Our forgotten frontline workers

Column for Mathrubhumi

(Translated in Malayalam)

Link: https://english.mathrubhumi.com/features/specials/forgotten-female-frontline-workers-in-times-of-covid-19-1.4908915

What will our lives will be like when and if this pandemic ends? Will some kind of normality return at some stage? These are questions everyone asks.

What is clear, however, is that what we considered "normal" yesterday is unlikely to return for a long time to come. The pandemic has brought with it some changes that are here to stay.

The cost of the pandemic is measured in human lives, and in the losses to the economy and people's livelihood.  Even these cannot be calculated accurately because every day there is a change.  Around the world, places that thought they had beaten the virus are now seeing new cases emerge.

But there are also hidden costs. We will know of them in the years to come. And one of them has to do with women, especially poor women.

Under the centrally-sponsored Integrated Child Development Services (ICDS), lakhs of children under six years, and pregnant and lactating mothers in rural areas get a hot cooked meal every day. The efficiency of the scheme varies from state to state.  Yet, often this is the only nutritious meal these children and women get. It is a lifeline for them.

The army of women who run the anganwadis, the backbone of the scheme, are rarely acknowledged for this crucial work they do.  We don't recognise the problems they face as women, the burdens they carry in their own homes, how they struggle to find the transport to get to work, or visit the families of the women and children.  They are our forgotten frontline workers.

Today, the absence of these women is being felt by millions of undernourished children and pregnant women.

The system has virtually broken down in many states because of the pandemic. Due to the lockdown and the absence of public transport, anganwadi workers are unable to go to work. As a result, anganwadis are closed.

The daily cooked meal cannot be prepared.  State governments have resorted to giving out dry rations instead. And pregnant women are not getting nutritional supplements, nor are infants being vaccinated.

The packet of dry rations helps but does not solve the problem.  In tribal areas, it is a challenge to ensure the rations reach the families. Even if they get them, the entire family shares the food. With women socialised to eat last, and least, a pregnant woman is unlikely to get the nutrition she needs.

This state of affairs, stretched over many months, will have a direct impact on the health of these children and women. The exact extent of this will only be known a year or so down the line when surveys establish the extent of child malnutrition and mortality as well as maternal mortality.

This is tragic because with all its faults, the ICDS has been a central part of improving the health of women and children, especially in rural areas.  India's statistics on child mortality and nutrition as well as maternal mortality have improved, although some states like UP and MP continue to lag behind.

It is equally worrying that in cities, like Mumbai for instance, the same thing is happening.  In slums, anganwadis have closed down.  There are no hot meals.  Pregnant women, who would earlier have been fairly confident of accessing a hospital for delivery, are now worried about infection, and the lack of available hospital beds. 

Such women include many who are married to workers from other states.  These men have no work, and no money. The women are not in a condition to travel and return to their villages. They live in dense slums without basic facilities of water and sanitation. What happens to such women during this time?

It is time to think about these hidden costs, and these forgotten frontline workers.

How about Ma Bachao?

The Hindu, Sunday Magazine, February 1, 2015

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This is a season of symbols. A woman air force officer leads the official guard of honour to welcome President Obama; contingents of women and girls march in step during the Republic Day parade; the Prime Minister launches a Beti Bachao Beti Padhao campaign in Haryana, the state with the worst sex ratio in the country. All of this is good. Symbols matter. But are they enough?

It is very well to talk about saving our daughters and educating them, but what about Ma Bachao, saving our mothers? For every daughter that is killed, there is a mother who is demeaned, not respected. If she accedes to the demand to abort a female foetus, it is only because she knows too well what life will be like for a daughter if she is born.

Of course, even if the daughter is not aborted before birth, and is permitted to enter this world, there is no guarantee that her mother will survive. India’s worst-kept secret is that it has the highest number of women dying during childbirth in the world. According to the latest United Nations report, an estimated 17 per cent of the 2.89 lakh women worldwide who died during childbirth in 2013 were in India. In other words, 50,000 women in a year, or 137 every day, or around 11 or 12 every hour die due to pregnancy-related health complications.

For a country that is preening and pretending to be an emerging power in the world, and whose leaders glibly rub shoulders with the most powerful, this is unacceptable. Our place in the family of nations when it comes to our mothers is in fact at the bottom. Even Nigeria, a country beset by so many problems including the brutal killings of girls, women and children by Boko Haram in its northern and eastern provinces, does better than India.

The reason for the high maternal mortality figures is not just the lack of institutional deliveries, which means ensuring that every woman who is pregnant reaches a hospital or medical facility in time. That would help and the rate of such deliveries is gradually improving although not fast enough.

