Women and Health

• When the questions around development become one with the straitjacket of the market and its needs, can women be saved from its clutches?

• When the poor health of women arises out of their subordinate status in a given socio-economic structure, can making the same structure even more stable and unrelenting open up possibilities for women's liberation?

• When 'Justice' is being restricted to the narrow residual spaces left by Structural Adjustment, when the majority of the poor are pushed to the wall, and the choice poor women are permitted is dying earlier or dying with their men-folk, suffering more intensely as women or suffering as acutely as all the poor; must women of the Third World let the international community have the right to narrow their choices?

• To correct structural malformations in the process of development, to strengthen democracy and to improve the conditions of life of the majority is one thing, but to "adjust structurally" so that the privileged can draw more benefits is quite another. What lies behind the politics of denying Third World's poor women the right to define their own adjustments of economic and social structures including that of health? Why must they be seen only as agents of reproduction?

In the area of 'advocacy' these questions are labeled as 'wasteful' and 'digressive' by those who are in a hurry. The pragmatism of the new world order demands that the poor realize that they have no real choices and accept existence within the boundaries created by the international order.

If the NGOs are to shake this kind of pragmatism, then it is binding on all to speak out at this juncture and reaffirm the social basis of health. The health of a people is a reflection of their political, economic, social and cultural well-being. Women's health, therefore, cannot be isolated from the societal and family web that enchains them. It is imperative that those who talk of women's health, particularly on behalf of the poorest women of the Third World, take a look at the reality.

The havoc created by Structural Adjustment for women and children is no more a figment of one's imagination. Studies from Brazil, Philippines, South Korea, and African countries have shown increasing morbidity due to diseases such as malaria, pneumonia, tuberculosis, diarrhoea, measles and schistosomiasis. There has been a deceleration in the decline in infant mortality. Health service costs have escalated and investments in health have declined. Resource allocations within health have been such that basic services and public health have suffered. The institutions dealing with the so-called diseases of modernity such as cardiac centres, kidney transplant units, and cancer institutes have mushroomed but remain beyond the reach of the poor. Nutritional status has declined specially for children and women and food intakes have gone down.

The outcome of the World Summit for Social Development is indicative of the intention of the First World. Instead of the promise of contributing 0.7% of the national income to overseas development, most developed countries, including the US, backed out. Norway, Sweden, Denmark and the Netherlands were the few exceptions. The issue was scuttled at the ICPD and rejected at the Social Summit by the North, which at present contributes only 0.3% of its GNP for the social development in the poorer nations. It was said that the North was suffering from 'Aid fatigue"!

The 20:20 proposal {putting 20 percent each of ODA (Overseas Development Assistance) and national funds into the social sector} was also diluted and it did not become binding on either side. In any case a fixed formula could be relevant only if the ODA remained constant. With diminishing ODA, this ratio loses its significance. The World Summit also refused to cancel the external debt of the 43 poorest nations. A few token reductions, such as 2.5 percent in the case of Uganda, indicate that .the Third World countries will continue to reel under the debt burden of 1.3 trillion dollars.

The issue of trade liberalisation has also been tackled selectively. It is acceptable when it is convenient for the developed countries and not acceptable when it goes against their interests. At the Social Summit the developed countries tried to use the weapon of 'social clause' to restrict competition.

What is Health?

• Potable water supply which is gradually becoming a scare resource threatened or polluted by the uncontrolled growth of hazardous industries.

• Better living and working conditions for women who are increasingly being pushed to take jobs in the unorganized sector of industry at low wages and high risk to their health.

• Social justice for women through revamping legal and institutional support structures.

• Education for the sake of learning and not only as a means to bring down fertility and control births.

• Comprehensive Primary Health Care (PHC), with a special focus on making health services accessible to those women who are the first to get marginalized in conditions of scarcity and financial constraints, and not selective PHC which emphasizes population control.

• Adequate intersectoral inputs - such as food, housing, transport, drinking water supply, etc. which make the Comprehensive Primary Health Care Services effective.

Markets alone are seen as the answer to Third World poverty. It is argued that without economic growth poverty can not be removed. But there is no discussion any more on distributive justice. There are no answers to the question of how the "benefits" of the market will reach those who are its victims or, what happens to those sections who are actually going to bear the brunt of the new economic policies?

Will such collective apathy at the macro-economic level be conducive to tackling the problem of poverty and ill-health of the most deprived of the world - its poor women? In the process of empowering women and catering to their health needs, can the issue of growth with equity be overlooked?

