Population Stabilisation: What does it mean today?

Many people live in hard to reach places
 like this village within a  Sanctuary

It is the 11^th of July today, the first world population day since the provisional results of the Census 2011 were released earlier in the year. As on all such occasions the discussions today are sure to be on the fact that we continued to add more than Australia to our population. However mention is certainly to be made that the population growth rate is now the lowest it has been in the last fifty years, denoting a success for a our population stabilization programme. However the disappointment of those who work on the issue of declining sex ratio around the census results may not be mentioned. This begs the question does population stabilization still concern itself only with numbers, or there are other things that need to be considered as well? In this article I will try to share some of the concerns that I feel need to be considered even though I feel that growth in numbers continues to dominate our mindset.

Right from the days of Malthus down to Hitler, population control has always appeared to be a way for controlling the population of undesirable persons – for Malthus it was the poor, for Hitler it was the Jews. However Population Stabilisation is not to be confused even remotely with population control even though some would like to believe they are more or less synonymous, or 'old wine new bottles'. To quote the National Population Policy 2000, which is the document which gave us this new phrase - “ a stable population ..., at a level consistent with the requirements of sustainable economic growth, social development, and environmental protection”. Clearly population stabilisation is a far more comprehensive term than the limited notion of population control or even family planning.

Have we invested wisely in our youth , our future?

However before proceeding further with population stabilisation and its connotations, one needs to confront one of the crucial concerns of many well meaning people – both in bureaucracy and in drawing rooms. Will India remain the world's second largest population, or will India's population exceed that of China? The answer is unequivocally yes. Without any major catastrophe like a 'nuclear war' or any such disaster 'assisting' us there is no way India's will continue to remain in its second place. The reason for this inevitability is not due to the failure of our family planning or development programmes, but simply the current nature and structure of our two different societies. For one, India's population is still in its growth phase, not because people are having more babies, but more people are having babies . China, on the other hand, is contending with 'bare branches' or single men without potential partners - its population is growing older and contracting. Both of these situations are a result of our past generation's reproductive behaviours, and we can do little to change the course now. In China, the drastic one child policy, coupled with son preference, has led to a skewed sex ratio among young people, while in India,  the fecundity of our parents,  has led to much larger proportion of reproducing young people in our society. This youth bulge is often seen as an economic boon and called the demographic dividend, especially when we do not worry too much about the race with China on the population front, and are more concerned about the economies.

Having dealt with the nagging issue of numbers, one needs to confront the crucial issue of resource crunch. There is no question that the world is facing a serious crunch of resources of every kind, land, forest, air, water, oil – you name it, and there is a sense that our generation and the ones immediately preceding ours have behaved in the most reckless and irresponsible manner – spent well beyond their means, wasted away their inheritance, emptied the collective coffers of mankind. Fortunately there are no debtors prisons, or bankruptcy courts to deal with such profligacy. Unfortunately there are no chances for a comeback like with the American billionaire Donald Trump (who has repeatedly filed for bankcruptcy and protected his billionaire status), because in this case there is little left for any one – not now, and perhaps not for a long long time to come. But the question that needs to be confronted is how does this situation relate to the large number of people living below the poverty line in India? You are right there is absolutely no relation between the acute shortage of natural resources, lack of clean water, pure air, carbon emissions or melting of polar ice-caps or Himalayan glaciers with the number of poor  in India, no matter which committees' measure you choose to use – Tendulkar, Saxena or Wadhwa. These poor do not drive cars, do not fly on jet planes, do not water their garden with clean drinking water or change their furniture as their moods change. On the other hand while millions get barely enough to eat, and some eat mud to quell their hunger, those who flirt with natural resource bankruptcy gorge chicken pigs and cattle with edible grain and pump them with hormones for delectable steaks and porkchops.

What will our children say about
the legacy we will leave behind ?

The reasonable reader must now be wondering, surely population stabilisation has to be related to family planning and to the total fertility rate. Haven't we been taught in schools and colleges and in our policy documents about the importance of a TFR of 2.1 and the need for family planning in order to achieve it? The reasonable reader is right that family planning, more specifically, contraception is essential for limiting the number of children in line with the desire and aspiration of the couple, especially women who have to take a disproportionate load of the reproductive burden. In developed societies, ones we wish to emulate, women, considering their disproportionate reproductive load often choose to have fewer than two children, which often makes mockery of the national desire of a TFR of 2.1. Today most countries in Western Europe are maintaining their population through immigration rather than birth among the native populations. However, the discerning reader will correctly point that situation is perhaps not even a distant reality for us. Women in India, especially those who live in Uttar Pradesh or Bihar or Rajasthan, hardly know how to read and write and choose to have more children. While it is easy to agree to the first quality – that they often do not know to read and write, it is difficult to contend with the assumption that they choose. In reality they do not 'choose' – when or who to marry, when and how many children to have or even when to stand up and say enough is enough when they are subject to repeated cycles of domestic violence. It is thus of utmost priority that women get education, become autonomous at least in decisions that affect their own lives. More often than not such women will choose to  have fewer children, Both my grandmothers, both of whom had a Master's degree, only went through two pregnancies each one in the late 1920's and in early 1930's. Unfortunately both passed away before I could ask them what they did to maintain the reproductive autonomy in those days. I am sure family planning or contraceptive methods are helpful, they have been helpful for me and my partner. However there is no guarantee that the holy grail of TFR 2.1 will be maintained. Even today Kerala has quietly slipped below the bar while the focus was on UP and Bihar.