The underlying cause is the persistent malnourishment and under-nourishment of millions of women, many of whom are not yet ready to go through childbirth. According to the National Family Health Survey-3, an estimated 60 per cent of women between the ages of 15 and 45 are anaemic. So even if you get such women to a hospital in time, they might not survive.

In any case, a large number of them are too young to bear children. They should have had the knowledge to protect themselves from pregnancy but know nothing about contraceptives or spacing. Even if they did, they are denied a voice, a say in whether they are ready to have a child. Also, even if such women survive childbirth, they succumb later to infections and diseases and their low birth weight children have slim chances of survival.

What is frustrating about this situation is not just this “silent epidemic”, as someone put it, of maternal deaths, but the fact that women continue to be seen mainly as baby-producing machines.

Since 1994, when India participated in the UN sponsored International Conference on Population and Development (ICPD) in Cairo, the world community accepted that women’s health needs to be addressed not just during pregnancy but at all times. If women are healthy, they will be healthy mothers, giving birth to children with a fair chance of surviving. That is such an obvious point that it hardly bears repeating.

Yet, despite the internationally accepted concept of women’s reproductive health and rights that includes giving women the choice to have or not to have children, to decide how many, and to access health care for their other needs, women continue to be viewed principally for their ability to reproduce. And hence, whether it is people like Sakshi Maharaj urging Hindu women to produce five or more children, or so-called ‘population’ experts telling them to have fewer children, a woman is reduced to the sum of her reproductive parts.

If mothers cannot be saved, who will care for the daughters? It is easier to come up with catchy slogans than to get to the root of the malaise in our country, where women are valued only if they produce babies of the accepted gender, i.e. male, and if they do so quietly without raising their voices.

Why did Vypari Bai die?

The Hindu, Sunday Magazine, January 23, 2011

THE OTHER HALF 

Women in rural India continue to die because of indifference and neglect by healthcare authorities...

Widespread anger: Adivasis protest Vypari Bai's

This is a public health warning. Do not express concern for the state of healthcare in this country. Do not express anger that women die because they are either denied care or help is delayed when they have complicated pregnancies. Do not demand that healthcare is an entitlement that the poor have a right to demand and that the government must deliver.

Chances are if you are too vocal about an issue like this, and if you happen to be working in an adivasis-dominated district anywhere in India, the district administration will hint that you have Maoist tendencies. And that alone is enough to land you in jail and even, as in the case of Dr. Binayak Sen who has spent a lifetime working as a doctor for the poorest, get you a life sentence for sedition under an antiquated law.

This is no exaggeration. On December 28, 2010, more than 500 adivasis demonstrated peacefully in front of the district hospital in Barwani, Madhya Pradesh. They were not demanding wages or forest rights. They were protesting the death of a 22-year-old pregnant adivasi woman, Vypari Bai, caused by callousness and negligence of the medical authorities.

Vypari Bai's story is not unusual. It is enacted hundreds of times in the poorer parts of this country. On November 27, Vypari Bai, who was eight months pregnant, developed high blood pressure and eclampsia, a life-threatening condition of pregnancy. She needed urgent medical help. From her village of Ban, her relatives carried her in a cloth sling for 10 km to the nearest Primary Health Centre at Bokarta. There she was told that the place was not equipped to deal with her condition. So she was sent to the Community Health Centre at Pati by ambulance. There again there was no help and the family was told to take her to the district hospital in Barwani.

Made to run around

The story did not end there. In Barwani, at the time of admission her blood pressure was high. The normal procedure in such situations is to try and normalise the blood pressure and induce labour. Although she was given some medication for the BP, nothing was done to induce labour. Instead, her relatives were asked to take her to a private hospital for an ultrasound in an auto rickshaw even though the facility existed in the hospital. The ultrasound confirmed that the foetus was still alive.

Yet, despite her relatives pleading for help, no doctor was ready to attend to Vypari Bai. Instead, they were advised to take her to Indore, 150 km away. For refusing to do so, they were asked to sign a statement that they took full responsibility for the consequences. By this stage, it would have required a miracle for this young woman to survive. She did not. On November 29, in the early hours of the morning, she died.

Her death has enraged the adivasis in Barwani district who have seen too much of this kind of callous neglect. A survey of maternal deaths in the district hospital from April to November 2010 revealed that there were 25 maternal deaths during this period, nine just in November.

