AK Jayasree



ABSTRACT---Abortion is a woman's experience. Research is not being conducted from women's experiential viewpoint. For a woman, it is an experience of physical pain, agony, guilt and shame. Yet, women desire to have it on occasions, when they are not prepared to conceive, or when the family members do not want her to deliver a female baby or when there is social pressure for not to have an "illegal child". Abortions are often opposed by pro-life movement and some religious groups. Anyway, one thing is certain that it has always been decided by the interest of the dominant cultural group in the society, whereas not much relevance is given to woman's agency. A woman feels guilty about abortion in a society where motherhood is glorified. In the Kerala context, a cultural change is inevitable to address the moral dilemma of abortion.

Abortion is a woman’s experience. Often the discussions about it take place around public policy issues, family planning, religious issues etc. Research is not being conducted from women’s experiential viewpoint. For a woman, it is an experience of physical pain, agony, guilt and shame. Yet, women desire to have it at occasions, when they are not prepared to conceive, or when the family members do not want her to deliver a baby or when there is social pressure on her not to have an “illegal child”. Now debate is going on about the rights of a woman to have abortions. It is often opposed by pro-life movement and some religious groups. Any way, one thing is certain, that it has always been decided by the interest of the dominant cultural group in the society, where not much relevance is given to woman’s agency. Women’s experiences are shaped by the socio-cultural factors. In a society where motherhood is glorified, a woman may feel guilty about undergoing an abortion. In media, it is commonly depicted that the woman suffers all pain, defamation and shame to protect the baby and motherhood, even when the father of the baby rejects her. In this situation, taking a stand for abortion or against abortion, is meaningless. On the other hand, we have to analyse the socio-cultural, economic and political factors, which determines a woman’s experience when she undergoes abortion. And also her agency should be considered as a relevant factor. This may leave our debate ‘to have an abortion or not to have an abortion’, open and finally it becomes a woman’s choice rather than a debate; the word ‘choice’ finds meaning in the context of maximum possible freedom. The socio-cultural factors are endless.But they are often masked by the overflow of statistics and urgency of population policies.

The gendered construction of sexual pleasure and its difference between the two genders are some of the socio-cultural factors that determine women’s experience. Sexual pleasure is mainly conceived as that of man’s pleasure in a male dominated society. But often the woman is punished for that pleasure in labour rooms and abortion clinics. The pain experienced by the woman in obstetrics and gynaecology clinics is the repayment given by women for the pleasure experienced by men. This does not mean that women do not experience any sexual pleasure. But the physical pain, mental stress and social pressure as the consequences to the sexual pleasure of the woman, outweigh the latter. Sometimes, either doing an abortion or continuing the pregnancy is painful to the woman, owing to different reasons. In such a situation choosing between them is difficult, but not having a choice is much more suffocating. Hence, the right of the woman to have abortion is not an absolute righteousness, but the righteousness amidst the wrong practices of male dominance.

Women feel guilty about abortion because our society does not easily accept it. Too much importance is given to motherhood and the foetus. Sometimes the foetus is given more importance than the woman. The messages prevailing are that abortion is wrong, women who do it, are selfish and irresponsible, abortion is murder etc. In such surroundings the woman will have traumatic experience associated with guilt and shame. Even in clinics, the health care providers, being insensitive, may communicate the same ideas through their behaviour and talks. The trauma continues for long time.

Abortion is often conceived as an unnecessary evil and the woman is blamed for it. Understanding it scientifically may help us to take it out of the realm of gossips or rumours. Abortion is the result of unwanted pregnancy and it is the consequence of the unmet needs to contraception. The situations may be different. The unwanted pregnancy can happen within marital relations and also pre-marital. Even in marital situations decision-making is very difficult for the woman. Sometimes, the husband or other family members, may not agree with it. Even if they agree, the emotional support the woman may need in that situation is not understood properly by the relatives. In situations where the woman is unmarried, it is a shame for the family members too. The brother of a girl who got pregnant before marriage told me, “ I am thinking of suicide. What is the meaning in life if my sister is rotten like this”. This reflects the severity of the shame and agony experienced by the family members, which augment the difficulties to get an abortion done, because they have to disclose it at least to the clinic staff. So, abortion will be done secretly. People do not mind, even if it is done by untrained people in such a moment. They prefer illegal abortion, irrespective of the available legal remedy, because secrecy is kept. In these situations the family members also will be under stress. So the emotional trauma of the woman is totally neglected. Sometimes she may be punished by the family members, thereby, adding to the trauma. The pregnancy can be the result of rape also. In such situations, there will be sympathy towards the woman. But the specific emotional needs of the woman are not met in the health care institutions. The family members, also, will be upset and they cannot handle the situation properly, unless there is support from the community. Often the family members want to hide it from others. There are instances where the even more community supports the rapist for different reasons. If the girl is a minor, the situation is even more complicated. If the rape is the result of incest, it is further worsened. In all these situations, women become victims of sexual taboo by the patriarchal society. Hence, abortion cannot be seen as a bio-medical problem alone without touching socio-cultural factors.

A notable feature, of the experiences of women undergoing abortion, is the diverse socio-cultural situations. The situations are different in developing and developed countries. Religion, race, cultural factors etc also make differences. In countries, where the population growth rate is high, the Governments promote abortion services, whereas it is prohibited in countries where the rate is low. Different standards are taken for different races, in the same country, also. But, even in places where it is legal, the attitude towards abortion has not changed. And no measures are taken successfully to meet the contraceptive needs of women ensuring safety. This contradiction shows that the abortion services are provided with the aim of population control alone, and not as an outcome of women’s struggle to liberate themselves from the sexual control by the male dominated value system.

Women’s movements for abortion rights have much relevance in this context. It can make changes in the attitude of society. In addition to it, health clinics run by women conduct abortions and their experience will contribute much to women’s freedom. They give importance to the uniqueness of each woman’s experience. It can be seen that even in the same cultural context, women have different experiences. Some women may feel positive; others negative, or sometimes they have mixed feelings. Women, often, feel more strength after taking the decision, since they have taken a vital decision. This can be experienced only in an atmosphere of freedom.

The situation in many countries is bad, since abortion is considered a criminal activity. In countries like Nepal, unsafe abortion, is the cause of 50% of maternal deaths. Unsafe abortion is one of the major reasons for maternal mortality in many countries. WHO (1995) defines unsafe abortions as a “procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both”. Abortion becomes unsafe, if it is induced by the woman herself, by nonmedical or unskilled persons in unhygienic conditions. Such abortions, are attempted by administering abortifacient preparations, either orally or by inserting the preparations into the uterus, or by an improperly performed dilation and curettage procedure, ingestion of harmful substances or exertion of external force. In the 1950s, about a million illegal abortions a year were performed in U.S., and thousands died each year as a result. A woman, living in a developing country, faces a risk of death upto 250 times greater, if she has to seek abortion services from an untrained, unskilled abortionist than if she has access to a skilled provider and hygienic conditions. The risk can be reduced, if safe abortion services are available.

There is no point in criminalizing abortion, because it neither reduces the incidences of unwanted pregnancies, nor reduces the number of unsafe abortions. Even, with the wide use of contraceptives, elimination of the need of abortion is not possible. Hence, legal prohibition of abortions is not appropriate. Decriminalisation of abortion is urgent in those countries where it is illegal at present. This will promote safe abortions. Any pregnancy terminated within 12 weeks --(less than 3 months)-- of gestation by a trained medical practitioner under clinic situation --(approved government or private health clinics)-- can be termed as “safe abortion”. Abortions are unsafe, if any of the three conditions mentioned above, is unfulfilled. However, legal measures alone, will not give results.

In earlier periods, abortions were more or less accepted in all communities. Women helped each other to abort. In developing countries, they th still practice it. In the middle of the 19 century, abortion became illegal in U.S., except those necessary to save the life of the woman. In 1969, Pope declared all women having abortions, to be subject to excommunication. Abortion became a sin and crime. Sometimes, it was based on the unsafe aspects of abortions, but it was interesting to note that more unsafe surgical procedures were allowed in the same period for other ailments. So the so-called protection of women was only a way to control women. It was to suppress the women’s movement, for rights of women. Male domination in the modern medical care system also wanted to eliminate the abortion practices of traditional women and midwives.Wherever there was a need for more population, and need for population increase of a particular race, women were not allowed to abort. On the contrary, as a part of the population control programme, wherever there was overpopulation, abortion was promoted. This shows the double standard of states. Thus, abortion, became an issue of the state, controlled by eugenics and population policies. It never considered the woman’s feelings.

It is observed, that even when abortion is illegal, it happens because the need exists. When women are determined, they will do it. But this will be dangerous. Sometimes, women themselves do it using needles, douches or herbal medicines or they seek the help of untrained persons. A recent study, in New York City, showed that over 45 % of women who had legal abortions would have tried to get them, even if they had been illegal. The problems are unnecessary death, costs and also lack of treatment if there is some complication.

Reform of law came in the U.S. gradually, allowing women abortions in certain circumstances --(e.g. pregnancy resulting from rape or incest, being under 15 years of age)-- but leaving the decision to doctors and hospitals. It was further liberalized in 1970 so that it can be done on demand if performed under medical facilities by a doctor. It was a continuous fight. There were cases in the Supreme Court urging repeal of all restrictive state laws. Legalisation, though necessary, is not sufficient. The enforcement depends on social movements and social attitude. Even when funds are provided, hospitals hesitate to provide the benefit for women. Experience from Italy shows this. Though, there was a law brought in 1978 in favour of abortion, the doctors themselves, refused to do it by the pressure from religion.

Finally, it came out, that right of privacy, founded in the concept of personal liberty, is broad enough to encompass a woman’s decision whether or not, to terminate her pregnancy. When abortion is illegal, women from low socio-economic class have to suffer more. They cannot afford it. They cannot go to other countries because they cannot meet travel expenses. The illegal abortionists charge very high rates, sometimes even demand sex with them. They want to finish abortion as fast as possible for their own safety, and there will not be any scope for follow up. Other hospitals deny treatment, if there is any complication. Moreover, there is no mechanism to deal with the issue of stress.

Situation in India
Medical Termination of Pregnancy Act was passed in 1971 in India. According to this, termination can be done under 5 conditions. They are:

1. Medical- Where continuation of pregnancy might endanger the mother’s life or cause grave injury to her physical or mental health.

2. Eugenic- Where there is substantial risk of the child being born with serious handicaps due to physical or mental abnormalities.
3. Humanitarian- When pregnancy is the result of rape.
4. Socio-economic- Where actual or reasonably foreseeable environments could lead to risk of injury to the health of the mother.
5. Failure of contraceptive devices.

At present there is no legal problem for women to seek abortions. But, even now, a large number of unsafe abortions are taking place due to various reasons. The decision making power of a woman, in reproductive matters is minimum, in India. There is lack of awareness and accessibility. A study done by an NGO in rural Uttar Pradesh shows that the husband’s consent was a major factor in the decision to seek abortion. In some cases, the husbands refused consent outright, and the women had to accept the pregnancy. In a few other cases, women attempted abortion without informing or consulting their husbands, mainly out of the fear that they would not consent. Those who wanted to limit their family size were more determined to seek abortion.

When induced abortion was attempted, some women relied more on methods like herbal concoctions, medicines, injections, inserting objects ( sticks)- unskilled providers, like traditional birth attendants and untrained medical practitioners. Then, only half of them, were successful. Women, who did not get support from their husbands, were more likely to try out these methods and turn to unsafe providers, as they wanted to do it secretly. Other factors were, higher costs involved in accessing surgical abortion, women’s fear of the surgical procedure and instruments. This, again, emphasizes that legal measures alone do not help women.

Situation in Kerala
Being a state, where the fertility indicators show high achievement, any body will expect appropriate use of contraceptives in Kerala. On the contrary, what we see in Kerala, is unmet needs of contraceptives. This is exemplified by the high rate of abortions. The rate is 15/1000 live births. In India, Kerala is the second highest in abortions, the first being Goa. This shows that though fertility rate is low, women do not have much control over their body. If women had choices, and control over their body, unwanted pregnancies could have been avoided. The accepted family planning methods are socially controlled. Tubectomy after two children became a norm, but temporary methods are not practiced effectively. MTP is widely practiced in Kerala. The number of unsafe abortions has come down in the past years. But, the cost of safe abortion is high for poor women in private hospitals. The quality of treatment and counselling should be improved. It is still a taboo area. The medical system has much control over women. The right to information for women is often denied. Even the service of MTP is denied sometimes in Government hospitals due to different reasons. It will depend on the perspective of the doctors. Some doctors insist on the consent of husbands. This makes it difficult for an unmarried woman to get an MTP done.

In Kerala 50% of young women’s (below the age of 24 years) pregnancies are unintended and unwanted. For these women, the need for reproductive health and contraceptives, are not met. The main reason is that child bearing is considered as the main duty of women. Marriages below 20 are high and awareness regarding contraceptives is low. Matters related to sexuality are considered taboo. The decision-making about child bearing is not done by the woman.

The attitude and behaviour of the professionals, is very important to the woman who undergoes abortion. She needs care, affection and kindness. But often the opposite is happening. The medical personnel will be harsh and hostile, because anything related to reproduction and sexuality are considered ugly. In some private hospitals, you can expect a better treatment, but the poor women cannot afford the cost. Legalisation alone is not helpful to women in a cultural milieu, which is against abortion. Anti-abortion propaganda is pervasive in our society. Hence, counselling services are essential in centres providing abortion services. Women should be treated with respect. Each woman, has the right to have painless abortions and treatment meted with dignity. There is discrimination in choosing anesthesia for the poor and rich women.

Right’s Movements
It is an enigma that in the so-called developed countries where women’s liberation is proclaimed, they did not have abortion rights. Still in some of the countries like Italy, it is illegal. In the U.S. also, the progressive legislations are slowly reverted, irrespective of the strong movements for abortion rights. The women who got opportunity to have abortion when they wanted it, feel that these options should be available to all women. They are not seeing it in isolation, but they want it along with other factors like positive environment for childcare, decent incomes, housing and education, elimination of racism etc. These movements have contributed much to women’s assertion of their rights.

Though, abortions became illegal at one point of time in U.S, there had been a strong movement for abortion rights. Most of the women in the democratic world think that no one else has any right to interfere with a woman doing what she needs to do with her body, according to her own wisdom and judgement. For a woman who decides to have an abortion, it is not a difficult task. But, they get confused and feel guilty, when others interfere. Then they question themselves and wonder whether it is a crime if she is not getting upset with abortion.

It can be understood that it is the wrong practices of society that makes it a dilemma to have an abortion. A woman who chooses to have abortion need not feel guilty about it, if she has the right to choose. In such a period, a woman can have the desire to continue the pregnancy, valuing the new life, even if there is an uncomfortable situation. Here, taking the risk is the woman’s choice. No one else has the right to ask her to do what others desire.

If there are abortion clinics run by sensitive women, emotional support can be given to the women who attend the clinic. There are examples of feminist health centres in countries like U.S., where trained counsellors give support to women and help them to sort out their feelings before and after the procedure. At the same time, if a woman needs privacy, that also should be accepted. If a woman does not want to share her feelings, that is also accepted. Also, the women themselves, can share and support each other. Detailed and correct information should be given to the women about the abortion procedure. A friend of the woman should be allowed to stay with her, if she wants it. Woman should have a major participation in decision-making. It is the right of the woman to get a respectful treatment, and women need not feel always thankful to the institution if they are treated well.

There are instances in other countries, where women’s health centres provide affordable services, sometimes even free services to poor women, even when it is considered a crime by the state. In these clinics, trained non-medical women provide services. Everything is done keeping the anonymity and security. Follow-up services are also rendered, such services including emotional support and reassurance. At the same time, awareness is given to women so that they can avoid dangerous measures like herbal medicines, chemicals, introducing crude instruments etc.

In India, women’s groups recommend IEC programmes to promote community awareness on women’s health issues, consequences of repeated pregnancies and abortion, the importance of seeking abortions early and from trained providers, the risks associated with home-based, traditional, trial-and- error methods. Availability of safe abortion services must be ensured, and male responsibility should be considered. More information, regarding contraceptives, should be given.

