cent of the retail price
(MRP) in case of a scheduled drug, but has not specified the margins for
non-scheduled drugs and these are over 70 per cent of all the formulations.
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The chemists’ associations are strong enough to coerce the drug manufacturers to allow higher trade margins on such irrational drugs and drug
formulations. This burden will eventually be passed on to the consumers.
The government should fix the margins on unscheduled drugs and drug
formulations.
Any cotravention of any of the provisions of DPCO 1995 shall be
published in accordance with the provisions of the Essential Commodities
Act (10 of 1955). But we do not find any such action having been taken in
the past, including those found guilty of glycerol tragedy at the J J Hospital.
Indigenously manufactured scheduled formulations have been allowed
100 per cent maximum allowable post-manufacturing expenses. Scheduled formulation means a formulation containing any bulk drug specified
in the first schedule either individually or in combination with other drugs,
including one or more than one drug or drugs not specified in the first
schedule, except single ingredient formulations based on bulk drugs
specified in the first schedule and sold under generic names. This means
single ingredient products sold under generic names will be out of price
control. With these changes the number of bulk drugs coming under price
control is reduced to 76 from the earlier list of 143 drugs and thus the span
of price control has dropped by about 50 per cent from the previous 70
percent.
}
In order to achieve uniformity in prices of widely used formulations
itis proposed to put ceiling prices for commonly marketed standard pack
sizes of price controlled formulations and it would be obligatory for all,
including small scale units to follow the prices so fixed. But at the same
time under the third schedule, category C, units with turnover of less than
Rs 1 crore per annum and having only formulation activity will be
allowed maximum 12 per cent pre- tax return on sales turnover while a
manufacturer of large units with turnover exceeding Rs.6 crore per
annum is allowed only 8 per cent. In the previous category many small
scale industries will fall and they will claim higher profits.
The table shows the 94 bulk drugs that have been removed from the
previous first and second schedule drugs that were price control. That
means these bulk drugs and their formulations will be free of price control.
One finds here that ampicillin and amoxycillin have been removed from
the controlled list, whereas cloaxacillin is kept in the first schedule. Thus
the combinations of ampicillin/amoxycillin and cloxacillin will come
under price control. (Adilox, Ampilox, Amplus, Ampoxin, Bilactam forte,
Bioclox, Babcilox, Klox, Lamklox, Novaclox, Penmix, Suprimox,
Termoxin, etc.). Likewise chloramphenicol has been decontrolled whereas
ciprofloxin and norfloxacin is controlled. This will at least prevent
deliberate wrong promotion of antibacterials and antibiotics. Baralgan
ketone has been removed from the price control, but by keeping Metamizol
(analgin) in the first schedule, the combination products like Baralgan and
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TABLE: DRUGS REMOVED FROM FirST AND SECOND SCHEDULE OF DPCO
Acetazolamide
Aluminium Hydroxide
Aminophyline
Amitryptyline
Amoxicillin
Ampicillin
Atropine
Baralgan Kitone
Benzathin Benz Pen.
Carbenicillin Sod
Levamisol
Lidocaine/Xylocain
Loperamide
Methylsalicylate
Metoclopramide
Metoprolol
Mitomycin
Neomycin
Norgestril
Oxyfedrine
Oxythazine
Oxytocin
Paracetamol
Parachloro Meta Xylenol
Phenobarbitone
Phenoxymethy] Penicillin
Phenytoin
Pilocarpine
Piperazine
Polymixin B Sulphate
Povidone Iodine
Procaline Benz. Pen.
Promethazine
Pyrazinamide
Pyrental
Pyrimethamine
Pyrithyldione
Quinine
Sodium PAS
Sulphacetamide
Sulphadoxin
Sulphamethiozole
Sulphamethopyrezine
Suphaphenazole
Terbutalin .
Thiacetazone
Thioridazine
Timolol
Triamcinolone
Triamterene
Trifluperazine
Tripolidone
Valproic. acid
Vitamin B6
Vitamin D
Xanthinol
Zinc Bactracin
Carbinoxolone
Cemetidine
Cephalexin
Cetrimide
_Chloramphenicol
Chlorhxidine
Chlorpheniramine mal.
Chlorpromazine
Clofazamine
Cyproheptadine
Dapsone
Diclofenac Sod.
Dichloro Meta xylenol
Diethyl Carbamazine
Digoxin
Dihydralazine
Diloxanide Furoate
Diphenoxylate
Dipyridamol
Ergometrine
1995,
.
Ethambutol
Ethisterone
Fluocinolone Acetomide
Folic acid |
Homatropine
Hydralazine
Hydrochlorthizide
Hydrocortisone
Hydroxycobalamine
Hysoline N. But. Br.
Imipramine
Iodoxuridine
Iron Dextran
Isoniazid
Isosorbide Dinitrate
Isoxurpine
Ketoprofen
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Oxalgin, etc can be price controlled. By removing the price control of
dapsone and clofazamine, injustice is being done to majority of the poor
leprosy patients. Cyproheptadine is solely but wrongly promoted as an
appetite and growth stimulant and by decontrolling the same further
chance is given to make many more irrational combinations and enhance
the price. Same is the case with diphenoxylate and loperamide that is
wrongly used for prevention of diarrhoea. With the decontrol of vitamin
B12 (hydroxycobalamine/cyanoccobalamine and vitamin B6, the multinationals will no doubt change their present controlled vitamin B 1 and still
.
claim the same indications for the same brand.
While decontrolling isorbide dinitrate (Sorbitrate, Isordil, etc) the
government should have controlled the prices of isosorbide-5-monoitrate
(Monosorbitrate, Monotrate etc.) that is very costly and is being widely
promoted and prescribed as anti-anginal. This is a product continuously
needed by cardiac patients and care should be taken to see that the prices
do not increase. Aspirin is under first schedule and let us hope that the
exorbitant price of 50 mg of aspirin (ASA-50 @ SO paise a tablet) is
reduced. Paracetamol (Crocin, Metacin, etc) is very commonly used and
is also sold as‘'an OTC (over the trade counter) product. In the Drug Policy
1994 it is said that as an experimental measure, drugs having adequate
competition may not be kept under price control and that it this proves
successful it would have the was for further liberalisation. Paracetamol
decontrol is one such example and one has to keenly watch how the prices
move. Another alternative is for the government to fix the ceiling price
for this product packs.
There is a likelihood of prices of oral contraceptives like Duoluton,
Ovral-G, Primovlar 30 etc increasing as norgestril is removed from the
price controlled list. Epileptics were already at disadvantage when the
chemists refused to sell phenobarbitone and doctor prescribed other
costlier products like carbamezapine (Tegretol, Carbatol, etc), phenytoin
(Dilantin, Eptoin, etc), sodium valproate (Valparin, Eptoin etc), mysoline
(Primidone, etc). Now excepting carbamezapine all other products do not
come under price control, and phenobarbitone is decontrolled. Chemists
will continue to refuse to sell phenobarbitone and thus treatment of
epilepsy will cost more.
