Locating Health

Historical and Anthropological Investigations of Place and Health

Erika Dyck, Christopher Fletcher, Erika Dyck, Christopher Fletcher

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317322771
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

The essays in this collection focus on the dynamic relationship between health and place. Historical and anthropological perspectives are presented – each discipline having a long tradition of engaging with these concepts. The resulting dialogue should produce a new layer of methodology, enhancing both fields.

1 PLACING MATERNAL HEALTH IN INDIA

Helen Vallianatos

When I began my work in India, I was struck by the incongruence between stereotypes of oppressed women and what seems like a powerful position attributed to them through the iconography of Hindu culture. Social statistics such as maternal mortality and morbidity rates, women’s poor literacy and educational status, and the striking numbers of missing women observable in sex ratios¹ all point to women’s inferior social position while the Hindu pantheon and the manifestation of these goddesses in living women (e.g. Indira Gandhi was often depicted as Durga) spoke to their esteem and power. These two images of women, as otherworldly and subjugated, point to the need for research on the women’s social condition that considers their status within a cultural tradition of gender and the social-structural conditions in which lives are lived. The timing of my research, in 1999 and again in 2001, corresponded with significant political and economic changes as India embraced neoliberal economic policies, opening her markets to the world. I emphasize that knowledge of maternal health, or any health issue, requires an understanding of the local sociocultural milieu, in order to grasp how social structures shape ‘local biologies’.² In other words, the biology of pregnancy and maternal health is not disconnected from the place where women’s everyday life is performed, a place which also encompasses past life histories of individuals, communities, and the nation-state. Emplacing maternal health then requires deconstructing the spatiotemporality of place.³ I do this here through examining how multiple forms of power are made sensible and contested, are emplaced and embodied. Because the body is critical to emplacement,⁴ and how a lived body interacts with place is variable and subjective,⁵ my analysis examines how healthy subjectivities are simultaneously shaped by adjustments and contestations towards structural power relations.

In this chapter I examine the health experiences of poor, pregnant women who lived in one particular jhuggi-jhopri community (squatter settlement) in New Delhi. I relate how women’s food acquisition, preparation and consumption strategies during pregnancy, and in turn their health and well-being, is influenced by place – by their positionings in physical and social spaces at a specific time. Social spaces of gender, age and social status (class/caste) produce and reproduce inequities. Individuals are not merely passive receptacles inhabiting social spaces, but respond and resist in myriad ways, and in the process create unique places. Time here is situated both at a macro-level, historically situating global and national policies and programmes that affect the health of populations, as well as a micro-level, in consideration of women’s reproductive histories and lived experiences. I begin by summarizing political-economic health and food systems in order to examine the factors affecting local health and foodways, and in turn how women’s individual experiences of wellness is shaped by such macro-level conditions and their social status. I then narrow my focus to family structures, to examine how interpersonal relationships and familial spaces construct gendered healthscapes. Thus, through my examination of ‘geopolitics of the body’,⁶ of the way political-economic and intrafamilial power relations and social inequities shape bodies and places,⁷ I portray how individual women daily navigate food and health challenges while simultaneously embodying histories of places.

This paper presents a rethinking of the role of place in understanding maternal health. I had previously examined multiparous pregnant women’s food-consumption practices, of how they navigated cultural food norms in light of their prior reproductive experiences, and the consequences on their nutritional and health status.⁸ Here, I consider how maternal health is shaped by place, of how the broader political-economic environment interacts with local family contexts in formation of gendered (un)healthy bodies.

Methods and Context

Research in jhuggi-jhopri communities is fraught with any number of difficulties. Each jhuggi-jhopri community has unique demographic and cultural milieus. In this particular jhuggi-jhopri community, residents were predominantly scheduled caste Hindus, with a significant minority of Muslims who clustered within a particular spot of the settlement, and a few Christians sparsely distributed. Although most participants had resided in Delhi for approximately fourteen years, they traced their origins to northern Indian states, predominantly from Uttar Pradesh and Rajasthan. This is unlike other jhuggi-jhopri settlements, that may consist primarily of migrants from South India, or Nepal. Family connections were thus forged across spaces, as jhuggi-jhopri residents still had kinship ties to their natal and affinal villages. The joint or extended family is the ideal family structure in India. This household would include the father and mother, their sons, daughters-in-law and their children, and unmarried daughters. Ideally, resources are obtained and shared in an equitable manner. Yet, tensions may arise around dissatisfaction with the hierarchical everyday family relations and practices. Family hierarchies are based on age and gender. Consequently, to understand how maternal health is influenced by the domestic spaces they inhabit, I also interviewed men and elder women.

