A video report on the milk bank at Mumbai’s Lokmanya Tilak Municipal General Hospital, popularly known as Sion Hospital. It gets donations from nearly 40 mothers every day and the milk benefits 3,000 babies every year. According to doctors, breastfeeding within the first hour of birth is one of the measures to fight infant mortality.
This report was aired on NDTV’s Every Life Counts campaign, supported by the Gates Foundation
Inside a community centre at Mumbai’s Dharavi slum, Umair Khan teaches a group of young boys the difference between good and bad touch.
The 20-year-old is a community organiser with Sneha – Society for Nutrition Education and Health Action. He works with the NGO’s youth programme Ehsaas which, since 2013, has reached out to over 6,000 adolescents and youth between the ages of 15-24 in Mumbai’s slums.
“Like girls, boys too are victims of sexual abuse,” says Mr Khan. “But boys rarely speak about it as they feel ashamed,” he adds.
As a young boy, Mr Khan experienced abuse. “The abusers were older boys in the neighbourhood. I was scared that I would be targeted again and it took me years before I spoke up. I don’t want anyone to suffer the way I did,” he tells NDTV.
At over 243 million, India has the largest adolescent population in the world, as per UNICEF’s 2011 report. However, down the decades, the focus of government programmes has been early marriage and early pregnancy, which is centered on young girls. Boys have been largely left out.
The National Family Health Survey (NFHS)-3 makes a compelling case for interventions among boys. Over 50% of boys between 15-24 years are in the labour force as per NFHS-3 data, while over 80% are married. One out of every five boys between 10-19 years is illiterate.
Over the years, there has been a growing realisation that there is an urgent need for specific interventions among young boys and men who too are victims of rigid gender norms. They struggle with notions of what constitutes a real man.
Being sexually active with various women is seen as a cultural sign of virility and the fallout is a lack of understanding of women’s rights.
Research has shown that men are also victims of many forms of violence, primarily at the hands of other men, and stand to gain from moving towards gender equality.
“Adolescent boys commit sexual crimes because there is a lack of appropriate orientation on sexuality and about matters like consent,” says Neeta Karaindikar, Associate Director, Ehsaas.
“Our films and advertisements show women in a very poor light and boys look at them as item numbers. We have to change this by working with the next generation, to make them see women as equal partners,” she adds.
Ehsaas does this through a mix of street plays and community meetings with adolescents and their families.
“Before I joined Ehsaas, I expected my sisters to do the household work,” says Shahid Shaikh, a community organiser.
“Now I know differently. We teach young boys to question stereotypes that allow boys to play outdoors but force girls into doing household chores. Gradually we are seeing a change,” he adds.
An impact report done six months after Ehsaas was launched in Dharavi has shown positive signs. Over 70% of boys and girls said that both genders should have equal freedom; nearly a 20% improvement.
Reaching out to boys comes with many challenges, as Pravin Katke, a coordinator with Equal Community Foundation points out. The foundation reaches out to boys between 14-17 years from low-income communities in the slums of Pune.
“In the areas that we work in, there is a high rate of school dropouts. There is also a tendency towards risky behaviour and addictions,” adds Mr Katke.
Through interactive sessions and games, the foundation tries to find out what is going on in the boys’ lives and the gender dynamics in the families.
“We have a curriculum where we talk about gender equality, violence, relationships, sexuality and adolescence,” says Mr Katke.
“We raise different situations and discuss their responses,” he adds.
To facilitate a larger change in the mindset, peer educators also meet with the parents every few weeks.
To prevent violence against women and build gender equality, one has to go back to the homes and communities where boys are raised, believes William Muir, co-founder, Equal Community Foundation.
“Boys across all environments are learning that successful men earn money and command respect through aggression and violence,” says Mr Muir.
“When you help them reflect on whether those messages are right or fair, they will start taking their own steps. The goal ultimately is to ensure that every boy is growing up in an environment where they are learning gender equality and in Pune, we are building that model,” adds Mr Muir.
When her son Hassan was born at 28 weeks, Saba Khan was told the baby had slim chances of survival.
“He was very weak and was rushed to the paediatric ICU. He stayed there for nearly 20 days and the doctor told me it would be nothing short of a miracle if he made it alive,” says Ms Khan.
To make matters worse, Saba was very weak and could not nurse her baby. Babies, like Hassan, who are born premature, have higher chances of recovery if they are given mother’s milk.
Luckily for Saba, Hassan started recovering quickly as he given milk from the mother’s milk bank at Lokmanya Tilak Municipal General Hospital in Mumbai. From 1.2 kg at birth, Hassan gained up to 1.8 kg within three weeks and was declared out of danger.