An antihistaminic cough mixture is-an unnecessary formulation. But
by decontrolling promethazine, a sedative antihistaminic, prices of
popular cough mixtures like Phensedyl and Tixylix will go up. Povidone
iodine was at one time recommended for banning by Drugs Technical
Advisory Board (DTAB) and now it is decontrolled.
In the anti-malarial drugs excepting chloroquin, to which widespread
resistance is reported, and amodiaquin all other drugs like sulphadoxin and
pyrimethamine (Crydoxin, FM, Malocide, Pyralfin, Rimodar, etc.), quinine are decontrolled. Glaucoma is a disease of eye characterised by
148
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increase in intraocular pressure resulting in atrophy of optic nerve and
blindness. The available medicines pilocarpine (Bio-miotic, Capro-miotic,
Pilocar, etc) and timolol (Glucorol, Ocupres, etc) have been decontrolled.
Patients suffering from depression will be further inconvenienced
because excepting trimipramine (Surmontil), other drugs like ami-triptyline
(Amiline, Amitrol, Amixide, Eliwel, Quital, Sarotena, etc.) and imipramine
(Antidep, Depsol, Depsonil,Prazep, Tancodep, etc.) are price decontrolled,
whereas all other (clomipramine, amoxapine, doxepine, flupenthixol,
fluoxetine, lithium carb., nortriptyline, dothiepin, nortriptyline, amineptine,
mianserin, and trazodone) were never under control. Likewise anxiety
patients will have to pass sleepless nights it prices of sedatives and
tranquilizers like chlorpromazine (Chlorprom, Megatil, Neocalm, Trazine,
Trinicalm, etc); thioridazine (Melozine, Ridazin, Thioril, etc) trifluperazine
(Gastabid, Tripheasine, etc), go up due to the decontrol. Over 15 other
anxiolytics were never under price control.
In the hypnotics not a single product is under price control as
phenobarbitone has been decontrolled and others like nitrazepam,
flurazepan,
triclofos, secobarbitone,
amylobarbitone,
etc never
were
under control.
There was no reason to decontrol the irrational product like xanthinol
nicotinate (Complamina) which is a cerebral vasodilator of doubtful
efficacy and which is not found in UK British National Formulary
or US Physician Desk Reference. Anti-cancer drugs are already
very costly and excepting mitomycin no other product was price
controlled. Now even mitomycin is price decontrolled.
A few years back cimetidine was a wonder drug for stomach ulcers.
This was soon replaced by famotidine. Now that famotidine has been put
under price control the newly introduced omeprazol (Lomac, Nulsec,
Ocid, Omalcer, Omezol, Peptilor, etc) will be vigorously promoted and
price hiked.
The Kelkar Committee had suggested higher taxation on irrational drugs and voluntary health organisations were demanding
rigorous price control on irrational drugs. But none of these
demands have been met in the new DPCO 1995 and one has to await the
Supreme Court decision of the public litigation case filed by Drug Action
Forum Karnataka, and AIDAN (All India Drug Action Network).
Wishwas Rane
Arogya Dakshata Mandal
2117 Sadashiv, Pune 411 030
Old Subscribers!
We request you to renew your subscriptions at the new rates so that we
can send you the coming issues and update our subscription list.
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REVIEWS
Government Expenditure on Health Care
Brijesh C Purohit
Health Care Expenditure by Government in India: 1974-75 to
1990-91 by K N Reddy and V Selvaraju, Seven Hills Publication; 1994,
pp x + 196, Rs 275.
FROM time to time, the area of health financing has attracted the attention
of various researchers. One of the major themes has been to estimate the
-amount of expenditure incurred by various partners involved in the
provision of health care. Even apart from the ambiguity pertaining to the
proportion of resources spent by the households and the private sector, it
is also not clear how much is being spent by the different levels of
governments, though presumably the information should be available in
the budgets of respective governments.
The study under review systematically attempts to estimate the
expenditure of central, state and union territories governments in India. It
makes a departure from the earlier estimates in terms of definition of health
care [See Duggal 1989;IIMA 1987; Raoetal 1987; Ravishankar 1989;World
Bank 1993]. Unlike the other studies which omitted the expenditure on
either of the items of health care, the present study defines the expenditure
on health care by the government comprising of (a) medical and public
health (b) family welfare (c) nutrition (d) water supply and sanitation and
(e) social security and welfare in respect of child and handicapped care.
Based on this definition the study presents estimates of the expenditure for
the years of 1974-75, 1978-79, 1982-83; 1986-87 and 1990-91. The
estimates are presented in nominal as well as real terms using 1980-81
prices.
The study is divided into seven chapters which include discussions on
conceptual and statistical problems in this estimation, trends in nominal
and real terms, inter-state variations in per capita health expenditure,
linkages between plan and non-plan expenditure and priorities and research issues in health care expenditure. In addition to this the study also
comprises of three appendices explaining: (a) health concepts used (b)
basis for apportionment of health expenditure between rural and urban
sectors and (c) determinants of health status in India.
The study provides useful and interesting insights pertaining to the
health expenditure by the governments in India. It is estimated that in
the year 1990-91, the central, state and union territories spent in total
150
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Rs 103,013 million or 2.18 per cent of GDP. In per capita nominal terms
it was Rs 123 or US $85, which represented an increase of 689 per cent
from the year 1974-75. The increase in real terms in the same period was
recorded as 98.28 per cent. In functional classification the study indicates
that between the years 1974-75 and 1990-91, the share of medical and
public health has been declining whereas the other components have been
growing. Thus, during this period the former in the total expenditure came
down from 62.14 per cent to 48.62 per cent and the components of family
planning, water supply and sanitat'on, nutrition and child and handicapped
- welfare increased by 150 per cent 166 per cent 501 per cent and 596 per
centrespectively. In terms of economic classification, the increasing share
of salaries (from 39.93 percent to 58.97 per cent) and declining share of
office expenses (from 4.37 per cent to 2.58 per cent) is depicted. Among
other components of economic classification almost a constant share of
machinery and equipment is indicative of the low level of invariant
investment in capital assets and therefore declining health facilities.
Further the study points out that among the three types of governments,
the role of the states in the total expenditure on health has declined from
83.07 per cent to 81.19 per cent. By contrast the central and union territory
governments have increased their share from 14.93 per cent to 15.39 per
cent and 2 per cent to 3.22 per cent respectively. There has been a
reduction, however, in inter-state disparities in health care expenditure.
