Whose body, whose health?
THE contemporary women's movement in India has been defined by its interrogation of patriarchy and modernity. The campaign for the right to control one's body and sexuality exemplifies this concern with challenging the structures and practices of patriarchy and the designs of modernity. The two main areas of critique have been the philosophy and practice of population control which has at its centre control over reproduction, and research and development of contraceptive technologies and their delivery - issues which both the nation as an entity is concerned about and women and men have to contend with in their daily lives.
In the dominant discourse, India is seen as having too many people, and too many poor people at that. Controlling our population is prescribed as a national duty, which unfortunately the poor and marginalised peoples are not performing. The middle and upper class are presented as the beneficiaries of the gains of smaller families. The official propaganda is that the fewer children you have, the happier and wealthier you will be. But if the spoils of modernity are so clear and linear, why isn't everyone running after them? This is the question for which the government has been trying to find a solution for the past few decades.
Today there are many more participants in the debate - international agencies, donor agencies, pharmaceutical companies, NGOs and last, but not least, women and health activists. In the process we have moved from family planning and population control to family welfare and now reproductive health.
Reproductive health, a key catchword of the decade gone by, has gained ground within both national and international discourses around women and health. The promotion of the concept was seen as marking an important shift from earlier family planning and population control perspectives which had guided the approach to women's health for the past five decades.
While the agendas of the Indian state and international agencies have moved away from the strident population control agenda of the 1960s and '70s to the more expansive notions of reproductive health
and reproductive rights, what has this change actually meant? Formally, at least, the approach aims to be broader, more client-centred and quality-oriented, one which seeks to address the needs of all age groups of girls and women for contraception, abortion, safe motherhood, sexually transmitted diseases, RTI's and other related issues.
At one level this can be seen as the success of the women's movement in influencing the agenda on women's health. On the other, the RH agenda has limited the issue of women's health to one of service delivery and quality while evading the structural issues of inequality and discrimination (Qadeer 1998). Thus the framework does not examine how macro economic factors such as SAP, loss of livelihoods or environmental degradation affects women's reproductive and overall health status. The population establishment has appropriated the language of rights and choice but without situating it within the political context of structural inequalities.
The government family planning programmes have over the past five decades targeted women in different ways. In the fifties and early sixties the focus was on spacing methods to control family size, but by the seventies permanent methods such as sterilisation gained currency. When the state felt that the decrease in birth rate and contraceptive acceptance rate was insufficient it turned to newer technologies such as injectables and implants. But by the nineties the consensus grew that the focus on numbers and contraception alone was unlikely to make a significant difference to population growth (even as the growth rate has been steadily coming down). This along with the outcomes of the ICPD led to the broader reproductive health approach.
However, it is clear that over the past few years the government has been backtracking, even on the commitments given at the ICPD in 1994. Several states have today introduced incentives and disincentives to control population growth - Andhra Pradesh, Maharashtra, Rajasthan, Madhya Pradesh. People with more than two children are being penalised by being denied the right to stand for elections, denied rations for the third child, made ineligible for government jobs and housing, and so on.
Despite a 100-member population commission which has come out with a National Population Policy that speaks a liberal language and does not advocate disincentives, many states are going ahead with their own policies of population control. With the birth of the billionth baby and the accompanying media blitz, the public perception is also veering towards Malthusian doomsday visions. In such a scenario, the government is once again attempting to push methods such as the injectables.
The results of the recently conducted census reveal that only a few
states have recorded significant decline in birth rate; this has resulted in a renewed focus on the states that have not brought down birth rates significantly. A new group, The Empowered Action Group for Stabilisation of Population, has been constituted in eight economically backward states. Its first decision was to introduce Net-en (a bi-monthly injectable contraceptive) on a trial basis in 12 medical colleges around the country. Emergency contraception (the morning-after pill) is also on the anvil for introduction in public health centres.
The state is clearly shifting focus towards new contraceptive technologies as the answer to the problem of growing population. Though the critique of women's health advocates has been taken into consideration, it remains superficial. There is recognition that human rights need to be respected and there has to be concern for the user. This manifests itself in both the liberal language of the National Population Policy, the RH approach, and the recent Net-en order advocating follow up and counselling for the introduction of injectables. But women's groups argue that the commitment often remains only on paper, and the political will to make genuine changes is missing.
The development and introduction of new contraceptive technologies has been linked to the need to control population growth and the right to control one's body and reproduction. The discourses around population control and modes of regulation, what Foucault calls the bio-politics of population (1978), have brought into public discourse the idea of the control of the species body and the regulation of numbers. Further, the body under modernity is disciplined and regulated less by the state and more by the discursive formations of medicine and the sciences. This has provided the ground upon which the women's movement has been able to generate public debate around this question.