A year earlier, in 2008, in a similar incident, a pregnant woman was turned away from the Primary Health Centre in Menimata in Barwani district when she had already begun labour because she would not pay. She was entitled to free treatment. As a result, she delivered her child literally on the road, outside the hospital. Those who expressed their disgust at this were charged by the district administration under various sections of the Indian Penal Code.

On December 28, the district administration once again slapped charges against some of those who demonstrated peacefully in front of the hospital and arrested Bachhiya Bhai on charges framed against him in 2008. He was finally released on bail after eight days. But the charges against him, under Section 146 IPC (unlawful assembly, rioting, armed with deadly weapon which when used is likely to cause death) and Section 186 IPC (obstructing public servant from discharge of public function) remain. Over 200 of those who participated in the December 28 demonstration have also been charged.

We know about Barwani because there is a group there, the Jagrit Adivasi Dalit Sangathan that is organising and working in the area. But there must be hundreds of similar stories from around the country.

The response of the district administration is shocking enough. What is worse is that this is happening five years after the National Rural Health Mission (NRHM) was launched to check precisely these kinds of incidents, where poor women are made to go from pillar to post for help when they develop complications during pregnancy. Institutional deliveries were seen as a way to bring down the unacceptably high maternal mortality rate. Yet, according to the National Family Health Survey – 3, only 13 per cent of births to the poorest women and 18 per cent of births to women with no education or who belong to the scheduled tribes are delivered in institutions. So no one will argue that increasing access to medical help when women need it most is an urgent need.

Only on paper

This need was supposed to have been addressed by the NRHM. Its guidelines state that every Community Health Centre — that comes between the Primary Health Centre and the District Hospital — is supposed to provide “24-hour delivery services including normal and assisted deliveries” and “Essential and Emergency Obstetric Care including surgical interventions like Caesarean Sections and other medical interventions”. Furthermore, specific districts have been selected in every state where the district hospital is designated as a Comprehensive Emergency Obstetric and Neonatal Care Centre (CEMONC). The Barwani district hospital is designated as such. Yet, despite a staff that includes four gynaecologists and two anaesthetists, no one was available to help Vypari Bai.

The real story of India's progress lies in the detail of how programmes like NRHM are implemented, or not implemented. It is a story that is not told often enough to make us angry. Occasionally, we pay attention to the needs of our children. But women like Vypari Bai, who die because no one cares, remain invisible, the ghosts of another India.

(To read the original, click on the link above)

In a class of our own

The Hindu, Sunday Magazine, October 3, 2010

THE OTHER HALF

KALPANA SHARMA

The Commonwealth Games fiasco, more than anything else, has exposed the hypocrisy of our attitudes…

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If toilets for the athletes were filthy, think of the 665 million Indians who do not have a toilet.

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Photo: Kamal Narang 

Reality check:The collapsed foot-over bridge near the Jawaharlal Nehru Stadium.

The Commonwealth Games have begun — and the common man or woman must wonder what all the fuss is about. Why has the media, those consuming the media, politicians, athletes, sports officials from around the Commonwealth, and even the Prime Minister and the Cabinet, been so hugely engaged in a 10-day event in one city in India? How does what happens over these 10 days make such a difference to the lives of India's 1.2 billion?

Yes, there has been huge corruption, the details of which will emerge once the games end. But is that new or all that surprising? Yes, the work is shoddy and the finish sub-standard. Yes, the toilets were filthy, liberally decorated with paan spit and stray dogs had a grand time. Is that so unusual? How and when did we delude ourselves into believing that things are now done differently in India? Merely because of the Delhi Metro or a handful of airports? Incidentally, systems even at these posh airports have broken down. Visit the toilets in the sparkling Mumbai domestic airport at night and you will see what is evident in the majority of public toilets around India.

Wrong lessons

We are drawing the wrong lessons from Commonwealth Games mess. We are told India's “image” has been damaged. That we should hang our heads in shame now. Why? Because we did not match up to the expectation of being “world class”, whatever that means? That we did not manage to put across to the world that India has changed, that it is now an efficient, non-corrupt, functioning democracy?

In my view, the Commonwealth Games fiasco is a much-needed reality check for us. It has not only exposed that we are a long way from being “world class”, but it has also reminded us that we remain a corrupt society and that our standards of efficiency, leave alone cleanliness — whatever Lalit Bhanot might think — are unacceptable.

If toilets for the athletes were filthy, think of the 665 million Indians who do not have a toilet. If the buildings where the athletes are housed are sub-standard, think of the millions who are without a roof over their heads. If some of the homeless get houses, courtesy the government, or some private builder availing a scheme, they usually leak, are lower than sub-standard and look like ancient relics within a few years of completion. Drive around Mumbai and you will see “new” buildings, constructed for the poor that already look decades old.

