May You Be the Mother of a Hundred Sons (48 page)

IN ANOTHER PART OF BHARUCH DISTRICT, ABOUT AN HOUR’S DRIVE FROM
where A. P. Christian made her rounds, two Gujarati doctors, a husband and wife, were running an unusual project directly challenging the Indian government approach to population control that I had just seen. Based at a forty-bed hospital in the village of Jhagadia, this voluntary program was described by numerous experts as family planning at its best. It had won an award from the World Health Organization, a grant from the U.S. Agency for International Development and, most significant, the attention of the Indian government. The project was called SEWA Rural—the Society for Education, Welfare and Action, and was no relation to Ela Bhatt’s SEWA in Ahmedabad. (SEWA was a popular acronym for rural-development groups across the country.)

This SEWA was the child of a group of seven Indians who had
known each other in the United States, chiefly a married couple, Anil and Lata Desai, and a friend of theirs, Dilip Desai. Anil and Lata Desai had met at medical school in India and then worked together at Brooklyn Jewish Hospital in New York. Inspired by the charitable works of the Hindu religious leader and teacher Swami Vivekananda, their plan had been to “earn and learn” in the United States and then return to work among India’s poor. In 1980 they took over the hospital in Jhagadia and began working as doctors among the local tribal population in a way that few people had tried before. Four years later, the Indian government shut down its own health-care and family-planning operations around Jhagadia and turned the entire area over to SEWA Rural. In effect, the government was introducing a minor revolution by permitting a voluntary project to operate as a government agency, but almost entirely on its own terms. (Once SEWA Rural became an arm of the government, it did, however, have to agree to meet family-planning targets like everyone else.) By the time I visited SEWA Rural in the fall of 1987, the project had grown into a comprehensive rural health care program covering thirty-five thousand people in thirty-nine villages. Its success was best defined by its statistics. The infant mortality rate in the area covered by SEWA Rural had come down to 61 per 1,000 births, compared with a rate of 109 per 1,000 births in a neighboring area of similar size that was covered by the Indian government health services and where A. P. Christian, Dr. Gharia and their colleagues worked. (In the United States, the infant mortality rate at the time was approximately 10 per 1,000 births.) Most significant, SEWA Rural had brought the birth rate in its area down to 25 per 1,000; the neighboring area had a birth rate of 29 per 1,000.

SEWA Rural’s method was deceptively simple: provide good health care first, worry about targets later. The Desais believed that the way to bring down the birth rate was not, for example, to pressure women into sterilization operations, but to monitor them carefully through their pregnancies, provide good follow-up care for the children and then, and only then, raise the sensitive issue of birth control by sterilization. One advantage of this integrated approach of delivering family-planning information with health care was that a mother, confident that her children would be properly cared for, might not feel the need to have more children as insurance. This “integrated” approach was also the official policy of the Indian government, but the reality was different. The government was still heavily dependent on
health workers who were not from the areas in which they worked, and consequently the villagers did not trust them. Government health workers were also spread so thin that in many cases the only time they saw a mother was when they tried to talk her into sterilization, a situation that caused villagers to think that the government did not have their true health interests at heart. “They don’t go to see a woman when she’s pregnant,” Anil Desai said to me. “They only go to see her when they want her to have an operation.” Lata Desai, Anil’s wife, agreed. “They are so obsessed with the targets,” she said. “They don’t ask the health workers about the problems in the field.”

The biggest advantage that SEWA Rural had over the normal government health services in the rural areas was its resources. The forty-bed hospital was unusually large for the area and attracted people from four hundred villages. Private donations and grants from international development agencies allowed SEWA Rural to start additional projects, including a health outreach program that brought doctors and medicine directly to villagers by a mobile dispensary. The Desais also attracted a young, idealistic staff of health workers and doctors, some of them just out of medical school, who worked with a dedication that was rare in the government. But these advantages merely underscored the Desais’ original point that quality of care and grass-roots work among villagers built up a sense of trust that brought results. One by-product of the trust, I discovered, was the collection of accurate statistics. In 1982, when the Desais were relatively new to Jhagadia, they organized a group of students and medical interns to survey the area. That group arrived at an infant mortality rate of 102 per 1,000. But a professional research agency, working in the same area during the same period, came up with an infant mortality figure of 60 per 1,000. To resolve the discrepancy, the Desais commissioned another survey a year later, making an effort to be more thorough and careful in their data collection. The Desais were hoping that the infant mortality rate would have gone down after their year of hard work, but to their dismay it had gone up instead, to a new level of 173 per 1,000—far worse than the Indian national average. As depressing as this finding was, the Desais suspected that the new figure was correct, since it had been gleaned by workers who had built up relationships with those surveyed. They also suspected that the Indian government statistics, much more favorable but collected by outsiders, were hopelessly optimistic.

One night, I watched SEWA Rural put its philosophy in action
when I went along with the staff in the “mobile dispensary,” a van carrying doctors and medicine to people who normally would have had to walk miles for medical care. In rural India, where 80 percent of the country’s population lives, there is an average of only one doctor for every 15,000 people. The van pulled up about six in the evening at Ranipura, a village as dusty and drought-stricken as the others I had seen in Gujarat. Most of the doctors and health workers got out to tend to the people waiting at Ranipura’s small health center, another dark little building, but I went with a health worker and a doctor, Nankishore, to see people too sick to leave their homes.

