Amidst the stream of news reports on the severe drought across India, here is one that didn’t make it to primetime.
It’s the story of Yogita Ashok Desai from Maharashtra’s Beed district who died of a heat stroke. The 12-year-old was dehydrated and collapsed after her fifth trip to the village hand-pump to fetch water. Just last month, a 10-year-old girl from Pimpalgaon village, also in Beed district, died after she fell into a well while trying to draw water.Both girls had been pulled out of school to help their families cope with the severe water scarcity.
The reasons for the worsening drought are many; many of them manmade like the indiscriminate digging of borewells and the cultivation of water guzzling crops. Decisions that women had little to do with. excluded as they are from choices relating to irrigation systems or what crops to grow. However, they are facing the worst impact.
A recent World Bank report, Shock Waves – Managing the Impacts of Climate Change on Poverty, highlights how ending poverty and addressing climate change is key to achieving sustainable global development. Addressing climate change is critical as it directly impacts availability of food and heightens health risks.
Most vulnerable are the poor and marginalized, and within that group, women and children. There are various studies that show that women, especially in developing countries like India, suffer the impacts of natural disasters and climate change more due to cultural norms.
In rural areas, women rarely work and are economically dependent on their husbands for survival. Faced with a severe drought, men have the resources and the independence to find ways to adapt. Women are denied those options.
Faced with a shortage of food, women place their husbands’ and sons’ needs above theirs or their daughters’, making them vulnerable to diseases.
Faced with income or food crunch, girls’ get hit the hardest. They get pulled out of school and are expected to help with the household chores. Their nutrition and health gets neglected. Climate change also affects availability of water. Women and girls’ are expected to fetch water for the family, often traveling long distances to do so.
As Rachel Yavinsky points out in her 2012 study, their secondary role and lack of decision-making power severely limits women’s ability to adapt to climate change.
“Without participation by women, programs to replace traditional crops with those better suited to the changing environment might focus only on the needs of men’s fields and not address the problems women face with household gardens’, says Yavinsky.
She points to various studies that demonstrate how women can be effective agents of adapting to climate change if equipped with information and power. In Bangladesh, for instance, women farmers switched to raising ducks because they kept losing their chickens to frequent floods.
Empowering women, especially rural women, is necessary to address climate change effectively. Climate change will affect all os us, most of all women, and unless we empower them, building a sustainable future will remain a distant dream.
“We get pushed around and treated like garbage because there is no one to speak for us,” says Chandni, the 18-year-old editor of India’s only tabloid paper produced by street-children journalists, Balaknama (Hindi for “voice of children”).
Like all editors, Chandni’s biggest challenge is to decide which stories will make it to the front page, and managing the egos of those whose stories don’t. “As editor, I want to play up stories that are most impactful,” says Chandni. “But many reporters get upset when their stories don’t make the mark. So, yes, I do have to tread carefully.”
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The monthly newspaper has a team of 60 reporters between 12 and 20 years old and is based in Delhi and neighbouring states of Haryana, Madhya Pradesh and Uttar Pradesh. Most of the street-children reporters were recruited from learning centres run by NGOs the Federation for Street and Working Children (Badhte Kadam) and the NGO Childhood Enhancement through Training and Action (Chetna), which started Balaknama in 2003.
A lot of time is spent on writing the stories. “Many of our reporters started school after joining the paper so writing is a struggle for them,” says Chandni. The copy is written in Hindi and later translated into English.
Each paper is priced at a token 2 rupees and over 8,000 copies, most of them in Hindi, are published every month. Many of them are distributed free to police stations and NGOs working in the field of child rights. The paper makes no profit and is entirely NGO-funded.
Regardless, the sense of pride and accomplishment is evident.
“We filed a report on how the police was forcing children living in railway stations to retrieve the bodies of people who were killed on the tracks,” says Shambhu, 20, a senior reporter. “Imagine forcing a child to go down those dangerous tracks and retrieve bloody, mangled limbs!”
Mainstream news outlets picked up Balaknama’s report and it led to a huge outrage. Eventually, the National Committee for Protection of Child Rights stepped in and action was taken against the police.
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An estimated 51,000 children live on Delhi’s streets, some as young as five-years-old. They make a living by begging or rag picking and are subject to verbal, physical and sexual abuse. Many are abandoned by their families or have run away from home.