Nonetheless the authors feel that it should not be interpreted as a reduction
in health status differentials across the states. The linkages between plan
and non-plan expenditures by means of regression technique has also been
attempted. However, the exercise is not extended to explore the factors
which influenced most the plan and non-plan expenditures.
The other interesting findings of the study relate to allocation of
resources by programmes and sectors. The study reveals, for instance, that
the proportion of resources for curative care have been the highest (60.25
per cent). Preventive care has received only 26.33 per cent and other items
like miscellaneous and direction and administration have accounted for
8.53 per cent and 4.88 per cent respectively. The much debated rural-urban
disparities gets highlighted by means of the estimate of this study. It is
found, for instance, that of the total expenditure only 33 per cent were
allocated to rural sector whereas the urban sector got as much 66.96 per
cent. Even states like Tamil Nadu, Andhra Pradesh and West Bengal with
a lower percentage of urban population allocated a higher percentage to
the urban sector. In terms of per capita in 1990-91, these estimates show
that only Rs 25.90 was spent in rural areas. By contrast, urban areas
received 5.85 times more (or Rs 151.56 per capita). The study brings out
thus, the necessary inputs for the health policy makers to re-prioritise
across rural-urban sectors as well as curative and preventive care. It also
raises the pertinent question whether such a sectoral bias in the health care
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is a natural outcome of our planning process or only an error of omission
owing to lack of appropriate accurate data. In either case, do we intend to
rectify this bias and if so when, and what could be the best approach?
The study is revealing and exploratory in nature. Adopting its methodology similar attempts extended to other years which have not been
covered by the authors may provide further useful inputs for analytical
studies dealing with the issues of theoretical and empirical interest. It poses
many questions which could be considered by researchers in health
financing in India. For instance, what is the amount of resources being
spent by local bodies and autonomous public sector organisations on
health? What is the proportion of resources being spent by private sector
providers, and what is the efficiency of this expenditure in terms of its role
and impact on the health status of the people? These require further
attention. With the current status of the data base pertaining to health
financing, the study is valuable to researchers, policy makers and others
interested in the area.
References
Duggal,R (1980): ‘Health Expenditure in India’,
FRCH Newsletter, Voll, Bombay.
Indian Institute of Management (1987): Study of Health Care Financing in India
(Based on Case Studies in Maharashtra and West Bengal), Indian Institute of _
Management, Ahmedabad.
Rao, N B, M E Khan and C V S Prasad (1987): Health Sector Expenditure
Differentials in India — A State and National Level Study, Operations
Research Group, Baroda.
Ravishankar
V (1989):
India:
‘Government
Expenditure
on Social
1976-77 to 1986-87’, Background Paper for 1989 CEM,
Services
World Bank,
New Delhi.
- World Bank (1993): World Development Report 1993: Investing in Health, Oxford
University Press.
CORRECTION
Superscript numbers for the endnotes were inadvertently left out in “Disease,
Death and Local Administration. Madras City in Early 1890s’, by V R
Muraleedharan and D Veeraragahavan Endnote | should have appeared on
page 9, para 1, after sentence ending “...have recieved far less attention’.
Endnote 2 should have appeared on page 11 at the end of para 2.
The following quotation on p 15 in the same article was left out:
medical institution under expert medical supervision. She has an abundant
supply of clean linen, plenty of nourishing food, and is lodged for a period of
10 or 15 days... under officers and nurses in constant attendance. The husband
pays only for the cart to and from the hospital, but saves even feeding charges
of his wife, the barber women and her fees. The poor man is relieved of all the
wofries and expenses of a delivery at home[9].
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DISCUSSION PAPER
Cultural Relativism, Ethical Imperialism,
and Reproductive Rights
Ruth Macklin
A LONG-STANDING philosophical debate surrounds the question of
whether ethics is relative to time and place. One side argues that there is
no evident source of a universal morality, and that ethical rightness and
wrongness are products of the cultural and historical milieu from which
they emanate. Opponents claim that even if a universal set of ethical
norms has not yet been articulated or agreed upon, ethical relativism is a
pernicious doctrine that must be rejected. The first group replies that
the search for universal ethical precepts is a quest for the Holy Grail.
The second group responds with the telling charge: If ethics were
relative to time, place, and culture, then what the Nazis did was ‘right’ for
them, and there is no basis for moral criticism by anyone outside the
Nazi society.
Both sides appear to capture a kernel of truth. There is no denying
that different cultures and historical eras exhibit a variety of moral beliefs
and practices. The empirical facts revealed by anthropological research
yield the descriptive thesis known as ‘cultural relativism’. But assuming
that cultural relativity is an accurate descriptive thesis, whether anything
follows for normative ethics is an entirely different question.
In Patterns of Culture, published in 1934, the anthropologist Ruth
Benedict (1934) stated that “Morality differs in every society, and is a
convenient term for socially approved habits’’. In this simple statement,
Benedict makes a subtle shift from a descriptive thesis to a prescriptive
conclusion. Benedict’s underlying assumption is the view that whatever
members of a society approve of is right, whatever they disapprove of is
wrong. But that view is easily rebutted. If morality were simply a
convenient term that described socially approved habits, the accepted
medieval practice of torturing criminals, the government-sanctioned institution of slavery, and the subjugation of women historically and in various
parts of the world today, would all have to stand as morally acceptable
because of societal approval at those times and places.
If ethical relativism were a logically coherent position, it would not
only follow that members of.one culture or historical era could never
criticise on moral grounds the socially approved practices of another time
or place. Also, there could be no such thing as moral progress. Abolition
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of slavery could not be seen as a moral victory, but only as political
change. The prohibition of cruel and unusual punishment could be
viewed only as a product of the beliefs of the framers of the Bill of
Rights. Granting social and economic equality to women and to racial,
ethnic, or religious minorities, thereby overturning centuries of
injustice, could only be viewed as peculiarities of mid-twentieth century
political movements.
If moral beliefs and practices of other cultures and earlier eras cannot
be criticised or compared from an ethical point of view, the notion of moral
progress is conceptually incoherent. But it does make sense to be able to
say that the practices of one time or place are more or less ethically
acceptable than those of another. If this is a good reason for rejecting
ethical relativism, on what basis can cross-cultural or trans-historical
ethical judgments be made?
One answer was offered by a philosopher, Walter T Stace (1972): In
order to render cross-cultural judgments about higher or lower degrees of
moral progress meaningful, we must appeal to some sort of absolutist
ethical theory. This suggestion has the unfortunate consequence of abandoning the frying pan of ethical relativism for the fire of ethical absolutism.