This young man was taking care of his two daughters
while running his small shop. He had also undergone
vasectomy. He is a poor Mishing tribal
but will other men follow his lead?

Availability of contraceptives, actually the availability of a variety of safe contraceptives, for differing needs and at differing points of time in the sexual life cycle of an individual or couple is a crucial component of population well being and reproductive autonomy. It is necessary to recognise the diversity of needs- across people and across ages and stages in a single person’s life. Thus young people first need couple counselling and then family planning counselling and temporary methods related services. Young parents also need family planning counselling and spacing services. We need to move beyond the overwhelming dependance of female sterilisation or tubectomy, which has little to offer to young people- the principal reproducing population in our country. However we also need to acknowledge sex as pleasure (not just disease and pregnancy), we need to see relationships as being potentially sharing and caring. We need to provide more options to couples, keeping in view all contraceptives can have undesirable consequences, and the choice is usually a tradeoff, but the decision should firmly be the user's own. Women's groups have rightly complained that the way the family planning programme is run appears to make it an effort to control women's reproduction. This has happened because we have in what appears to be an anxiety to reach goals easily focussed on 'targeting' women, rather than involve men in a relationship of equality. Simply by addressing men as caring husbands and fathers and responsible partners an equal number of potential users of contraceptives become available for counselling. Small experiments in different parts of India have shown that the Indian male needn't be maligned as being uncaring and incorrigible, where contraceptive use is concerned.

Two other areas where the Indian man needs to stand up and take responsibility is in his role as caring father and husband in the area of early marriage and pregnancy. As a father the Indian man should keep the concerns of his daughter central and refuse to marry her before she is able deal with the physical and emotional responsibilities of marriage and parenthood. As a husband he needs to explicitly state his care for his partner by delaying childbirth – both in the first and subsequent instances. Appropriate contraceptive service delivery is essential and supportive state mechanisms like strengthening the vital registration system a must. The laws relating to child marriage need to be implemented in spirit and much more attention needs to be paid to its successful implementation and prosecution in case of violation.

We need many more MEN to take much more responsibility for the family.
 Just being the provider is not enough. And this is not just for the poor.
Without gender equality we will not have much we can cherish.

Another social concern which is central to discussion on population stabilisation, is the issue of male or son preference. Son preference affects this discussion in at least two substantial ways. For one the practice of sex preselection has challenged the demographer's assumption that a TFR of 2.1 automatically leads to a Net Reproductive Rate of 1 or replacement fertility. The core substance of this assumption is that if there are an average to two children per woman then there will be one reproducing woman replacing her mother. Unfortunately the social desire to have a male child makes a mockery of this demographic desire – so we have a situation where couples prefer either to have one single male child, one male and a female child, two male children, but in no way is a single daughter or two daughters a preferred family distribution. Thus replacement fertility will not be achieved or maintained if the current social desire for the male child persists. While religious and cultural norms are often mentioned as reasons behind son preference, it must also be understood that current inheritance practices and lack of state sponsored social security mechanisms also contribute to a phenomenon of dependance on the son or male heir.

As a society we need to be sure
that the old don't get left behind. 

The lack of social security mechanisms also affect another dimension of population well being, and that is of ageing people. Old age is a time when one is least able to deal with the costs of care on an individual basis. During childhood there is an explicit support of parents, however with smaller (socially desired) and fragmented families, the elderly population needs mechanisms for support of different kinds including healthcare. Demographers examine this phenomenon through the dependency ratio.  Both childhood and age contribute to dependancy ratio similarly in terms of numbers, but the policy responses need to be drastically different. Unfortunately we have little in place for the needs of the elderly even though ageing of the population has already started in some of the earlier fertility transition states.

The review of population stabilisation strategies that is being attempted through this essay is being done in the context of many successes, some continuing concerns and some new emerging priorities.

Some of the successes that need to be acknowledged and stated upfront have been the successful transition to replacement level fertility in many states across the length and breadth of India. People from all regions desire smaller families. Contraceptive prevalence rates have increased in all states and fertility rates have declined. If individual desire was to be taken as the key measure of success then we would have reached our goal. Unfortunately health system support has not been adequate in many places, leading to high unwanted fertility. Childhood mortality also has seen high declines in most states but once again poor health systems in the same states have resulted in suboptimal decline in child mortality rates, one of the predictors of high fertility. Similarly other social sector programmes like education for girls has seriously hampered women's autonomy in these states. Thus a seemingly old problem, that of high fertility now needs to be viewed through a new lens. It is not longer higher desires which need to be addressed through policy prescriptions, but poor health systems, and as mentioned earlier lack of quality services and of choices.

Population on the Move

This brings me to an issue that is surely to be mentioned in today’s meetings and discussions i.e. give NRHM a chance – it has already led to a ‘remarkable’ reduction in maternal mortality and we will see the similar gain on the population stabilisation front. Current experience shows that while the NRHM has led to some changes in peripheral health service delivery, it is not going to be enough. Additional efforts are also necessary like improving choices of safe contraceptives and involving men as responsible partners. The need for counselling cannot be over-emphasised. However there are many other solutions which lie beyond the ambit of the health system as well. Principal among these is to change our mindset from targetting the poor to supporting the poor. We will need to strengthen social security mechanisms for the poor as well as for the old. However the poor and old need not be the only groups of concern. The consumption patterns of the rich need to be challenged and last but not the least women's empowerment needs to be central to all policy efforts.

