Tuesday, October 15, 2013

The instinct to care, the will to heal

Published here on September 20, 2013.

The right to health is a human right. First, human rights violations such as harmful traditional practices (for instance, female genital mutilation), slavery and torture have health consequences. Second, health policies and practices can have human rights dimensions, such as discrimination or loss of privacy. Finally, respect for human rights usually goes along with better health care policies and access. The “right to health” idea works mainly as a “call to action.” The “call to action” in this short article centres on four challenges that stem in different ways from the cocktail of patriarchy and poor health care.

Maternal mortality

“In India, we worship women as mother-goddesses.” We hear this all the time. Notwithstanding such devotion, India’s Maternal Mortality Ratio is officially 212 per 100, 000 births but others estimate it may be as high as 450 maternal deaths per 100,000 live births. Data controversies should not detract from the unacceptable reality that too many Indian women die from pregnancy, childbirth and unsafe abortions. A 2009 Human Rights Watch (HRW) report says that one in 70 Indian women who reach reproductive age will die this way.

Why? Working in Uttar Pradesh in 2008-09, the HRW team identified four factors. The first was the difficulty of accessing emergency care. If complications arose, women were sent from clinic to clinic in search of one with the right facilities. The second factor is that at a very fragile time, women had to travel long-distances to be able for instance, to have a caesarean section. No proper transport was available to help them, either. Non-existent post-natal follow-up and care, ergo post-birth complications, were the third factor they identified. Finally, the researchers found that even free health-care cost money because of the expectation that health-care workers would be tipped for every service—from cutting the umbilical cord to cleaning up. Failing to pay once, meant that the next time families approached the hospital, they could be faced with the nightmare of referrals.

For the same study, Tamil Nadu provided some pointers to good practices (though not to remedy the above factors), from awareness campaigns around maternal health to better death reporting to better training for health workers on how to report death with a view to improving health facilities in both public and private hospitals.

Universal access and sex-selective abortion

Modernization and increasing access to health facilities, usually considered factors that are good for women, have made sex-selective abortion more accessible and contributed to India’s declining sex ratio. Modernization has promoted the small family norm without getting rid of male child preference. Dowry is more common and lavish weddings a common aspiration. Simultaneously, more and more people have access to pre-natal diagnostic tools. This partly explains why rise in female foeticide correlates to affluence and the richest cities in India have the worst sex ratios.

Technology and patriarchy have together taken sex determination and sex-selective abortion to every corner of India. In 2010-11, the Health Ministry’s report stated that 39854 ultrasound and scanning centres had been registered under the Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994. Many of these were being used as mobile units—in addition to registered and unregistered mobile clinics. Access to diagnostic techniques that can be used for sex determination plus the availability of legal abortion have also placed sex-selective abortion within the reach of NRIs who live in places where this is not an option.

The solution here is not to limit access to pre-natal diagnostic tools and make abortion illegal. It is to ensure safe and universal access to both along with strict regulation, honest and rigorous implementation of laws and parallel programmes to create awareness. Creating universal access without regard to its unintended gendered consequences is irresponsible and boomerangs on the most vulnerable—here, the female foetus.

Violence as a public health issue

Sometimes it seems as if an epidemic of sexual and gender-based violence has overtaken India.
A recent report found that, worldwide, violence against women is one of the most common causes of death and injury among women. Experiencing or witnessing violence leaves women (and others) with mental health illnesses, including depression. Those who experience violence are found to be far more prone to alcohol abuse (and this probably extends to other substances). They are also far more vulnerable to sexually transmitted infections, and in some regions, to acquiring HIV. Finally, not only is sexual violence likely to leave a woman pregnant, but in the quest to have an abortion where this may be neither legal nor safe, she puts herself at great risk all over again. The report also stated that women who experience partner violence are more likely to have a low birth-weight baby.

In the context of sexual and gender-based violence, two care-related issues come to mind. The first concerns the level of preparation among doctors and nurses to recognize and respond to signs that someone before them may have experienced violence. Having good protocols to follow is one part of this, but inculcating sensitivity is the other. The second has to do with the availability of crisis support—not just crisis support for victims of sexual violence, but immediate and intermediate term medical, psychological and social support that is available to anyone experiencing violence. As a society, we are unable to stop the incidence of violence. Are we able to provide survivors with the opportunity to heal?

Trauma care in conflict zones

Innumerable Indian women live with conflict, whether in areas with insurgency and counter-insurgency operations or in the middle of a communal riot or inter-caste violence. They experience conflict differently from men—be it bereavement and widowhood with all the stigma it carries in India; being left as head of the household without proper title to property; living with fear; experiencing sexual violence as part of conflict; being displaced and homeless. In the immediate aftermath of violence (or disaster), the everyday tasks of reconstruction are typically undertaken by women—finding belongings in the rubble, gathering up and caring for family, making arrangements for food. They are raised to disregard their physical and mental health needs, and society and state take this as their cue. As the habit of violence—as protest and in response to protest—takes root in Indian society, so should an instinct to provide trauma care.

A 2011 study by the Centre for North East Studies and Policy Research set out to speak to women suffering from post-traumatic stress disorder in Nagaland and Assam. Their conversations in Nagaland suggested to them that in addition to the trauma of experiencing assault, women internalised the trauma that others around them experienced or that they had witnessed. They were traumatised by hearing, across generations sometimes, of the experience of violent assault; and by displacement, which deprived them of home and history. Forced interaction with and having to adapt to others was a source of trauma and despair did not help. In Assam, livelihood anxiety also caused trauma. But in both states, counselling facilities were rare and people knew very little about what was available.

And on a final note: I believe you can read the state of women’s health in a society by the absence or availability of clean, safe and functional toilets that women and girls can use. This is the most fundamental measure of how much we value women. High maternal mortality, female foeticide, gender-based violence and neglected post-conflict trauma—none of this should surprise us at all. The fact that millions of Indian women still have to risk sneaking out in the dark for the most basic bodily needs, says everything. It is the picture that speaks a thousand words.

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