Stace characterises ethical relativity as “any ethical position which denies
that there is a single moral standard which is equally applicable to all men
at all times” [ Stace 1972:51]. He contends further that any form of ethical
relativity can be shown equivalent
Jo radical subjectivism, which reduces
ultimately to the position that there is nowhere “to be found a moral
standard binding upon anybody against his will... Even judgments to the
effect that one man is morally better than another become meaningless. All
moral valuation thus vanishes” [ibid: 61]. Stace’s absolutist, on the
contrary, “believes in moral commands, obedience to which is obligatory
on all men, whether they know it or not, whatever they feel and whatever
_ their customs may be” [ibid: 57] (Stace wrote these words in 1937, when
writers used the term ‘men’ when they really meant ‘people’.)
Something is amiss if ethical theory allows only these two alternatives:
an ethical relativism that reduces to radical subjectivism, an ‘anything
goes’ morality; or an ethical absolutism that posits the existence of moral
commands obligatory on everyone but neither universally acknowledged
nor clearly articulated. I think there is an alternative to these two unacceptable philosophical positions. One way of spelling out that alternative lies
in an analysis of the concept of moral progress. This concept is explicated
as resting on two basic normative principles, which can serve as criteria for
judging whether moral progress has occurred [Macklin 1977: 370-82].
However, adherence to the principles does not require a prior acceptance’
of some particular absolutist ethical theory of ethics.
The first of these two principles can be termed ‘the principle of
humaneness’:
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degree of moral progress than another if the first shows greater sensitivity
to (less tolerance of) the pain and suffering of human beings than does the
second, as expressed in the laws, customs, institutions, and practices of the
respective societies or eras [ibid: 371-72].
The second principle I call ‘the principle of humanity’: One culture,
society, or historical era exhibits a higher degree of moral progress than
another if the first shows more recognition of the inherent dignity, the
basic autonomy, or the intrinsic worth of human beings than does the
second, as expressed in the laws, customs, institutions, and practices of
the respective societies or eras [ibid: 372].
The key terms in these two principles are admittedly somewhat vague.
They denote properties that are hard to measure, such as ‘sensitivity to’
or ‘tolerance of pain and suffering,’ and ‘recognition of the dignity,
autonomy, or the intrinsic worth of human beings’. Despite this vagueness, the application of the principles is based on clear, observable
evidence drawn from laws, customs, and allowable practices in particular
societies or historical eras. For example, the prohibition of cruel and
unusual punishment is a sign of moral progress over earlier eras when
criminal offenders were tortured on racks or pilloried in public. Arguably, —
the same prohibition also judges laws mandating punishment of thieves
by cutting off their hands as morally inferior to non-mutilating sanctions.
A further indicator of moral progress is found in the arguments given to
justify enacting laws that protect the health and safety of workers, thereby
ensuring them protection against sweatshop conditions and the dictates
of unscrupulous employers.
It is also clear when one culture or historical era greater respect for the
inherent dignity, the basic autonomy, or the intrinsic worth of human
beings. An example is the Bill of Rights, which according to the US
constitution guarantees people the preservation of their dignity and
autonomy in the form of certain freedoms-freedom of religion, freedom of
speech, freedom of assembly, A protection against unreasonable search
and seizure by the government, etc. Attempts to change laws or social
institutions in order to enhance human dignity or promote justice and
equality can be viewed as efforts in the direction of moral progress. Fair
employment legislation, child labour laws, equal rights amendments,
judicial decisions aimed at rectifying discriminatory practices all exemplify conscious efforts to ensure the preservation or autonomy and dignity
of all citizens. To the degree that laws, practices and ethical beliefs
change in the direction of greater recognition of these human attributes,
to that extent moral progress has taken place.
The growing acknowledgment of human rights throughout the world
provides evidence that certain fundamental ethical principles are now
recognised as universally valid. As we know too well, there remain some
individuals in power, along with their military forces, and perhaps a few
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cultures as a whole, that violate ethical prohibitions against torture,
maiming, degradation and exploitation. But these instances are not counterexamples to the universality of fundamental ethical principles. Instead,
they represent malevolent, corrupt, inhumane, or insensitive behaviour,
conduct that violates fundamental ethical precepts rather than being
ethically valid alternatives.
A judgment that moral progress has occurred does not entail the proposition that human nature has changed. Nor does it mean that there have been
no lapses or regressions by individuals in power or even by entire societies.
The Nazi era in general and the behaviour of Nazi doctors, in particular
[Liften 1986; Proctor 1988], serves to show that despite a general historical
progression toward greater humaneness and humanity, egregious regressions and moral backsliding have occurred within this century. ‘Ethnic
cleansing’ in Bosnia and mutilation and slaughter of peaceful civilians by
rival ethnic groups in Somalia are more recent examples.
ETHICAL IMPERIALISM
Some people from traditional societies express resentment of attempts
to impose what they take to be peculiarly ‘western’ values on their
cultures. It is sometimes said that this is a new form of imperialism, |
termed ‘ethical imperialism.’ It has been a long-standing practice among
cultural anthropologists to refrain from making value judgments of the
culture they are studying, and especially to refrain from seeking to bring
about any changes in cultural and traditional practices. This attitude
presumes either that there are no universal ethical values, or that even if
there are such values they should not be imposed on cultures unwilling
to accept them. From a different perspective, however, it would be
unethical not to criticise or seek to change practices that can be demonstrated to be violations of human rights.
Views about the natural inferiority of women remain widespread in
developing countries and are very difficult to change. After I made a
presentation on reproductive rights to a meeting in Jamaica of the
Commonwealth Medical Association, I was approached by a young
physician from the Seychelles. He had received his medical education in
Czechoslovakia, and commented on the disintegration of society that had
resulted from granting women equal rights. Encouraging women to work
outside the home and to receive education equivalent to those of men has
led to ahigh divorce rate—he said about 50 per cent of the marriages end
in divorce in Czechoslovakia. This young physician characterised the high
divorce rate as the disintegration of the family, and hence, the society as
a whole. Therefore, he argued, granting women reproductive rights,
among others, is a sure way to undermine traditional cultural values and
eventually, the culture as a whole.
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Not surprisingly, this man buttressed his argument with a number of
highly questionable and unsubstantiated claims about the ‘natural order’
of things. Men are naturally superior to women—they are stronger, more
aggressive, more equipped to lead. Women are naturally weaker, more
subservient, naturally subordinate. Given the natural order of things it is
perfectly reasonable to fashion societal norms in a way that reinforces
nature. He added into this picture that women want men to be superior, to
lead them, and to take responsibility. “Women want it that way,” he
argued, so the conclusion is, apparently, that they cannot be wronged by
such arrangements.