But more than the sub-standard structures that have apparently brought such disgrace to India, we should be worried about sub-standard attitudes. Why is no one really concerned about the workers injured when a foot overbridge collapses? Why do we know nothing about the workers who built these “world class” facilities, where did they come from, and what happens to them now that the work has ended? If some of them are guilty of having messed up the toilets, do we know whether they had access to sanitation, or even clean drinking water, where they lived for months, perhaps years, as they slaved over these “world class” facilities?

And then there is corruption. Blatant. In your face. Yet, we cannot forget that the real price for the deep-rooted corruption in this country is being borne by the poorest, those without the ability to pay their way.

In the welter of the scandals emerging every day from the Games, an important report on the real picture of India's maternal mortality rate was lost in the fine print. “No Tally for the Anguish” is based on a study by Human Rights Watch on the conditions women face in Uttar Pradesh when they seek help during and after pregnancy. The stories are chilling. They speak of women dying as they are pushed around from one facility to another, of husbands begging doctors and nurses to treat their dying wives, of petty corruption at every level that exacerbates an already scandalously high death rate amongst Indian women.

Other realities

One such story, which I quote below, will suffice as an illustration:

“One man I know had taken his wife for delivery to the CHC. He had sold 10 kilos of wheat that he had bought to get money to bring his wife for delivery. He had some 200-300 rupees [US$4-6]. Now in the CHC they asked him for a minimum of 500 rupees [US$10]. Another 50 [rupees] to cut the cord and 50 [rupees] for the sweeper. So he started begging and saying he did not have more money and that they should help for his wife's delivery. I... asked them why they were demanding money. The nurse started giving us such dirty [verbal] abuses that even I was getting embarrassed and wanted to leave. You imagine how an ordinary person must feel who wants help. –Activist from a local non-governmental organisation in Uttar Pradesh, March 2, 2009.”

And finally, the differing standards of hygiene that Lalit Bhanot so famously spoke of when those inspecting the site mentioned how appalled they were to see a member of the staff urinating in the public area. Well, here is a reality that even the most skilled managers of an event in India will not be able to hide. And although a part of the problem does arise from the lack of toilets — not all of it does as far as Indian men are concerned. For some reason, regardless of facilities available, the nearest wall is the favoured spot for urinating.

A recent study on women and sanitation in the slums in Mumbai by the activist group Jan Jagruti revealed that while men can use pay public toilets free of cost if they want to urinate, women must pay one rupee each time they use it. Yet, you see only men urinating in public and not women.

Long way to go

I know these are not pleasant subjects to write about when we are trying to project an image of ourselves as “world class”. But every time I hear that phrase, I shudder at our rank hypocrisy. How can a country where children die within days of being born, mothers die while giving birth to babies, millions die from communicable diseases, malaria and dengue are even today wreaking havoc in many parts of the country, still continue to harp on growth rate and some illusory standard of “world class”?

I hope some of our athletes, who in non-Games times are not given anything resembling the facilities available in Delhi now, do well in these games. And I hope that when the Games end, heads do roll and the men who have made this mess are held accountable.

But more than anything, I hope the Commonwealth Games drama will make many of us who live in comfortable homes in India's cities spare a thought to those who build our homes, those who clean them, those who have no homes, no toilets, no access to healthcare, no food and little work. That is the real India. And I don't know what “class” it is but it is a far cry from the concept of “world class” that we have been bombarded with for the last many months.

(To read the original, click on the link above)

Dying of indifference

The Hindu, Sunday Magazine, September 5, 2010

The Other Half

KALPANA SHARMA

Every eight minutes a woman dies in our country due to pregnancy-related complications. Why aren't we able to devise an accessible healthcare system?

Photo: A.M. Faruqui 

Filled to the brim: The state of our maternity hospitals, where they are available.

“She gave birth, died. Delhi walked by”. This was the headline of a six column news item on the top of an inside page in Hindustan Times (August 29, 2010). Illustrated with four telling photographs, the story was about a pregnant destitute woman, who lay on the footpath of Delhi's busy and well-frequented Shankar Market, which is adjacent to the iconic Connaught Place. Thousands of people must have passed her, but no one spared a glance at what appeared a bundle of rags covered in a red cloth.