IN POWERFUL COMPANY Taking on the Challenge to End Child Marriage with The Elders

Old palace of King Haile Selassie, now University of Addis Ababa

In the space of twelve hours I shared a drink with one ex President, had dinner with one ex Prime Minister, sat next to the only lady in the world to be both a minister and First Lady of two countries and greeted one Nobel Laureate. In the meeting I was attending, I had very august company. But I guess you need such fire-power if you have to start a global campaign to end one of the most persistent, shameful but extremely common forms of traditional practice that plagues large parts of the world. This traditional practice, which many choose to believe is a thing of the past, but is openly endorsed by political and religious leaders in India, is child- marriage. Sixty concerned persons from all over the world had gathered together at Addis Ababa for a meeting called by The Elders, to discuss ways of ending this regrettable practice. The four stalwarts Desmond Tutu, Gro Bruntland, Graca Machel and Mary Robinson represented the group The Elders, which had been brought together by Nelson Mandela on his 89^th birthday in 2007 to deal with pressing global issues. The Elders had now decided to put their considerable political and moral clout to take the issue of child marriage head on.

While I still consider my daughter of 19 years to be my baby, many fathers don’t hesitate to send their 15 year, or 12 year or even 10 year old daughters off to a stranger’s house in marriage. The meeting started with the screening of a documentary giving a grim and poignant portrayal of a child-bride’s travails and helplessness. It covered girls from Afghanistan, Yemen and also from India and they are also part of a story in the National Geographic . With the stage set The Elders provided the gathered group how they had earlier missed identifying this issue as important even when they had been tackling related issues like child rights and maternal mortality in their official capacties, and explained why they are working on it now. A recent study highlighted the chilling statistics that nearly one third of all 12 year olds are married in one region of Ethiopia and nearly half of all 18 year olds in India are married. The discussions showed how this one social injustice affected over 10 million girls every year, and if eliminated would influence six of the eight anti-poverty millennium development goals which all countries of the world were committed to.   

In India we can be proud that we have had a law against child marriage for over 80 years, we can also be ashamed that this law has hardly ever been used to stop child marriage. In states like Rajasthan thousands of child marriages take place on the auspicious occasion of “akha teej”. Everyone knows and looks the other way, even the police. The political and religious leaders come to bless the child bride. One study done by a group in Lucknow had come up with the remarkable finding that the law against child marriage was exclusively used by parents when they wanted their daughters to stop marrying a man of her own choice. They would fudge the records to show adult daughters as being under-age and charge their son-in-laws of both kidnapping and child-marriage. The well-known Bhanwari Devi case in Rajasthan ( filmed as Bawandar), recalls the ugly event in 1992, where a group of upper caste men raped a lower caste worker of a women’s development scheme for stopping a child marriage. The judicial system also failed her when the trial court acquitted the accused. Years later in 2005, a woman’s hand was chopped off in Madhya Pradesh for daring to interfere in the practice.    

Indian society has been resisting efforts to end child marriage for well over a hundred years. In the late nineteenth century, there were two cases one of Phulmonee Devi in Bengal who died of vaginal bleeding at age eleven and that of Rukhmabai in Maharashtra who was married at eleven and refused to go and live with her husband. Both these legal cases demanding raising age at marriage, were bitterly opposed by Hindu religious critics. The Indian law against child marriage ( Child Marriage Restraint Act 1929) could only come about because Rai Harbilas Sarda, the chief proponent of the Act realized the dangers of child marriage after his child bride died in pregnancy. The risk of maternal mortality is many times higher in young girls, but even today a significant proportion of 18year old girls are married and have children as well.

Old Palace of King Menelik II on Entoto Mountain

While India has a law which is flouted, we learnt in the meeting that some countries don’t even have laws around early marriage and even in advance nations like the US. In the US three states don’t have any minimum age, while in many others minors can marry with parental or court permission! We learnt that the problem in the US or in Europe is not as acute with the median age at marriage being quite high, despite weak laws. But in many African countries, just like in India, the law is no protection against child marriage. Studies have suggested that in South East Asia, this ugly phenomenon has disappeared in a couple of generations and education of the girl child was considered as the most important factor. The meeting ended with all of us agreeing to come together and highlight this issue at all levels. Hopefully with such energy and inspiration this practice will soon be challenged within our passive and accepting society.

Carrying one's shopping back from Mercato market

Having gone all the way to Addis Ababa it would have been a pity if I did engage in some tourism. For those interested in history or more precisely prehistory there was an excellent collection of fossils on human evolution in the local museum. The Merkato market reminded me of the old city bazaars like Chandni Chowk (Delhi), Burrabazar ( Kolkata) or Chowk-Aminabad ( Lucknow). The Ethiopians were very friendly and greeted us with a Namastey wherever we went. However my pleasant Ethiopian experience came to a crashing end when I was off loaded from the Ethiopian Airlines flight to Delhi. I had a confirmed ticket, I had checked in on time, I had a boarding pass, but still I was left behind. It is not surprising that it is a government enterprise, and I shared the same fate that many tourists must have faced with our very own Air India. I stoically spent the extra day in Addis in the true spirit of South-South solidarity.   

