Why India Needs Sex Education

In a country that reports high rates of teenage pregnancies and sexual abuse, one would think that the need for a curriculum focusing on gender equality, the importance of consent, and boundaries, would not be a matter of debate.

The reality, however, is that sexuality education for adolescents is a highly controversial topic in India. It is seen as offensive to Indian values, and concerns that it might lead to risky sexual behaviour and promiscuity.

Take the reaction when the central government in 2007 announced the launch of the Adolescence Education Programme in schools, along with the NACO, NCERT and UN agencies. Thirteen states called for an immediate ban as they felt that comprehensive sexuality education was against the Indian culture. Little has changed in the last 10 years. There is still a ban on Adolescence Education Programme in at least five states across India, and there is no uniformity in the way the subject is approached.

Sexuality education, as the UNESCO defines it, “provides opportunities to… build decision-making, communication and risk reduction skills about many aspects of sexuality…. encompasses the full range of information, skills and values to enable young people to exercise their sexual and reproductive rights and to make decisions about their health and sexuality”.

“The myth is that everyone is going to talk about sex”, says Dr Sunil Mehra, Executive Director of MAMTA Health Institute for Mother and Child which is hosting the 11th World Congress on Adolescent Health from October 27 to 29.  “In fact, it is about knowing your body, consent, interaction with the opposite sex, colleagues and friends,” adds Dr Mehra.

Research shows that comprehensive sexuality education delays sexual initiation and leads to a fall in sexually transmitted diseases.

“The fact is that there is sexual activity going on,” points out Dr Mehra. “Earlier it was within marriage but it is still happening at an explorative level. “The more one understands that, the chances of risky behaviour are lower. So are chances of coercion and physical violence.”

This is critical in a country like India where rates of sexual violence against women are high and discriminatory attitudes towards women persist. For a meaningful social change, reaching out to boys and girls on issues like consent and gender equality becomes critical.

Programs on the ground like Ehsaas by SNEHA in Mumbai and YP Foundation in Delhi, to name a few, are trying to plug those gaps.

“We have to go beyond looking at controlling adolescent fertility from the perspective of reducing unwanted pregnancies,” says Ishita Choudhry, Ashoka Fellow and Founder of The YP Foundation.

This article was published on NDTV here

Time For India To Turn The Spotlight On Adolescent Health

In the list of health priorities, adolescent health lags far behind maternal and child health in India. It’s a dangerous oversight given that India is home to the largest number of adolescents in the world. An estimated 253 million adolescents live in India, and one in every fifth adolescent in the world is Indian.

There is enough evidence to show that the period of 10 to 24 years is a critical one as the behavior patterns that form now shapes the health for a lifetime. Yet the world over, two-thirds of the adolescent population is growing in countries that are grappling with issues like child marriages, early pregnancies, HIV/AIDS and depression.

The International Association for Adolescent Health’s 11th World Congress on Adolescent Health, which begins in New Delhi in October, will turn the spotlight on this vulnerable and neglected age group. It is held once in every four years and is themed ‘Investing in Adolescent Health: the Future is Now’.

The Congress aims to push the case for developing a stronger primary care focus on adolescent health as well as kick-start investments in the health force to better respond to the needs of adolescents.

India has many challenges specifically the rise in underage marriages, especially of girls. Despite strong laws, the situation is grim even in rich states like Maharashtra where 16 districts figure in a countrywide ranking of the top 20 districts reporting an increase in child marriages, according to a study by the National Commission for Protection of Child Rights (NCPCR).

“Investment in adolescence has huge implications for productivity and enhanced life skills which has a significant impact on a country’s overall productivity,” points out Dr Sunil Mehra, Executive Director, MAMTA Health Institute for Mother and Child, which are hosting the Congress along with a consortium of partners supported by the Ministry of Health and Family Welfare.

“India has missed out on investing in this age group, which explains the high rate of child marriage which has serious implications for infant and maternal mortality and early pregnancies.”

As a Lancet 2016 study points out, puberty sets off a process of brain development and emotional change that carry through to the mid-20s. This is also a phase where most health problems and risk factors for disease in later life emerge.

Adolescence is starting earlier now and we know better now that these years reverberate across their lives,” says Dr Susan Sawyer, President, International Association for Adolescent Health.

“If we can keep girls in school longer, their marriages will be delayed, they likely to have children later, breastfeed their babies, immunize them and this will have affect health indicators like infant and maternal mortality”.