At a meeting in Bangladesh on reproductive health technologies, one
participant stated that confidentiality is a western concept and therefore
may not be applicable in the research setting in Bangladesh. She said that
it is customary to share medical information with family members, and
that insisting on confidentiality for the purpose of research would not be
accepted in Bangladesh. This is only one example of a ‘western’ value
viewed as alien to non-western cultures. However, as biomedical research is a global practice, with organisations like the World Health
Organisation sponsoring research in many developing countries, the
argument that traditional practices in specific countries should prevail
rests on a moral error. WHO has published ethical standards to be
followed by researchers in all parts of the world, confirming the view that
the ethics of research involving human subject is universal in scope.
Another commonly cited example is the ethical requirement of
informed consent. In North America and Europe, it is now an ethical and
usually also a legal requirement to obtain patients’ informed consent to
treatment or for the purpose of biomedical research. But for doctors to
obtain their patients’ informed consent is not widespread in most Asian
and African countries. The question is therefore posed: Is it ethical
imperialism for western doctors doing research in collaboration with
Chinese doctors to require informed consent? If the World Health
Organisation sponsors research in Africa and requires that African
researchers obtain informed consent, is that ethical imperialism?
These standards and procedures are sometimes viewed as narrowly
‘American’ in scope and content. At a conference sponsored by the World
Health Organisation in December 1980, the WHO’s ‘Proposed International Ethical Guidelines for Human Experimentation’ were first presented. One conference participant from the US described the guidelines as
“essentially based on American standards of ethical review as well as on
the international codes” —the Nuremberg Code, the Declaration of Helsinki,
and the Tokyo Amendment. The participant reported that critics at the
WHO conference from developing countries objected to ‘ethical imperialism’. “How far, they wondered, can western countries impose a certain
concept of human rights? In countries where the common law heritage of
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individuality, freedom of choice, and human rights do not exist,
the...guidelines may seem entirely inappropriate”.
Nigeria provides a number of examples that compel attention to
cultural and ethical relativism. The plight of women, including young
girls, is worse in a number of striking respects than that of women in other
developing countries. For example, genital mutilation is widely practised
on newborns, infants, adolescents during puberty, and on pregnant
women and after childbirth. Millions of women throughout Africa have
been genitally mutilated, and one estimate for Nigeria alone puts the
prevalence at 50 per cent of all women, totaling more than 30 million.
Polygyny is prevalent among non-Christian Nigerians, including
educated people. Most people who practice polygyny are Muslims, many
of whom simultaneously adhere to one of Nigeria’s traditional religions.
Men have as many as five wives, sometimes more. Successive wives tend
to be younger women, adolescents, and even girls as young as eight or
nine. Families are paid a bride price for their female children and many
poor Nigerians are eager to receive the money and at the same time have
one less mouth to feed in the family
The health consequences for these young women are disastrous.
Because they are physically immature, they are at high risk in carrying
the pregnancy. But the greatest risk comes with childbirth. Because of
their underdeveloped anatomy, many experience obstructed labour. Because most Nigerians live in rural areas with no western-trained doctors
they use traditional healers and traditional birth attendants (TBAs) for
medical care. A great many of these TBAs are ignorant of human anatomy
and hygiene, and they employ ritualistic practices such as the ‘gishiri
cut’—a blind incision in the anterior vaginal wall—to enlarge the passage
for the emerging infant based on the false belief that obstruction can be
remedied in that way. The result in some cases is hemorrhage and death.
In many other cases this incision cuts into the bladder, resulting in a
permanent condition of leaking urine, known as WF—vesico-vaginal
fistula. The woman (often a young adolescent) who leaks urine smells and
her husband throws her out of the house. She goes back to the home of her
parents, who sometimes accept her but who often also reject her because
she smells from leaking urine and anyway, they already gave her out in
marriage. She then turns to the streets and tries to survive by begging and
prostitution.
Genital mutilation and early marriage thus pose the classic problem of
ethical relativism: Is it legitimate for those outside a particularculture to
criticise traditional beliefs and ways of life? On what grounds can such
criticism be ethically justified, and is outside ipterference with local
customs ever permissible? We can begin by making a general statement of
priorities: The value of protecting life and health should take higher
priority than traditional customs when these come into conflict.
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Beyond that, it is useful to distinguish between general ethical principles and particular moral rules that mandate or prohibit specific modes
of conduct. The former can command wide assent even when disagreement exists over the latter. Although particular moral rules, such as
the Ten Commandments in Judeo-Christian religions, may appear to be
clear and universally applicable, upon closer inspection they are fraught
with exceptions and open to varying interpretation. A prohibition against
killing is universal, but the exceptions and areas of dispute show the
moral rule “Thou shalt not kill” to be entirely empty of content. Is killing
in self-defense ethically acceptable? Killing in time of war? Any killing
in wartime or only some instances? What about officially sanctioned
killing by the state, such as capital punishment for murder, treason, or
trafficking in drugs? Is the killing of fetuses prohibited by the religious
commandment or beyond its scope? Moral rules that enjoin particular
types of behavior are as much in need of interpretation as are general
ethical principles.
Although philosophers will continue to debate whether any ethical
principles are truly universal, it remains true that cultural beliefs and
practices in some parts of the world depart from the tenets that have come
to embody respect for human rights in a large part of the modern world.
Examples in the sphere of reproductive rights of privacy and confidentiality of sensitive information concerning women’s reproductive health
practices, and punitive behavior by health professionals toward women
who seek abortions or suffer complications of abortion.
If it can be established that genital mutilation is a violation of human
rights (and I argue that it can), then criticism from outside the cultures
where it is practised is ethically justified. Just as torture of political
prisoners can be criticised and condemned from outside the country
where it is practised, so too can rituals like female genital mutilation. But
female genital mutilation is an extreme practice, easier to cite as a clear
case of violating human rights. Where do we draw the line?
The end of the 20th century is a time when human rights are taken
seriously. Governments in democratic societies have imposed economic
sanctions on countries that flagrantly violate human rights. The United
Nations and other international bodies have put forth declarations and
treaties defining and seeking to guarantee the protection of human rights.
Yet there is one arena in which rights remain highly controversial: the
realm of reproductive rights.
Since the first World Population Conference, held in Bucharest 1974,
more than 130 countries signed on to the following statement regarding
reproductive rights: “All couples and individuals have the basic right to
decide freely and responsibly the number and spacing of their children and
to have the information, education and means to do so.” That statement
was reiterated 10 years later at the Mexico City world population confer-—
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ence, and strengthened even further in 1994 at the International Conference on Population and Development in Cairo.
The claim that reproductive rights are human rights is resisted in
many countries. Even more problematic, the Vatican has refused to accept
the very concept of reproductive rights. While preparations for the world
population conference in Cairo were being mounted, the Roman Catholic
Church and some Islamic leaders denounced the idea of reproductive
rights as a ‘peculiarly western notion’, and as an example of the United
States trying to impose its values on the rest of the world.