A short slideshow on the St George's Church 

THE ROMA: EUROPE’S BEST KEPT SECRET

Mr Pavon (middle) supervising the barbeque

This year I had occasion to participate in May Day celebrations in far away Romania with a group of  young Roma who have come together to form a social association and now want to work on health rights issues of the local Roma community. The setting was idyllic. We were in a wooded hollow of an artificial lake. We had a splendid barbeque picnic with pork chops, veal steaks and sausages, topped with home-made white and red wine. But we weren’t the only group having fun. Even though communism is history for over twenty years, May Day continues to be an occasion for the whole family to enjoy themselves in Romania. While we were enjoying our barbeque, a stream of visitors came down to enjoy a meal at the floating restaurant or to take a pleasure boat ride.

The lake and floating restaurant

Mr Pavon, the leader of the local Roma community was the master at the barbeque, and he has also been the inspiration behind the younger generation taking up their social cause. Many among this group are students, employed in the local municipality or engaged in business, but the situation of most of the Roma in Romania is far from satisfactory. Earlier in the morning Alfredo, (Mr Pavon’s son) and other members of the youth group, had shown us around what could be termed a Roma ghetto or in more familiar terms a slum. These two multi-storeyed buildings used to be workers quarters for a cement factory. But now the factory which had earlier employed 6000 people, needed just 300 employees and as a result unemployment is high in the community. Many of the unemployed are Roma. These buildings were abandoned by the factory, but now Roma squatters have occupied them. We were told over 100 families occupied each building. There was no running water, no plumbing, no sewage, and the electricity was stolen from the pole just like in India. However an ubiquitous dish antenna stuck out of nearly each ‘apartment’ confirming that TV is the new opium of the masses. There was a primary school close to this building but even though schooling is free, Roma children from these two building do not attend school. They are not even encouraged by the teachers because they are dirty and smelly. But the real reason could be that they are actually busy begging at the street lights or near the supermarket doorway.

Without running water but with dish TVs

Roma or gypsies as they were earlier called are the ‘dalit’ of Europe. Hitler had considered them as much a ‘problem’ as the Jews and had also sent them to concentration camps. Last year Sarkozy had deported ‘migrant gypsies’, raising a controversy in the European Union. Today there are an estimated 10 million Roma living in almost all the countries in Europe, and making up nearly 10% of the population in some countries in Eastern Europe like Bulgaria, Romania, Macedonia and Serbia. Though they are citizens of European countries, they are discriminated, being subject to hate crimes, lack proper health and education services and their living conditions, as I was to see later in another place called Vanatori, barely better than poor rural or slum homes in India. It was difficult to imagine how they survived the winters, with temperatures dropping well below freezing.

This child hadn't been immunised

Historically the Roma are supposed to have migrated to Europe from India nearly a thousand years ago. From some accounts they went from Rajasthan, and according to others from Punjab. Genetic studies have confirmed these links. A more obvious connection is the many similar words that Romani language shares with Hindi or Indian languages. The words for eyes, nose, teeth in Roma are also ‘aankh’, ‘naak’, ‘dant’ an eerie similarity. Many Roma look so similar to us South Asians, that they can be easily mistaken as either Indian, Pakistani or Bangladeshi. My colleague Sunita and I were very warmly greeted whenever we met some Roma.

It was tragic to see children who don’t go to school or have not been immunized. We were told that nearly fifty percent of Roma children do not receive the compulsory vaccines. We saw a one month old baby who had been born at home with the support of her grandmother. None of her three older siblings had also been born in hospital. The local health system of general practitioners and insurance based coverage, seemed totally inappropriate for the Roma, who still need to be convinced of the value of modern medicines in many places. The social distance between the Romanian or Bulgarian doctor and the Roma woman, seemed as much as that between a dalit or tribal woman in north India and the PHC doctor. The big difference was that most Roma did not have health insurance, even though they were citizens, and thus had no claim to the service. However over the last five years efforts are on in Europe through the Decade of Roma Inclusion to make special provisions for the all round development of the Roma. A system of Roma Health Mediators (community health educators) has been started in Romania and is also being piloted in other countries like Bulgaria and Macedonia. The EU has provided special funds to these countries to improve the situation of the Roma. Unfortunately, the overall financial situation in Europe is poor and there are widespread cuts in social spending and we heard of hospitals being closed during our short visit. The one silver lining that I saw was that the more educated and professional Roma are coming together to provide additional support to their community. While some have started NGOs, others are providing volunteer services. It is my privilege to have worked with some of them and strengthen their efforts.

With some Roma women volunteers

A Different World – Sadarghat, Dhaka

The road was teeming with people, gaily painted rickshaws, green CNGs and roadside stalls and I sat watching from inside the small cage of the three wheeler which I knew earlier as the ‘baby’ but now christened ‘CNG’ in deference to the fuel it used. I had been in Dhaka many times before but today I was eager in my anticipation of seeing the Buriganga and the Sadar ghat. I had heard stories of this venerable river and also of how the river transport from Sadarghat formed a backbone of the transport system of Bangladesh. Dhaka had always reminded me of Kolkata, the city I grew up in and so my expectation of Sadarghat was that it would be somewhat like Chandpal Ghat or Babughat on the Strand Road. The CNG deposited me in front of a long red and yellow brick building which looked like cross between a warehouse and a railway station. There was not a hint of a river in sight and I asked the driver whether he was sure this was where the Buriganga was. He assured me and I tentatively bought myself a platform ticket from went inside the not so crowded building. Passing through some doorways I walked over a footbridge on to the floating pier or jetty.