Given their significant presence, India needs to look at building a health force targeted at adolescents. Most adolescent interventions are targeted at tobacco and alcohol use and there is a mind block about teaching sexuality education in schools.

One of the most sensitive problems in many parts of the world is that young people are sexually active outside marriage, says Dr Sawyer.

“Given the many challenges, it is important to build health care systems to deal with the challenges that come with adolescence,” she adds.

This article appeared on NDTV Online here.

 

Tackling the diabetes challenge

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.

This article was published on the SNEHA website 

Break the Silence on Menstruation

Standing outside the gate leading to her school, Anjali, a resident of Ghatkopar, Mumbai, 15, points inside to a partially broken door.

“This is the only toilet in the school which has running water. Now do you understand why I prefer to stay home on ‘those’ days”?

“Those” are the days when Anjali is menstruating when she, and most of her friends miss school. That is nearly seven days every month and the frequent absences Anjali fears will come in the way of her dreams of becoming a doctor. Many girls in her neighbourhood have dropped out totally shortly after hitting menarche.

What is a natural process marking the onset of adolescence in girls is fraught with huge challenges for girls in developing countries. Studies in different parts of Africa have documented how menstruation significantly compromises the education of girls.

The same is the case with India where according to an pan-India sanitation study by Dasra and Forbes Marshall, almost 23% of girls drop out of school when they start menstruating, and as many as 66% of girls skip school during this time. The same study also highlighted that 88% of India’s 355 million menstruating women have no access to sanitary pads – a lack that affects the health of women and adolescent girls.

An unsupportive environment in schools that includes lack of adequate toilets, absence of gender-segregated facilities, poor sanitation and inadequate water is one of the main causes. Another factor that explains the low school attendance is access to sanitary products that girls, especially in rural India, face.

A recent study focused on 53 slums and 159 villages in Madhya Pradesh, Chhattisgarh and Uttar Pradesh found that 89% of girls and women used cloth during their menses, with over half of them using the same cloth for more than one period. Two per cent used cotton wool and ash. Just 7% used sanitary pads.

The reality seems to have been taken note of at the policy level. In his Teachers Day address in 2014, PM Narendra Modi expressed concern about the large number of girls dropping out of school and the need to find ways to make sure girls don’t quit school early. The Swachh Bharat, Swachh Vidyalaya mission aims to build “at least one incinerator in the girl’s toilet block and a niche to keep sanitary napkins”.

What hold out greater promise is innovations in this field. Among the most prominent are those by A. Muruganatham, the Tamil Nadu-based creator of low cost sanitary napkin making units, who is aiding the Uttar Pradesh government’s efforts to reach total menstrual hygiene.

Guided by the UP government and Arunachalam, a pilot unit was set up in the village of Mahoba in 2013 to produce low cost sanitary napkins. The unit employs only women and is part of a decentralized enterprise model. This was coupled with a massive drive on menstrual hygiene across nearly 15000 schools in the district. The program was a massive success with the demand for Subah napkins far outstripping the supply and the UP government plans to take it across the state.

Also effective has been the UNICEF program in Kanchipuram district, Tamil Nadu, under which a vending machine disposing sanitary napkins was installed in schools.

Awareness too has to go hand in hand with affordability and availability. There is tremendous shame and stigma associated with menstruation and schools must address this, among boys and girls, to break the silence.

This blog was published in healthyurbanworld.com 

Breastfeeding promotes a smarter, healthier & equal world

The lives of over 800, 000 children and 20 000 mothers could be saved each year with universal breastfeeding says a new series by the respected medical journal The Lancet.

Breastfeeding leads to fewer infections, enhanced IQ, probable protection against obesity and diabetes, even breast cancer prevention in mothers, says the series which has been hailed as the most in-depth analysis done so far into the health and economic benefits that breastfeeding can lead to. It also highlights that breastfeeding leads to economic savings of 300 billion dollars

The data published is based on analysis led by scientists at the Federal University of Pelotas in Brazil who looked at data from previous research.

Reporting on the findings, The Independent, a UK daily, quotes the study head Professor Cesar Victora as saying, “There is a widespread misconception that breast milk can be replaced with artificial products without detrimental consequences…. The decision not to breastfeed has major long-term negative effects on the health, nutrition and development of children and on women’s health.”

However, globally, only 37% of children under the age of six months are exclusively breastfed in low and middle-income countries.

Women avoid or stop breastfeeding due to many reasons ranging from medical, cultural, and psychological, to physical discomfort. Turning to formula milk, which is heavily pushed by multinational companies and many hospitals, becomes a convenient option.