The answers to questions about reproductive rights as human rights
appear to rest on the answer to a prior question: What is special about
reproduction? Providing an answer to this question is a key element in
being able to justify claims about the existence of reproductive rights: The
right to procreative liberty, the right to decide on the spacing of children,
the right to decide not to bear a child (i e, carry a pregnancy to term) as well
as the right to decide when and how many children to have. One recent
writer offers the following compelling account:
The moral right of to reproduce is respected because of the centrality of
reproduction to personal identity, meaning and dignity. This importance makes
the liberty to procreate an important moral right, both for an ethic of individual
autonomy and for ethics of community or family that view the purpose of marriage
and sexual union as the reproduction and rearing of offspring. Because of this
importance, the right to reproduce is widely recognised as a prima facie moral right
that cannot be limited except for very good reason [Robertson 1994 30].
It follows from this view that reproductive rights are especially
important rights and therefore, deserve to be classified as a species of
human rights. In that case, violations of reproductive rights within one
country could not be ignored by the world community any more than acts
of torture or the taking of political prisoners can be ignored.
In Mexico, the question whether reproductive rights should be sub' sumed under the broader heading of human rights came up in discussions
[had with various groups. Would it be a useful political strategy to employ
in Seeking to achieve reproductive rights for women? The tentative answer
given in one discussion was that that manouevre would not result in any
gain since Roman Catholics place ‘fetal rights’ under the category of
human rights. Therefore, talk of reproductive rights would not help in the
attempt to secure a woman’s right to terminate an unwanted pregnancy by
decriminalising abortion in Mexico.
In another meeting a rather different problem emerged. One participant
contended that human rights defense organisations should integrate these
reproductive issues into their human rights agenda. She cited the traditional position of human rights groups—that human rights can only be
violated by the state, arguing that this idea needs to be changed. Another
participant said that members of the human rights community are only
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interested in political prisoners and torture. Even women who serve on the
Commission for the Defense of Human Rights in Mexico failed to see the
beating of women by their husbands as a violation of human rights. In the
words of one staunch critic, this is because “women are not viewed as
people”. Many Mexican women come to the Commission for their cases
to be presented, but lawyers for the Commission do not listen and will not
deal with them. Thus issues such as rape within marriage and violence
against women within or outside of marriage are rejected by the Commission as not constituting human rights violations.
In March 1994, an international group of ethicists, lawyers, physicians, women’s health advocates, religious leaders, and social scientists
participated in a round-table on ethics, population and reproductive
health preparatory to the Cairo conference. This group produced a
declaration of ethical principles that they contended are applicable
throughout the world. To say that they are universally applicable is not
to predict that these principles will, in fact, be accepted throughout the
world. The declaration identified three kinds of rights essential for the
promotion of reproductive health: a) rights to health care and information
regarding health; b) rights relating to liberty and security of the person;
and c) rights relating to women’s status and equality in society.
Like other important social goods, reproductive health can only
flourish in a climate of respect for human dignity and protection of
fundamental human rights. These are universal values that deserve to be
acknowledged and should be adopted throughout the world. Anyone who
holds that the concept of human rights is meaningful should be prepared
to extend it to the realm of human reproduction.
References
Benedict, Ruth (1934): Patterns of Culture Mentor Books, New York.
Lifton, Robert J (1986) The Nazi Doctors: Medical Killing and the Psychology of
Genocide, Basic Books.
Macklin, Ruth (1977): ‘Moral Progress’, Ethics 87.
Proctor, Robert N (1988): Racial Hygiene: Medicine Under the Nazis, Harvard
_
University Press, Cambridge, Massachusetts.
Robertson, John A (1994): Children of Choice: Freedom and the New Reproductive Technologies, Princeton University Press, Princeton.
Stace, WalterT(1972): ‘Ethical Relativity’, Paul W Taylor (ed) Problems of Moral
Philosophy, Dickenson Publishing Company, Encino, California.
Ruth Macklin
Department of Epidemiology
Albert Einstein College of Medicine
1300 Morris Park Avenue
- Bronx, New York 10461
RJH
(NewSeries)
VolI:2
1995
161
FACTS AND FIGURES
Status of Indian Women
Production and Reproduction
Asha Vadair
Sandeep Khanvilkar
THE health status of women is a reflection of their social status. In order to get a
clear picture of the health status of Indian women, we need to have reliable data on
‘mortality, morbidity, nutritional status,problems related to reproduction,access to
and utilisation of services,etc. Unfortunately, none of these data have been
adequately collected or documented. Generally, health data for women is confined
to maternal health statistics and family planning (that is contraception, abortion,
etc) figures. Even here there have been doubts about their reliability.
Social status can be assessed by such data as access to food, education, age at
marriage, ownership of land, employment and work participation, and the existence of enabling enactments relating to public welfare. Even here the range and
spread of data is such that they cannot all be accessed. For instance, it is only
recently that employment or work participation data on women have been
seperately collected. What we have tried to do here is to put together data to give
a glimpse of the poor and deteriorating status of women. We also hope to draw .
attention to the lacunae in health dataon women and the problems of gathering such
data as exists from diverse sources. There is clearly an urgent need to create an an
easily accessible and comprehensive data base on women’s health.
HIGHLIGHTS OF TABLES
Work Participation Rates: Between 1911 and 1961 food, beverages and
tobacco, textiles, wood and wood products and ceramics accounted far over 90 per
cent Of women’s employment in manufacturing (Table 1). Since then, two notable
developments heve occurred in this regard: a 5 per cent drop in their combined
share and the emergence of some new industries. In the miscellaneous group and
in chemicals, metallurgical and engineering group are important employers of
~ women. Today female employment has grown in rubber, plastics, petroleum and
coal. Among the 20 non-agricultural industrial categories which employ the most
women, the number of women employed exceeds that of men in only one sector:
manufacture of beverages; tobacco and tobacco products mainly due to predominance of females in the bidi industry. Categories in which women form a large but
not dominant portion of the work force are: Tea plantation (42 per cent); manufacture of wooden and cane boxes (48 per cent) and laundry services (35 per cent)
(Table 2). Indeed even when women work for larger formal sector firms they
themselves often remain in the informal sector, ie as casual workers or under the
putting out system.
Mean Age at Marriage(MAM): The age at marriage of a population influences
patterns of fertility because it determines the length of the ‘effective’ reproductive
162
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(New Series) Voll:2
1995
span. The mean age at marriage for girls increases with education.At matriculate
level the mean age at marriage exceeds the currently prescribed minimum marriage
age of 18 on both rural and urban areas (Table 3).