Interviews were conducted with forty husbands, spouses recruited from the 154 women participants. In addition, three focus group discussions, each with five to seven mothers-in-law, were also completed. Interviews were conducted in Hindi, with the aid of a research assistant – a man for the husband interviews and a woman for the mother-in-law interviews. Interviews with the husbands were conducted in their homes, while mother-in-law focus group interviews were conducted in ‘community centers’ to accommodate the group. Both Muslim and Hindu family members participated; almost a quarter (23 per cent) of the husbands who were interviewed were Muslim while a third of the mothers-in-law(one focus group) were Muslim. Two-thirds of the husbands lived in a nuclear household. The husband sample mirrored the basic demographic characteristics of the woman participants. Focus group discussions with mothers-in-law were conducted according to area of residence (block), and one focus group was conducted in the block where most Muslims lived.

Political-Economic Spaces

In 2001, 13.8 million people lived in the national capital territory of Delhi.⁹ An astonishing number – more than 45 per cent – lived in jhuggi-jhopri communities or other unauthorized and unplanned settlements.¹⁰ In the particular squatter settlement where I worked, 50,000 people lived within four square kilometres. Resources and sanitation were inadequate. Untreated sewage and other garbage accumulated in open spaces contaminating the water where livestock slacked their thirst and, during the monsoon floods, where children played to escape the heat. These conditions enabled the spread of infectious diseases, including cholera. Drinking water was available at block hand pumps; however few blocks had working pumps. Furthermore, water was available only twice a day due to the times when electricity was available for pumping water. The result was long lines at working water pumps, as women and often children waited in queues to fill multiple containers. The daily organization of time was heavily structured around the sources of water and served to emphasize the precarity of life in the jhuggi-jhopri. In the summer, when water and electric shortages were particularly problematic, the Government of Delhi sent water trucks to provide residents with water. Within the settlement, there was the odd food store, as well as a meat market within the Muslim block. Just outside this squatter settlement, both food and health resources were available. There was a small produce market, consisting of about ten vendors, in addition to the roving produce vendors. Government stores providing dairy and staple grains (the latter called ‘fair price shops’, described in more detail below) were also within a couple of blocks. Both voluntary non-governmental and private health care clinics were located on the outskirts of the community. Dispensaries, or pharmacies, providing both allopathic and Ayurvedic medicines were within walking distance. Furthermore, unauthorized health practitioners (i.e. those without recognized qualifications) were practising both within and outside this community. Thus in this particular jhuggi-jhopri settlement, there was a relative plurality of resources. Arguably the most restricted access was for water. A variety of food and healthcare options existed, although access was of course limited according to financial means.

Those living in the marginal poverty of the ad-hoc social and economic space of the jhuggi-jhopri are particularly vulnerable to challenges arising from changes in the political-economic socioscape. One of the major impacts on the provision of government social services has been the implementation of structural adjustment programs (SAPs), which began in India in 1991, with further economic liberalization ensuing in 2001. India’s debt burden in 2001 accounted for 20 per cent of the gross national product.¹¹ Countries that borrow money from international lending agencies, like the International Monetary Fund (IMF) and World Bank divest themselves of power over macroeconomic policy and are required to follow specific loan conditions, designed to ensure a return on the investment for the lenders. These conditions include tightening of government budgets (with resulting cuts in social services), exchange rate adjustment, deregulation, privatization, and an increased shift towards an export-oriented economy. Such economic policies can have severe consequences for the poor. The negative consequences of such policies from the perspective of those living at or near poverty has been documented not only in South Asia, but throughout the world.¹² Here, I summarize¹³ how healthcare and food security affected the lives of individuals in one locale. I hope to contribute to a person- and family-centred understanding of the global and local dialectic of poverty, policy and agency.