There is a need to create a supportive environment for a mother who is breastfeeding says Dr Armida Fernandez, Founder, SNEHA. This includes addressing the many myths and misconceptions that are still widely prevalent.

“Mothers, and this includes women from poor backgrounds, want to breastfeed their babies. But if their baby keeps crying, and this happens due to many reasons, they feel it’s because they are not producing enough milk and so they resort to formula or diluted cow’s milk leading to malnutrition”, says Dr Fernandez.

She believes that doctors need to aggressively and consciously encourage breastfeeding.

“I find many doctors do not support it at all. The moment the baby is a little underweight they tell the mother to start a top feed. “ Dr Fernandez suggest that health centres and clinics must have counsellors on their staff who actively encourage women to breastfeed.

Currently India is still some distance away from reaching its targets on improving infant nutrition as per an assessment report by the Breastfeeding Promotion Network of India (BPNI) and Public Health Resource Network (PHRN) published in late 2015.

The report says that nearly 15 million babies, who comprise of 55% of newborns in India annually, are deprived of optimal feeding practices in their first year after birth.

The assessment also points to gaps in policies and programmes outlined for enhancing breastfeeding rates. Countries like Afghanistan, Bangladesh and Sri Lanka fare better than India in comparison.

Aggressive promotion of baby foods by companies, lack of support to women in the family and at work places, inadequate healthcare support, and weak overall policy and programmes were some of the reasons identified as responsible for lack of improvement in infant and young child feeding practice indicators.

This article was published in healthyurbanworld.com 

Dumped, Abandoned, Abused: Women in India’s Mental Health Institutions

Following the birth of her third child, Delhi-based entrepreneur Smita* found herself feeling “disconnected and depressed”, often for days at a stretch. “Much later I was told it was severe post-partum depression but at the time it wasn’t properly diagnosed,” she told IPS.

“My marriage was in trouble and after my symptoms showed no signs of going away, my husband was keen on a divorce, which I was resisting.”

After a therapy session, Smita was diagnosed as bi-polar, a mental disorder characterised by periods of elevated highs and lows. “No one suggested seeking a second opinion and my parents and husband stuck to that label.”

One day after she suffered a particularly severe panic attack, Smita found 10 policemen outside her door. “I was taken to a prominent mental hospital in Delhi where doctors sedated me without examination. When I surfaced after a week I found that my wallet and phone had been taken away.”

All pleas to speak to her husband and parents went unheeded.

It was the beginning of a nightmare that lasted nearly two months, much of it spent in solitary confinement. “The nurses were unkind and cruel. I remember one time when my entire body was hurting the nurse jabbed me with an injection without even checking what the problem was.”

On one occasion, when she stopped eating in protest after she was refused a phone call, she was dragged around the ward. “There were women there who told me they had been abused and molested by the staff.”

Not all the women languishing in these institutions even qualified as having mental health problems; some had simply been put there because they were having affairs, or were embroiled in property disputes with their families.

Days after she was discharged her husband filed for a divorce on the grounds that Smita was mentally unstable.

“I realised then that my husband was building up his case so he would get custody of the kids.”

Isolated and afraid, Smita did not find the strength or support to fight back. Her husband won full custody and left India with the children soon after. “My doctor says I am fine and I am not on any medication but I still carry the stigma. I have no access to my kids and I no longer trust my parents,” she told IPS.

Smita’s story points to the extent of violence women face inside mental health institutions in India. The scale was highlighted in a recent Human Rights Watch (HRW) report, ‘Treated Worse than Animals’, which said women often face systematic abuse that includes detention, neglect and violence.

Ratnaboli Ray, who has been active in the field of mental health rights in the state of West Bengal for nearly 20 years, says on average one in three women are admitted into such institutions for no reason at all. Ray is the founder of Anjali, a group that is active in three mental institutions in the state.

“Under the law all you need is a psychiatrist who is willing to certify someone as mentally ill for the person to be institutionalised,” Ray told IPS. “Many families use this as a ploy to deprive women of money, property or family life. Once they are inside those walls they become citizen-less, they lose their rights.“

Ray points to the story of Neeti who was in her early 20s when she was admitted because she said she heard voices. “When we met her she was close to 40 and fully recovered, but her family did not want her back because there were property interests involved.”

With the help of the NGO Anjali, Neeti fought for and won access to her share of family property and was able to leave the institution.

Those on the inside endure conditions that are inhumane.