In the Kerala context, a cultural change is inevitable, to address the moral dilemma of abortion. In Kerala, safe abortion facility and information regarding contraceptive practices are not lacking. But, women’s power to control their own body, is lacking here. We should be sensitive enough to understand the risks taken by women in other countries to help their sisters, even when it is illegal. Here, it is legalised, but it is done with shame and guilt. Even if there is no shame and guilt, the woman’s stress is not properly addressed by others, because sexuality and related things are still not open. And, also, the legalisation of abortion was not the result of the assertion of rights of women. It was part of the population policy. If women have proper access to contraceptives and control over their body, the incidents of abortion itself can be reduced. But, it is entirely different from legal control. The number is reduced through autonomy and choice of women in the former situation, and therefore, safety is ensured. In the latter situation, rights of women are denied and it will lead to unsafe procedure. Here, the number of abortions are more, because women are not allowed to have control over their body, not allowed to decide their role in sexual interaction, not allowed to choose contraceptives which is not harmful to her body. So, the rights are essential to correct the wrongs in our society. Legal sanction alone is not enough. A pro-choice movement can make a difference.

JAYASREE AK. Medical doctor with M.D. Noted feminist activist. Chairperson, Foundation for Integrated Research in Mental Health; Guest Lecturer in Sree Chitra Thirunal Institute of Medical Science and Technology, Thiruvananthapuram and Mahatma Gandhi University, Kottayam. Resource person for State AIDS Control Society, Kerala; Member, Task Force on Health and Family Welfare, Kerala State Planning Board, Monitoring Committee on Women’s Development in Kerala, Advisory Committee SAKHI Resource Center for Women, Kerala Sasthra SahityaParishad and Stree Vedi. Presented papers in national and
international seminars and conferences. Published articles in scientific journals, magazines and newspapers.

B Ekbal

Womens health care

Author:B. EKBAL

ABSTRACT---Gender discrimination becomes a serious issue when it has its repercussions on the health of women and leads to unethical practices like female foeticides, female infanticides, higher death rate among women, lower life expectancy, higher morbidity and an adverse sex ratio. The 1991 census reflects the worsening status of women in Indian society despite the rhetoric about the Women's Decade and the Year of the Girl Child. Against this background, the presence and activities of many significant gender conscious People's Health Movements in our country provide immense relief and optimism in dealing with women's health problems. The National Health Parliament held at Kolkatta in December 2000 by a coalition of 14 health related networks covering more than one thousand non-Governmental organizations discussed the various aspects of women's health problems and came out with concrete policy options to tackle them.

The gender discrimination against women in society has its repercussions on the health of women as well. The consequences of the unfair attitude to women have found expression in several forms-female foeticides, female infanticide, and a higher death rate among women, lower life expectancy higher morbidity and an adverse sex ratio. In India the sex ratio is unfavorable to women 929 for 1000 as per the 1991 census. This reflects the worsening status of women in Indian society, despite the rhetoric about the Women’s Decade and The Year of the Child. Shailaja Bajpai reported earlier that in India every year 12 million girls are born; 1.5 million die before their first birthday; another 8,50,000 before their fifth and only 9 million will be alive at the age of 15. Several later studies confirmed these findings but no radical change has happened after this startling exposure of the pathetic health status of the Indian women.

The gender bias against women rests on the fact that women are seen only as child bearers and as a liability rather than as assets to the society. Contrary to popular notion, the gender bias cannot be explained away by economic reasons. In Kerala, a state with one of the lowest per capita income in the country, the sex ratio is favorable to women (1034) while in Punjab, one of India’s most affluent states, it is below the national average (879); This phenomenon can only be attributed to the cultural dogmas existing among the dominant communities in Punjab. Punjabis have one of the most imbalanced sex ratios in the country, largely because their patriarchal system necessitates a preference for the male child.

The gender bias against women starts from the unborn girl child. It is now well documented that with the help of modern technologies like ultrasound scanning and amniocentesis female infanticide is rampant in our country. This problem came to light as early as 1990 when a young scholar in the Delhi University in her M. Phil thesis entitled ‘The Silent Deaths: A Study of Female Infanticide in Delhi” focused on the widespread nature of this practice in the capital, and highlighted the brazenness with which several clinics are propagating and conducting sex determination tests, followed by abortion if the result showed a female baby. Surprisingly most of the women clients and their husbands were highly educated. Though the doctors performing the tests and subsequent abortions claimed that they chose only those women who had had two or more daughters, this claim was proved false as the researcher found that several of the women who opted for the test already had a son. The study also discovered a sinister nexus between physicians, sex determination clinics and abortion centres. Later, several other studies revealed that this problem was not confined to Delhi but was prevalent in most of the states. The Government, because of the pressure from women’s organisations and peoples’ health movements, has now come out with regulations against the sex testing in the scan centres. But whether the authorities are sincere enough in monitoring this is doubtful.

Several studies conducted in urban and rural areas in India have shown that the girl child is given less breast milk and for shorter periods than boys. It has also been shown that the girls are given less nutritious food than boys and fewer girls than boys receive timely medical attention. Since the diet is inferior, more girls than boys in the same age group suffer from malnutrition. The girl child is often given less food, eats last and obviously gets only the leftover. Despite the Child Labour Prohibition and Regulation Act, children, particularly girls, continue to work in hazardous and less-remunerative occupations. The work of girls is usually invisible, located as it is primarily in the domestic sphere, which is considered as beyond quantification. Girls help with household chores of cooking, cleaning, caring for the younger siblings and fetching water, fuel and fodder. Because of all these factors naturally mortality among the girls is more than that of the boys. The adolescent years of the girls are filled with the trauma of early sexual maturity, early marriage, precarious pregnancies and childbirths, when the girls are physically unfit as a result of malnutrition, discrimination and from overwork.

The medical profession or health planners in our country have not specifically addressed the health problems of the working women. Low wages, long and erratic working hours, deplorable working environment, absence of gender conscious workers’ union, coupled with the several survival and reproductive tasks can only have adverse consequences on women’s health. It is estimated that 94 percent of the women are engaged in the unorganized sector, of which 81 percent in agriculture and the rest in other occupations mostly unskilled and ill paid jobs. It is unfortunate that the laws and policies relating to women have been obeyed more in breach than in compliance. The condition of women in the organized sectors is also not any different. A large percentage of the women in the organized sector work as stenographers, typists and secretaries primarily because it is easier to find women to fill these underpaid jobs. Denied equal opportunities, equal wages, equal service conditions and subjected to all forms of discrimination and harassment, it is no wonder that they suffer from physical and mental trauma.

Traditionally women as mothers, wives and sisters were the providers of health care within home. Their knowledge about childcare and several home remedies was handed down from one generation to the next by an oral tradition that is part of our socital heritage. However with the ‘pharmaceuticalisation’ of health care and the medicalisation of childbirth, women have been relegated to the background. Although not less than 75 % of our health workers are women they are largely at the periphery. They have no decisive powers, acting only as agents of a system out of their control. Although 67% of the deliveries are conducted by dais they are regarded as untrained health assistants who do not form a part of the formal health care system. Even trained personnel like nurses play a subservient role vis-à-vis doctors and are given little or no support or understanding. Thus as long as caring, nurturing, nursing and healing were part of satisfying a family’s needs, women were regarded as ‘wise’ and their knowledge and skills respected. Once these activities became associated with profits and economic gains, the medical profession came to be dominated by men and capital-intensive technology. Not only were women marginalized in terms of their role as providers of health, but also their own health became the focus of warped and distorted notions. The uterus came to be looked upon as the source of all their problems which came to be diagnosed as mere ‘hysteria’ uterus centred.

Women’s access to health services is vital. Because women have the responsibility of caring for the health of her entire family, her knowledge of nutrition and health is important both for herself and the health of the family. Hospital records from several states in India have shown more male admissions than female and more hospital beds being earmarked for men than for women. Women’s access to health services is constrained by several factors. First, the time spent on child care, house work and workplace leaves them with little time to think about their health, often resulting in their illnesses at early stages. Second, the clinics offer women no privacy. Third, most clinics are staffed by men, and women show a reluctance to be treated by men. Finally, the women’s awareness of available medical facilities is lower than that of men.

The new reproductive technologies (NRTs), which are fast gaining ground today, are equally degrading to women. They are primarily post-natal technologies many of which are introduced as a therapeutic cure for infertile women. The NRTs include: Artificial Insemination of Donor Sperm (AID), Invitro Fertilisation (IF) and IFET (Invitro Fertilisation and Embryo Transfer (IFET) etc. These technologies are beyond the reach of most people. Yet, because of our patriarchal society in which the son is seen as critical, even those who can least afford will try every means to be able to use these technologies. Women’s groups are rightly questioning the ethical, legal, social and economic implications of such technologies. Just as amniocentesis was initially promoted to detect birth defects, NRTs were introduced as an answer to infertile mothers; But as amniocentesis has become a sex determination test, fertile couples who wish to rent the womb of a surrogate mother and yet own the baby produced by the fertilization of their ovum and sperm are increasingly using NRTs. With the introduction of NRTs, childbirth has become yet another business venture, even a profession among some in metropolitan cities. With the number of couples willing to pay handsomely for the services of a womb, it is no wonder that less affluent women from the developing countries are more than willing to become surrogate mothers. It is interesting to note that adoption has never been seriously regarded as an alternation

In the area of family planning also women bear the responsibility, with scientists focusing their research on female contraception and government policy promoting terminal methods involving women. Moreover, several contraceptives developed in the West, totally unsuitable to the Indian context, were introduced without adequate trials in India. The women in the West have a free and informed choice regarding contraceptives and the efficient medical services there ensure proper screening to exclude women unsuitable for a particular contraceptive. Proper follow-up to ensure timely treatment in the event of any side-effects are available in those countries. Introducing such methods without any of these facilities is definitely hazardous to the health of our women. In a number of states illiterate women were subjected to the trial of long-term injectable contraceptives. Appropriate use of new contraceptive technologies depends on the context in which the method is used. The long-term health related economic and social consequences of the methods must be examined and prerequisites and conditions for safe use determined before distributing them on a wider scale. If the method is used in a relatively coercive family planning programme, then a woman’s right to choose freely from a range of contraceptives and her right to discontinue the method are likely to be violated.

In this context the family planning or rather the population control programme in India should be analysed from a gender perspective. A dispassionate assessment of the family planning programme in India in its four and half decades of existence raises many interesting issues. Experiences within, as well as outside the country, show that a reduction in population growth rates follow an overall socio-economic development. Except in conditions of war and famine, they seldom precede such development. Yet this has largely been ignored during our planning process, possibly as it prevents our planners from blaming the country’s tardy development rates on the pressures posed by population increase. As a result, family planning strategies have tended to be paternalistic, prescriptive and coercive. It is a strategy, which starts from the belief that the poor breed prodigiously and it is the nation’s duty to cap their unbridled fertility. Thus programmes are aimed at the poorest sections, and more specifically at women. Tubectomy rates in the country are fifty to hundred times higher than vasectomy rates, though the latter is a far simpler and safer procedure. Hormonal methods aimed at women find precedence over propagation of condoms, in spite of widespread reports that the former are associated with a large number of health hazards. In this whole process the supposed beneficiary -- the impoverished rural woman -- has virtually no choice. She is at the receiving end of technologies which the state or society believe are necessary. Such programmes are inappropriate not only because they victimise women, but also because they are not efficient. Such a strategy has undermined the effectiveness of the general health care infrastructure as well as the faith that women have in this infrastructure to address their real concerns. Most programmes tend to view women as assembly line appendages required to produce babies.

New strategies have to be designed to increase women’s access to and role in the health care system in order to ensure better health for the women, as also better child survival. The World Conference in Nairobi to review and appraise the UN Decade for Women put forth the following recommendations:
• Creating and strengthening basic services for the delivery of health care
• Increasing the participation of women in higher level health institutions through legislation and training
• Integrating fully and constructively female traditional healers and birth attendants into the health system
• Strengthening promotive, preventive and curative health measures through supportive health infrastructure, free of commercial pressure
• Designing and constructing accessible and acceptable health facilities in harmony with patterns of women’s work, needs and perspectives
• Encouraging local women’s organizations to participate in primary health care activities and devising ways to support women in taking responsibility for self-care.

Though made in 1985, these recommendations are still relevant. The presence and activities of large number of Peoples’ Health Movements with gender consciousness in our country gives us a lot of optimism in tackling the women’s health problems in India.

(I express my gratitude to Dr. Mira Shiva of the Voluntary Health Association of India and Dr. Amit Sen Gupta of the Delhi Science Forum in helping me to prepare the article.)

Sen Gupta, Amit. A Paradigm Shift. Delhi Science Forum: Delhi, 2001.

Bajpai, Shailaja. The Lesser Sex. Indian Express Magazine. 1990.

Chaterjee, Meera. Implementing Health Policy. New Delhi: Manohar, 1988.

Dankleman, Irene and Joan Davidson. Women and Environment in the Third World: Alliance for the Future. Earthscan Publications, 1988.

SAARC Year of the Girl Child. The Girl Child in India. 1990.

Shiva Mira. Women and STD: A Tangled Web. Health for the Millions, April,1989.

State of India’s Health. Voluntary Health Association of India. 1992.

B.EKBAL Eminent neuro-surgeon and health activist. Chairman, Health Subcommittee, Kerala Sastra Sahithya Parishad and National Convener, Jana Swasthaya Abahayan.

Chetty Rajendra

Farida karodia's other secrets


ABSTRACT---Farida Karodia, born and raised in the Eastern Cape in South Africa, has taught in South Africa and Zambia and spent twenty-six years in Canada. She has reworked her first novel, Daughters of the Twilight, published by The Women's Press in 1986 but not available in South Africa at that time because of the apartheid regime's proscription of alternate black writings. She has turned it into an epic three part novel, Other Secrets, newly published by Penguin, which explores the mother-daughter relationship in the running crisis of the apartheid situation, updating it to include new family alignments in the post-apartheid South Africa.

Farida Karodia was born and raised in the Eastern Cape in South Africa. She has taught in South Africa and Zambia and spent twenty-six years in Canada where she wrote radio dramas for the Canadian Broadcasting Corporation. Karodia returned to South Africa from exile in Canada in 1994 during the time of the first democratic elections in the country. She has reworked her first novel, Daughters of the Twilight, published by The Women’s Press in 1986, but not available in South Africa at that time because of the apartheid regime’s proscription of alternate black writings. She has turned it into an epic threepart novel, Other Secrets, newly published by Penguin. It explores the motherdaughter relationship in the running crisis of the apartheid situation, updating it to include new family alignments in the post-apartheid South Africa.

Karodia’s oeuvre includes Coming Home and Other Stories (1988), A Shattering of Silence (1991) and Against an African Sky (1994). Two of her short stories of note are ‘The Red Velvet Dress’ in Opening Spaces: An Anthology of contemporary African Women’s Writing (1999) edited by Yvonne Vera and ‘Friends’ in Her Mother’s Ashes 2 : More stories by South Asian Women in Canada and the United States (1998) edited by Nurjehan Aziz.

A pertinent question in the analysis of Other Secrets is how did the exile from South Africa for over three decades influence Karodia’s writing? Her response is that if she had not gone into exile, she might never have written. It was a whole chain of circumstances that got her started. One of these was writing radio plays for the Canadian Broadcasting Corporation. She wanted to write, but did not know how to get started. A producer suggested that she do a script. The theme of those radio plays was what was happening in South Africa during the years of the struggle. The radio plays served as a springboard to writing short stories and then novels.

Other Secrets is written into three distinct parts, Daughters, Mothers and Other Secrets.