Twelve-year-old Rustam is one of the lucky ones. He lives with his construction-worker parents but, like his three brothers and sister, missed out on school because he had to supplement the family income.
He started feeding Balaknama reporters stories last year and got a front-page splash when he alerted a senior reporter about a child marriage in June 2015. He was taken aback by what followed. “Local activists held protests and the police were forced to step in and stop the marriage from taking place. I became known in my neighbourhood and my parents felt so proud,” he glows.
For nearly a year now, Rustam has stopped begging and studies at a learning centre. He is paid a small fee for every story lead that he gives.
This feeling of empowerment is what Balaknama wants to foster among street kids. It does this by highlighting, not just the difficulties they face, but also stories of hope.
Positive reports about street kids who return lost items or help get back stolen goods get prioritised. “Street children feel worthless and hated by the world and we are trying to change that,” says Sanno, 20, a former Balaknama editor, who now advises the team.
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Balaknama also looks at larger policy-level issues. The paper campaigned to get street kids in Delhi national identity cards called Aadhar, which give proof of residence and when available, date of birth.
The paper has recently been focusing on the implications of the changes to the Juvenile Justice Act that allows children between the ages of 16-18 years to be tried as adults for crimes like rape and murder. The amended act has been criticised by child rights activists who say it could be misused to implicate innocent minors and that it would undermine the aim of reforming juvenile criminals. Balaknama has taken a strong position on the issue.
“Many street kids don’t have families,” says Chandni. “They don’t even know their date of birth and they have become vulnerable now. A 15-year-old can be turned into a 19-year-old.” She believes it’s a sign of how much farther they have to go to make India’s estimated 400,000 street children visible to those who matter.
“When authorities talk about children’s rights, they are looking at school-going children, with homes and families. No one is looking at the child living on the streets, or labouring inside homes and hotels. They still don’t exist.” Balaknama is determined to change this attitude by enabling street children to tell their own stories, in their own words.
This article was published in The Guardian dated April 14, 2016
That the Indian government is thinking on the lines of imposing a tax on sugary drinks and junk food is welcome news. Given the alarming rise of diabetes in India, there is active intervention needed to control the rise.
A WHO report says that the number of people with diabetes in India is likely to cross 101 million by 2030, while Lancet published a study just a day before World Health Day that said there has been a fourfold increase in the number of diabetics from 1980 to 2014 – from 108 million to 422 million. It ranks China, India and the US are among the top three countries with the most number of people with diabetes.
Prevalence has more than doubled for men in India and risen 80% among women. While the incidence is higher in urban areas with states in the South reporting especially high rates, what is worrying is the rise in rural India, a result of rapid urbanization.
Of special concern is Gestational Diabetes Melitus (GDM), which remains neglected in India and has a severe impact on child and maternal health. G
DM is linked to hypertension, eclampsia and obstructed labour, and is among the leading causes of maternal deaths.
India has one of the highest rates of GDM in the world, with over five million women affected every year. While the worldwide prevalence figure is 15%, in India it is 22 to 25%.
The increasing prevalence of GDM is linked to growing urbanization, reduced levels of physical activity, and changes in dietary patterns and rising obesity
Women with gestational diabetes are also more likely to develop Type 2 diabetes in the future and therefore special attention needs to be paid to this population in India.
A 2013 study by the Kerala-based Achutha Menon Centre for Health Science Studies found that women diabetics are even more vulnerable as they cannot abandon their role of looking after the family and are expected to put the health of other family members above their own. This leaves them with far less time and resources for their own health.
One major reason for the rapid rise in India is lack of awareness. A 2012 study by the Brussels-based International Diabetes Federation found that over 60% of diabetics in India had never been screened or diagnosed because of this, while over 63% were unaware of the complications that arise from the disease.
A combination of food patterns, sedentary lifestyles, obesity and genetics makes Indians more vulnerable to diabetes. It is time we acknowledge that and tackle the problem at a war footing.
Apart from nationwide screening programmes, early detection and treatment must become a part of primary health services. Awareness has to be created about dietary habits as well, with greater emphasis on fiber rather than sugar and starches.
From April this year, injectable contraceptives will be available in district hospitals across India.
At the recently held International Conference on Family Planning in Bali, top health ministry officials from India said that they were determined to meet their stated target of providing 48 million women with access to contraceptives by the year 2020.