“The milk saved his life,” says Saba. “He is gaining weight and now that I have recovered I am able to nurse him in addition to the milk from the bank.”
Started in 1989, the milk bank at Lokmanya Tilak Municipal General Hospital, popularly known as Sion Hospital, is Asia’s first and largest such bank. It gets donations from nearly 40 mothers every day and the milk benefits 3,000 babies every year.
According to doctors, breastfeeding within the first hour of birth is one of the measures to fight infant mortality.
“Mother’s milk is a complete food. It is nutritionally optimal and protects the babies from different diseases,” says Dr Jayshree Mondkar, who heads the milk bank at Lokmanya Tilak Municipal General Hospital.
Most of the banked milk is given to the babies who are either underweight or to babies who are transferred from other hospitals with jaundice.
Dr Mondkar says there are many situations when the mothers are unable to nurse their infants after birth. In such a case, the milk from the bank is the next best option.
“We have as many as 14,000 deliveries in a week and mother’s milk is only an interim measure,” she says.
Before the milk is collected from the donor mothers, their blood reports are checked for any infections. Good care is taken to ensure that milk is collected hygienically, pasteurized and stored under the correct conditions. The banked milk can be stored for six months but is typically used up in 15 days.
“We tell the donor mothers why we are using the milk and how it is vital to keep another baby alive,” says Sister Sunanda Suryavanshi, a lactation management nurse at Sion Hospital.
“Even if there is some initial hesitation, all the mothers agree to donate when they hear that,” she adds.
A two-year-old app is helping women in Asia’s largest slum, Dharavi, to stand up against domestic violence. The Little Sister app, working in 3 languages, is helping women report instances, however small, and get help.
Home to a population of over one million, Mumbai’s Dharavi sees many such cases, say the women who are part of the initiative started in 2014 by a non-profit, SNEHA – the Society for Nutrition, Education and Health Action.
“Physical abuse and sexual violence is most common,” said Rashida, a sangini or worker in Little Sister.
Violence against women is listed as one of the top 10 reasons of death for women and domestic violence, also known as intimate partner violence, accounts for five in 10 reported crimes against women in India. Even so, many cases go undocumented, and various studies show nearly seven out of 10 women in India have suffered some form of domestic violence.
A report released last year by Population Reference Bureau, a Washington DC-based think-tank, said India — along with Nepal, Pakistan and Sri Lanka – shows a very high rate of violence, with one in three women reporting sexual and/or physical violence, mainly from a partner.
One of the many reasons why domestic violence goes unreported is because it has cultural sanction. “Everyone, including the mother-in-law, thinks the man has rights over the woman’s bodies, regardless of her feelings,” said Rashida.
“We recently counselled a woman who had been beaten by her husband for 22 years, right through their marriage,” added Saira Shaikh, another Little Sister sangini. “She kept thinking it was OK because her husband was providing for the family.”
Married twice, Rashida was abused both times. She finally found the courage to walk out when she nearly died after consuming poison in a fit of despair. “While in hospital I realised that by suffering violence, I was damaging my children.”
These are not easy decisions for any woman, especially those who are poor, uneducated and lack family support.
This is where the app greatly helps, believes Rashida – its biggest advantage being that women can express their pain in safety and secrecy, until they are ready to speak out.
Registering instances on the app gets immediate response.
Depending on what she wishes, the sanginis contact her and provide counselling. In case of physical violence, they can even contact the police and hold family counselling sessions.
“The project was designed to mitigate under-reporting of violence by providing a tool for women to record instances,” said programme coordinator Damini Mohan. “Most cases are reported to authorities as a last resort, when the violence has severely escalated. It helps us capture instances of violence at an early stage and helps us prevent its escalation.”
Since it was launched in June 2014, Little Sister has recorded 1,062 cases of domestic violence, compared to 200 cases recorded in 2013-2014.
While there are laws against domestic violence, what is not widely understood at the policy level are the health consequences, doctors say.
Women who suffer domestic violence are twice as likely to suffer from depression and about 50% more likely to become HIV positive. Other outcomes are post-traumatic stress disorder, gastrointestinal infections, suicide, and chronic pain. It is also linked with higher risk of unintended pregnancy that compromises maternal, infant and child health.
“Whenever there is violence, physical or otherwise, the physical impact shows up in the form of scars but the impact, internally, is 25% more,” said Praful Kamble of SNEHA. “There is depression, a sense of shock and a major impact on children who witness it. Even verbal abuse can affect pregnancy outcomes.”
This article was published on the NDTV website. To view the video report click here
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.
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.