Karodia’s first novel, Daughters of the Twilight (1986) was reworked to form the first part, Daughters. Why and how did she rework the text to form the opening section of Other Secrets? Karodia explains that Mothers and Other Secrets, the new parts, are a continuation of the opening Daughters. Basically Daughters has remained the same; just some of the details like names have changed – the writer fictionalised the name of the town from Sterkstroom to Soetstroom. But, in fact, all three parts can be considered as distinct books within the one new book. She adds that she wrote them initially as a trilogy. Thereafter, she had to go back and change it to read as one novel. In the old Daughters of the Twilight, there was always the promise of a later book. Karodia outlines that she always knew that she had to come back to Yasmin, the chief protagonist, and tell the rest of her story. She was motivated to write the text by a few things that happened in her life.

Other Secrets covers four generations of women’s lives spanning two continents. When Karodia was asked to share her feelings on writing this work, she replied:

It took a long time. I started parts two and three in 1994. I have
been working on it since then. The way I write is that I don’t sit
down and work on just one project. I work simultaneously on
different projects to maintain my interest. 1

When writers work simultaneously with more than one text, one is inclined to question the occurance of overlaps in the themes or cross-pollination among the different works in progress. Karodia insists that no such overlaps are evident in the texts and her illustration is interesting:

I have just finished an early draft of a new manuscript that I have
been working on together with Other Secrets and it is a totally
different story. It is a story of an old woman and is set in Canada.
It is her last day; she dies at the end of that day. She does not
know it and reflects on her life.

One of the most remarkable characteristics of the writings of Karodia’s text and those of other African exiles like Ezekiel Mphahlele, Can Themba, Breyten Breytenbach, Lauretta

Ngcobo, etc. is the fine South African nuance that creeps into their writing during exile.

Karodia succinctly outlines the influence of exile on the psyche of the writer:

I was so homesick. It is reflected in Other Secrets. It took me
about 10 years to get over my despair with living abroad and
being away from South Africa. You need strong feelings for
writing. If I hadn’t been homesick, I am sure that I would not
have been able to write. I find solace and comfort in my writing.
You never lose those images of the landscape; they are always
there with you. If I shut my eyes I can see the landscape of the
Eastern Cape where I grew up. I have not been back there, yet I
still conjure images of the area.

Several of the post-1994 South African stories are autobiographical or semi-autobiographical, where the childhood self is treated as other, and challenged by changes taking place in the present. Memory effects the passage into the future and enables moral re-alignment. Texts like J.M. Coetzee’s Disgrace (1999), Gillian Slovo’s Red Dust (2000) and Farida Karodia’s Other Secrets are examples of the evocative, and unmistakably new South African writings that exemplify the seeping, cumulative signs of change. How are Karodia’s personal feelings reflected in Other Secrets?

They are not all personal experiences at all. I really got into the
head of Meena, the main character and narrator. I don’t think
Meena is really like me. She is a character that I created and that
I felt very sympathetic towards. I also admire her sister Yasmin,
a very gutsy woman. I did use some of my personal experiences
in Meena’s and Yasmin’s characters, although I never had a sister
myself. They are two totally different characters. But, I could
link some of my experiences. Maybe, they were the emotions
that I felt at particular times of my life, which I linked to the two.
It is almost like a schizophrenic kind of thing with the two girls.
I grew up in Sterkstroom, a very lonely life. I did not have many
friends and we were the only Indian family in the town. So the
setting is quite authentic. However, while I gave the town the
name of Sterkstroom, I became bogged down psychologically,
emotionally and intellectually in that setting, but then as soon as
I changed the name to Soetstrom it released me. One can’t really
pin down autobiographical experiences in Other Secrets. There
are things like exile, my passport was revoked – but those were
just little things by comparison.

Karodia notes in her text that it was relatively common in the days before mass relocation (the Group Areas Act decreed that the different races shall live apart) to find solitary Asian traders living and conducting business in the heart of the white rural communities. Isolated because of their racial and cultural differences, the Indian families, who were mostly traders in the white areas, built walls around themselves - ‘surviving like bits of flotsam in a hostile sea, practising their religion and conducting their daily routine as inconspicuously as possible’. Sisters Yasmin and Meena, their parents and grandmother are among those who live behind the walls, helpless to control their destinies in the arid years of apartheid, but not entirely without hope… Yasmin’s strivings bring her some of what she wants in life, but not without the tragedy of rape and exile compounded by long-concealed secrets that seem to be passed from mother to daughter.

The leitmotif in Other Secrets, like in Jung Cheng’s Wild Swan’s (1991), is the complex relationship between mothers and daughters. Karodia acknowledges that the motif existed right from the inception of her writings. She wanted to write about really strong women. However, she emphasises that she didn’t want to sideline the father, but she saw him as absolutely helpless. Karodia articulates very strongly from a gender perspective that:

Women, I feel, always had the power to change and create. For
me, they are the most important elements in the story. I come
from a family with very strong women. That was the influence
on me. It was a natural progression to write about strong women.
With such a strong gender standpoint, one would be inclined to easily categorise Karodia’s writings as feminist. Interestingly enough, she strongly refuses to be categorised as a feminist. She thinks that every writer uses some of the influences that she had on her lives.

One has to delve into one’s own history, and Karodia’s evolves from such strong women. She does not see it as a feminist tendency. She was very protective of Papa, not in a feminist way, perhaps in an endearing way. This is what he was, an old man, and she loved the character of Papa, but she could not give him power that non-feminist writers would have liked to see because that was not his character. A recurring theme in the text is that of “fatherhood”. It is significant that both in Yasmin’s and Soraya’s lives, the issue of fatherhood is questioned and the theme is juxtaposed within the dominant female discourse of the text. Karodia takes delight in explaining the use of the theme since it correlates with the title of the text:

The secret is in the lives of both sisters. This is the other secret,
the irony of the story; the father was so attached to Yasmin, yet
he was not really her father. Who is her father? This is where the
other secret comes in. It is not your ordinary run of the mill
secret. It is the final secret. I loved that secret.

Another reason to put Karodia’s writings in the feminist box is the absence of the male voice in this text. She is quick to point out that it is just not a male story, because you couldn’t be a strong male in the apartheid society. As a male you never had the power, no political power, no economic power, so where would your strength be? The ordinary non-white men ended up as alcoholics. A lot of them became derelicts.

Even if I had given Papa the strength, even if I had made him a
younger person he would never have been able to do anything to
alter their circumstances, not in that particular era.
Women, on the other hand, held the family together at home.
The kitchen was a site of comfort, it created a feeling of being at
ease and it was a familiar site. Their power was in the house.
You find this everywhere. Wherever you have a group of
women, they open up to each other. There is a bonding that goes on –
female bonding.
I speak from personal experience. I feel very comfortable in the
kitchen. Maybe it is a historical thing too. This is where we have
always been. This comment is going to get me into a lot of trouble,
especially with women in the workforce, women in positions of
power, etc.

Central to the South African texts is the question of race and identity. Most South African writers have a morbid fascination for politics, and opposition to apartheid motivated much of their writings. Examples that come to mind are Bloke Modisane, Ellen Kuzwayo, Alan Paton, Nadine Gordimer, Ashwin Desai, and Athol Fugard. The invasion of the private realm by politics meant that even writers who might usually have ignored politics were forced to deal with it. The personal relationships that might otherwise have been their focus were moved into the political realm. Karodia also addresses race and identity questions in her text. However, she insists that, unlike A Shattering of Silence (1991), she did not want to write from a political context.

But, I couldn’t do it without referring to the political situation of
the day because it affected your life in many ways.
Reclassification of race did take place and people were forced
out of their homes, so how could I avoid those issues?

Karodia outlines the difficulty of growing up under apartheid, the repression and oppression that prevented the young girls from experiencing life to the fullest: ‘It was like having your legs cut off just as you were learning to walk. You saw others - whites - living differently, having what you could never have simply because you were not the right colour. It made you bitter. Yasmin was beautiful and vivacious and thought she had the world at her feet, but she was stopped dead by the system which controlled our lives’ (2000:431).

The tragedy of growing up under apartheid is that despite the fact that Yasmin had ‘more in her little finger’ than all the white girls in Soetstroom put together, she was always on the outside looking in. They were envious of her because she was beautiful and confident, but at the same time they disdained her, knowing that she would never be their equal because she was a coolie meid. The terms “coolie” and “meid” were derogatory labels used against Indians and black women respectively. It is interesting to note that as part of the Black Consciousness Movement, the vulgar labels used against the oppressed were juxtaposed in their life narratives, but this time within an affirmative context, as part of black pride.

Examples of “coolie “ texts that come to mind include Kesaveloo Goonum’s Coolie Doctor (1990), Jay Naidoo’s Coolie Location (1989), and Reshard Gool’s Cape Town Coolie (1990).

Issues of sexuality were markedly absent from black South African writings pre-1994. Writers like Breyten Breytenbach, Andre Brink and Stephen Gray did not hesitate to include sexual issues in their poetry and novels. When one compares Other Secrets with Karodia’s earlier writings, one has to acknowledge that the directions on sexuality in this text is unexpected, and one is keen to know what the catalyst was?

You couldn’t really be honest about Meena and Yasmin without
touching on it. The sexual issues are part of their characters, of
who they are: Meena being a virgin at twenty-two and Yasmin
obviously not. I deliberately set out to do this. Nothing influenced
me. I just wanted to be honest about their characters.

Farida Karodia is considered one of the important writers within the sub-genre of South African Indian writings in English, alongside Ahmed Essop, Ronnie Govender, Jayaprega Reddy, Achmat Dangor, Essop Patel and Shabbir Banoobhai. South African Indian writers have their own authentic identity they have their own necessity, they seek their own forms and often, through a combination of simplicity and daring, by directness and an unembarrassed handling of feeling, achieve artistic effects of insight and profound disturbance. The black writers (African, coloured and Indian) had to carve their own literary path through a myriad of obstacles: state harassment, academic hegemony over literature, resource constraints, western literary codes, prejudice of critics, racism, etc. The academe (largely white) also arrogantly posited a distorted conception of what literature is, how value should be appropriated and, more specifically, what constitutes South African cultural capital.

The marginalisation of indigenous knowledges and African writers is currently being addressed by the academe, which is transforming from an elite, exclusive institution to embrace all the writings of the land. Pertinent questions that one needs to ask black writers would concern the dynamics and process of writing. Karodia outlined that when she embarked on Other Secrets, she did have a plan, however, her writing style defies description:

I knew the end of the story. I work backwards. However, I don’t
always stick to the end of the story – it changes. In Other Secrets
I did change the end. The story ended much earlier. But then, I
had to go back; I wanted to add more to the story. The original
ending is still in the book, but I went beyond that, further.

Do other writers influence an author’s writing style, and what is the nature of this influence? Ahmed Essop Notes that he was influenced by V.S. Naipaul, R.K. Narayan, Ruth Jhabvalla and Anita Desai while Ronnie Govender’s repertoire of influence is wide and they include Arthur Miller, Philip Roth, Paulo Freire, Augusto Boal, Wole Soyinka, Bertolt Brecht, Rabindranath Tagore, Dambudzo Marechera, R.K.Narayan, Rohinton Mistry and J.M.Coetzee. Karodia’s response to the greatest influence on her as a writer was a stark contrast to Essop and Govender:

There has been no other writer that has had a great influence on
my work or me. I am fairly solitary. It can’t be a person. I read
a lot of diverse stuff. I read everything. I like the more obscure
writers. I don’t focus on one particular writer. I rather not read
South African writers. Not because of any reason – I don’t want
to be influenced. I am moving away from South African settings.
I want to branch out and write things that are also set elsewhere.
Hence my new book is set in Canada. I went to India and wrote
a collection of short stories during the monsoon.

However, she does acknowledge that the influence could be other than a writer. Coming back to South Africa has been one. It was the experience of coming back just before the first democratic elections of 1994. It was then that Other Secrets took off the ground in terms of the writing.Karodia is a hot publishing property, like many black female writers in South Africa due to the marginalisation and exclusion of women’s writings by the academe and the androcentric publishing houses. She has just completed a novel set in Canada. The working title, A long journey home, has to be changed since it sounds like Rohinton Mistry’s Such a Long Journey (1999). She confesses that she has used some interesting concepts and techniques. The structure is also quite different from her other novels, she claims:

I wrote in the first person narrative and the rest of the story is told
in the third person. Some of the story is told in the immediate
present, while the rest is in the past. They are not flashbacks. It
is the way the story develops. There is this old woman trying to
figure out what went wrong in her past, what has brought her to
this point in time. Once again, an extremely strong woman. But,
I do have some interesting men in this novel.
My other work is set in a small town in the Karoo (in South
Africa); it is more of a young person’s story. A film crew arrives
in a small town that has not been part of the South African change
after democracy. My other concurrent project is the collection
of short stories that reflect my experiences in India.

Who does a South African Indian writer envisage as her audience in the new democratic South Africa? Karodia maintains that she would like to write for everyone. It is interesting to note that although she refutes the categorisation of her text as feminist, she thinks Other Secrets is especially written for women. She states succinctly that her text mirrors particularly the experiences of South African Indian women, however, it is a story that everybody can get something out of.

1. This article is based on an interview that Rajendra Chetty conducted with Farida Karodia on the occasion of the release of Other Secrets in July 2000 in her home in Gauteng, South Africa.

Karodia, F. Other Secrets. Johannesburg: Penguin. 2000.

RAJENDRA CHETTY Is Associate Director of Research at ML Sultan Technikon, Durban. His current research project is South African Indian Writings in English. His MA in South African Literature focused on black autobiography and his Ph D provided a genealogical study of South African Literature. Published widely on language policy issues, literature teaching and post colonial writings

Dasgupta Sanjukta

In a double bind


ABSTRACT---Indian women had been writing poetry in Prakrit, Pali, Sanskrit and the regional languages long before the problematics of nation-states, nationality, postcoloniality, feminism or naribad, nativism or desivad, power structures and the politics of identity and difference had claimed attention. From a Vedic hymn attributed to one Apala to the Buddhist Therighata of the Sixth century B.C., often regarded as the world's oldest surviving collection of poems by Buddhist nuns, as well as the poems by the bhakti women poets, the poetry of women expressed overtly or covertly the powerlessness of women and their exploitation as subjects in a patriarchal society. After centuries of darkness, formal education for women in India became a reality in the nineteenth century.

Indian women have been writing poetry in Prakrit,Pali and Sanskrit and the regional languages long before the problematics of nation-states, nationality,postcoloniality, feminism or naribad, nativism or desivad, power structures and the politics of identity and difference had claimed attention. From a Vedic hymn attributed to one Apala, to the Buddhist Therighata of the sixth century B.C., often regarded as the world’s oldest surviving collection of poems by Buddhist nuns, as well as the poems by the bhakti women poets, the poetry of women expressed overtly or covertly the powerlessness of women and their exploitation as subjects in a patriarchal society. Many of them, as the talented Avantisundari, the wife of Rajshekhar, a ninth century poet, were forbidden to use Sanskrit, as the language was generally regarded as exclusive to male Brahmins. After centuries of darkness riven by plunder, rapine and frequent inter and intra civil strife between kings, tribes, factions and alien marauders, formal education for women in India became a reality in the nineteenth century.

Macaulay’s historically significant Minute On Education announced that it was possible to make the natives of India “good English scholars” and soon afterwards the British government passed the resolution in India, on March 7, 1835 that “the great object of the British government ought to be the promotion of European literature and science among the natives of India, and all funds appropriated for the purpose of education would be best employed on English education alone”. Macaulay, however, revealed his supreme ignorance of the culture of the people to the East of the Suez when he made that notorious statement of arrogance- “ a single shelf of a good European library was worth the whole literature of India and Arabia”. In the fiftieth year of India’s Independence, Salman Rushdie asserted quite categorically, that Indian writing in English (read prose) is proving to be a stronger and a more important body of work, than most of what has been produced in the eighteen recognized languages in India, the so-called ‘vernacular’languages, during the same time. Harish Trivedi stated in the ICLALS newsletter that the sheer audacity of the statement took one’s breath away.Despite his Eurocentric responses to India, Karl Marx had remarked with insight that the English were causing a “social revolution in India” by becoming “ the unconscious tool of history”.The urban affluent class and the urban middle class became proud Anglophiles and enthusiastically appropriated the colonizer’s culture, which Fanon has diagnosed as a common tendency among the colonized- “The native intellectual will try to make European culture his own.He will not be content to get to know Rabelais and Diderot, Shakespeare and Edgar Allen Poe;he will bind them to his intelligence as close as possible”.(Fanon:1970 p.176).