In 2012, at the London Summit on Family Planning, India had pledged to commit almost $2 billion dollars until 2020. As a result, today more women and girls have access to family planning. In 2013 alone, three million additional women and girls in India were equipped with the tools and the information needed to choose a modern contraception method.
To fulfil this goal of 48 million, the government will increase the basket of contraceptive choices offered to women, and promote spacing between births. Apart from injectables, this will include Centchroman, a non-steroidal agent, and POPs or progesterone only pills.
Centchroman, marketed as Saheli, is a once-a-week oral contraceptive that acts on the hormones produced in the body, especially progesterone. POPs thicken the mucus in the cervix, stopping the sperm from reaching the egg.
“We are determined that no woman should be left behind and no partner be left behind,” said C.K Mishra, Mission Director, National Health Mission.
Phase 1 results from the fourth National Family Health Survey or NFHS-4 for 2015-16 that covered 13 States and two Union Territories are quite promising with total fertility rates or the average number of children per woman dropping considerably, ranging from 1.2 in Sikkim to 3.4 in Bihar.
All states in this phase, except Bihar, Madhya Pradesh and Meghalaya have either achieved or maintained replacement level of fertility and this is a major achievement in the past decade.
However, what remains problematic is the female sterilisation rate, which at 34% is very high. Health officials hope to bring down the numbers by offering more contraceptive choices and improving service delivery.
“All along there has been greater emphasis on terminal methods of family planning and we have not given spacing the attention needed,” said Mishra. “The goal ahead is to focus on adequate spacing”.
Also of concern is the total unmet need for contraception in India, which at 21.3% is the highest in the world. Bringing down the unmet need was a key Millennium Development Goals target that India was unable to meet.
A high unmet need for contraception translates into a high number of unintended pregnancies and has tremendous health implications. India accounts for 19% of the world’s maternal deaths and meeting the need for contraception is critical to saving lives.
“Today more girls and women have access to contraception but we are still 10 million behind in terms of what the figure should be,” said Chris Elias, president of the Global Development Program, Bill & Melinda Gates Foundation, while speaking to a group of journalists on the sidelines of ICFP 2016.
Last November, the Gates Foundation had announced that it would invest an additional US$120 million in FP programs over the next three years to meet the Family Planning 2020 goal of giving 120 million additional women and girls’ access to contraceptives.
“If there is spacing, half of the lives lost would be saved. Women should be able to decide when they should have babies,” believes Elias.
Health ministry officials in India seem to be moving forward in the right direction. However, there is quite some distance to travel before the revised plans are implemented, cautions Poonam Muttreja, Executive Director, Population Foundation of India.
“Apart from issues like inadequate budget allocation, the bigger challenge India faces is wide disparities and inequities in women’s access to healthcare and family planning. Access to health services still depends upon where one lives, how educated one is, and economic and social status”, says Muttreja.
Clearly, the approach will have to go beyond simply making these choices available at various health centres. “It is not just about making the full range of methods available,” says Elias. “Women have to be empowered to make those choices”.
Every morning I would take a broom and tin plate to the homes of the upper caste thakurs to pick up their faeces. I would collect the waste in a cane basket and later throw it in a dumping ground outside the village.”
As you watch a confident Ranikumari Khokar educate a group of boys and girls on how to file a police case, it is hard to imagine that this 21-year-old spent most of her adolescence working as a scavenger.
Today she is a “barefoot lawyer”, an initiative started by Jan Sahas, an NGO that has been campaigning against the practice of manual scavenging for 12 years. Since the launch of the programme in 2014, 800 girls and young women have been trained in the states of Madhya Pradesh and Rajasthan.
A caste-based role, manual scavenging condemns mostly women to clean excreta from dry latrines with their hands and carry it on their heads to dumps. Men from the community clean open gutters and sewerage lines, often with no protective gear.
Derogatorily called bhangis, which means “broken identity,” most of the scavengers are dalits, ranked lowest in the caste system and expected to carry out tasks regarded as beneath the dignity of those higher up in the hierarchy.
“We were looked down upon by the villagers,” recalls Ranikumari. “They would never walk with us. At the village well, we were made to wait at a distance until everyone else had filled up.”
Even worse was the discrimination in school. “The teachers would call us bhangans [children ofbhangis] and expect us to clean the toilets and the classrooms. We sat apart from everyone else and were never given a chance to participate in school functions,” adds Ranikumari.