It was a mind-boggling sight. The bustling road outside without a glimmer of a river and the quiet, dim interior of the building hadn’t prepared me for the colour, clamour and bursting vivacity of the jetty. It was a world of its own separated from the bank by a twenty foot sliver of fetid water with floating plastic bottles and other flotsam. Huge metal steamers over fifty feet long towered over the jetty which was neatly numbered into berthing platforms. Each of these giant boats had romantic names recalling places that I had heard and read of in my childhood. They were in decked in gaudy colours and the ‘conductors’ were calling in passengers, just like they did for private busses and mini-busses in Kolkata. Just the scale was different –those vehicles were like toys in comparison with these three-storey giants. There were some people who were in a hurry and rushed with their bags and boxes. Some families were waiting patiently in a corner with their luggage. Vendors selling fruits were everywhere. There were others selling cigarettes and ‘paan’. There were around twenty berths, and the jetty was over a hundred feet long, but because it was only 25 or 30 feet wide the crowd seemed overwhelming. But as I rushed from one side to another trying to get a good angle for my pictures I did not feel claustrophobic. There was a sense of liveliness a joie de vivre that is difficult to describe.

The sight that really surprised me on the jetty was a paddleboat steamer. I had seen pictures of such boats in history books and had also seen a couple of stern wheelers or boats with a paddle at the back on the Mississippi river during a visit to New Orleans, USA. Those boats were being used as tourist boats. But this was the real stuff – a 50 foot steamer with two large side-paddles and with the used, tired and antique look which made it jump out of a history book. I took a few pictures and tried to peer inside to see if the internal design was different from the large open spaces of the contemporary boats, but was not successful.

If the people who have come rushing to take the big steamers back home to Barisal or Patuakhali or Kaliganj make one side of the story at Sadarghat, the swollen river, the local Dhaka person stepping on or off the small boats ferrying people across the river and solo ‘majhi’ manipulating the long pole like rudder while he cruised up or down the river formed a different picture. Here the mood was more languid, the pace less hectic, somewhat serene and perhaps eternal. The river has been part of the story of Dhaka since historical times and perhaps generations of passengers and boatmen have had shared similar stories and jokes as they crossed the river.

I spent nearly an hour on the jetty at Sadarghat, busily clicking pictures and soaking in the strange but familiar mileu. I had never seen such a ghat, but the language that I heard around me, the names of the places the crowds were so very familiar. Dhaka today is a very crowded city and the traffic is as chaotic as one can imagine. I did not want to miss my colleagues who were planning to go out in the evening and so I tore myself from this fascinating place and made my way out of the building and looked around for the CNG driver who would be willing to take me back to my hotel in Mohakhali. 

A short slide show of the photographs I took that day

Janani Suraksha – An unfulfilled promise

Barwani is a small district in the South-western corner of Madhya Pradesh, where it abuts Maharashtra. It has been a district since 1998, being earlier part of West Nimar or Khargone district. Before independence it was a princely state and the remnants of the princely state are visible as the incongruous Ranjeeth Club in the middle of the city. Barwani is a small sleepy town with little claim to fame, and my visit to this place was occasioned by reports coming to us earlier in the year that an exceptional number of maternal deaths were taking place at the district hospital there, and the local people had protested. As many of you may know the Government of India is currently obsessed with the issue of maternal deaths and has launched a large scheme – Janani Suraksha Yojana to reduce maternal deaths. I was part of a small team of public health experts trying to understand the reasons behind these deaths and if they indicated any kind of systems failure.

The barren landscape of Barwani

We left Indore early in the morning and drove down the Indore Mumbai highway. At one point we left the highway and took a smaller road to Badwani. The landscape changed drastically. The golden fields of wheat waiting to be harvested were replaced by the barren Satpura hills. We drove through miles upon miles of barren hill slopes with little or no tree cover. We drove across the Narmada, and were told that the Narmada Bachao Andolan was once active in the district. Three and a half hours after starting from Indore we reached the small hotel which was to be our base in Barwani. We were told that a famous Jain pilgrimage called Bawangaja was close by and that it had a huge statue of Mahavira etched on the mountain side. Unfortunately we didn’t get to see it and instead focused on our immediate task of trying to understand the health system and the reasons behind the maternal deaths.

We met with a large group of villagers at Piparkund near Bokrata Primary Health Centre in Pati Block. The site of the meeting was under the shade of a few large mango and peepul trees which grew by the side of a stream – Piparkund. The Barela tribals who lived in this region were part of a people’s organization Jagrit Adivasi Dalit Sangathan and they had become perturbed by these maternal deaths at the district hospital. Matters had come to head when one woman Vyapari Bai, whose mother and mother in law were both ASHAs ( village health worker – known as Accredited Social Health Activist), died at the Barwani District Hospital. On being asked for reasons behind her death, the district authorities hadn’t been forthcoming. This led to the villagers coming in large numbers and holding a peaceful rally outside the district hospital. Instead of meeting them and addressing their concerns the district authorities arrested a few of their leaders on charges of disturbing peace and using a microphone within a hospital compound!