The first Indian woman poet Toru Dutt, knew Sanskrit, English and French and her English verses made Sir Edmund Thompson compare her to Sappho and Emily Bronte.After her untimely demise The Saturday Review opined, “There is every reason to believe that in intellectual power Toru Dutt was one of the most remarkable women that ever lived. Had George Sand or George Eliot died at the age of 21, they would certainly not have left behind them any proof of application or originality superior to those bequeathed to us by Toru Dutt”.(Sinha p.123).

In India as elsewhere, colonial culture and literature, customarily exuded the hegemonic norms, values and practices of the colonizer’s culture and admirable adaptations, mimicry, imitations and ventriloquizing the colonizer’s voice were common features of the writings of the colonized.Gordon Bottomley had described Indian poetry in English as being curiously gender and garment specific, “Matthew Arnold in a saree”--Arnold as transvestite provokes the imagination but why not a dhoti Gordon Bottomley?-- while the Indian poetcritic, V.K. Gokak, stated that such poetry could more appropriately be described as “Shakuntala in skirts”. (Kulshresthe 1980 p.27).M. K. Naik becomes extremely excited about possible sartorial preferences by British writers and suggests- “ or a Shelley in a salwar, or a Byron in a burkha or a Lawrence in a lungi, or a Joyce in jodhpurs or a Babu Beckett”.(Naik 1995 p.290).

It is, therefore, doubly remarkable that young Toru Dutt is able to transcend the hegemonic culture of the colonizer quite instinctively in her sonnet “Lotus”, which heralds the beginning of cultural fusion without surrendering indigenous identity. So, “Love” is personified, the Western classical literary tradition is invoked through the poet’s familiarity with the allusiveness integral to such referents as Flora, Juno, Psyche, as well as the conventional nuances that references to such traditional images as the rose, the lily, and the bard who sings their praise invoke. Also, remarkable, is Toru’s qualifying the bards as versifiers of power, thereby deviating significantly from Keats’celebrated romantic encomium to the bards of passion and mirth. The young poet’s ability to discern the power of poetic language, is indeed commendable. It is language that conveys and decodifies the inherent message of sense impressions and Toru was aware of the poet’s responsibility as the addresser of power. The cultural fusion is effected through harmonious assimilation of the Occidental red rose and white lily, the innate chemistry that empowers the lotus, the national flower of India. Toru answers Kipling’s oracular dictum that the East and West are irreconcilable, through the innovative projection of an apparently simple icon.Toru adroitly employs and fuses Western icons of mythic power to emphasise the superiority of the national icon. In this respect, the “Lotus” can be assessed as a profoundly political poem


Love came to Flora asking for a flower
That would of flowers be undisputed queen,
The lily and the rose, long, long had been
Rivals for that high honour. Bards of power
Had sung their claims.” the rose can never tower
Like the pale lily with her Juno mien”-
“ But is the lily lovelier?” Thus between;
Flower-factions rang the strife in Psyche’s bower.
“Give me a flower delicious as the rose
And stately as the lily in her pride”-
“ But of what colour?”- “Rose-red”, Love
first chose,
Then prayed,-” No, lily-white,-or, both provide;”
And Flora gave the lotus,” rose-red “dyed,
And “lily-white”-the queenliest flower that blows.

Can this poem be cited as the trail-blazer of cultural decolonization, a subtle but confident rejection of cultural hegemony of the West that seemed to appropriate the colonized urban Anglicized intellectuals’ psychic terrain?( Indian Literature pgs 208-209 )

The other woman poet, who wrote inspired and impressive Romantic poetry, which skillfully appropriated the popular nineteenth century English lyric form, despite sometimes its excesses of rhythmic jingle was Sarojini Naidu(1879-1949).Edmund Gosse’s advice to her outlines the culture specific expectations of foreign readers from Indo Anglian poetry- “ I implored her to consider that from an Indian of extreme sensibility, who had mastered not merely the language but the prosody of the West, what we wished to receive was not a rechauffe of Anglo-Saxon sentiment in an Anglo-Saxon setting, but some revelation of the heart of India, some sincere penetrating analysis of native passion, of principles of antique religion and of such mysterious intimations as stirred the soul of the East long before the West had begun to dream that it had a soul.”(Sinha p.141) Of the many poems that Sarojini wrote, The Pardah Nashin is a short gender specific poem in three stanzas.It interrogates the suffocating constrictions of the segregated space of the antapur and the veiling of women. The ghunghat,burkha and chaddar are all gender specific garments specifically designed to provide anonymity to the female body, and even in the twenty first century, Hindu as well as Muslim women belonging to the disadvantaged classes are entrapped in clothes that mask their identity. So Sarojini reports:

Her life is a revolving dream
Of languid and sequestered ease
...But though no hand unsanctioned dares
Unveil the mysteries of her grace,
Time lifts the curtain unawares,
And Sorrow looks into her face...
Who shall prevent the subtle years, Or shield a woman’s eyes
from tears? (Gokak p.149-150)

The referents in the first stanza - life, revolving, languid, sequestered ease promise the assurance of security and happiness, but the concluding third stanza debunks the myth and underscores the dis-ease as the signifiers time, sorrow and tears overwhelm that no pardah can shield. Sarojini used evasive strategies of indirection as she raised the issues of gender and marginalization, but she left it to a much younger postcolonial poet Imtiaz Dharker(born 1954) also educated in Britain to powerfully interrogate, explore and expose the gender specific strait jacket, the politics of textile or women’s clothing in her first book of poems Purdah.Imtiaz writes in Purdah

One day they said
she was old enough to learn some shame
She found it came quite naturally.
Purdah is a kind of safety.
The body finds a place to hide.
The cloth fans out against the skin
much like the earth that falls
on coffins after they put the dead men in.
(De Souza p.50)

By juxtaposing the referents in an ironic combination as purdah, safety, hide, coffins and dead men Imtiaz privileges her agenda of demythification and demystification of women in purdah. In her poem, “An Introduction”, Kamala Das exposes the social and cultural construction of femininity-

...Dress in sarees, be girl,
Be wife, they said. Be embroiderer, be cook,
Be a quarreller with servants. Fit in. Oh,
Belong, cried the categorizers.
( Gokak 1995 p.273)


The post-Independence Indian woman poet writing in English is in a double bind, firstly she experiences the marginality of gender, the inevitable biological construct, and the associated cultural construct, and secondly her choice of the English language for creative expression, doubly marginalises her.The critic, M.K.Naik announces the agenda of post independence Indo Anglian poetry and deplores the aping of British poetry- “One expects the Indian poet in English not to repeat parrot-like, with greater or less efficiency, what his master of the day has been saying; we have had enough of Indian Miltons and Indian Shelleys and Indian Eliots- what we really need is the “Indian” Indian poet in English.(Kulshresthe 1980 p.36). The post-independence Indo-Anglian poets experienced a most debilitating embarrassment for using the language of the Other, that was alien to indigenous culture. English was accepted as the link language for communication, higher education and technical knowledge. But English, as the medium of expression for creative writing, invited censure and such poets felt not only marginalised, but ostracized. So, S.K. Desai observed,” Marginality affects the Indian writing in English in a significant way, even with regard to where he should stay. He chooses to do one of the following: either he goes to England or America and be an exile there or stay here in India and be an exile here.”[ Indian Journal of English Studies xxvi].

Oppressed by a guilty conscience, the Indian poets, both male and female writing in English shared a sense of identity-crisis and as a result their integrity was flawed by lack of confidence,uncertainty and indecision. Their distress and desperation, are registered in their poems which clearly signal their uneasiness and their simultaneous inability to use the mother tongue for the purpose of writing poetry. Tension, anxiety and schizophrenia are some of the recurrent problems of such poetry and the insecurity as well as the agony of the poet are expressed in such lines as

He had spent his youth whoring
after English gods
There is something to be said for exile:
you learn roots are deep.
That language is a tree loses colour
under another sky.

Both male and female poets share this guilt syndrome in opting for English as a medium for their creative expression. The extract from R. Parthasarathy’s poem Rough Passage written over a period of fifteen years between 1961 and 1975, grew out of lived experience and moral dilemma. The long poem is divided into three sections, “Exile” “Trial” and “Homecoming” and the quoted extract is from “Exile”. Parthasarathy further reiterated his schizophrenic distress, as he lamented:

My tongue in English chains,
I return, after a generation, to you.
I am at the end
of my dravidic tether,
hunger for you unassuaged.
I falter, stumble.
( Parthasarathy 1994 p.80 )

In “An Introduction,” however, the woman poet Kamala Das, seems more self confident as she engages in a debate with the accusing Other, arguing that her medium of expression is a sincere and natural choice, and does not in any way interfere with her Indianness or nativism-

I am Indian, very brown, born in
Malabar,I speak three languages, write in
Two, dream in one
... Don’t write in English, they said,
English is not your mother -tongue. Why not leave
Me alone, critics, friends, visiting cousins,
Every one of you? Why not let me speak in
Any language I like? The language I speak
Becomes mine, its distortions, its queernesses
All mine, mine alone. It is half English, half
Indian, funny perhaps, but it is honest,...
(Gokak 1995 p.273)

In an interesting essay on multiculturalism, G. N. Devy, identifies a triple decker structure of cultural narratives emanating from indigenous inspiration and cross-cultural fertilization.Locating relationships between the categories, Sanskritization and westernization generates an impression of a dynamic bicultural intellectual environment.The three co-ordinates that Devy locates are (1) the marga traditions --of Sanskrit, scriptural,and brahminic origin --(2) the alien or videsi traditions --gradually nativised, but of Arabic,Persian or English origin--,and (3) the desi tradition --of local,indigenous regional-language origin. - A serious cultural split is often the result of the Indian English writer’s endeavour to translate and fuse the marga and desi traditions into English or the videsi linguistic patterns.Devy further locates four distinct styles in Indian English writing that emanate as a result of the multicultural context

(1)Style in which internationalism and nationalism meet and collaborate, where the alien cultural features work together with the marga cultural features.

(2)Style in which nationalism or the marga cultural features merge with the local or the desi cultural features
(3)Style in which the international cultural features are in conflict with the national or the marga features, where irony and sentiment constantly thwart each other.

(4)Style in which the national and the regional , the marga and the desi cultural features are at cross purposes.

(Devy p.17 ).

Despite, Devy’s pioneering efforts, at erecting a scaffolding of structured theoretical principles for Indian writing in English, simple determinants as the above ignore the multifarious problematization that such texts incorporate. From an initial space of cultural confusion to a space of existential fusion and acculturation and more commonly hybridism, are some common routes that Indo-Anglian literature pursued, as the hyphenated term “IndoAnglian” highlights.The main problem with the use of the English language in creative writing, is that it is not the language of any regional space,and therefore lacks a following and tradition at the grassroots level where it remains as alien as when it was introduced as a formal discipline of study in the nineteenth century.Rather than acculturation, therefore hybridism or the blending of different cultural influences seems to be a natural consequence of such cultural conditioning.Generally the descendants of settlers,the nativised Indians and the affluent sections of the natives themselves who have studied English as their first language feel the urge to express themselves in English, rather than their mother tongues. “Is it possible to feel in English?” is a common query that the Indo-Anglian poet invariably faces from even discerning writers and critics who use their mother tongues as their medium of expression.

Bruce King responds to this question by stating,“ English is no longer the language of colonial rulers; it is a language of modern India in which words and expressions have recognized national rather than imported significances and references, attending to local realities, traditions and ways of feeling.” ( King p.45) However, the problem seems to emerge from the fact that the English language continues to occupy a distinct position of privilege and power as it is the language commonly used by metropolitan intellectuals, English medium school educated members of the urban bourgeois and petty bourgeois class.In the process , privileging of the language despite decolonization, leads to the language remaining alien and elitist.In India, English is still the language of a minority group,it is economic class specific in application especially in the areas of creative writing and non-technical intellectual discourse.

Aijaz Ahmad, however argues that English has survived in India because it has undergone a process of steady Indianization , a characteristic of Indian civilizational ethos that transforms the intruder into a native- “ English is simply one of India’s own languages now,and what is at issue at present is not the possibility of its ejection but the mode of its assimilation into our social fabric, and the manner in which this language, like any substantial structure of linguistic difference, is used in the processes of class formation and social privilege, here and now.”[Ahmad:1994 pg.77].Nevertheless advocates of nativism or desivad spearheaded by Ganesh Devy argue that English as a medium of creative expression is not viable or authentic, being a curious maladjusted synthetic synthesis of Sanskritization and Westernization. They suggest that the colonial legacy, English language, can be put to effective use as the target language in translating regional texts.

So, the elements of guilt, hesitation,uncertainty and alienation linger in the psyche of Indian poets writing in English, and therefore the problem of the choice of language medium for Indo Anglian writers is common to both men and women. Ketaki Kushari Dyson who is a widely known bilingual poet writes in her English poem, “Dialogues” about her sense of uneasiness in using English in creative writing to express herself

A dialogue in English
can be difficult for me.
Like talking to a flighty friend
while trying to clear a rain forest.
I cut down a tree
He is hiding behind another
I’m afraid I might axe
him accidentally.

In the concluding section of the poem, Ketaki, expresses her sense of ease as she writes in her mother tongue-

A dialogue in Bengali
is arrival in that space won from the jungle.
Hut is thatched, pumpkin planted,
cow tethered, milk frothy in bowl.
Child plays in beaten-earth yard,
naked, without nappies.
Beyond, sun shines
on ridge-divided rice-fields.
We rest for a while in a charmed circle.
But if in these lines I have made some meanings clear
I shall have overcome, I shall have overcome.
(Dyson: 1983 p.70).

Interestingly, again, it will be noticed that Indian women poets who write in English have either received their education in first world countries or have worked for a considerable period in the metropolitan centre or are expatriates or if residing in India have mostly studied English as their first language.They belong to an exclusive minority group, alienated from the desi mainstream. Among them Kamala Das, Ketaki Kushari Dyson, Mamata Kalia and Sujata Bhatt are bilingual poets writing in their mother tongues as well as English.Ironically, however, sometimes it seems that the poet is more at ease writing in English than in her mother tongue.

Dr. Shefali Balsari-Shah critically analyses Sujata Bhatt’s bi-lingual poem significantly titled “Search for my tongue”. It is an eight page poem using Gujrati, extensively followed by Romanized script and the translation of the same in English.Dr. Balsari-Shah’s comments on Sujata Bhatt’s poem highlight the peculiar problem of an Indian poet writing in English:

“Sujata Bhatt’s experiments in bi-lingual poetry explore the
conflict of the self divided between different cultures. While some
of the poems which make extensive use of Gujrati are elaborately
wrought and can occasionally seduce the bi-lingual reader into
easy, instant empathy, they don’t necessarily work as good poetry.

At the most obvious level the Gujrati sections serve to shut out, rather than include the general reader for whom presumably the poems are written.One could of course argue that the incomprehensibility is a deliberate part of the poet’s design to draw the reader into her own sense of otherness in order to experience a predicament which allows only a fragmented or peripheral existence.

The mother--tongue foreign language controversy has several aspects which are open to debate. One rather facile assumption is that the Indian self can be truly defined only in purely Indian terms whether of ethos, myth or language; all genuine feeling can only be in the mother- tongue. But Sujata Bhatt’s poetry works against this ideology. Her Gujrati is plodding, unremarkable, or simply banal, nowhere conveying the ineffable quality that eludes translation , while her poetic voice in English can be sensitive, vivid and evocative.”(D’Souza p.71 ) Eunice D’Souza makes similar comments about the Hindi poems of Mamata Kalia, and states that her poems in English are more compact and organized.