Caste-based discrimination or untouchability was banned in India in 1955 and down the decades several policy measures have been announced to end the inhumane custom of manual scavenging. Article 17 of the country’s constitution clearly abolishes the practice, while the 1993 Dry Toilets Prohibition Act forbids the employment of manual scavengers.
But none of these policies have been effective because manual scavenging was categorised as a health and sanitation issue, a responsibility implemented by state governments. Many states like Delhi and Rajasthan did not even bring the policy into force, and those states that did showed little will to enforce it on the ground. People remained unaware they had the right to refuse this role. The few who dared to came under intense social pressure, and received no support from local government officials. They risked violence and eviction.
The International Dalit Solidarity Network, which works towards ending caste-based discrimination, estimates that there are about 1.3 million manual scavengers in India, most of them women. These women are victims twice over: looked down upon by the upper castes and discriminated against within their homes.
“People from my village would walk far away from us as if we gave out a smell they could not bear,” says Mayu, a resident of Sava village, Rajasthan. “We were made to draw water from a well in which dead animals and birds were found and if anyone gave us any food, it would be thrown in our direction. Even my husband would tell me to bathe many times because I was cleaning other peoples’ shit although he had no problem eating the rotis I brought home.”
It was these attitudes that Jan Sahas had to battle when it started its campaign in 2003.
“They were socialised to believe that they have to be low caste,” says Aashif Shaikh, the founder of Jan Sahas. “They would tell us ‘this work has been given to us by god and we are at an advantage as we get food’. The reality was that they were being treated worse than animals.” Because they were rarely paid in cash, they were dependent on the upper castes for the basics – food, clothing and shelter.
Jan Sahas started working in two villages in Rajasthan. It would take nearly two years before they were able to convince the community to put down their brooms. The gamechangers were the children, especially girls.
“The girls were determined to end the practice,” says Shaikh. “They were deeply unhappy about the discrimination they faced in schools so we would make them speak at our meetings.”
But there was fierce resistance from the upper castes; some Dalit homes were even burned down. The local police refused to act and it was only after district level officials intervened that action was taken.
Since 2003, Jan Sahas claims to have liberated more than 21,000 women in Madhya Pradesh, Bihar and Rajasthan. These women have become ambassadors for the movement and it was their countrywide agitation in 2013 that led to the Indian parliament enacting a new, stronger law against manual scavenging.
Those who employ manual scavengers face a one-year prison term and a fine of 50,000 rupees (over £500). For repeated violations, the prison term is two years and a fine of 100,000 rupees (£1,000).
Stronger penalties apart, the Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013 makes it mandatory to rehabilitate rescued manual scavengers. They now get 40,000 rupees (over £400) as compensation from the government and get trained for alternative employment.
Many women now work in government-funded construction projects and small factories. Others have enrolled in community initiatives started by NGOs that offer training in skills like tailoring and embroidery.
Changing minds, however, remains a challenge as caste-based discrimination is still deeply entrenched in Indian society.
“You can change your religion in India but you cannot change your caste,” says Shaikh. “You hear of people converting to another religion but their caste remains the same, and this is true for even Muslims and Sikhs although neither religion has the caste system. Even politics runs on the basis of caste.”
The way forward, activists believe, is to educate the younger generation, who are open to change. The barefoot lawyers initiative, which trains men and women from all communities, is a step in that direction.
“I go to different villages and educate the youth about laws relating to caste discrimination, sexual assault and rape,” says Ranikumari. “I even speak to school authorities if I hear complaints of discrimination. As a child I could not speak up for myself but now I have a voice.”
At the recent International Conference on Family Planning, Indian health ministry officials committed to make available better quality family planning services and expanding contraceptive choices. How much of that will translate into action will depend on the money allocated to health care in this budget.
India has promised to meet the FP2020 goal of providing 48 million additional women and girls in the country with access to modern contraceptives by 2020. Family Planning 2020 is a global partnership that is working with governments, civil society, donors and the private sector to enable 120 million women and girls to decide for themselves, whether, when, and how many children they want.
Reaching 48 million, however, seems like a tall order. India spends just 1.3% of the GDP on health care, which is lower than other countries. China, for instance, spends 2.8% and South Africa 4.1%. Budget 2014-15 saw an 87% drop in funds allocated to family welfare and this was reduced even further by 34% in 2015-16.