“There is hardly any air or light. Unlike the male patients who are allowed some mobility within the premises, women are herded together like cattle,” says Ray. In many hospitals women are not given underclothes or sanitary pads.

Sexual abuse is rampant. “Because it is away from public space and there is an assumed lack of legitimacy in what they say, such complaints are nullified as they are ‘mad’,” adds Ray.

Unwanted pregnancies and forced abortions impact their mental or physical health. They languish for years, uncared for and unattended.

“One can’t help but notice the stark contrast between the male and female wards,” points out Vaishnavi Jaikumar, founder of The Banyan, an NGO that offers support services to the mentally ill in Chennai, capital of the south Indian state of Tamil Nadu.

“You will find wives and mothers coming to visit male patients with food and fresh sets of clothes, while the women’s wards are empty.” Experts also say discharge rates are much lower when it comes to women.

The indifference towards patients is evident not just in institutions, but also at the policy level, with mental health occupying a low rung on the ladder of India’s public health system.

According to a WHO report the government spends just 0.06 percent of its health budget on mental health. Health ministry figures claim that six to seven percent of Indians suffer from psychosocial disabilities, but there is just one psychiatrist for every 343,000 people.

That ratio falls even further for psychologists, with just one trained professional for every million people in India.

Furthermore, the country has just 43 state-run mental hospitals, representing a massive deficit for a population of 1.2 billion people. With the District Mental Health Programme (DMHP) present in just 123 of India’s 650 districts, according to HRW, the forecast for those living with mental conditions is bleak.

“Behind that lack of priority is the story of how policymakers themselves stigmatise,” contends Ray. “The government itself thinks [the cause] is not worthy enough to invest money in. Unless mental health is mainstreamed with the public health system it will remain in a ghetto.”

Depression is twice as common in woman as compared to men and experts say that factors like poverty, gender discrimination and sexual violence make women far more vulnerable to mental health issues and subsequent ill-treatment in poorly run institutions.

Gopikumar of The Banyan advocates for creative solutions that are scientific and humane like Housing First in Canada, which reaches out to both the homeless and mentally ill. The Banyan is presently experimenting with community-based care models funded by the Bill and Melinda Gates Foundation and the Canadian government.

“Our model looks at housing and inclusivity as a tool for community integration,” says Gopikumar. “The poorest in the world are people with disabilities and most of them are women. They are victims of poverty on account of both caste and gender discrimination and its time we open our eyes to the problem.”

*Name changed upon request

This article was published in the Inter Press Service news agency here

iPill, uChill

Male attitudes may be changing but some things are still seen as a woman’s job. Birth control seems to be one of them

Since we have never heard of her partner, Mother Nature evidently is a single mom. And like most mothers, she clearly bears the brunt of her brood. Anupama Rohidekar, consultant, obstetrics and gynaecology, Columbia Asia hospital, Bangalore, however, is considerably luckier.