Another significant aspect, apart from the language issue in Indian women’s poetry in English, is the extremely personal confessional mode in which these post-independence women poets write. Their arena of representation is restricted to their microcosms of personal experience, and the macrocosm of public issues and the world of ideas occupy them only as a part of indirect experience. In this respect, they might seem rather elitist and exclusivist,obviously alienated from the local culture, the poetry being affluent English-speaking-Indian class specific. Interestingly, though, Ketaki Kushari Dyson, Imtiaz Dharker, Meena Alexander and Gauri Deshpande prioritize woman’s independence, poets such as Kamala Das, Mamta Kalia, Tara Patel among others merely record their bitterness as the second sex, in a patriarchal society and crave harmonious interdependent androgynous relationships. Such poetry, is often monologic due to intense pre-occupation with the self. They speak of their marginalization, oppression, and exploitation, but do not have any concerted agenda for consciousness raising and demanding of equal rights, rather they seem to weakly implore understanding and compatible heterosexual relations.

It is, indeed, in this respect that Indian women poets writing in English differ from their Indian sisters writing in the regional languages. In Indo Anglian women’s poetry rarely does a poet interrogate the humiliation of Sita in the Ramayana as Ketaki does in her Bangla poetry, no poet demands an explanation from Marx and Freud about gender inequality, unpaid domestic labour, and marginalization, as Mallika Sengupta does. There is rarely any evidence of privileging of a political agenda, interrogating the marginalization of women in Indo Anglian women’s poetry, as we find in many overtly feminist Bengali poems written by women. In Freudke Khola Chiti --Open Letter to Freud-- written in Bangla, Mallika interrogates patriarchal complacency with scathing sarcasm and self confidence-

This is primal man’s sexual politics
Freud, because you belong to the extra limb group
You assume women are inferior and hence envious.
During my childhood I felt no penis envy
My self assurance was total
Even today I am a confident, complete woman
A sensitive dark girl of the Third World
Shall stand against you from today
Who is inferior who superior which is more or which less
Who has given you the responsibility of solving
Such a diplomatic debate Mr. Freud?
(Translation mine)

Interestingly, like Mallika, who writes in Bangla, the Pakistani woman poet, Kishwar Naheed, who writes in Urdu, has been accused of obscenity and inflammatory feminist writing. In a poem titled, “We Sinful Women,” Kishwar Naheed writes

.It is we sinful women
who are not awed by the grandeur of those who wear gowns
who don’t sell our lives
who don’t bow our heads
who don’t fold our hands together.
It is we sinful women
while those who sell the harvest of our bodies
become exalted become distinguished
become the just princes of the material world.
It is we sinful women
who come out raising the banner of truth
up against barricades of lies on the highways
who find stories of persecution piled on each threshold
who find the tongues which could speak have been severed....
(Mongia 1997 p. 345).

For Indo Anglian women poets the personal is the political and their poems are overtly monologic, but there are exceptions too. In an ardent voice, but not without irony, and a sense of outrage, Ketaki implores, in her poem in English titled “After Reading Nawal El Saadawi’s book The Hidden Face of Eve”

Also, in a powerful poem, that interrogat

.Peeling Egyptian potatoes in my kitchen,
I reflect that the
women who helped to grow them
had probably had their clitorises cut off.
In such a world, where we
come to each other so maimed
fractions, not integers, less than our whole selves.
What can our laughter,
our articulate loves,
art, science or
separate lusts achieve?
Clitorises? Tongues? Hair?
Noses? Uteri? Breasts?
The centuries. And all of us connivers.
Words. Silences. Structures we uphold;
those ornate arches
we so love to laud.
I implore you,
all who read my lines,
if you have mothers,
sisters, wives, or daughters,
remember those
who have been forced to pay
in the high-inflated currency of pain
for being born women.
And should a woman
dare to speak out loud
about how she has been
mauled by love or hate,
suffer her to speak.
Do not shut her up.
(Dyson 1983 p. 75-76)

es Hindu marital rituals and relationships, Charmayne D’Souza uses irony with disturbing effect

.I have marked this woman out
for me.
We will be tied together
by the scarlet sari
of her blood.
Seven times around
the fire of my shots.
What I have done
is done
for all my unborn sons.
Her mangalsutra
will be a bullet
to her breast,
My garland
a hempen rope
around my neck
and a swift sharp
into death
(Charmayne D’Souza p. 4)


In general, contemporary Indian women poets, writing in English apart from Ketaki and more recently Imtiaz Dharker rarely address public issues.Probably, they share the diffidence that Arundhati Roy’s Rahel, a sensitive symbol of Yuppie culture does, in The God of Small Things- “That Big God howled like a hot wind, and demanded obeisance.Then Small God (cosy and contained, private and limited) came away cauterized, laughing humbly at his own temerity. Inured by the confirmation of his own inconsequence, he became resilient and truly indifferent. Nothing mattered much. Nothing much mattered. And the less it mattered, the less it mattered. It was never important enough. Because Worse Things had happened. In the country that she came from poised forever between the terror of war and the horror of peace, Worse Things kept happening.”( Italics mine- Roy 1997 p.19).

Expectedly, therefore, we find Charmayne D’Souza, whose first book of poems, A Spelling Guide to Woman includes such titles as “I Would Like to Have a Movie Cowboy for a Husband,” comments about her neutral culture as represented in her poetry: “The poet must write as if he had no brother nor sister, no cousin, aunt, uncle nor constitution.I’m tempted to say no country, but then I have always been accused of writing as if I did not have one. It’s not that I have a sense of rootlessness and alienation, but I think I write about vivid inner experiences rather than of localized spaces. Maybe I will change as I become far-sighted with age.”( D’Souza p.82). Quite inadvertently, Charmayne raises the formidable issue of the presence or absence of local, global and national issues in a poetic text.She, however, steers clear of such problematizations by stating that with age she might change and become “farsighted” but experience tells us that even inner experiences discourage near sightedness.

Boehmer perhaps sums up the presence of such neutrality and cross cultural elements with insight “... a crucial feature of postcolonial women’s writing is its mosaic or composite quality: the intermingling of forms derived from indigenous , nationalist, and European literary traditions. Coming from very different cultural contexts themselves, writers emphasize the need for a lively heterogeneity of styles and speaking positions in their work.”( Boehmer 1995 p.227). Also Boehmer forecasts, “ In the 1990s the generic postcolonial writer is more likely to be a cultural traveller, or an “extra-territorial”, than a national. Ex-colonial by birth, ‘THIRD World’ in cultural interest, cosmopolitan in almost every other way, he or she works within the precincts of the Western metropolis while at the same time retaining and/or political connections with a national background.”(Boehmer 1995 p.233).

Indian women poets writing in English use intensely personal, subjective and confessional modes of creative expression and their rage, protest and dissatisfaction, are therefore sometimes uncomfortably, candid and sincere. The poems mostly lack aesthetic distancing, effected through skilful ironic and parodic strategies, that generate a willing suspension of disbelief.Whether a dialogic free for all, is superior to a monologic representation is a matter of individual response to any text.Nevertheless, the post independence Indo Anglian women poets speak with their own authentic voices of power and have proved that their voices are not merely an echo of British and American poetry“ unafraid, motivated, clear-sighted... they use English with a sense of ease. Their language, style, rhythms and forms are inventive, original and contemporary.”( De Souza 1997 p.6).I shall conclude with references to two poems that illustrate the double bind in which Indo Anglian women poets write-- the politics of gender and the politics of language for creative expression. So Sujata Bhatt queries and dismisses the politics of using the alien or videsi language as being imported, a consumable commodity with no links with the native soil in, “A Different History”

.Which language
has not been the oppressor’s tongue?
Which language
truly meant to murder someone?
And how does it happen
that after the torture,
after the soul has been cropped
with a long scythe swooping out
of the conqueror’s face-
the unborn children
grow to love that strange language.
(D’Souza 1997 p.76)

On the other hand, Tara Patel in her poem, “Woman”, expresses her sense of exploitation at being born a woman and pathetically confesses her intense yearning for love, care and understanding, as she is traumatized by the phallocratic establishment’s indifference and utter callousness.Her peculiarly powerful poem engages a dual, sadist- masochist approach, of torture and self flagellation and an escape that merely intensifies the longing to be healed and cared for. Her poem, as most Indo Anglian women’s poetry, does not outline any feminist agenda but claims and compels attention as woman in search for identity, recognition and a space of her own obliterating the barbed margins

.A woman’s life is a reaction
to a crack of a whip.
She learns to dodge it as it whistles
around her
but sometimes it lands on the thick,
distorted welt of her memory,
reminding her of lessons learned
in the past.
Then in rebellion she turned her face
to the whip,
till pain became a river in flood
wreaking vengeance.
She ran away to live as an escaped convict,
or a refugee,
or a yogi in the wilderness of civilization.
Beneath the thick, distorted welt of her memory,
she dreams,
Anyone could have touched baby-smooth skin
with kisses.
(D’Souza 1997 p.90)

Indian women poets writing in English express, interrogate and deconstruct the double bind with power and understanding, though often a need for traversing a wider trajectory of the cultural diversity arises along with the ideological positionality of the subject’s voice of power, both features more readily represented in the poetry of Indian women writing poetry in the regional languages.

1. See Tharu and Lalita, Women Writing In India vol 1& II, OUP, India 1993. This is an excellent pioneering endeavour that anthologizes quite comprehensively representations of Indian women’s writing from the 6th century B.C. onwards.
2. Some relevant paragraphs from my essay “ Post Independence Indian English Poetry” published in Indian Literature vol 187, 1998 has been included after due revision. The essay was intially presented as a paper at the Oxford Conference on Teaching Poetry held at Corpus Christie College, Oxford in 1997.
3. The seriousness and the magnitude of this problematic issue can be gauged from the Sunday Express, 23 January,1994 news item titled “Thumb imprint will do for burqa-clad;EC” records that certain sections may be averse to getting themselves photographed so the Election Commission has decided to “show relaxation in the case of burqa-clad women...In a recent order the Commission said”: In any area where- due to sentimental and other reasons- electors are averse to being photographed, the thumb impression may be affixed to the card instead of the photograph. A similar exception may be made in the case of pardanashin women.”
4. See my translations of Mallika Sengupta’s poetry in KAVYA BHARATI 12. SCILET Madurai, India as well as my interview with Mallika in the same issue. My translations of Mallika’s poetry can also be read in Indian Literature vol 184, 1997 and Exchanges, No 10, 1998 Iowa University journal.

Ahmad, Aijaz. In Theory. India: Oxford University Press, 1994.

Boehmer, Elleke’ Colonial and Postcolonial Literature. United Kingdom: Oxford University Press, 1995.

Dasgupta, Sanjukta. Indian Literature. India: Sahitya Akademi, vol 187 Sept-Oct 1998 Devy, G. N. In Another Tongue. India: Macmillan, 1995.

De Souza Eunice. Nine Indian Women Poets, India: Oxford University Press, 1997.

Dyson, Ketaki Kushari. Spaces I Inhabit, India: Navana 1983.

Fanon, Frantz. The Wretched Of The Earth, United Kingdom: Penguin, 1970.

Gokak, V.K.. The Golden Treasury Of Indo Anglian Poetry, India: Sahitya Akademi 1995.

King, Bruce. Three Indian Poets. India: Oxford University Press, 1994.

Kaul, H. K. Poetry India. India: Virgo Publications, 1993.

Kulshrestha, Chirantan. Contemporary Indian English VerseAnEvaluation. India: Arnold, Heinemann, 1980.

Mongia Padmini. Contemporary Postcolonial Theory Oxford University Press, 1997, 1997.

Naik, M. K. A History Of Indian English Literature India: Sahitya Akademi, 1995.

Roy, Arundhuti. The God Of Small Things, India: India Ink, 1997.

Rushdie, Salman ed. The Vintage Book Of Indian Writing, United Kingdom: Vintage, 1997.

Sharma, T. R. Essays on Nissim Ezekiel, India: Shahab Bahashan, 1995.

Sinha, R. P. N. Indo Anglian Poetry. India: Reliance Publishing House, 1987.

SANJUKTA DASGUPTA Head, Department of English, Calcutta University. She is a poet, critic and translator. Her published books are The Novels of Huxley and Hemingway : A Study in Two Planes of Reality and Snapshots. Participated in the Oxford Conference on Teaching Poetry held at Corpus Christie College, Oxford in 1997. She received the British Council Scholar grant and the FulbrightPostdoctoral research fellowship. Member of many councils and associations including the Women’s Studies Research enter, Calcutta University. Associate Editor of The Journal of Women’s Studies, Calcutta University.

J Prakash

Reservation and social mobility


ABSTRACT---Theory building occupies an important place in Social Science research. It helps one to grapple with social realities, to relate the seemingly unrelated and isolated social phenomena with each other and establish their causes and effects. The primary task here is to comprehend and put in a proper perspective the existing body of thought in the field of investigation and beat them into a desired shape to suit one's enquiry. This paper seeks to relate reservation with social mobility and develop a theoretical framework to analyse their dialectical interaction.

Theory building occupies an important place in Social Science research. For, it helps one to grapple with social realities, to relate the seemingly unrelated and isolated social phenomena with each other and establish their causes and effects. The primary task here is to comprehend and put in a proper perspective the existing body of thought in the field of investigation and beat them into a desired shape to suit one’s enquiry. In the process new theoretical insights emerge. This paper attempts at such an exercise. It seeks to relate reservation with social mobility and develop a theoretical framework to analyse their dialectical interaction.

Reservation is considered as the best tool in ameliorating the lot of the disadvantaged sections in a society. The disadvantaged are those who suffer multiple deprivations, economic, political and social. They have little or no means of subsistence, no representation in the power structure and hence lag behind in social esteem. Reservation targets at drastically altering this existential reality by improving their economic condition, giving them greater share in power and thereby enhancing their social status. In this way the social rejects are made social acceptables and are further encouraged to integrate progressively with the mainstream society. In this sense it promotes social cohesion.

Democratic justification for reservation lies in its majoritarian principle and concern for equality. It may be remembered that the bulwark of democratic governance is majority support. As such the State primarily directs its energy to cater to their needs and interests. Needless to say, in every society it is the disadvantaged who form the largest chunk of the population. Therefore, it is only in the fitness of things that democratic governance postulates special care strategies for the upliftment of such individuals

Reservation could also be justified in terms of equality, which is the very basis of democracy. In fact, as Sunitha Pathania had pointed out, reservation is a catalytic agent of social justice (“ Is Reservation the Solution?” The Hindu. th 29 Dec. 1996). It is the modem refinement of the concept of equality, one based on the premise that strictly equal treatment meted out in inherently unequal 1 situations can hardly be considered equitable . It, thus conflates equity with justice and paves the way for equi-justice, a concept which denotes not equal justice but adequate justice determined on the basis of one’s existential conditions with the worst off being offered preferential treatment over the better off. Conceived in these two senses, reservation fosters the greatest good of the society and informs the principle of equality with a new dynamism, which enables it to winnow the most deserving from the non-deserving/least-deserving and accordingly hammer state policies into desired shapes. Viewed thus, the theoretical underpinnings of reservation could be traced to the principles of Utilitarianism and John Rawls’ Theory of Justice.

Reservation, Utilitarianism and Rawls’ Theory of Justice
It is a little noticed fact that the Utilitarian theory justifies the cause of reservation. Based as it is on pleasure-pain theory, it measures utility in terms of the greatest happiness of the greatest number. It believes in distributing the good things of life according to the above principle (Faundez 7). In relation to state policy this means that its intrinsic worth depends on the population size it seeks to serve or on whom it wants to confer its beneficial attributes. Accordingly if the social benefits brought about by reservation out-weigh the harm to which it gives rise, then under utilitarian approach such a measure would be justified.
(Faundez 7).

In the specific context of India, it won’t be difficult to understand that reservation policy seeks to protect the interests of the Backward Classes who constitute a large majority of the country’s population. Apart from this, it also generates much good for the society as a whole. One could very well imagine the social turmoil it would have created had these people continued as social rejects. By providing them a share in state power, reservation tries to prevent such a contingency. In this sense it furthers social cohesion and integration by reducing socio-economic inequalities (Faundez 7). Thus reservation becomes the catalyst of the greatest happiness of the greatest number.