The low priority is baffling given that India has among the worst maternal and infant mortality rates in the world. The role family planning plays in achieving broader development goals, including poverty reduction has been well documented.
Population Foundation of India figures show that 46% couples in India do not practise family planning, About 21% of births every year are unplanned, due to lack of access to contraceptives. The cost of unplanned children, according to a PFI study ranges from 2% of state GDP in Tamil Nadu to 14% in Bihar.
In this context, the Health Ministry’s decision to introduce injectable contraceptives in government health centres is a welcome move. The decision was pending for nearly 15 years due to protests from many women’s rights groups. It also plans to promote spacing methods and improve quality of care.
“Meeting the FP2020 goal would need an investment of approximately Rs 13500 crore over seven years (2014 to 2020)”, points out Poonam Muttreja, Executive Director, Population Foundation of India. An additional Rs 11,150 crore would be needed over the next four years, which is Rs 2800 crore per year, adds Muttreja.
Supplying injectables alone will not is be enough say experts. The government needs to rethink its approach towards family planning.
“If you are talking of FP2020 goals, a lot depends on involving men”, says Ashok Dyalchand, Director, Institute of Health Management in Pachod, Maharashtra. “Not enough has been done to involve men and you have a significant proportion of women using contraception without their husbands’ knowledge.”
“The emphasis has been largely on methods for women historically”, adds Muttreja. “The public health system, FP programmes and communication strategies have to change to encourage male engagement”.
For decades India has depended on female sterilization as a means of contraception. It conducts the highest number of tubal ligations – nearly five million in a year. Data from the first phase of the National Family Health Survey (NFHS-4) shows that female sterilisation accounts for 34% of modern contraceptive methods, while less than 1% men go for a vasectomy
One of the main reasons for the low prevalence are the many myths and misconceptions relating to vasectomy says Emily Jane Sullivan from the London School of Hygiene and Tropical Medicines.
“A tubal ligation is a more complicated, costly, and risky procedure than vasectomy”, says Sullivan. “However, in India, more than 1 in 3 women choose to have a tubal ligation while only 1 in 100 men choose to have a vasectomy.”
Countries like Bhutan, Brazil, Nepal, and Rwanda have countered these myths effectively through campaigns that frame men who choose vasectomy as responsible and caring towards their families.
“There is an opportunity for these countries to share their ‘lessons learned’ with other national family planning programs that are looking to thoughtfully, ethically, and effectively promote vasectomy”, says Sullivan.
India needs to look at similar approaches instead of simply adding more to the basket of choices say experts.
“The only addition to the basket is injectables. We do not have male contraceptives. I am in favour of injectables but whether diligence will go into administering it in the government sector is a concern. There is also the question of a strong provider preference towards tubectomies”, cautions Dyalchand.
For decades India has followed a targets and incentives based approach towards family planning. Achieving the FP2020 goal involves a shift away from that. It is not just about technical solutions or contraception, but also about women’s agency, choice, quality of reproductive health services and dignity.
Thie article was published in The Indian Express here.
The fear and panic over the spread of the Zika virus disease has helped highlight the inadequacies many countries face in providing family planning and reproductive health services. The outbreak may be far from India’s shores, but those lessons hold true for us as well.
Zika has been declared a global public health emergency. There are fears, not entirely proven, that it is linked to birth defects in babies whose mothers contract the virus during pregnancy. Over 3000 cases of microcephaly—an oddly small head and an immature brain—have been reported in Brazil.
Given that the virus is spreading rapidly, with no proven vaccine in the horizon, women who are pregnant, or are likely to become pregnant, are in a spot.
In many of the countries affected, abortion is illegal. In some regions, contraceptives are in short supply. But going by the statements coming from political leaders, the onus seems to be entirely on women.
In El Salvador, women have been told to postpone getting pregnant for up to two years. How will they given that it’s not always accessible?
The public health system in many of these countries is in a poor state, much like in India. Rural areas, which are understaffed, are worse off. Again, much like in India. There is also great stigma attached to contraception.
Like India, the societies in many Latin American countries are deeply patriarchal. Cases of rape, including marital rape, are high. So where is the question of women exercising the choice to not get pregnant?
Zika is already out of the headlines, swept away by another crisis in another part of the world. But the outbreak has thrown up relevant questions. Like the need to build a strong public health infrastructure, make available a range of contraceptive choices, and most important, empower women to exercise those choices.
This article was published in the blog healthyurbanworld here.