The foundation for health services in independent India was based on the Bhore Committee’s (1946) report, which recommended universal health coverage, provision of healthcare to rural areas through primary care centres, outlined plans for dealing with diseases and population growth, and inclusion of non-biomedical practitioners in the health system.¹⁴ A number of committees were formed thereafter, including the Jain Committee (1966), the Kartar Singh Committee (1974), the Srivastava Committee (1975), and the ICMR-ICSSR Joint Panel (1980), but all emphasized the importance of universal health coverage.¹⁵ The core of such a health system was primary health centres, imagined not only as a means of provisioning health services to the masses, but simultaneously gathering information on local needs and issues that would in inform future national health policies and programmes.

This feedback system of incorporating local voices in national policies is not isolated from the influence and agendas imposed by SAPs and donor agencies. Even before implementation of SAPS, neoliberal international development policies of the 1980s shaped healthcare in India through changes in funding donor agencies and their priorities. The major funding sources for health programmes became the World Bank and the Asian Development Bank, as opposed to country- or religious-based aid organizations.¹⁶ This shift in funders resulted in changes in health policies and priorities, including alterations in which diseases get funding, as well as reallocation of funds from services and infrastructure towards training, supplies and research.¹⁷ In light of these changes in funding and priorities, it has been argued that health sector reforms ‘have become instruments to promote markets rather than a means to improve the health sector and ultimately, health’.¹⁸

Following implementation of SAPs conditions in 1991, the Government of India diminished its grants to state governments for the health sector by 6.7 per cent and by 2001, national government expenditure on public health services accounted for only 0.6 per cent of the gross domestic product.¹⁹ The arguable outcome is heavy reliance on the private and voluntary sectors – and this has substantial ramifications for families living at or near the poverty line, such as inequitable access to care (e.g. many private facilities congregate in spaces serving wealthier clientele while voluntary facilities are dependent on potentially insecure donor funds). The push towards increased reliance on voluntary and non-governmental organizations has also been supported by the World Bank.²⁰ It was estimated that approximately 7,000 voluntary organizations provide health services in India.²¹ State governments that are financially unable to continue, let alone improve public health services, hand over responsibility for healthcare to non-governmental organizations (NGOs). Government control remains in that grants are provided to the organizations for their expenses and user fees may be fixed at state government levels in order to (attempt to) ensure universal access.²²

A key aspect to SAPs is the emphasis on exports in order to earn money to repay loans and for many countries including India, there is pressure to reallocate agricultural lands to produce commodities for export. Concurrently, hunger and malnutrition continue to be problematic.²³ The Public Distribution System (PDS) is the Government of India’s primary means of providing food security. The PDS supplies wheat, rice, sugar, edible oils and kerosene at subsidized rates to consumers via ‘fair price shops’. Because of the recognition that those in need were not obtaining access to foods through the PDS, it was revamped in 1997 to target the ‘poorest of the poor’. The central government allocates food staples to state governments according to a formula enumerating the number of families living below the poverty line (BPL), plus each state’s average need in the past ten years for families living above the poverty line (APL). Families who were BPL received 10 kg per month of wheat and/or rice at a highly subsidized rate.

While this description suggests substantial assistance for the poor, the reality was less auspicious. Since the introduction of the TPDS in 1997 until 2001, the Delhi government had not used any of its allotment from the federal government for BPL families.²⁴ Fair price shops charged higher prices than those fixed by the Government, so in Delhi, in contrast to the national PDS subsidized prices for rice and wheat of Rs. 6.1 and 4.65 per kg, average prices for these two staple foods were Rs. 10 and 9 per kg respectively.²⁵ Furthermore, the allocation of 10 kg per BPL family was irrespective of family size – and larger families are more often poorer than families smaller in size.²⁶ In fact, it is argued that the PDS throughout India has been weakened in the 1990s in large part due to implementation of liberalization policies. Evidence for this is the decrease in tons of food grains distributed (the highest distribution was in 1991), and the reduced price differential for grains between fair price shops and open markets.²⁷

The Government of India is responsible to the people of India but must also balance this against its obligations of loan repayments. To provide more social assistance would cos...