However, the best defence for reservation, it seems, comes from John Rawls. His Theory of Justice is moderately equalitarian, reformist in nature, progressive in outlook and social in consciousness (R. Sushila, “Rawls and his Critics” Unpublished Ph. D thesis, Delhi: Department of Political Science, University of Delhi, 1987, 467). It is true that he never argues for a non-stratified, non-hierarchical society. Neither does he envisage the abolition of inequality as such. All the same, it shouldn’t be overlooked that he also advocates the redressal of socio-economic inequalities by elevating the worst-off (R.Sushila 211). Here he is not merely rationalising the need for economic justice, but goes beyond and argues for the equal sense of worth of each and all; for afterall man does not live on bread alone (Allan Bloom 650)

Rawls’ Justice stands on the tripod of equal liberty, fair equality of opportunity and the maximin or difference principle. According to him, in matters of liberty every individual has to be placed on an even keel, irrespective of his natural assets or initial position in society. Each is to have an equal right to the most extensive total system of equal basic liberties compatible with a similar system of liberty for all (Rawls 302). This could well be interpreted to mean that in a caste-based stratified system, the birth of an individual in a particular caste (in Rawlsean sense, natural asset or initial position in society) should not come in the way of computing his social status or economic and political positions in society. Constructed reversely, it means that a person who is subjected to discrimination on that very basis be treated equally and at the same time accorded certain preferential consideration as compensation for the ill-treatment suffered by him. In this perspective Rawls’ equal liberty principle is not a sterile one standing for same treatment under all circumstances. This would be clearer as one examines the other two legs of the tripod.

For Rawls, Justice further means providing fair equality of opportunity. Under this, positions are to be not only open in a formal sense but all should have a fair chance to attain them (Rawls 73) Here one should take serious note of the fact that what Rawls emphasizes is not equal opportunities but fair equality of opportunities. The two propositions differ fundamentally. The former is a sterile and negative concept as it considers individuals as equals without any regard for their differential endowments. Fair equality principle, on the other hand, is dynamic and positive as its focus is on the individual with all his advantages and disadvantages and hence justifies providing differential opportunities depending on one’s needs. Thus fair equality of opportunity means adequate opportunity or as stated in the Indian Constitution ‘equal protection of the laws’. Opportunity provided to an individual is linked to his special circumstances, the disadvantaged being provided with preferential treatment while the same being denied to those placed in vantage positions. Only in this way the equality of opportunity provision be saved from usurpation by those who have an initial advantage over others by virtue of birth and social stratification (Rawls 75)

Here one comes across the much controversial issue of merit and talent. What is the position of these attributes in Rawls’ scheme of Justice? He cautions us in laying too much emphasis on these qualities. He says:
…merit and desert are social attributes [than individual and hence
are] to be harvested for society as a whole. It is just a matter of
chance or a natural lottery that these talents are so randomly
distributed in individuals. [As such] . . . individuals do not have
a prior right to use these talents to their own advantage. As society
has decided that certain attributes are important the fortunate
individuals who have these talents cannot claim them all for
themselves. (Rawls 72 – 74 )

Roland Dworkin succinctly presents Rawls’ contention in this regard and shows how it could be used as a justification for reservation. Like Rawls, Dworkin too believes that what counts for merit cannot be decided in the abstract but in terms of what society values and considers relevant.In other words:

It all depends upon what society thinks should be cherished and the kind of institutions that it would like to uphold. Therefore, nobody has a prior right to go to Medical College or become a lawyer. Society will decide which mix of attributes it considers suitable for admission into medicine and law. Admission may not be only on the basis of marks scored, but on the additional basis of, say, colour of skin or caste background. As one’s attributes do not belong to the individual but to society, it is up to [it] to decide which attribute, or bundle of attributes, it considers relevant. At a certain point in time society could decide that being black or belonging to an ex-untouchable caste is a socially useful colour in which case, then, academic Merit alone will not count. (Roland Dworkin, cited in Dipankar Gupta’s “Positive Discrimination and the Question of Fraternity: Contrasting Ambedkar and Mandal on Reservation” )

This, then, makes it clear that the quest for merit and deserts has to be kept in check. This, however, does not mean that Rawls rejects them altogether. He only pleads that the basic structure be arranged in such a manner that these contingencies work to the benefit of the least advantaged (Rawls 102) This he terms as the difference principle. When applied to Government policies it means that they ought to be formulated keeping in mind the interests of the worst off. Utilitarians and Rawls thus become the best exponents of the policy of reservation, of course indirectly.

The aforesaid exposition of reservation and its theoretical underpinnings clearly establishes the organic linkages it has with the concept of social mobility. Reservation in the broadest sense is a process of social churning as it attempts at restructuring the existing system on an equalitarian basis. It shakes the privileged position of the dominant sections and offers the disadvantaged a helping hand to intrude into the hitherto denied social, economic and political slots in the system. The net result is intra-stratum movement or social mobility. Once this linkage is established, the next logical course is to develop a theoretical framework to comprehend the intricacies of the process of mobility.

Social Stratification and Mobility
In every society, ancient or modern, democratic or otherwise, the positions, which individuals come to occupy, vary very much in terms of power, privilege and status. This has its definite impact on the dialectical interaction among individuals, their social prestige, influence and importance. In Sorokin’s phraseology its essence consists of unequal distribution of rights and privileges, duties and responsibilities, social values and privations, social power and influences (Sorokin 11).The fundamental basis of this phenomenon inevitably lies in the manner in which societies are lacerated into layers and their hierarchical ordering. Thus social stratification becomes an important field of investigation in Social Science. More often than not, primary focus of attention here is on social formations with which various strata are composed and the manner and degree of movements among them.

One confronts different philosophical conceptions regarding the above problematic. Take for instance the issue of social formations. Here one usually comes across much of a juxtaposing of the uni-dimensional construct of Marx and Engels with the multi-dimensional analysis of Weber and others of his ilk, Runciman and Sorokin in particular. For Marx and Engels stratification rests on the pedigree of class i.e., place of individuals in the system of production and property relations. Weber while accepting the class conception of Marx and Engels brings in two additional categories - status groups and parties - and thereby provides a social and political dimension to an otherwise economic 3 construct . Runciman more or less follows the Weberian typology with a slight modification. He introduces the concept of power instead of parties, though in 4 reality both stand for the same thing . To Sorokin, economic, political and occupational are the three principal dimensions of stratification (Sorokin 12)

A hindsight however reveals that there is a common thread that runs through and binds all these schools of thought. Nobody from Marx and Engels down to Sorokin, seems to be in doubt about the centrality of economic factors, or class formations to be more precise, in social stratification. Also it won’t be far-fetched to maintain that other factors, be they status, party or power, about which Weber or Runciman is specific are laced firmly with class. This, however, should not be construed to mean that one is denying the salience of other factors or the differential contributions of Weber et al to the study and analysis of social stratification. But the purpose is rather a restricted one, to point out the significance of economic interest in the formation of social collectivities.

Linked to the above, but much more important than it, is the effort at theorising the process of the movement of individuals from one stratum to the other or change in placement within the same stratum. A rich but variegated body of literature already exists in this realm, of course with the usual contradictions inherent in the analysis of such complex social phenomenon.

Literature on social mobility relates the phenomenon with social change and/or movements of individuals in social space. Theoretically the first proposition is valid as all social changes, violent or peaceful, induce structural changes in varying degrees resulting in greater inter-and intra-stratum traffic. However it has one important lacuna as it is couched in general terms ignoring the specificities of such changes. The second formulation sounds better, though it also has certain shortcomings on closer scrutiny. Sorokin, for instance, defines mobility as transmission of an individual or social object or value-- anything that has been created or modified by human activity — from one social position, economic, political and occupational, to another (Sorokin 133). While this covers a lot of ground lost sight of by the first proposition, applying this in societies with caste-based stratification system becomes problematic. This is more so in the case of upward mobility. It may be noticed that mobility for an individual in the final analysis becomes meaningful only when his elevation to a higher slot and consequent status change is accepted by the larger society and his peers in the new stratum. For instance, in India an individual belonging to Scheduled Castes who is inducted to a higher position (profession-wise) may not be acknowledged by his official subordinates or his peers or even the clientele belonging to the upper or intermediate castes. Sorokin misses situations like this.

It would be appropriate here to introduce Lipset and Zetterberg who view social mobility to be the product of shift and ranking of occupations, consumptions, social power and social class composed of individuals who accept 6 each other as equals and qualified for intimate association . We could beneficially use this with some modifications to the latter part. For, qualifying for equal treatment and intimate association alone won’t suffice our need. It is also crucial that the mobile individuals are accepted and accorded due respect befitting their newly acquired positions by their subordinates in the official hierarchy and the larger public outside, irrespective of their caste status. This may be termed as social acceptance . Social Mobility, thus, means positional shift of individuals in the social, economic, occupational and political structures in such a manner that the new incumbents qualify for social acceptance irrespective of their caste or ascriptive ties.

The linkage between social and political mobility also assumes salience here. The two are inter-linked processes with social mobility leading to political mobility and this in turn leading back and inducing greater social mobility. For instance, Verba et al hypothesize that social mobility leads to political participation and activity (Verba et al. 69) and Barbara Joshi considers it (political mobility) as a means of greater social and economic mobility (Barbara R Joshi 25).

Political mobility is a broader concept, which stands for greater political power and role in the decision-making process, both at the party and governmental levels. It has also a social acceptance dimension when applied in a caste-linked stratification and status system. Like the socially mobile individual the politically mobile should also be accepted by the society. To be more specific, his authority and status should be accepted and respected by his subordinates and accorded due regard by his peers and superiors, both in the party as well as in the Government. And this should come irrespective of his ascriptive identity.

Further, social mobility also influences political preference. This has been accepted by both Instrumental and Expressive Theories. According to Lipset, intergenerational mobility affects the relation between social class and political preference . Hence it is held that the political preference of a mobile person will be more or less the same as the class of his destinations (Newbeerta and Graaf 30, 48). As his class position changes upward, his political preference oscillates between left-wing radicalism to right-wing conservatism. By implication this means that a person in a lower position has a higher chance of having a left-wing political preference than someone in a high-class position whose leniency will be towards right of centre political formations. Abrams and Rose have proved this point while investigating the reasons behind the Labour Party’s defeat in three successive General Elections (1949, 1954 and 1959) in England. Their conclusion is that the Labour voters failed to identify with the party because of their relative affluence (M.Abrams and R.Rose 484). The theory is that as a community experiences material prosperity, it develops a vested interest in maintaining the status quo in property relations and this in turn leads to its opposing activities, adversely affecting its material interests (T.K. Oommen 166) Consequences of social mobility on political mobility and preference thus become a focal point of attention in mobility studies.

Types, Directions and Mechanisms of Mobility
Viewing mobility as positional shift brings to the fore two crucial aspects of the phenomenon, types and directions of the shift, and the process through which individuals seek elevation to higher strata.

Four types of mobility are commonly identified; Ritual and Secular, and Contest and Sponsored. Ritual Mobility is often initiated through group efforts aiming at a higher ritual position or rank in a society where ritual status forms one of the important criterion of social stratification (Chandrashekhar Bhat 124) Secular Mobility, on the other, is movement in public sphere-- particularly educational, occupational and political-- and deals with the exercise of state power. Owen Lynch points out political participation as an important channel of this type of mobility (Owen M..Lynch 8 )

The second typology -- Contest and Sponsored Mobility is a distinct contribution of Ralph Turner. When mobility is the product of open competition between individuals it becomes Contest Mobility. The contest is judged to be fair only if all players compete on an equal footing and victory here is solely by one’s own effort . Under Sponsored Mobility, however competitiveness as well as own effort are at a discount. Here the mobiles are chosen by the established elite or their agents and is like entry into a private club where each candidate must be sponsored by one or more of the members.In other words here, for mobility to take place, sponsorship or sympathetic disposition of the establishment becomes a sine qua non. Turner points out the recruitment to the Catholic priesthood in US as a typical example of this type of mobility. Recruitment of Scheduled Castes and other Backward Classes to the Government service under the Indian Constitution also, in a sense, belongs to this category as they enjoy the sponsorship of the State in the form of reservation.

From typologies of mobility as one moves on to its directions, one comes across two principal dimensions with the possibility of each getting further fragmented into a series of sub-divisions. Sorokin analyses it in terms of Horizontal and Vertical forms. Horizontal Mobility means hopping of individuals along the surface i.e., movement within the same stratum and level with hardly any ups and downs in status. Contrariwise in Vertical Mobility status shifts stand out in bold relief. Vertical Mobility thus is the relations involved in a transition of an individual from one social stratum to another (Sorokin op.cit) Theodore Caplow’s description seems to be more crisp — movement of individuals upward or downward with a gain or loss in social rank.(Theodore Caplow 59)

Turning back to Sorokin, it could be discerned that he divides Vertical Mobility into ascending and descending currents. While the former denotes social climbing or ‘Upward Mobility’, the latter points towards social sinking or Downward Mobility. Each of these, in turn, is divided into two categories depending on the individual or collective nature of the mobiles (Figure 1) (Sorokin 133— 34). In both currents there is the possibility of stray individual or whole groups being catapulted to a higher plane or ejected out of it to a lower one.

Source:Pitrim A.sorokin,social and cultural mobility,Illinois:the free press of glencoe, 1959,p. 136.

Two other classifications that could be progressively adopted in analysing the direction of Social Mobility are the ones presented by Melvin Tumin and Ray Collins, and K.L. Sharma. Tumin and Collins identify four types of mobility situations by co-relating the status of parents and their progeny: High Stationaries (high status children of high status parents) – horizontal. Upwardly Mobile (high status children of low status parents— vertical; Downwardly Mobile (low status children of high status parents)— vertical; and Low Stationaries (low status children of low status parents)— horizontal.1 (Melvin M. Tumin and Ray C. Collins, “Status Mobility and Anomie: A Study in Readiness for Desegregation”, British Journal of sociology, Vol. 10, No. 3, 1965, p. 161.)Sharma concentrates on Downward Mobility (Decline) and in the first instance, classifies it into two (Figure2).

Source: K L sharma,social stratification and mobility, Jaipur:rewat publications, 1994, p. 216

General Decline (Total decline of a unit of society-individual, family etc.) and Domain Specific (Downward mobility of the above units in a particular aspectoccupation, economic etc.). Generalised Decline in turn comes for a two-fold classification-Structural Decline (Changes in the organizational principle of the society) and Positional Decline (Movement of persons within a continuing structure of society). The classification finally ends with the division of Structural Decline into Primary Structural Decline (radical change which may be due to pressure from above, for example, from the threat of war by a big power and/or from elites and reformative policies or pressure from below, for instance, a Maoist revolution) and Secondary Structural Decline (indirect and immediately less effective changes to which individuals and groups are exposed) (K.L. Sharma 211— 25). Sharma considers Domain Specific Decline as the one to affect the depressed classes very much since all their attempts at mobility in caste hierarchy are frustrated by the forward castes consequent to which they lose their traditional occupation and find themselves in a state of unemployment (Sharma 225). Parenthetically speaking, it may be noted that it is Vertical Mobility and its various forms which are more important than Horizontal Mobility.

Merton’s Reference Group Theory and Srinivas’ Concept of Sanskritization
Another important problem in the study of social mobility is the identification of the process or mechanism through which individuals/groups seek upward mobility and theorizing it. Merton’s and Srinivas’ are two valiant attempts at this.

Merton tries to weave his theory of mobility with the help of three conceptual categories-Relative Deprivation, Reference Group and Anticipatory Socialization. It aims at systematizing the determinants and consequences of those process of evaluation and self-appraisal in which individuals take the value or standards of other individuals and groups as comparative frame of reference (Robert K. Merton 234). The theory is premised on: a feeling of deprivation by mobility aspirants relative to some dominant groups (Relative Deprivation); an endeavour to identify a group/groups whose behaviour is considered worthy of emulation (Reference Group); and finally the adoption of its/their norms and values in anticipation of its acceptance by the referent group/ groups (Anticipatory Socialization). In his framework Merton develops four types of Reference Groups: Normative-group/groups providing a frame of reference; Comparative-group/groups providing a comparison relative to which one’s deprivation is evaluated; Positive-group/ groups involving the ‘motivated assimilation of norms or standards of the group as a basis of self-appraisal; and finally the Negative Reference Group - one involving motivated rejection and the formation of counter norms (Merton 300) He also acknowledges the possibility of plurality of Reference Groups, more so in the case of Normative and Comparative Groups.

