May You Be the Mother of a Hundred Sons (47 page)

But trying to change people’s attitudes through an advertising campaign was an uphill fight. Even legislation had its limits. Although the legal marriage age for girls in India is eighteen, in rural areas this was almost completely ignored, and the government estimated that three million out of the four million marriages in the country each year involved an underage bride. The government also had tried offering incentives to families practicing birth control, such as preferences on loans for water buffalo. But there was fraud and cheating, and the program had a mixed success.

By far the most controversial aspect of India’s family-planning program, both the revised strategy and those that preceded it, was the use of targets. Every year in New Delhi, the Health and Family Welfare Ministry set goals for the number of couples to be protected from conception by each of four methods: sterilizations, intrauterine devices, birth-control pills and condoms. For example, for the years 1980 to 1985, the ministry determined that it would protect one million women with oral contraceptives. By the end of the period, the ministry reported that it had actually surpassed its goal and had motivated 1.29 million women to use birth-control pills. It was an utterly meaningless statistic, and even family-planning officials admitted that most village
women taking the pill did so erratically, sometimes only a few weeks a year. But taken together, the targets helped the government achieve a “couple protection ratio,” or the proportion of couples of childbearing age using some sort of birth-control method relative to the entire population in that age group. Over the years, India had consistently met its targets, and the couple protection rate had more or less steadily risen, at least according to the volumes of statistics churned out by the government. But the real problem of overpopulation persisted. Despite this stellar performance on paper, there was no corresponding drop in the birth rate.

Critics of the family-planning program for years had said that the misguided overreliance on statistics came from the “target fever” throughout the bureaucracy. The fever started in New Delhi, where the ministry dispensed targets to the states. The states then sent them down to the health centers, which distributed them among the health workers in hundreds of thousands of villages. Ultimately, each health worker in India had personal targets each year and would be docked pay or demoted if the targets were not met. Under this kind of pressure, health workers resorted to an amazing variety of distortions. They sometimes had both husband and wife sent for sterilization operations, or had the same person sterilized twice. More typically, older women with six or seven children—who had already done their damage to the birth rate and probably weren’t expecting more children anyway—were sent for the operation. In other cases there was outright fraud. In 1983 and 1984, for example, the state of Maharashtra was apparently so eager to win a national family-planning award that, according to an estimate by the
Indian Express
newspaper, 180,000 of the state’s claimed IUD insertions—25 percent of the total—were fictitious. In a statewide investigation, the
Express
alleged that medical officers had made up the names of IUD recipients and had entered in the books the names of real women who had never received IUDs at all. In one village, the paper reported, health workers had recorded three hundred IUD insertions for the year, twice the number of women who were eligible. In another village,
Express
staffers found that two current “recipients” of IUDs had been dead for more than two years. As one person involved in family planning had told me: “Things are happening in the files, and not in the field.”

ABIGAYAL PATRIO CHRISTIAN WAS THE MOST PROFICIENT HEALTH WORKER
in her area of Gujarat. I am sure of that, because otherwise her superiors
would not have let me speak to her. I was usually able to interview anyone I wanted in India—it was not only the world’s largest democracy, but also one that never stopped talking—but population control remained a sensitive subject. I had discovered in Tamil Nadu, for example, that village health workers were extremely nervous about talking to me without permission from district officials, who were themselves reluctant to grant approval without authorization from state officials and, ultimately, Delhi. This time I knew I had to start at the commanding heights of the bureaucracy. I sent the central government in Delhi a letter saying I wanted to interview health workers in Gujarat, specifically in a western area called Bharuch District, which I chose because I wanted to visit a rural hospital in the same area. My request made its way from Delhi through Gujarat’s state capital and then down to a village in Bharuch District, where it landed on the desk of Dr. Gharia, the man who had overseen the laparoscopy camp. I told Dr. Gharia that in addition to observing the camp, I wanted to accompany a health worker on her rounds for a day, and to talk to her about her job and her targets. Clearly made nervous by instructions sent all the way from Delhi, Dr. Gharia obediently took me along with one of his subordinates to meet his star health worker, Abigayal Patric Christian. Then he and his subordinate sat in on the interview, and the four of us went together on her rounds. It was not, to say the least, a perfectly authentic experience. On the other hand, it gave me a hint of the quality of village health care in India and what life was like for the women who delivered it.

The day began shortly before nine in the morning, when Dr. Gharia and his assistant and I arrived by car in Jabugam, a village of mud huts and dry fields that was suffering, like most of the state, from a disastrous three-year drought. Jabugam and the surrounding district were populated largely by what India called tribespeople, villagers believed to be descended from the country’s original tribes, who lived in India before the Aryan invasions of thirty-five hundred years ago. Although many tribespeople have darker skins, they look no different from other Indians. Yet they retain a separate ethnic identity, and although they are supposed to receive extra benefits from the government, they remain among the poorest and most backward people in India. Delivering health care to them was especially challenging, but as it happened, both the village and the surrounding district that we were visiting had a relatively low birth rate and a good “couple protection ratio.” Local population-control officials thought the probable reason for the success of family planning was that the tribal families were
more desperate for the money received for sterilization operations than most other people in India.