Two male midwives

In Badwani I came face to face with the grassroots level implementation of a successful programme initiative – and what I saw reminded me so much of my previous experiences in Uttar Pradesh. “The more things change the more they remain the same !”

Over the last five years the Government of India has been ‘successfully’ implementing the Janani Suraksha Yojana or the maternal health safety programme. Under this programme all women from the poorer states of the country are given an incentive of one thousand four hundred rupees to come and deliver their babies in government mandated ‘institutions’. The idea is that at these institutions a trained provider will be available and if necessary quick referral will be provided to higher centres for emergency obstetric care. Madhya Pradesh has been a star performer in this scheme and was recently awarded a trophy for its achievements under the National Rural Health Mission. Barwani is a secluded district, but surprisingly according to the state Health Management Information systems many of its health related parameters are better than the state average.

Earlier all Barela women delivered at home. Here there was also a tradition of male birth attendants. We met two such male birth attendants in our meeting. From our discussions it emerged that now the villagers are very keen that the pregnant women receive the necessary services for safe pregnancy and childbirth. On many occasions the villagers have gone and asked the local nurse (Auxillary Nurse Midwife or ANM) to come and provide antenatal care at the village. On other occasions they have taken the pregnant women to the Primary Health Center at Bokrata. Unfortunately while the Barela communities in these villages have made changes in their expectations and health seeking behaviours, supported by the cash incentive from Janani Suraksha Yojana, the government services seemed careless, almost callous, in addressing these changed expectations. The same government which proudly counts the numbers of ‘institutional deliveries conducted’ at various national and international fora, was pathetically underprepared to provide the same services. The Bokrata Primary Health Centre was the first port of call for many villages in the region we visited. Unfortunately the labor room in this PHC appeared unused for a long time. The records revealed that almost all the recent deliveries noted in the PHC records had been ‘born on the way’. This seemed a unique response to support the anxious bureaucracies’ efforts to get all pregnant women to have an institutional delivery. We found that in the last 10 days 18 women had delivered in the PHC according to the records, fifteen had delivered on the way and three had been referred. Effectively no infant had been born at this government mandated ‘institution’ which we later found contributed about 50 – 60 institutional deliveries each month to the district records.

I found an even more interesting practice of meeting the MDG goal of 100 percent skilled attendance at birth by 2015 on examining the health records. Pati is one block in Barwani district and even though it is classified as remote and inaccessible it provides very impressive statistics for maternal health services. For the month of January 2011 it was noted that there were 295 deliveries in the block, of which 123 were delivered by skilled birth attendants at home, and 172 were delivered in public institutions. There were no complicated deliveries or caesarian sections for the women who had delivered during the month. There were 8 still births and 261 new born infants had been weighed at birth, none of whom were below 2.5 kg in weight and all had been breast fed within an hour of birth.  If this were true then Pati block would be among the best places in the world for any expecting Barela woman to be in, but unfortunately this official ‘data’ was a dangerous ‘fairy tale’.

PHC records showing 'born in the way'

On asking the block officials we learnt that they were not certain about who is qualified to be called a ‘Skilled Birth Attendant’ and were noting all traditional birth attendant deliveries as SBA deliveries, which they clearly are not. I personally have no issue with traditional birth attendants and consider them an important resource, but today they are untouchables in the policy arena. So here was a situation where about 50 of the 172 odd institutional deliveries were certainly not taking place in institutions and 123 of the 123 home deliveries were not being attended by so call skilled attendants. Thus the 100 percent safe delivery record of the district was at least doubtful by half ( ie. 173/ 295).

An even more interesting picture emerged when we visited the District Hospital. Barwani District Hospital works round the clock delivering maternal health services ( unlike the PHC and CHC we visited during our trip). Its workload in terms of deliveries conducted is close to 600 deliveries a month. This is a three fold increase since the Janani Suraksha Yojana incentives were announced. Unfortunately not much has increased in terms of the hospital’s capacity to serve this additional workload. Of the three gynaecologists who are posted here, two are busy half the week conducting female sterilization camps all over the district of Barwani and also in neighbouring districts as well. One of the star performers we met had conducted over 13,000 laparoscopic tubectomy operations last year. On asking her whether she felt that this huge load could actually be leading to violation of surgical norms, she pleaded helplessness in the face of government pressure to meet sterilization targets. To add to this shortage of doctors, there was only one nurse and one ayah/dai on duty for two of the three shifts during the 24 hour duty cycle. These two women are managing the labour room and a 60 bedded hospital with post operative, post partum women. Clearly the nurse is extremely busy attending to the patients needs, managing the IV drips, giving injections and medicines according to the prescribed schedules and so on. So who manages the delivery in the district hospital labour room? It did not require genius to find out that all the 15 ‘normal’ deliveries that had taken place in the last 24 hours had been conducted by a dai. Even in a district hospital the women of Barwani were not being delivered by a skilled birth attendant – the minimum ‘official’ condition for achieving safe motherhood.

While we had the privilege to see the micro level reality of the safe motherhood programme in one district of the country, the juggernaut of the Janani Suraksha Yojana continues to roll on. Every one whose life is not touched by the risks of an obstetric emergency which could need the support of this scheme, has declared it a success. Meanwhile the poor in our country continue to come to public institutions attracted by the cash incentive. The story of the many women who suffer afterwards, dies in the din of a self congratulatory applause of policy makers, donors, health managers and even nurses and paramedics. It is unfortunate but it may need many more and louder protests from the poor, like the one at Barwani before the system concerned will be able to hear them and take note. 