Two conditions, however, are stipulated for the theory, particularly anticipatory socialization, to become functional stratification system should be under dispute, and the society should be open. In Merton’s own words:

If the structure of a rigid system of stratification is generally
defined as legitimate, if the rights, perquisites and obligations of
each situation are generally held to be morally right, then the
individuals within each stratum will be less likely to take the
situation of the strata as a context for appraisal for their own lot.
They will, presumably, tend to confine their comparison to other
members of their own or neighbouring social stratum. If however,
the system of stratification is under wide dispute then members
of some strata are more likely to contrast their own situation with
that of others and shape their self-appraisal accordingly. It appears
further that anticipatory socialization [and therefore of the
Reference Group Theory] is functional for the individual only
within a relatively open social structure providing for mobility.
For, only in such a structure would such attitudinal and
behavioural preparations for status shifts be followed by actual
changes of status in a substantial proportion of cases. By the
same token, the same pattern of anticipatory socialization would
be dysfunctional for the individual in a relatively closed social
structure where he would not find acceptance by the group to
which he aspires . . .. (Merton 267— 68)

But it seems that Merton is over-stating his case. For, in the first instance, openness or closeness of a society is relative than absolute. Therefore, anticipatory socialization rather than becoming dysfunctional would be functional relatively. Further even in the so-called ‘closed societies’ reference group theory has its relevance. Speaking about the rigid caste-based stratification system in India, Damle clearly states this:

The paradox of caste lies in the fact that although lower caste
persons cannot expect to be included in a higher caste (Jati) and
also because higher caste persons need not fear their exclusion,
positive orientation for reference and imitation is permitted and
even encouraged. Anticipatory socialization can thus occur and
even if it does not ensure ultimate absorption or inclusion ... it
can be functional for the persons concerned ... where a higher
varna is used as a reference model.

Many studies have also shown the utility of this theory even in relatively closed societies. K.C. Alexander’s study of the Pulayas of Kerala, Owen M. Lynch’s study of the Jatavas of Agra, Chandrasekhar Bhat’s study of Waddars of Kamataka, all stand testimony to this. More than all these, Srinivas’ concept of Sanskritization clinches the issue in favour of this argument. This is exactly what he does by establishing the possibility of the lower castes emulating the behavioural pattern of the twice born castes and thereby trying to move up, though the conceptual framework he uses and the social reality he seeks to encapsulate are distinct.

Srinivas endeavours to analyse the mobility of ascriptive categories in the specific context of India. He finds the middle castes moving along the ritual axis and attributes this to their propensity to imitate Brahmanical values. He calls this process Sanskritization. To quote him:

The caste system is far from a rigid system in which the position
of each component caste is fixed for all time. Movement has
always been possible and especially so in the middle region of
the hierarchy. A low caste was able, in a generation or two, to
raise to a higher position in the hierarchy by adopting
vegetarianism and teetotalism, and by sanskritizing its ritual and
pantheon. In short, it took over as far as possible the customs,
rules and beliefs of the Brahmans and the adoption of the
Brahmanic way of life by a low caste seems to have been frequent,
though theoretically forbidden. (Srinivas. The Cohesive Role of
Sankritization and other Essays. Delhi : Oxford University Press,

Later he has amended the ‘Brahmanical model’ of emulation and stated that any superior caste could be taken up for the purpose.

Srinivas further identifies three fundamental traits of the process: it is a group process not strictly applicable to individuals; it is a long and protracted one, some times taking generations to meet the target; and finally it is unhelpful for the untouchable groups below the ritual barrier of pollution.17 Besides, a minimum of economic and political power is alsoneeded for the caste to move up (Andre Beteille 120) By implication this means that Sanskritization as a concept is not applicable to movement in the secular status hierarchy. It becomes operational only when an intermediate caste after gaining economic and political mobility attempts at corresponding change in the ritual hierarchy. In other words it is only useful for a caste whose economic or social rank has improved and is therefore out of place with its low ritual rank and through Sanskritization that is also raised (Lynch 11). Here it is also worthwhile to remember that Sanskritization accepts the legitimacy of the caste system. Social mobility takes place only within its parameters and not outside it. Viewed thus, it does not lead to any structural change.

In retrospect, it could be seen that though Reference Group Theory and Sanskritization help a great deal in analysing the process of social mobility, still both leave a lot of ground uncovered. The consequence of a failed attempt at mobility— for instance a person who lacks social acceptance— best illustrates this point. In this case there is no congruence between the achieved status and accorded status. This may create disillusionment in him. Neither of the theories is equipped to meet such contingencies with the result that one is forced to seek the support of other theories. Homans’ Theory Of Status Congruence, Oscar Lewis’ Culture of Poverty, Milton Gordon’s Ethclass and Paranjpe’s Ethnocentric and Contra-identification are some useful theoretical and conceptual categories in this regard.

A person who feels status discrepancy is an aggrieved person. He is anxious about his slot in the society. Homans seeks to explain this in terms of status congruence/incongruence and status anxiety (Homans 98). He has developed his theory in the specific context of acquired statuses in a work organization (Nandu Ram 27) Congruence (inness) between statuses creates satisfaction whereas incongruence (outness) between them breeds anxiety. To Homans, for the person concerned inness is the symbol of distributive justice and the contra position that of injustice (Homans 168 ).

The consequence of status incongruity for a person also needs investigation. Any one of the following situations unfolds in such an eventuality: one may resign to one’s fate and progressively get alienated. Oscar Lewis terms this as culture of poverty. He uses it in the context of a class stratified and highly individuated capitalist society and considers it as ‘an effort to cope with the feeling of hopelessness and despair which develop from the realization of the improbability of achieving success in terms of the values and goals of the larger society. 18 The second situation is a little bit complex. Needless to repeat, a person lacking in social acceptance is the one who attains mobility in the achieved status but wanting in mobility in the accorded status. This means he had already moved away from his primary membership group (in-group) but denied access to the group of destiny (out-group). He thus remains suspended between the two. In such a contingency he might be forced to interact with his ethnic-class group i.e., those members of his ethnic/caste group belonging to the same class status as his. Here one finds a new group emerging at the confluence of class and ethnicity/caste. Milton Gordan calls this Ethclass. According to him:

With a person of the same social class but of a different ethnic
group one shares behavioural similarities but not a sense of
peoplehood. With those of the same ethnic group but of different
social class one shares the sense of peoplehood but not behavioural
similarities. The only group which meets both these criteria are
people of the same ethnic group and same social class.

In the above group one feels at home and can interact with greater ease. The last situation is one in which one identifies with his own ethnic/caste group. The issue raised above could be analysed with the help of Paranjpe’s Theory of Ethnocentric and Contra-identification as modified by Nandu Ram. Paranjpe visualises two situations of identification-one in which the individuals identify with their ethnic/caste group (ethnocentric identification) and the other in which they identify at the class level (contra-identification) (Paranjpe 106— 14). Nandu Ram adds a third dimension of identification: non-caste class level. This situation arises as they may not believe in any identification whatsoever in the stratification system and may have a frame of reference of non-stratificational identification (Nandu Ram 15). This he considers as another dimension of Paranjpe’s Contraidentification.

Integration of the Theoretical Framework
Social Mobility of Scheduled Castes is analysed in this study by lacing together the following theoretical formulations: Lipsets’ and Zetterberg’s theory of Social Mobility, Srinivas’ Theory of Sanskritization, Homan’s Theory of Status Congruence, Gordon’s Theory of Ethclass and Paranjpe’s Theory of Ethnocentric and Contra-identification.

The organic linkage between the reservation policy adopted in India and Utilitarianism and Rawis’Theory of Justice is transparent. True to Utilitarianism, it also facilitates the greatest happiness of the majority of the populace. Similarly like Rawlsean justice it is also one of the fairest ways to uplift the worst off. Further, as is already made clear, the leitmotif of reservation is social mobility of depressed classes. It is believed that once their stigmatised identity is removed by changing for the better their social, economic and political lot, these people would get progressively integrated with the rest of the society qualifying for intimate association and social acceptance. Lipset’s and Zetterberg’s theory of social mobility with some modification as already stated will suit our purpose here. However, social power and consumption dimensions of their theory have been dropped as both are beyond the purview of this study. At the same time, the concept of social acceptance is brought in to see whether their assimilation with the rest of the society and thereby their mobility has been complete. Thus social mobility here is considered as a multi-dimensional concept involving changes in education, occupation, political power and income and social acceptance of the mobile (both social and political) persons. Sanskritization will help to grapple with this dynamic process.

However the Scheduled Castes who may attain mobility in terms of education, occupation and income or political mobility may not be accorded social acceptance by the rest of the society because of their low caste status. Such people, at least a section among them, may find themselves suspended between the two worlds, neither in the primary group nor in the fold of the upper caste/ class. Harold Issacs calls the situation as one of ‘semi-limbo. With whom does such a person identify himself in Caste? Class? Caste-Class level or non-Caste-Class level? Will he become resigned to his fate and get alienated from the system? Paranjpe’s ethnocentric and contra-identification theory, and Gordon’s Ethclass concept become crucial in analysing the situation.

1.G. Patel, ‘Equity in a Modem Society’, Mainstream, Vol. XXII, No. 11, 29 January 1994, p. 53. Also see Charles Valentine, Culture and poverty:- Critique and Counter Proposals, Chicago: The University of Chicago Press, 1969.

2.Dipankar Gupta, “Positive Discrimination and the Question of Fraternity: Contrasting Ambedkar and Mandal on Reservation”, Economic and Political Weekly Vol. XXXII, No. 31, 2-8 August 1997, p. 1972.

3.Though Weber is in considerable agreement with Marx in this regard— for example he accepts the latter’s proposition that
social stratification is a phenomenon closely linked to the distribution of and struggle for power – he also differs from him
in several respects such as the conception of power, assessment of the course of European history and the conception of what constitutes a satisfactory explanation in Sociology to this phenomenon. For details see Max Weber, The Theory of
social and Economic Organization, (Trans. A. M. Henderson and Talcot Parsons) New York: Oxford University Press,
1967 and H. H. Gerth and C. Right Mills, From Max Weber, Essays in Sociology, New York: Oxford University Press,
1959. Also see James Little John, Social Stratification, London: George Allen and Unwin, 1972.

4.For details see W. G. Runciman, “Class, Status and Power” in J. A. Jackson.(ed.), Social Stratification, London:
University Press, 1968.

5.S.M. Miller, “Comparative Social Mobility: A Trend Report and Bibliography”, Current Sociology, Vol.1X, No. 1, 1969,
n. pag. in Dr. Leela Viswanathan, Social Mobility Among Scheduled Caste Women in India (A Study of Kerala), New
Delhi: Uppal Publishing House, 1993, p. 36.

6.S.M. Lipset and Hans L. Zetterberg, “A Theory of Social Mobility” in R. Bendix and S. M. Lipset (eds.). Class, Status,
and Power, London: Routledge and Kegan Paul, 1966, p. 563

7.This differs fundamentally from Earl Hoppers concept of Legitimization. For, it consists only of adjusting one’s status
position to a level that approximates one’s new economic position and realizing the potential prestige to which one
hasbecomebr ‘entitled’ through having changed one’s occupation by becoming a member of the relevant core status
group. This is primarily because he focused his attention only on class-stratified societies where social acceptance of
one’s position is not a problematic. However the two concepts are also related in a way. For, to get social acceptance
of one’s status and authority one should oneself realize it. In this sense status legitimisation precedes social acceptance.
For details see his Mobility. A Study of Social Control and Instability, Oxford: Basil Blackwell, 1981, p. 150.

8.The basic idea here is that voting behaviour is rational and has an economic purpose. People within a certain class are in the same economic and social position and have the same interests. Consequently people within a certain class will vote for
the same party that serves their interests best. For details see Paul Nieuwbeerta and Nan Dirk de Graaf,
“Intergenerational Class Mobility and Political Preferences Between 1970 and 1986 in the Netherlands”, Netherlands
Journal of Social Sciences, Vol 29, No. 3, June 1993.

9.The theory perceives voting as a social rather than an economic act. The assumption is that one’s political attitudes and
preferences are influenced by the people one associates with. For details see Ibid.

10.For details see S. M. Lipset, Political Man, New Delhi: Arnold Heinemann India, 1973

11.Ralph H. Turner, “Sponsored and Contest Mobility and the School System” in Celia S. Heller (ed.), Structural Social
Inequality: A Reader in Comparative Social Stratification, New York: Macmillan Co., 1969, p. 354.


13.Ibid. p. 362.

14.Y. B. Damle, “Reference Group Theory with Regard to Mobility in Caste” in James Silverberg (ed.), Social Mobility
in the Caste System in India, The Hague: Mouton, 1968, p. 98.

15.Today there is a proliferation of terms arising on the Sanskritization analogue such as Kulanization, Kshatriyaization,
Desanskritization, Palianization etc. depending on the particular caste chosen for emulation. In regard to
Kshatriyaization a different interpretation is also presented by Hermann Kulke. According to him, in its functional sense
the concept denotes social change from above, ie., a process initiated in tribal areas by Kshatriyas, Zamindars, Chiefs or Rajas to strengthen their claim to legitimacy in the society and to broaden the basis of economic and political power.
For a discussion in this regard see his work “Kshatriyaization and Social Change: A Study in Orissa Setting” in
S. Devadas Pillai (ed.), Aspects of changing India: Studies in Honour of Prof. G. S. Ghurye, Bombay: Popular
Prakashan,1976. For Sanskritization analogue refer Narmadeshwar Prasad, The Myth of the Caste System, Patna: Samjna Prakashan, 1957; S. K. Srivasthava, “The Process of Desanskritization in Village India” in Bala Ratnam (ed.), Anthropology on the March, Madras: The Book Centre, 1963; and Eleanor Zelliot, “Buddhism and Politics in Maharashtra” in Donald E. Smith(ed.), Religion and Politics in South Asia, Princeton: Princeton University Press, 1966.

16.Srinivas used the term Sanskritization instead of Brahmanization, as the customs and habits of Brahmans were different.
Had that term been used, it would have been necessary to specify which particular Brahman group was meant and at
which period of its recorded history. For details see his “A Note on Sanskritization and Westernization” in Bendix and
Lipset, op. cit.

17.Srinivas, “A Note on Sanskritization and Westernization” in Bendix and Lipset, op. cit., p. 58.

18.Here it may be remembered that Lewis differentiates between Poverty and Culture of Poverty and observes that
‘While the lower castes in India may be desperately poor, they are not certainly afflicted by the disease of the culture of poverty. [This is because] ... most of them are integrated into the larger society and have their own Panchayat organs which cut across village lives and give them a considerable amount of power. In addition to the caste system, which gives the individuals a sense of identity, and belonging there is still another factor, the class system. Wherever there are
unilateral kinship system or class, one would not expect to find the culture of poverty because a class system gives
people a sense of belonging to a corporate body with a history and a life of its own thereby providing a sense of
continuity, a sense of past and of a future.

Ramashray Roy and V. B. Singh fault Lewis on several counts: First the sense of continuity in respect of the
Scheduled Castes is also a sense of degradation. Their history and their life are nothing but an unending series of
misery, woe and frustration. They do not represent anything to be proud of unless the way of life thrust upon them by the larger society is felt by them to be not only proper but also edifying. This, however, is not the case. Secondly, it is true
that the class system gives a sense of belonging to a corporate body. However, this corporate body along with the
Caste Panchayats Lewis talks of, have usually been the instruments for safeguarding traditional caste norms. Even in
recent times when their functioning might be said to be influenced by a new consciousness, they have neither been able to wield political leverage nor offer a reliable base for political mobilization and action. For a detailed discussion see Oscar Lewis, La rida: Puerto Rican Family in the Culture of poverty San Juan and New York, New York: Random House, 1966; Ramashray Roy and V. B. Singh, Between the Two Worlds: A Study of Harijan Elites, Delhi: Discovery
Publishing House, 1987.