Christian ministered to the tribespeople from a small health subcenter in the village, which doubled as her home. It looked like the other health centers I had seen across India: a primitive one-story building of cement and plaster, although in this case there was a sign on the front saying
U.S. AID ASSISTED
, a reference to grants from the Agency for International Development that helped build it. Christian, a slight figure in the all-white sari of a nurse, was waiting for us at the door. She shyly said hello and then led us into a small sitting area, where Dr. Gharia explained to her what I wanted. She seemed too apprehensive to speak, so I began by asking a few simple questions that Dr. Gharia translated into Gujarati. Slowly, she told me that she was fifty-two years old, a widow, and the mother of three sons and one daughter. Her father had been a mill worker and her mother a primary school teacher. Her late husband had been a primary school teacher too, but she had only finished the seventh grade. Trained by the government as a nurse and midwife, she had worked in Bharuch District for twenty-five years, and now, from her base at the health center, was responsible not only for Jabugam, but also for the people in two other villages and five outlying hamlets. Her days followed a pattern: door-to-door village visits from nine to twelve-thirty, lunch and a nap during the heat of midday, then follow-up paperwork for her village rounds from four to six in the evening. She also delivered babies and held a health clinic for mothers and their children on Tuesdays. Her salary was $115 a month, and her biggest worry was making her targets.

I asked what her targets were, and she knew them by heart. That year, out of the three thousand people in her area, Christian had to persuade fourteen villagers to be sterilized, fourteen women to use IUDs, thirty-five men to wear condoms and five women to take birth-control pills. Not surprisingly, she had already met her condom and pill targets; it was easy, after all, to give them to villagers, who most likely would never use them. Her sterilization target, however, was a problem. She had persuaded only seven people—one man and six women—to have operations. With only four months left in the year, which ran from April 1 to March 31, Christian needed seven more cases. As it was, she had been forced to use part of her salary to bribe the first seven to have the operations. The government awarded her an incentive of fifty rupees, or four dollars, for every sterilization case she achieved, but inevitably she gave all of it to the people who had
the operations, even though they were already receiving twenty-four dollars from the government. “There are poor people in the tribal areas,” Christian said matter-of-factly. “They demand more money. They all know that I am getting fifty rupees, so they think they should get the money instead.” Christian was actually fortunate. I had heard reports of villagers in some areas of Tamil Nadu demanding larger sums of money and jewelry before agreeing to the operations. Well aware of how health workers were held hostage to their targets, other villagers demanded that the workers take care of their children and do the family’s cooking and cleaning while they rested after the surgery.

After explaining this dismal situation to me, Christian was ready to leave on her morning rounds. It was a pleasant mid-November day, not too hot, and all four of us piled into the car and headed for the hamlet of Vadafalia, another collection of mud huts, about a mile down the road. Normally Christian walked on her rounds, sometimes up to four miles a day, so a small commotion erupted when the inhabitants of Vadafalia suddenly saw their health worker arriving in a cloud of dust kicked up by the car. Christian got out, made her way through the clusters of gaping children and headed for a hut indistinguishable from the others. But this was an important stop for her. Inside was a potential sterilization case, a twenty-five-year-old mother of two. The woman had earlier told Christian that she would have the operation, and today, if Christian was lucky, she might get case number eight. Dr. Gharia, his sidekick and I followed Christian into the hut, where we found the woman sitting on the mud floor near the cooking fire, a baby at her breast and another half-naked child nearby. The air was damp, smoky and suffocating. The woman’s mother-in-law, a gruff-looking woman, stood near the door. With no preliminaries, Christian asked the woman if she was ready to come with her for surgery. The woman looked up at us silently, expressionless, then stared back down at her baby. She must have been terrified, I thought, by four intruders who had just barged into her home, demanding that she come with them for a mysterious and frightening operation. After an awkward moment, the mother-in-law spoke up. “The baby has been vomiting,” she said. “My daughter-in-law doesn’t want to go.” Dr. Gharia, speaking up for the first time, suggested that the woman bring her baby with her to the health center, but the woman refused. None of these health specialists, I noticed, went over to look at the baby, and no one offered help. After some more discussion, the woman’s mother-in-law spoke up again. “My daughter-in-law does not have permission
for the operation from her husband,” she said this time. Conveniently, the husband was not home but out cutting field grasses. The mother-in-law, to bolster her case and take the onus off herself, then added that while she personally was in favor of the operation, the woman’s own parents were not (although usually a woman’s parents have little say over what happens to her in her in-laws’ house). The mother-in-law had won, Christian gave up and the four of us went out, leaving behind an atmosphere of tension inside the hut.

The next stops, in the nearby village of Choramala, were uneventful. Christian gave a woman pregnant with her fourth child a supply of folic acid tablets to help prevent anemia, then listened to the woman explain that she had wanted to be sterilized after her third child but couldn’t go for the operation because one of her children fell sick. Quickly moving through the village, Christian gave iron tablets to another pregnant woman and to the mother of a four-month-old. At still another hut, a woman approached Dr. Gharia about reversing her laparoscopy. One of her two children had died of an unexplained fever, she said, and now she wanted to have another. Dr. Gharia patiently told the woman about recanalization, a complicated operation that might or might not reopen her fallopian tubes. The procedure required eight days in a hospital and a month of rest afterward, and the government would pay. It seemed to me that the solution to problems like hers should have been sufficient medical care to ensure that Indian children do not routinely die of fever.