ORCHA

Orcha is a small village 18 kilometers from Jhansi but during the time of the Mughals it  was the capital  of Bundela kings of the region.  It was much later that that Laxmibai and Jhansi became famous during the first war of Indian Independence. Orcha is a small village – divided into two by the main road. On one side is the more bustling part which includes the famous Raja Ram temple while the more stately palaces are on the other side. The river Betwa flows quietly past the palaces and forms the other axis.

Passing through the rustic scenary of 21^st  century Bundelkhand the sudden sight of these grand 17^th century palaces are truly astounding . The temple of Raja Ram means more to the local pilgrims and many sadhus add colour to this small place. The palace complex is remarkable with two huge palaces – the Raj Mahal and the Jehangir mahal. Today they are mute, but three hundred years ago the lives of the residents of these palaces were intimately intertwined with those of the mughals who lived not far away in Agra.

Today the walls are mostly bare but in a few rooms the frescos that have survived the tide of the times are breath-taking. Scenes from fights, from the royal courts as well as illustrations which depict scenes from history and the epics are now preserved and there are English, Italian, French and Spanish speaking guides that show tourists around. During the evening the palace complex comes alive with the sound and light show which captures the palace intrigues of the bygone days in many hues.

Around the main palaces are the lesser ruins, principal among them the house of the royal courtesan – Parveen Rai. Legend has it that the Mughal Emperor coveted her but with her ready wit and grace she won over the empire and her way back to Orcha. The pleasure garden the frescoed pavilion today is an undisturbed haven where we found a group of baya weavers busy with their nest making.

   

The river Betwa is an important character in this hideaway. Today it is a public bathing and washing place but earlier it was a spectator to history which is present today as the splendid chattri’s or memorials to the Bundela kings of Orcha. There was brief shower before we reached this place and the vultures spread out their wings to dry them creating new patterns on the domes and spires.
A short video on Orcha

IN ALEKSANDER’S LAND

Mother Teresa's memorial

The immigration officer at Aleksander the Great Airport studied my Macedonian visa and consulted a page on his desk and shook his head. He consulted his colleague in the immigration officers ‘cage’ next to him, but she didn’t have the answer he wanted and he went to consult the Immigration Police booth behind him. An officer dressed smartly in blue uniform came up to me, asked me to sit on a bench and disappeared into his cubby hole with my passport. While the line of passengers at the immigration desk grew rapidly shorter I wondered whether I was being denied entry as an Indian in the land of Alexander, for bringing an end to Alexander’s world conquering campaigns two and a half thousand years ago! Soon the officer came back and asked the immigration officer to stamp my passport – my paperwork was in order and I was free to get into the land of Phillip and his more illustrious son.

The Old Stone Bridge

Macedonia is a small country of a little over 2 million people in the Balkans, north of Greece, with which it has a tense sibling rivalry. Here too it is Alexander ( or Aleksander as the Macedonian’s prefer to write) who seems to be the bone of contention. Greece holds Alexander as their own, and would prefer the ‘northern’ Macedonians to remember their geographic place on the map. On the other hand Macedonians are intensely possessive of Aleksander and are planning a 25 metre tall statue of the old warrior king astride Bucaphelus in the centre of their capital Skojpe ( pronounced ‘skopia’). At present the ten metre high pedestal is being constructed in the central square which is peppered with statues of all kinds – heroes from the past on their horses, women talking to each other with their, a shoe shine and even a bikini clad woman taking a dive into the river Vardar which flows past. Erecting statues seems to be an obsession with the current government which has apparently spent over 2 million euro each for installing four gigantic lions on each end of a city bridge. It is not surprising I found the topic very politically sensitive when I ventured to ask about them. The small memorial to Mother Teresa and her statues in the centre of town provided an assurance in an unfamiliar land.

The old Skojpe bazaar is dominated by the Kale fortress. It is a jumble of small shops and eateries and narrow lanes. Since it was a Sunday evening it was empty when we explored it but the morning bustle could easily be imagined. There are a number of dome shaped buildings from the Ottoman times some are mosques, some have been converted into museums. The most interesting building that I noticed was a mosque which gradually morphed itself into a barber’s shop. Macedonians has many religions – Islam, Orthodox Christian being principal among them. The people too are from many ethnic strains – I felt comfortable as an Indian with similar hybrid vigor.

Skojpe Bazaar

The business end of my Macedonian trip was a workshop in Ohrid, a lake resort 160 kilometers away. The 2 hour journey from Skojpe to Ohrid twisted and turned through snow covered mountains. It was an unusually cold year I was told. Ohrid lake was a sight to behold – a vast expanse of blue ringed by snow clad mountains. The old town of Ohrid is a Unesco heritage site and reminded me of our own hill resorts like Nainital and Ooty with its steep roads and paths crisscrossing the hillside overlooking the lake. Ohrid is famous for churches. They say it had 365 churches, one for every day in the year, even today many of them are standing – from small twenty by fifteen feet structures to massive monuments. Ohrid is still discovering its past through excavations in many parts of the town. There is an old amphitheatre and even today it is used during the tourist season for holding events.