Our first stop was along a dirt road, where a little boy and a little girl lay motionless on two charpoys outside their hut. Both were dangerously sick with malaria. On a third charpoy lay an old man—either their father or grandfather, I couldn’t tell—who was emaciated and wheezing from tuberculosis. Dr. Nankishore, a slight young man who had the earnest, cautious manner of someone just out of medical school, sat down on the charpoy alongside the old man, gave him chloroquine for the children, then made some notes. It was now so dark that it was nearly impossible to see, and the air had become heavy with the sweetly pungent smell of burning incense. Two oxen rumbled past, pulling their carts home from the fields, and in the distance I could see the flickering lights of small cooking fires.

Our next stop was to see a man with an oozing abscess on his thumb. Dr. Nankishore wrote out a prescription for antibiotics, told the man to go to the health center for the medicine and a tetanus shot, then moved on to check up on a mother who had recently given birth. She and the baby were healthy, so we quickly headed for another patient, this one on a far edge of the village. When we arrived at a sagging mud hut, Dr. Nankishore peeked inside and saw the outline of a young woman silhouetted against the flames of a cooking fire. When he called to her she came and leaned weakly against the door. Her face was only half lit from the fire inside, but I could see a pained, vacant look in her eyes. Her sari was dirty and torn, her hair tangled, and when she stepped out a bit from the door I could see that she was horribly thin. She began to cough and wheeze from deep in her chest. Dr. Nankishore told me she had pulmonary tuberculosis and then asked the woman to squat down in the dust by the door so he could listen to her chest with his stethoscope. Stepping away to leave the doctor alone with his patient, I wandered to the back of the hut and saw the view that the woman looked at every night: a flat, black plain, its bleakness broken
only by a few lights in the distance. There were stars in the sky, but it, too, was so black and enormous that anyone who lived under it must surely have felt small and defenseless in a world of disease and death. Feeling desolate, I walked back to the door of the hut. Dr. Nankishore had finished his examination and was asking the woman’s husband to get medicine for her. He wrote out a prescription, then headed back to the van, stopping first to see another young boy and a girl, these two with 105-degree fevers from malaria. “They will survive,” Dr. Nankishore assured me. “It’s amazing the kind of fevers that these people can tolerate.”

That morning I had seen another part of SEWA Rural’s outreach work when I went with Gayatri Giri, a supervisor of the health workers, to a meeting for village midwives, or dais. The meeting was held at another health center, this one in the middle of an arid plain ripped open by coal-mining fields. The dais had arrived by foot from across the barren landscape, all of them noisy and boisterous and dressed in the wildly colored saris—bright reds, blues, greens and pinks—of tribal women. Their ears were pierced in three places with big silver hoops, and they wore heavy silver bracelets on their ankles and wrists. With their leathery faces and gnarled, wrinkled hands, they reminded me a little of gypsies. They were at the bottom of India’s caste hierarchy, and, as often happens, their low status had freed them from repressive village traditions. They never bothered to veil their faces, they often spoke their minds, they drank and smoked, and many of them had two husbands. In that sense, they were among the most liberated women in India. On that morning, in fact, one of the dais was already drunk by the time of the nine o’clock meeting; this represented a considerable improvement over previous meetings, when all of the dais had arrived drunk. The problem was that the earlier meetings had been training sessions, held at SEWA Rural’s headquarters in Jhagadia, a two-hour walk for the dais, who had kept up their strength by drinking homemade liquor along the way. SEWA Rural finally decided it was easier to move the meetings closer to the dais, as they had on this morning, than to attempt to teach classrooms of drunken women the techniques of proper childbirth.

For thousands of years, dais had delivered all of the babies in India. In the 1980s, they still delivered most of the babies in the rural areas, using methods that were a grotesque distortion of the concept of folk wisdom. Katherine Mayo’s description of dais in
Mother India
(“dirty claws,” “vermin-infested hair”) is overwrought, but the situation has not changed as much in sixty years as might have been expected. Most
dais were untrained village women of the lowest castes, and as I have already described, many of them pushed on a mother’s stomach the moment she went into labor, risking rupture of the uterus. Dais often cut a baby’s umbilical cord with the nearest sharp implement, usually a dirty stone, knife or a sickle, and afterward smoothed the wound with cow dung, which they believed to be an antiseptic. Dais frequently told mothers not to give their babies milk until two or three days after birth, and also not to drink milk themselves during their pregnancies, since milk was believed to cause the baby to stick to the uterus during delivery. Dais further advised expectant mothers not to eat too much, saying that the baby would grow too big and not come out. Some dais told mothers that eating green vegetables caused miscarriages.

To counter these superstitions, and in an attempt to bring down one of the highest infant mortality rates in the world, the Indian government had in recent years sent trained midwives into the country’s rural areas to displace the dais. But many village women would have nothing to do with the outsiders, most of whom were unmarried young girls. “They don’t have babies, and the women won’t listen to them,” Lata Desai told me. “The dais have been in the community for years.”

In 1977, the government of India decided to train the dais themselves in the proper techniques of delivery and hygiene rather than attempt to replace them. SEWA Rural’s dai training program was more extensive than that of the government and was held once a week for a year. What I was attending on this morning was not a training session but a meeting to elicit information from the dais about expectant mothers and the couples who might be ready for family planning in their villages. SEWA Rural was forced to get the information this way because the woman who normally compiled such statistics had quit and not yet been replaced. While waiting for the meeting to begin, the dais sat down on the cement floor of the health center and directed questions at me. One asked if there were dais in my country. I told her there were midwives, but that most babies were born in hospitals. She then asked me why babies weren’t born at home in the villages, and I told her that people thought hospitals were safer, and besides, there weren’t many villages in the United States, and none like those in India.