“We were clear that we wanted only one child. So after our daughter was born I underwent a vasectomy,” says Deepak Rohidekar, 48, laparoscopic surgeon, Manipal Northside Hospital, Bangalore. “My wife had been through the whole stress of pregnancy and labour, and I felt I should take on the responsibility of birth control.”
Don’t start celebrating this as a coming of age of the 21st century Indian male—Dr Deepak Rohidekar bucks the larger trend. Mumbai-based gynaecologist Rishma Dhillon Pai, who works at the Lilavati Hospital and Research Centre, says most Indian men regard birth control as a “woman’s business”.
Not that there are too many options available to men. When it comes to contraceptive products, women are spoilt for choice, be it pills, gels, injections or implants. And condoms too. Men, on the other hand, have just two, vasectomy or condoms.
Vasectomies, though reversible, are generally rejected as drastic. National Family Health Survey (NFHS) figures for 2010-11 show that a little over 4% of the Indian male population opted for it compared to 95.6% women, who underwent tubectomies despite state governments offering various incentives. Tubectomy is an invasive, irreversible sterilization procedure, done under anaesthesia. There is a risk of damage to the internal organs.
And when it comes to condoms the accounts are not too encouraging either. “A lot of men virtuously tell me they use a condom but not every time,” says Vijaya Sherbet, a gynaecologist at the Columbia Asia hospital. “There is no realistic way to decide when you need protection. Most married couples I know in my practice seem to prefer the natural or withdrawal method which has a high failure rate. There is probably sheer mental and physical laziness (certainly not sexual though) at work here.”
The fallout, doctors say, is that many women end up using the i-pill to prevent a pregnancy. “I see women who have messed up their period cycles by using the i-pill as much as four-six times a month,” says gynaecologist Duru Shah, who consults at some of Mumbai’s top hospitals. “Or the i-pill fails and they come to me for a medical termination of pregnancy (MTP).”
Dr Sherbet adds: “The number of married couples who use the option of MTP to plan their family never ceases to amaze me. We have a very liberal MTP under which a woman can have her pregnancy terminated if a condom fails. In urban India, termination is used as a contraceptive, which puts women at huge risk!” Both Mumbai and Delhi reported over 20,000 MTPs each in 2010-11, according to official figures.
A 42-year-old upper-middle-class homemaker, who has been married for 12 years and has never used a contraceptive, says, “I have a hormonal issue so I cannot take pills.” The former advertising executive says: “Insertions caused infections. It was incredibly frustrating as I wanted the men to take responsibility and use the rubber but they always refused because it took away from the pleasure. Now, I am happier not to have sex!’’
The onus of contraception falls mainly on women. NFHS figures for 2010-11 show there were 16 million users of male condoms compared to over 83 million women using oral pills. “Once the family is complete, it’s always the woman who opts for permanent methods,” says Dr Dhillon Pai. “Vasectomy today is down to very low numbers. There is huge expertise available but I find men are too scared.”
“The biggest fear is loss of potency,” adds Dr Rohidekar. “Even educated men think they will become weak, and not just sexually. They feel they have to earn for the family and this will affect their overall strength.” Mumbai-based sex educator and counsellor Mahinder Watsa, who has a popular newspaper column, “Ask the Sexpert”, agrees.
“‘Will it stop my discharge?’ ‘Will I be able to perform?’ These are the commonest misconceptions about vasectomy that I hear,” says Dr Watsa. “Birth control is regarded by most men as a women’s issue because they do not like the other option available, and that is the condom. And women prefer to undergo tubectomy because they fear that if something goes wrong (with the operation), the (family’s) breadwinner is lost to them.”
The Brihanmumbai Municipal Corporation’s figures for Mumbai for 2011-12 are telling. In that period, 1,584 men opted for vasectomies, while 18,651 women underwent tubectomies even though vasectomy is less invasive than a tubectomy, requires no anaesthesia and can be reversed. It also has fewer risks of complications. Infections are rare.
But why is male involvement in birth control such a big deal, some may ask. “In more conservative families where reproduction is keenly anticipated by everybody other than the potential mother, who might have education or career goals, her partner’s support and participation would help ward off the pressure,” says Dr Sherbet.
Over the years, countries in Africa have shifted the focus of family planning programmes to men. In African society, much like in India, decisions that affect family and political life are made by men. Male involvement in birth control, it is believed, would not only take the load off women, it would also promote more quickly the need for family planning.
Apart from encouraging condoms and vasectomies, government programs rely on mass media, all-male clinics and workplace interventions to encourage male participation. In Côte d’Ivoire, for example, a joint government-UN Family Planning Association (UNFPA) programme is working to promote condom use among soldiers. In Niger, the Schools for Husbands project, also supported by the UNFPA, encourages married men to discuss family planning.
Part of the blame for the indifference back home, Dr Rohidekar believes, lies with the medical community. “The general trend is that since the woman is here anyway, make her undergo a tubectomy. We need to involve men aggressively. When a couple comes in for a pregnancy termination, there is almost always no one to counsel them on family planning. No one is telling them what methods are available.”
A gap that PRACHAR, a community-based intervention project in Bihar, is trying to fill. The project reached out to young couples to change reproductive behaviour.
“Men don’t opt for vasectomy because no one has explained to them the right time to do it,” says Rema Nanda, the former country representative of Pathfinder International, a non-profit family planning organization working in developing countries, which launched PRACHAR in 2001. “Through community meetings, male workers provide contraceptive information and counselling to young married men and adolescents. When you have male workers reaching out, rates of contraceptive adoption rise dramatically. In the first phase of the project between 2001-2004, interventions led to an increase in contraceptive use among young couples from 4.3% at baseline to 20.7% at end line,” she adds.
This is an approach Dr Rohidekar believes in as well. At his hospital in Bangalore, he strongly advocates vasectomies. “I give them my example. I tell them ‘Look at me. I am fine. I have suffered no loss of strength, so you should consider it.’”
But most men don’t. And fatherhood is small beer compared to becoming a mother.
The above piece was also published in the newspaper Livemint.