Ohrid Lake

Macedonian food generously uses cheese. They even batter fry cheese somewhat like paneer pakora- but instead of a snack it is eaten as a main course. Another Macedonian speciality was a baked fluffy pastry which first made circular like a pie and then sliced up into cubes or diamonds or regular cake slices. Chopska, fresh vegetable salad which uses grated fresh cheese as the principle dressing, also seemed very popular. I was told that the lake serves a excellent trout which is now endangered due to overfishing. The scales of a different fish are also fashioned into Ohrid pearls which are then turned into jewelry and sold in every corner of the town. The restaurants ringing the lake served a variety of cuisine, and even though it was very cold most of the customers preferred to sit outside with heating through different kinds of heaters for comfort. Macedonians still love to smoke, the new visual warnings on the cigarette packets notwithstanding.

The Macedonian currency at 43.50 dinar to the US dollar provided a familiar exchange rate and there was no need to indulge in crazy multiplication for conversion every time I bought anything. The best buy in Macedonia were chocolates. They make reasonably good chocolates and the prices are unbelievable. 

FLAME OF THE FOREST

Flame of the Forest

Patnagarh was once a princely state, but is now a small town in the district of Bolangir in Western Orissa. Even though there have been three ministers from the erstwhile royal family in recent times, the region clearly hasn’t benefited too much from their interventions in the state government. The forty kilometer drive from Bolangir (where we were staying) to Patnagarh was resplendent with ‘palash’ trees in full bloom. Even though I was familiar with the flower, prinicipally through its reference and use during ‘basanto utsav’ in Shantiniketan, it was only here that I realized why it is referred to in English as the ‘flame of the forest’.

 Women Carrying Mehula flowers

Bolangir is one of the poorest districts in Orissa, part of the infamous KBK districts, where hunger deaths, distress sale of children were reported during Rajiv Gandhi’s time as prime minister of India. Since then many hundreds of crores must have been provided as development assistance to this district, but not much development is in evidence. The Humanity is a small voluntary organization started by group of youth, fresh out of University in Bhuvaneswar, who decided to work with the poor rural and tribal people of the district in the mid- nineties on issues of development. Today they continue to be committed to the work and in keeping with the times today much of their work revolves around ensuring that the people are able to get the full benefits of state run programmes like NREGS (National Rural Employment Guarantee Scheme), PDS ( Public Distribution System), Mid-day Meal and so on. We have been working with this group over the last few years for informing the rural population about the National Rural Health Mission and its different provisions.

Even though we are in the twenty first century of malls and supermarkets, I saw the ‘barter’ system working in the village of Tentulikhunti. It was quite accidentally that I saw a little girl clutching a tin in one hand and a twisted plastic bottle in another walk resolutely down the village path. On asking my associates I came to know she was going to the village shop. I followed her as she waited patiently at the shop window for the woman who ran the shop to appear. She took the tin full of rice and filled the bottle with some oil and handed it back to the girl. The little girl put the bottle in the tin and walked home where her mother may have been waiting to complete her cooking for the afternoon.

Our meeting at the village anganwadi centre started late because the villagers hadn’t returned from their ‘mehula’collecting trips. Early in the morning each family designates someone to go to collect the ‘mehula’ flowers ( also known as mahua) that have fallen below the trees in their small parcels of farm land. From a distance these flowers look like grapes – a little smaller in size and a few shades paler. This flower is then dried for a few days in the courtyard and then sold to the local traders. Today it sells at 9 rupees a kg, and a family with a few trees can manage a collection of up to twenty kilo’s a day. But it is back breaking work of picking the flowers one by one before the sun becomes too hot. Later in the day the cattle eat up whatever is left behind. The dried ‘mehula’ becomes the base for the local country liquor. Today the major production comes from Government registered distilleries, but the home made stuff is supposed to far superior. Unfortunately we didn’t get an opportunity put these claims to the test.

Transparency is an important buzzword in contemporary development circles. The World Bank has made it an important criteria for judging aid effectiveness and Transparency International, an international NGO compiles annual rankings of countries’ around the world and India doesn’t rank very favourably. The Right to Information is considered to be an important tool for transparency. The full blown practice of transparency was very much evidence in the villages of Patnagarh. Many of the village walls were painted with the provisions of different government schemes, and the walls of the Primary School were painted showing amounts that had been received from the government for different provisions like maintenance, books and stationery and even the names, date of joining and birth dates of the teachers. The names of all the members of the Village Health and Sanitation Committee and their responsibilities were painted in four inch tall alphabets opposite the Anganwadi Centre. However not one of the literate villagers we spoke to had taken the trouble of reading through the information. So much for transparency! You can live in glass house but if people don’t care they won’t look inside to see what you are up to, let alone throw stones at you.

Sunflower : A cash crop

The children of villages around Patnagarh were a very animated lot. In the school, they burst into a song on the instruction of the teachers to welcome us. The smaller ones were playing adult roles to perfection. I have already talked of the girl who went shopping. I saw another slip of a girl, not more than five years old, busy trying to fill two vessels of water from the hand pump. After many attempts to carry both filled vessels at the same time, she went home with one filled vessel and the other swinging from her other hand. The smaller children had plump cheeks and a glint in their eyes. It is unfortunate that some of these children will not grow into adults, many girls will be married and forced into motherhood well before they are physically or emotionally prepared, and if the circumstances are desperate some may even be sold. Surely, children in India deserve better.