On July 26, this woman gave birth, unaided by anyone. The cries of the newborn infant caught the attention of some of the shopkeepers and one of them, the owner of a garment shop, picked up the baby. The mother apparently refused help and died on that same spot where she had given birth, four days later. The police came and removed her body and took the child, who had been in the care of the Good Samaritan until then, to a foster home.

This is an item that should have been on the front page of all our newspapers because it illustrates two things. One, the increasing indifference of people who live in our metro cities, who are so absorbed with their own lives that they don't even look around to see how other people survive or die. We have lost our ability to see, to feel. No one wants to get involved. There is a fear that you might be asked to commit more of your time, your resources, your emotions than you are willing to do. So our eyes glaze over, we look the other way and we walk away.

And two, it brings home the reality of maternal mortality in this country where even as we boast of becoming an economic super power and the media celebrates the few Indians who are joining the list of the richest in the world, millions of our women are dying in the process of giving birth to a child.

Of course the story of this woman, whose name we do not know, is one extreme. But it should remind us that this is the reality that we have to address in this country.

Countless more

One can just imagine with rains and the floods that have taken place in the last months how many more such nameless women there must be on the streets of Mumbai, Delhi, Chennai, Bangalore, a part of the thousands who have no shelter, who have to sleep out in the open. All our cities, particularly Delhi but other cities too, are in the midst of a huge construction boom. This is bringing in thousands upon thousands of people from the surrounding areas. Those who have a skill and find regular work in these construction sites are possibly provided temporary shelter by the contractors. But many more do causal work, as and when it is available. The rest of the time they do what they can to earn a few rupees everyday, sometimes send their children out to beg and find whatever place they can to sleep.

In Mumbai, for instance, the fancy new skywalks that have been built connecting railway stations to business hubs have become temporary homes for these homeless people. It is an eerie spectacle to see these bodies laid out in a row, all ages, men, women and children, some sleeping under mosquito nets strung to the side of the skywalk, somehow catching a few hours rest under the relentless yellow light that shines all night. By morning the skywalk reverts to being what it is meant to be, a pedestrian walkway. No one can complain or say anything because there is no solution. But what happens to the children, especially the small babies, what happens to the women, some of them fairly young who become pregnant and have no recourse to any healthcare?

For the other side of this tragic story from a busy street in our national capital is that one woman dies every eight minutes due to complications arising due to pregnancy such as sepsis, haemorrhage or obstructed labour. These deaths could be avoided if there is timely medical intervention. But such help is hard to come by if you live in a remote area or if you are poor woman in city or village. Even if you get some help, it is often too late to make a difference between life and death.

India's current Maternal Mortality Rate (MMR) is 254 in 100,000 live births. According to the World Health Organisation (WHO), half of all maternal deaths in South Asia occur in five Indian states — Rajasthan, MP, UP, Bihar and Orissa. We have committed ourselves as part of the UN's Millennium Development Goals (MDGs) to bring the MMR down to 109 by 2015, in just five years. Is that possible?

The central government has launched the Janani Suraksha Yojana (JSY) to specifically address the problem. It provides cash incentives to women who choose institutional delivery in the belief that this will reduce maternal mortality. If we believe official data, then it would appear that many poor women are benefitting from the scheme. For instance, according to one report, two months before the destitute died in Delhi's Shankar Market, another poor woman living in an open park near the Nizamuddin Dargah was lucky enough to be found by an NGO that helped her get the benefits under this scheme. As a result, the baby girl she delivered in the park has a chance to live, she has a birth certificate unlike others like her, and the mother too is receiving healthcare.

Different reality

Sadly, just as the exception in the case of the woman who died on the street does not make the rule, neither does the woman who survived in the park. Cash incentives in this country have usually led to corruption and fudging of data. This is already evident from reports from Bihar and Jharkhand. Also, the media often remains content with reporting official figures without investing in investigating what is actually happening on the ground. The few investigative stories that do appear on healthcare — on websites like indiatogether.org or infochangeindia.org — tell a very different story. They inform us of the struggle poor women face to reach a hospital, how they are either turned away or have to wait as there are no trained personnel around. As a result, regardless of new schemes or incentives, they are either too weak to survive childbirth or die because the promised help never turns up.

Maternal mortality means women are dying of causes not related to diseases or epidemics. Their ability to survive something like childbirth is inextricably linked to poverty, malnutrition and the absence of basic healthcare. We can set ourselves all kinds of targets but a realistic plan to improve the survival chances of millions of Indian women is to ensure that our systems of healthcare actually cater to those at the bottom of the economic pyramid, women like that poor, nameless destitute in Delhi.

(To read the original, click on the link above)