A loose network of groups (including women, health and civil rights groups) have come together in different campaigns against population control policies and new contraceptive technologies and for reproductive rights. Since few of these groups are mass-based, their strength lies more in their ability to lobby with different sets of actors, including scientists and the state. In addition, they have also produced texts in the form of booklets, films and articles. They have been effective in getting their voices heard through the media, demonstrations and protests. Further, these groups have been very successful in forging international networks. The global nature of production and circulation of scientific knowledge and setting of agendas has led to a situation where it has become essential to act globally in order to address all sets of actors. The field today is extremely wide with NGOs and activists intervening in different ways. Women's groups too differ in their
approach to engagement with the government and international agencies. While some groups have steadfastly refused to enter into dialogue with the state, others decided on a strategy of engagement to broaden their sphere of influence. For example, the Health Watch network has taken on the task of monitoring and assessing the changes resulting from the introduction of the RCH policy at the grassroots level. Some groups are in dialogue with agencies like UNFPA or Population Council, even as others have continued to engage primarily in confrontationist politics.
There is also an increasing trend towards privatisation of healthcare, as in all other fields, given the growing influence of processes of globalisation in India. This has led to a greater involvement of NGOs and international donor agencies in the delivery of healthcare, including family planning services. This has resulted in a situation where injectable contraceptives, till recently not officially cleared for mass use, are being provided by NGOs as a contraceptive option.
Both the changing critique and strategies of resistance can be better understood within the context of the changing political and economic scenario. The condemnation of all contraceptive technologies as provider-controlled, long acting and invasive was predominant in the eighties. The globalised '90s witnessed the emergence of new political formations with a bigger role being played by the NGO sector alongside international donor and bilateral agencies in setting national agendas. If the earlier groups were more confrontational in their stance, the strategy now involves dialogue, negotiation and partnership, in addition to confrontation.
The greatest strength of the women's health movement lies in its ability to dialogue with different sets of actors. At the global level women's health advocates have managed to effect dialogue with scientists, funding agencies and international organisations. In India too, women's groups have been interacting with the state, drug regulatory authorities, ICMR, doctors and scientists. Women's activists have had to acquire a certain level of expert knowledge to interact with these experts. This has led to a greater involvement in research, policy planning and programme implementation, especially over the past decade.
The emerging resistance is directed both against the overall framework of population control as also contraceptive technology itself (including the process of research and clinical trials). Some of the major campaigns over the past two decades are those against hormonal injectibles (Depo Provera and Net-en), Norplant, quinacrine sterilisations and anti-fertility vaccines.
Activists have challenged the biomedical constructions of contraceptive technologies and stressed how social and cultural factors impinge on scientific and medical technologies. All new
contraceptive technologies - from the hormonal pill developed in the fifties to those providing long term protection through hormonal injectables, subdermal implants and anti-fertility vaccines - are seen to carry similar features in that they are invasive, long-acting, and provider controlled for application as well as for removal, and often cause side effects such as irregular bleeding, nausea and weight gain. Women's health activists foreground the potential hazardous impacts because these new technologies have not been sufficiently tested and may have long term adverse effects, both on women's bodies and future generations.
Scientific research does accept that there is an element of risk inherent in each method and weighs it against possible benefits and the efficacy level of the method. Women's health advocates concerned with both women's reproductive and other aspects of their everyday lives charge that contraceptives taken even by healthy women over long periods of time generate side effects which are unacceptable. Further, these contraceptives are prone to abuse in the present healthcare system, especially in Third World countries. Because hormonal injectables and anti-fertility vaccines exploit the high acceptability of the injection as a medical technology, they potentially jeopardise existing immunisation programmes as well.
The promoters emphasise that women need contraception that they can use without knowledge of the rest of the family, including their partners, and consequently the injectable is ideal. More so since women are rarely in a position to decide about their own bodies, given the nature of power relations in families. Women's activists, however, argue that technology cannot be a solution to social problems. For example, technologies designed for pre-natal sex determination have been used to further reinforce son preference and have not in any way led to women's empowerment. And this is a serious problem if the preliminary results of the 2001 census are any indication, with the 0-6 child ratio coming down to 927 from 945 in 1991 and 976 per 1000 in 1961.
The design of research too brings into focus many of the issues that health activists have constantly articulated. They argue that at every stage of research, scientific as well as non-scientific factors play a role in deciding the area of research, the design and protocol, and the interpretation of the data. In clinical trials certain physiological changes are followed up whereas others are ignored. For instance, in the case of Norplant, the only parameter that was checked at the end of the five year period was whether there was return of fertility, even though long term use of the drug could have resulted in many other disturbances and side-effects in the body. Similarly, though women were being fitted with Intra Uterine Devices (IUD) from the 1960s, the high rate of reproductive tract infections linked to IUD use was exposed by feminist researchers only in the 1990s (FFWH 1995).