Age Specific Marital Fertility (ASMFR):The social pressure on young married
girls to prove their fertility is reflected in their age-specific-marital fertility rates
(ASMER). In Table4 in 1978 among 15-19 age group, the ASMFR was 175.2 in
rural areas and 197.2 in urban areas (ie birth occured in 1978 17.5 per cent of
married in the age group 15-19 were in rural areas and 19.7 per cent were in urban
areas).
Maternal Health: A significant proportion of these deaths are attributed to poor
birth practices. In 1987, deaths related to pregnancy and child-birth accounted for
13.2 deaths among rural women aged 15-45 years and for 14 of those in the 15-24
year age group who are most at risk of maternal mortality.
The common causes of mortality are mainly associated with malnutrition,
viz,anaemia. Other major causes such as toxaemia and septicemia reflect the
inadequate health care facilities available to women during ante-natal care;
infranatal and post-natal care,also the fact that over 80 per cent of all births take
place at home without any kind of trained medical attention (Table 5).
Only half a million pregnancy terminations were performed through the health
services in the year 1987-88, which is 9 per cent of the total abortion induced during
the same period (Table 13).
;
Utilisation of Services: A survey conducted by NSS, 42nd Round, showed that
about 81 per cent of births in rural and nearly 47 per cent in urban areas takes place
at home. Of these 33 per cent rural and 26 per cent in urban India are unattended.
Table 7 shows that for both prenatal and postnatal care, public hospitals areused
more than the private hospitals. In urban areas women prefer to go to public
hospitals for both prenatal and postnatal services. There is not much difference in
health utilisation patterns between sexes, although females tend to use private
health facilities more, perhaps because of the inaccessability of the public health
services.
Family Planning: As expected, women are most familiar with female sterilisation
closely followed by male sterilisation. Women are almost equally familiar with the ©
other three modern spacing method ( pills, IUDs and condoms) which contribute
to 60 per cent of these (Table 9).
Table 10 shows that the public sector which comprises of government/
municipal hospitals and PHCs and other government health facilities contribute as
much as 79 per cent. On the other hand, the private medical sector including private
hospitals, clinics,private doctors and chemists supply only 15 percent of users. The
blend of public and private sources varies according to the method of contraception. In rural areas the usage of public sector is more predominant than in urban
areas especially for sterilisation services.
Note
National Family Health Survey (NFHS):The survey covered 24 states and the
national capital territory of Delhi , comprising 99 per cent of the total population
of India. In all 89,777 ever married women age 13-49 and 88,562 household were
- covered using uniform questionnaire. The data collection was carried out on a
state-by-state basis during April 1992 to September 1993.
RJH
-(New series)
Vol1:2
1995
|
163
TABLE 1: PERCENTAGE DISTRIBUTION OF FEMALE WORKERS
IN MANUFACTURING INDUSTRIES
Food and Beverages and Tobacco
Textiles
Wood and wood products
Paper and Printing
Leather and leather products
Chemicals
Ceramics
Miscellaneous
Note:
Source:
1911
193]
1961
198]
S213
41.70
8.92
0.03
4.63
3.01
8.91
0.87
26.87
46.48
9.76
0.02
3.98
2.00
8.15
1.34
23.86>2/°33.Al
49.49
32.30
11.98
10.27
0.23
0.85
Bo |
0.56
6.11
8.69
5.24
9.68
1.58
4.33
Rural and Urban Sectors Combined.
Census of India, Vol I, 1961 I and 1981.
TABLE 2: FEMALE WORKFORCE
As per cent of Total
1
Education
27.08
2
3.
4
5
Manufacture of Bidi
Domestic Services»
Medical Care/Health
Manufacture of Wooden Products
$527
46.94
27.47
39.93
6
Weaving and Finishing of Textiles
21.18
7
8
9.
Service: NCC
Laundries
Tea
12.82
34.67
47.86
10 | Cotton spinning
11
Manufacture of All Types
12.
Cattle and Goat Breeding
13. Vegetables and Fruits
15.50
10.94
14.17
15.14
:
14.
15
Public Services (ST)
Manufacture of Earthernware
4.30
21.25
16
17.
Repairing Enterprises
Grain and Grocery
13.06
4.72
18
19
20
21
22
Manufacture of Food Products
Manufacture of Stucturals
Public Services (local)
Sanitation
#@Coffee
23.46
24.12
10.86
29.13
42.39
Source: Poverty in India, World Bank country study.
TABLE 3 MEAN AGE AT MARRIAGE:, 1981
Rural
Urban
All
16.5
17.6
Illiterate —
Literate: Primary School
16.3
17.1
16.8
17.4
Middle School
Matriculates
Graduates
17.8
19.3
21.5
18.1
19.8
21.9
Source: Census of India 1981 Series I, India, Part II.
164
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1995
TABLE 4: AGE-SPECIFIC MARITAL FERTILITY RATES, 1978
Age Group
Rual
Urban
15-19
20-24
25-29
30-34
35-39
40-44
45-49
175.2
270.7
243.4
181.5
122.8
62.0
26.5
197.2
278.4
204.2
123.9
73.4
28.3
10.5
.
Source: Survey Report on Levels; Trends and Differentials in Fertility, 1979.
TABLE 5: PERCENTAGE DISTRIBUTION OF DEATHS BY CAUSES RELATED TO CHILDBIRTH AND PREGNANCY, 1981-1987.
Specific Cause:
1981
1982
1983
1984
1985
1986
1987
Abortion
Toxaemia
Anaemia
Bleeding of Pregnancy
and Puerperium
Malposition of
Child Leading to
Death of Mother
Puerperium Sepsis
Not classifiable
Total
Sample size
13.7.
SO
17.7
10.4
128
244)
210.7
212
189
108°
aes
23.3
13"
BO
6.7119,
+.°23.1--170:,
TS
64
498
23:4"
26.2%:
235.
ARS
159:
92-712
13.1
8.3
14:9
11.32
100
100
175.
168
8.3:
16
146
100
206
6.2
10.8:
193.
100
176
Ted <- B23
IOS
..13:9. 13.1:
16.7
21i23o 2225188
100
100
100
208
176
NA
215. - 279
Source: Survey of Causes of Death (Rural) 1984 and 1987.
TABLE’6: DISTRIBUTION OF DEATHS DURING PREGNANCY
_ Age group
15-24
25-34
35-44
All
Abortion
Toxaemia
Anaemia
Bleeding in Pregnancy
Malposition of foetus
Puerperal Sepsis
Not classifiable
40.0
46.2
31.4
43.6
35.0
23.8
29:9
46.6
46.2
31.4
47,3
3310.
61.9
57.9
13.4
7.6
37.2
9.1
30.0
14.3
Lz,
100
100
100
100
100.