Instead of splitting hairs on protection against the onslaught of the 'diseases of modernity', and the 'dangers of pregnancies', our concern for women's health should be expressed in demands for gainful employment for all women and men. This is critical in the light of the fact that in India the minimum wages of a single individual are calculated under the assumption that both adults of a nuclear family are employed. One person's wage is therefore half the family's requirement. In view of the high proportion of single parent families, rising unemployment, shrinking welfare investment, and a dwindling food security system, even partial employment can play havoc with families, especially women-headed households.

We should therefore call for an end to wasteful overexploitation of natural resources such as land, forests, and water, which constitute the livelihood of a large number of people, to ensure food security and that people retain their rights over natural resources central to their survival and health.

Health then is not a simple issue of distributing pills (be they nutritive, curative or contraceptive), but of ensuring full employment and women's right to protect themselves, their jobs, their land, and their children. To have access to public distribution system and welfare services that extensively cover the deserving and cater to their needs.

For women's health, there are two basic prerequisites:

1. A multi-pronged attack on poverty, social injustice and cultural myths; and

2. Identification of critical health needs and developing basic as well as secondary and tertiary support services to provide Comprehensive PHC around them.

Both these prerequisites, however, are contradictory to the proposals of the IMF and the World Bank - the main fund providers to Third World countries. The above basic tenets of women's health have been gradually undermined through international policy decisions heavily influenced by monetary interests of the North.

After the Nairobi Conference in July 1985 that attempted to talk of "forward looking strategies" for women's development, efforts to circumscribe these strategies were palpable in the focus on "women's special needs" (interpreted as reproductive health) in isolation from needs crucial though not special. The International Conference on Population & Development (Cairo, 1994) converted women's health into issues of 'safe abortions' and 'reproductive rights.' It marginalised the issue of comprehensive PHC, social security and investment in building infrastructural facilities.

The Economic and Social Commission for Asia and the Pacific (Jakarta, June 1994) attempted to camouflage the same effort by using 'gender sensitive' language. Despite its apparent concern for women it did not fail to state unambiguously that more than women, its concern was the "health care providers within households" and for the "potential" of the children they bear.

Given their perception of women, it wasn't surprising that the Commission's agenda placed reproductive health as the topmost health care need of women. It argued that the concept of reproductive health broadened the original theme of maternal health. The justification for including services for reproductive tract infections, infertility, AIDS, and further expanding family planning services as a part of Primary Health Care was derived not from any epidemiological reasoning but purely from a cultural view point. It was argued that "unexpressed needs," because of the "culture of silence" of women, demands that their needs (as assessed by the observers) be met.

This logic is belied by the Indian experience. Firstly, not more than 20 percent of the home deliveries in rural India are conducted by trained personnel. This happens not because people consider it to be desirable but because trained personnel are inaccessible. Exploitative private practice by doctors flourishes in the countryside due to unmet needs of women as the majority of Rural Health Centres do not have lady doctors. What then is the point in expanding the scope of maternity care services when the most basic maternity care cannot be provided?

In addition, the traditional concept of pre-and postnatal services, along with natal care, included within it gynaecological and contraceptive services as an integral package. Where then is the need for introducing the same as "special services"? Indian experience shows that such changes in language herald shifts in emphasis of a dwindling public health infrastructure. Family Planning (contraceptives safe and unsafe) and AIDS control programmes get larger and larger shares of diminishing health budgets at the cost of other health needs.

Secondly, by emphasizing the "culture of silence," at one stroke peasants as well as industrial working class (organized and unorganized) women are transformed into mute objects - their struggles for better lives derecognized and their forms of protest ignored. In addition, stealthily, the view of the observer gains primacy over the view of women who actually suffer. What is observed thus becomes more important than what the suffering woman talks about. This could be her tuberculosis, her child's hunger, her husband's death due to malaria or his unemployment. The master stroke of 'silent suffering women' thus breaks the link between women, their families, and communities. It brings to centre-stage interventional medical technology to cure diseases. It marginalizes the expressed concern for "innate dignity" and "empowerment of women" and for equality among sexes and for social transformation.

We need to ask then, who can poor women talk to, where the service infrastructure does not exist, or is not accessible? Should her silence be used to further distort her own perceptions of her life and its priorities?

The Commission for Asia and Pacific at Jakarta, as well as the Commission on the Status of Women at New York, underplayed the issues of communicable diseases. The inadequacy of public health services and their iniquitous distribution were recognised but no effort was made to identify the real priorities of the poor.

Health of Liberalized India

• National Sample Survey data indicates that expenditure on health care is the second most common cause for rural indebtedness.