Women's groups and health activists have charged that the protocols and phases of clinical trials are summarily changed to hasten the process of the introduction of these methods. They point out that both Depo Provera and Net-en were introduced in the market even though insufficient clinical trials had been conducted in India, merely on the presumption that post-marketing surveillance would help confirm the acceptance of these contraceptives by a larger number of women. Incidentally, in both cases, the phase IV trial has been bypassed.
Similarly, Norplant, while still at the stage of clinical trials, was incorporated into the Indian family planning programme on grounds that it was in use in other countries. The example of quinacrine sterilisation is even more disastrous as this is an untested method and is popular with private medical practitioners, specifically in third world countries.
Women's groups have challenged the nature of informed consent, in different trials for contraceptives, claiming that women have never been given complete information on the nature of the contraceptive. Neither were they clearly appraised of the various side-effects or the experimental nature of the technology. Most women who are enrolled as part of trials are poor women who seek the services of government healthcare centres. The doctors display a patronising attitude towards them and feel that they are incapable of taking decisions for themselves. And even in today's liberal times, counselling is simply reduced to convincing women to put up with the side effects, as they are seen as 'non-serious'.
The campaign against injectables began in the mid-80s when women activists in Hyderabad discovered that Net-en was being given to women without complete information and a case was filed in the Supreme Court to prevent its use in the family planning programme. In 1994 a similar campaign was launched against Depo Provera which was brought in through a multinational pharmaceutical company. In this case too, a writ petition was filed in the Supreme Court, preventing its introduction in the government programme and the market on grounds of insufficient trials, adverse side effects and lack of complete information.
With the recent completion of the post-marketing surveillance by Upjohn, the multinational pharmaceutical company which manufactures Depo Provera, this campaign has been revived. Another catalyst has been the conclusion, in August 2000, of the Net-en case filed in 1987. The government clarified that the drug would be introduced in the national family welfare programme only where adequate facilities for follow-up and counselling are available, a clear indication that it intends to introduce it in the family planning programme.
The campaign for the right to control one's body and fertility has raised several different issues, including the right to safe contraception and freedom from coercion in deciding how many children to have. It has also challenged the state for looking at people merely as numbers to be controlled and for treating women as wombs.
The strategies have involved dialogue with different actors - the state and regulatory authorities, international agencies, pharmaceutical companies and the public - using such means as the media and public protests. The greater acceptance of women's health advocates in this arena has been facilitated by two factors: first, they are seen as representing the voice of users and second, their technical competence and ability to dialogue with different sets of actors using the appropriate languages. This has led to a situation where, alongside other experts, they too are seen as representing a form of expert knowledge. Simultaneously, given the greater concern about the growing population (a billion plus) and with the unmet need for contraception being translated into the need for more and better contraceptive technologies, it has become easier to paint activists opposing population control and new technologies as insensitive to both women's needs and the wellbeing of the nation, i.e. both anti-women and anti-national.
The limited success of confrontationist politics has prompted many women's groups and activists into working with the state and international agencies in order to impact programmes and projects. It is a recognition of the need to engage with institutions in a meaningful way. The language of co-option is too simplistic to comprehend the nature of alliances and appropriation that are taking place today. It is only because the women's movement went beyond confrontation that it is an important player today. Yet it would be foolish to underplay the hegemonic power of dominant discourses and the state with its various allies.
The movement clearly needs to rework its strategies. If despite fifteen years of sustained engagement with these issues, it still remains bogged down with the same set of fears and charges, clearly something has gone wrong. The movement needs to comprehend the global character of knowledge production and the process of agenda setting to carve out efficacious spaces for intervention. How to simultaneously address the continuing problems of poverty and inequality, adverse sex ratios (particularly juvenille sex ratios) and violence on women while being mindful of a growing middle class, its aspirations and lifestyles is the challenge. It is within this frame that we must address both the rhetoric of population control and women's need and right to control their fertility.
FFWH, Contraceptives: Our Choices, Their Choices. In Malini M. Karkal (ed.), Our Lives, Our Health. Coordination Unit for the Beijing Conference, New Delhi, 1995.
Michel Foucault, A History of Sexuality: An Introduction (Transl. Robert Hurley). Vintage Books, New York, 1978.
Imrana Qadeer, 'Reproductive Health: A Public Health Perspective', Economic and Political Weekly, 10 October 1998.
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