100
100
Source:
Survey of Causes of Deaths (Rural), 1987.
RJH
(New Series) Voll: 2
1995
- 165
TABLE 7: MOTHERS REGISTERED FOR PRE-NATAL CARE
(Per cent)
Percentage of Mothers Registered
Public Hospital
PHC
Public Dispensary
Private Hospital
Nursing Home.
Charitable Institution
Private Doctors
Lady Health Visitor
Others
Total
Pre Natal
Rural
Urban
Post Natal
Rural
Urban
21.15
25.42
11.01
0.60
20.71
1.09
0.45
10.75
24.51
172
100.00
12.60
20.51
10.44
1.16
16.44
0.92
0.34
9.97
91.85
1.71
100.00
46.83
50.33
3.92
0.68
22.81
7.45
1.10
Tae
4.09
0.79
100.00
23.76
39.37
3.30
0.53
22.95
7.68
0.73
9.88
4.40
1.92
100.00
vy
TABLE 8: KNOWLEDGE OF CONTRACEPTIVE Metuops, INpIA 1992-92
(Per cent)
Contraceptive Method
Rural
Urban
Total
Any method
Any Modern Method
Any Modern Temp Method
94.7
94.5
70.7
98.7
98.6
91:2
95.8
95.5
76.1
59.4
52.9
30.2
93.5
82.1
85.5
83.1
80.2
97.7
91.1
66.2
60.8
58.1
94.6
84.5
Any Traditional Method
36.0
48.8
39.3
Periodic Abstinence
Withdrawal!
31.7
17.8
44.0
26.4
34.9
20.1
Pill
IUD
Condom
Female Sterilisation
Male Sterilization
-
TABLE 9: EvER USE OF CONTRACEPTION
~
(Per cent)
Contraceptive Method
Rural
Urban
Total
Any method
Any Modern Method
Any Modern Temp Method
42.5
<i Bi |
9.9
59.4
43.9
26.5
46.9
41.5
14.2
Pill
IUD
Condom
Female Sterilisation
Male Sterilisation
4.1
3.2
4.6
26.3
Bi
8.7
10.5
14.3
30.4
a
5.1
ed
Zi
3.4
Any Traditional Method
10.5
14.6
Withdrawal
Other Methods
4.8
0.7
7.0
1.0
166 -
RJH
(New Series)
8.6
5.4
0.8
Voll:2
1995
TABLE 10: SouRCE OF SUPPLY OF CONTRACEPTIVES
Category
Rural
Urban
Total
62.4
79.0
26.3
10.4
15.0
5.4
Public Sector
87.0
Private Medical Sector
Other
9.6
2.9
Don't Know
0.1
0.4
0.2
0.4
100.0
0.4
100.0
0.4
100.0
p
NR
Total
;
‘Source: Tables 7- 10 NFHS.
:
TABLE 11: COUPLES EVER STERILISED BY FRACTILE GROUP
(Per cent)
:
Ever Sterilised
Sterilised during
last year
Received FP
Services
‘Rural
Urban
Rural
Urban
Rural
Illiterate
17:92 =~ 30.71
1.62
1.90
Rees Bl AT aedpf
Literate but Below
Primary
Primary but Below
Secondary
Secondary and Above
24.81
28.25
1.86
1.66
4:59:
76:55
27.44
31.03
2.07
tl
6.48
10.48
24.07
26.65
|e
1.30
9:90
17209
Urban
Source: Sarvekshana, NSS 52nd Round, Vol XVI, No 1, July-September 1992,
NSSO Department of Statistics Ministry of Planning, GOI, pg- s-6.
TABLE 13: LEGAL ABORTIONS
Number of — PercentIncreasin
Approved
Institutions Over
Year
Institutions
Previous Year
1972-76
1976-77
1977-78
1978-79
1979-80
1980-81
1981-82
1982-83
1983-84
~ 1984-85
1985-86
1986-87
1987-88
1988-89
1989-90
1990-91*
Totals
1,877
2,149
2,746
2,765
2,942
3,294
3,908
4,170
4,553
4,921
5,528
5,820
6,126
6,291
6,681
6,859
27.8
0.7
6.4
12.0
18.6
6.7
9.2
8.1
12.3
5
5.3
Dah
6.2
pie |
*Provisional.
Number of
Average No
MTPsDone _ of MTPs per
Institutions
3,81,111
2,78,870
2,41,049
3; LT, 32e
3,60,838
3,88,405
4.33,527
5,16,142
5,47,323
5311951
5,83,704
5,88,406
5,84,870
5,82,161
5,96,357
5,80,744
75,65,170
_
130
90
115
123
118
11?
134
120
Ee
106
101
96
93
89
85
;
Source: Family Welfare Year Book, 1991-92, Government of India, New Delhi, 1992.
RJH
(New Series)
Voll: 2 1995
167
ECONOMIC
AND
POLITICAL
REVIEW OF WOMEN STUDIES
April 29, 1995
Gender Issues in Theory and Practice
Theory and Practice of Women’s Movement
in India: A Discouvse Analysis
... Supriya Akerkar
Marathi Literature as a Source for
Contemporary Feminism
...Vidyut Bhagwat
Search for Women’s Voices: Reflections on
Fieldwork, 1968-93
Gender in Field Research: Experiences
in India
...Malavika Karlekar
...L. C Schenk-Sandbergen
Gender in Neoclassical Economics:
Conceptual Overview
... Ritu Dewan
The Review of Women Studies appears twice yearly as a supplement to the last issues of April and October. Earlier issues have
focused on: Women’s Movement in Third World (October 1994);
Gender and Structural Adjustment (April 1994), Women and Public
Space (October 1993); Community, State and Women’s Agency
(April 1993); Gender and Kinship (October 1992); Women: Rights
and Laws (April 1992): Women and the Media (October 1991).
For copies write to
Circulation iia ge
Economic and Political Weekly
Hitkari House, 284, Shahid eee nee Road,
Bombay 400 001
a
“Science and art are two very different forms of
mastering reality, and any direct comparison
would be misleading. Yet it is equally true of art
that it also discovers new areas of reality,
making visible and audible what had been
invisible and inaudible before.
“In future, machines will eventually relieve men
of all mechanical labour, which will come to be
regarded as unworthy of human effort. But as
machines
become
more
and more
efficient and
perfect, so it will become clear that imperfection
—
is the greatness of man. Like cybernetic
machines, man is a dynamic, self-perfecting
system —
but never sufficient unto himelf,
always open towards infinity, never capable of
becoming a creature of pure reason obeying
only the laws of logic... This passion, this
impetus, this creative imperfection will always
distinguish man from the machine.”
Ernst Fischer
in
The Necessity of Art
e
S
e
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