• Between 1990 and 1994 ten out of fifteen major states, were forced to cut their health budget care.

• Communicable diseases such as tuberculosis, malaria, filaria, cholera, kula azar are all up and back in epidemic proportions. Half a million people die of TB. every year and there are two million cases of malaria which is once again becoming a killer disease.

• Major concessions have been granted to pharmaceutical firms under the new Drugs Policy of 1994 by reducing price controls. Within a year the prices of many essential drugs rose by 150%. Even before the policy came into force, prices had gone up by 25% and profits increased by 46%. An estimated 80,000 brands of drugs are marketed in India.

• Allocation on family planning has gone up by 50% in three years and stands at half a billion dollars in 1995-96. This is nearly one and a half times the budget set aside for health care.

• Government hospitals are being privatized and a user fee is now charged for services earlier available free. Medicines have to be purchased from the open market. 130 million people in India have no access to health services. India's share of public financing of health services at 22 percent is half of that of the US government which swears by privatization and the market.

• While the government claims 90% immunization coverage, 200,000 infants die every year of tetanus.

• While the government claims that 80% of the villages have potable drinking water, one million children die every year from diarrhoeal diseases caused by drinking unclean water.

• The country has the largest buffer stock and is exporting food while people starve. Two out of three children suffer from malnutrition and a half have stunted growth, four out of five women suffer from anaemia during pregnancy. Per capita food consumption has been falling despite rising production.

In India, 65 percent of all deaths among women are caused by disease groups that are predominantly infectious in nature and only 2.5 percent of deaths are related to childbirth. Even if one focuses on the women in the reproductive age group, 28.6 percent of deaths among them are caused by major infectious diseases (like TB., malaria, cholera, pneumonia, diarrhoea, dysentery, jaundice, etc.) and 12.5 percent deaths are due to childbirth and conditions associated with it. Despite this reality the only communicable disease that is emphasized is HIV/AIDS. Even here its link with poor health systems is not adequately emphasized.

Focusing on the reproductive age group is short-sighted as well as fraught with dangers. It is well recognised that the real burden of infectious diseases, malnutrition and poor health begins in the tender years of life. According to national statistics, in India girls under 15 years of age contribute 28.4 percent of the total mortality among women in India. To permit young girls to suffer from communicable diseases and ill health and to concentrate on the reproductive health of women in the child-bearing age group is bound to be self-defeating.

It must be asserted then that when investment in health is being curtailed and the existing health infrastructure is unable to provide for all the needs of the population, epidemiologically significant and socially expressed needs must be attended to first. Based on this logic, control of communicable diseases and provision of basic maternity and child care still continues to be the primary task of any public health service worth its name.

UN preparatory committees have addressed the issue of inequality and lack of access to health services. Their vision, however, is narrow and limited to reproductive health care facilities and that too to inequality between the First and Third World and between sexes but not between classes and regions of the same country. It needs to be recognised that accessibility is determined by a host of socio-economic, political, cultural and physical (geographical) factors, and the presence of services alone is not sufficient. The increasing gap between classes and the rapidly expanding private sector in health care with sky high price structures is bound to affect access to health care for women in disadvantaged classes adversely.

The responsibility of national governments in providing basic medical care and public health services therefore needs to be reasserted. When the First World is moving towards state control of social services, the Third World people must not permit their government to hand over this responsibility to the private sector or the NGOs. The latter can be partners but they cannot replace government services per se.

New and genuine concerns such as mental health and occupational health of women have been medicalised because they are profitable. It needs to be highlighted that these are outcomes of the current socio-economic transition where women are seeking work for survival and independence against heavy economic and social odds. Mental tensions and work-related illnesses are rooted in family and work relations and it is these social structures that need to be changed. The answers do not lie with physicians.

It needs to be recognized that the same social structures that are responsible for poverty are also responsible for the feminization of poverty. There can be no defeminization of poverty without attacking poverty-itself.

Those who argue that women can be helped to break out of the trap they are caught in without integrating the question of class are only attempting feminization of the strategies of control.

If women are to be targeted for social development in deteriorating economic conditions, then, this can only be the means for stability in chaos. In this chaos, a woman strengthened will be a source of labour for love - a better "caretaker" of an uncared for house-hold. She will do what the state is refusing to do - to provide basic services. This new kind of development and peace is too costly a myth.

This is the text of a paper on women and health presented at a Coordination Unit workshop on the subject, held at the Centre for Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University.

Dr. Imrana Qadeer is a Professor and Head of the Department in Centre for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi

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Ibid, Table 2, p.48-52.