19.Milton M. Gordon, Assimilation in American Life, New York: Oxford University Press, 1964, pp. 46-54. Also see Celia
S. Heller, “Ethnicity, Race and Class” in Heller, op. cit.

20.The theory was originally propounded by W. G. Sumner. Social Psychologists like Adorno T. Wetal, G. W. Allport,
Robert A. Levine, Donald T. Campbell et al. have also made notable contributions in this field. According to the theory,
an individual or a group identifies with an ethnic group and claim ethnic superiority in comparison to other ethnic groups.
In some cases, one hates and takes revenge on them. If in certain cases an individual or a group does not identify at the
ethnocentric level, then identification may be at a level other than ethnocentric. For details see W. G. Sumner, Folkways,
New York: Mentor, 1965; Adorno T. Wetal, The Authoritarian Personality, New York: Harper -Collins, 1950; G. W.
Allport (ed.), The Nature of Prejudice, New York: Doubleday, 1955; Robert A. Levine and Donald T. Campbell,
Ethnocentrism.. Theory of Conflict, Ethnic Attitudes and Group Behaviour, New York: John Wiley, 1971; Paranjpe,
Caste Prejudice and the Individual, New Delhi: Lalwani, 1970; and Nandu Ram, op. cit.

21.Harold R. Isaacs, India’s Ex-Untouchables, Bombay: Asia Publishing House, 1965. pp. 128-42; Marc Glen, Johnson
and Sipra Bose, “Social Mobility Among Untouchables” in Giri Raj Gupta (ed.), Main Currents in Indian Sociology-III: Cohesion and Conflict in Modern India, New Delhi: Vikas Publishing House, 1978, p. 10.

Abrams, M and R.Rose. Must Labour Lose? New York: Free Press, 1959. Alexander, K.C. Social Mobility in Kerala. Poona : Deccan College, 1968. Beteille, Andre. Caste : Old and New : Essays in Social Structure and Social Stratification. Mumbai: Asia Publishing House, 1969.

Bhat, Chandrashekhar. Ethnicity and Mobility : Emerging Ethnic Identity and Social Mobility among the Waddars of South India. New Delhi : Concept Publishing Company, 1984.

Bloom, Allan. “Justice : Rawls Vs The Tradition of Philosophy”, American Political Science. 69.16. 1975.

Caplow, Theodore. The Sociology of Work. New York : McGraw Hill Book Co., 1964.

Taking Dworkin, 331 . Reservation London Rights :Duckworth, Roland. and Seriously Social Mobility: 1977. A Theoretical Construct

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Living arrangements of the old







ABSTRACT---By 2021 the growth rate of elderly persons in Kerala
will be one and a half times higher than the growth rate of general population.
Most of the states in India including Kerala have not decided on Old Age
Policy though the Qovernment of India has formed a National Policy on
Older Persons in 1999. The growing elderly population is a threat to the
socio economic conditions of the State. One consolation is that the elderly
themselves are doing a purposeful socialization for themselves. Now the
trend is that the elderly do a lot of mental exercises on various patterns
of living arrangements and then choose best according to the socio economic



       According to preliminiary
information of the census data 2001, the rate of growth of population
is one of the lowest in Kerala (0.6%), unlike the elderly population which
is increasing at a rapid rate. The state of Kerala lies in the southern
tip of the Indian peninsula with all the features of the Indian subcontinent
with little variations. The proportion of elderly persons in India has
risen from 5.63% in 1961 to 6.58 in 1991 and is expected to be 7.08 in
2001 and 9.87 in 2021. As of 1991 the highest proportion of the elderly
among the states and union territories was found in Kerala with 8.77%.
By 2021 the growth rate of elderly persons in Kerala will be one and a
half times higher than the growth rate of general population. The pressure
on the state is very high due to this dent category of population as the
state is over- burdened by looking after them. Most of the states in India
including Kerala have not decided on Old Age policy though the Government
of India had formed a national policy on older persons in the year 1999.
The states are silent about this policy though the Constitution of India
through Article 41 and through the Fundamental Rights made the social
security of older persons the concurrent responsibility of the Central
and State Govermnents. The growing elderly population is a threat to the
socio economic conditions of the state. Kerala is a state with a high
quality of life (Amarthya Sen) and long lifespan both for men and women
(68 years for men and 73 years for women) and the consequent problems
of elderly people are also more in Kerala.

       The cultural flame of Kerala
gives a higher status to women, which always gave confidence and status
for the women (Government of India, Towards equality 1975). Added to this,
high rate of literacy (90.85%) and the employment opportunities which
give the women of Kerala an edge over the women of other states in terms
of power and thereby a special status, is referred to as empowerment.
The elderly women of Kerala wielded power due to the matriarchal system
followed by a dominant section of the population. Historically the women
of Kerala had many opportunities to strengthen their status Polyandry,
ownership of property-- matrilineal and matrilocal - and this tendency
continues. Today the elderly women of Kerala have a paradoxical situation
to face, due to the changing society and life style.

       D’Souza(1989) observes
that change in living arrangements, family structure and mode of sudden
retirement adversely affect the old, and further, the old people are in
increasing proportions losing the status and security which they enjoyed
in the traditional Indian family structure. With regard to the transformation
in Indian family system, Dreze (1990) views a considerable overlap between
the problems of widows and old age in rural India i.e., for an economically
independent couple the decision regarding co-residence with the children
(sons in particular) is based on the situations and preferences of the
older as well as the younger generations. Another study by Kaur et al
(1987) also emphasized the fact that the present generation treated the
old people as a burden and their presence in the family irks most of the
family members. The status of the aged in the changing social structure
has been investigated by social scientists from different perspectives.
In most of the families of Kerala the young and the old relationship has
taken a new turn in the context of increased migration of people from
Kerala to other parts of the country, and outside India, women going for
work and a new outlook towards life (Nayar, 1987). Such investigations
have more or less concluded on the breaking down of kinship and family
organizations which has put the elderly in a state of helplessness, isolation
and economic dependence (Sharma and Dak, 1987).

       Social change and its consequences
namely modernization or globalization is increasingly seen in the life
styles of people directly and indirectly. Direct changes can be seen in
the material aspects and the indirect changes can be seen in the behaviour
patterns and attitude formations. One of the consequences of globalization
is the increasing individuality and the freedom people gain to choose
their life. Habermas has rightly pointed out that today the A Study of
the Elderly Women in Kerala culture is not ascribed as the people have
an opportunity to choose one’s own culture unlike the past. The post
moden society where we are living is so competitive and complex that people
are crazy to choose the culture under the influence of other societies
or social institutions. The old are also not far away from this as the
State and other agencies discuss their issues in public. Mass media too
helps the old people by making them aware about their issues and to choose
a life of their interest. This is the impact of globalization. All over
the world, society is experimenting with the old and vice versa and these
exercises are widely publicized so that the patterns of the life of the
old in the developed counties are spreading to developing and underdeveloped
counties. Institutionalized living is a classical example in this context.
As pointed,out ‘in various subaltern studies on the methodology to
study the weaker. Thus there is a close relationship between elderly,
modernization and their life patterns which is the theme of this paper.

       The main objective of this
paper is to find out a pattern of living arrangements of the elderly women
in the context of modernization. The second objective is to study the
living arrangements of both institutionalized and others who are living
in families and to find out the comparison in the anticipatory socialization
of these sections. Both qualitative and quantitative analysis are simultaneously
used to find out the fixation pattern of living arrangements of the elderly
women. A pilot study revealed the importance of literacy in the pattern
of living arrangements and therefore the literacy of the state is taken
into account while the study is designed. Prior to the collection of data
the sample of the study showed a correlation between income and attitude
formation which changes the life style. Weightage is given to all these
factors while the sample is decided. Taking all these factors into consideration,
it is decided to take ‘income as the main independent variable, along
with age, religion and education. The universe of this study is Trivandrum
city and the concentration was two old age homes and their neighbourhoods.
As the study was not to frame macro level theories but to formulate micro
level conclusions (hypotheses), the sample size is reduced to 150 which
is distributed among the major religious groups taking into account their
income, education, religion and age.

       Table below (T. No. 1) shows
the distribution of the sample keeping income as the main independent
variable and age, religion and education as the other variables. This
proportionate sample is based on samples mentioned above. The elderly
women are concentrated ‘m the middle income group rather than the
lower and upper income groups.




& below)



















to 5000)



















(Rs. 5000 & above)













       Elderly people are widely distributed
among all the groups. Therefore one has to study the elderly women and
their problems taking all the variables available. The women living in
the two old age homes are also taken for this study. Among the lower income
group, majority are with their families whereas in the upper income group
40% of the elderly women are living in their homes. The old age care in
Kerala is understood in many ways according to this study. The elderly
are studied in their families and also in institutions.

       Development of institutional
care for the handicapped, infirm and aged persons in India has a long
history. The first old age home in India is supposed to have been started
in early 18th century, but information is available from 1782 onwards.
Today, the services are mainly provided by the non-government, private,
voluntary, non-profit and particularly the religious and charitable organizations.
The central and state governments still play a very negligible role in
providing care to the deprived sections of society. The Madras Institute
of Ageing, in its monograph, listed 329 institutions which are caring
of the elderly. lrudaya Rajan reports that Tamil Nadu & Kerala has
the highest number of old age homes when compared to other states of India.
As of 1998, there were 71 old, age homes in Tamil Nadu & 70 in Kerala.
But compared to other states in India, Kerala leads the list in having
the highest number of aged persons in institutions ( 21.89%). (lrudayaRajan
et al. 1995)

       The institutionalization of
old can be seen in two ways: - first total institutionalization and the
second type is a partial institutional care. In the latter, elderly ladies
go during the daytime and spend their time either by engagmg themselves
in some work or they spend their time in the company of other elderly
ladies. Among the existing institutions in Kerala, 92% provide total care
3% offer day care service and the remaining institutions are engaging
in health care and self employment activities for the elderly. This type
of institutional care is emerging in Kerala as self-employment schemes,
as many day care centers are ready to take care of the elderly on payment
basis. In this study it was found that 10% of the lower income group,
20% of the middle and 28% of the upper income group are in the partial
care category. There are elderly women who are staying on their own or
staying with friends and the trend again is slanting towards the upper
income group. On the whole, the present study reveals that it is the upper
income group who face problems, as there is nobody to look after them
during old age.

Income Group

(Rs. 1 000 & below)
24 (60%)

7 (17.5%)


5 (12.5%)



(Rs. 1 000 to 5000)




12 (20%)

6 (10%)




(Rs. 5000 & above)

7 (7.14%)



14 (28%)

9 (18%)







       Among the lower income group
the women go to old age homes after the death of their husbands. The main
reason is the adjustment problem with their daughters-in-law or the hesitation
of their daughters to look after them for want of money. Many elderly
women go to free homes run by Government or voluntary agencies. ‘
A visit to these homes will reveal that these women adjust well even when
the conditions are bad, unlike others in their families. They prefer this,
as the surroundings here give them peace. Almost 90% of the elderly women
who participated in this study have children but their children have either
migrated or they have acute adjustment problems which lead them to institutions.
A survey of old age homes in the state of Maharashtra by Dandekar (1993)
reveals that the prime reason for the aged moving into old age homes is
due to the lack of proper care for them within family set up. Another
study of the inmates of old age homes in the state of Gujarat (Shah, 1993)
lists lack of home care as the prominent reason cited by the elderly for
their preference to stay in old age homes. Besides economic reasons, family
quarrels and handicaps were found to have induced the elderly to move
into old age homes. The study done in Kerala and Tamill Nadu also reports
similar reasons (Imdaya Rajan et al., 1995).

       The living arrangements were
made mainly by themselves. 34.7% of the sample living in their families
are happy to stay there as they feel secure in the company of their kin.
Among the 32% who have decided to got to institutions only 52.1% chose
to go to the homes. Among the others, 20.8% were forced to go as they
had no other place to go. Their children are away from the state and they
themselves are migrants from other parts of the State. A conversation
with one lady revealed that she neither felt at home in her native place
nor was she in a position to go along with her daughter, in spite of the
fact that she was economically sound. It was her friend who suggested
the old age home and she decided to go there. In the homes, women who
have contact with their families are happy.

Income Group

Nobody at




(Rs. 1 000 &










(Rs. 1000 to








(Rs. 5000 &
















       The main problem of the elderly
is that they never anticipate this part of their life. It is a natural
phenomenon that people are conscious only about their children as the
social law says the elderly will be taken care of by their children. This
social law is fading away in the background of modernization and the elderly
are left with themselves. One has to understand that taking care of the
old is not that easy in the present society especially in the nuclear
family set up due to many encumbrances the family faces. Women going for
work, lack of proper housemaids, erratic office timings, lack of traditional
holdings etc. contribute to the difficulties faced by the young in taking
care of the old. Though the elderly knew all these things during the pre-old
phase, they lived in “hope”. This study gives an interesting
result on these issues.

Patterns of Anticipatory Socialization of the
Elderly Women
Income Group


(Rs. 1 000 & below)


2 (5%)


Not Prepared

38 (95%)




(Rs. 1 000 to 5000)

27 (45%)

33 (55%)




(Rs. 5000 & above)

12 (24%)

38 (76%)




Income Burden Govt. Policy Various Avenues
Institution Group
Various Avenues

(Rs. 1 000

& below)



1 0


1 1















(Rs. 1 000

to 5000)




















(Rs. 5000

& above)




























       The study shows that the women
of middle income groups are more prepared than the women of upper income
group. When 75% of the lower economic groups women felt that they would
become a burden to their own families in future, 20 % of the upper income
group felt like that. 58.3% of the middle income group also felt that
they would become a burden in the future. This shows that the changed
life pattern of the former groups would be quite acceptable whereas the
latter group would not face it, as they never anticipated that they would
become a burden. In the case of upper income group, the life style is
such that they never planned for the loss of income or they never took
into consideration the individuality of growing children. They always
concentrated on life around themselves. Thus the mental shock would be
acute among these groups when living arrangements are shattered. It is
found that the transition of living arrangements is made without any problem
among the upper income groups unlike the lower and middle income groups.
Irwm Deutscher notes that much of the descriptive studies indicate that
it is a difficult period of life and that both theory and clinical experiments
suggest that most people would have difficulty in making the transition.
(Irwin Deutscher, 1962)

       According to this study the
transition to old age is smooth among the middle income group as they
are well prepared. 45% of the middle income group ladies thought in advance
about their future and as a result, almost 58.3% of the middle income
groups knew that they would not be looked after by the family members
and therefore they took precautionary measures for their old age. This
trend is just the reverse as far as the women of the upper income groups
are concerned. Sharma et al in their study of India’s elderly cites
that the middle income group showed a serous concern with regard to life
preparatory measures. The idea of savings was strongly advocated for a
smooth independent life in old age. Gore says that care given by the young
largely depends upon the support system as caring is inspired by the material
or the non-material support the young derived from the old (Gore, 1992).
In Sharma’s study it was proved that saving otherwise was termed
to supplementing the sudden dip in income level soon after active working
years of life. Thus the study finds that the middle income group was seen
to be more comfortable in their old age.

       When they are prepared for
old age, the women are concerned about the avenues available for them
during the old age. Social Security Schemes, help from voluntary organization
and the old age homes are some issues analyzed in this study. The International
Labour Organisation defines social security schemes as one that provide
the citizen with benefits designed to prevent or cure deceases or to support
them when they are unable to earn and to restore them to activity. There
are varioius voluntary organizations for the aged like the Age Care India,
A Study of the Elderly Women in Kerala CARITAS India, Helpage India, Indian
Association of Person, Department of Pension and Pensioners Welfare. Again
lower income groups know more about these aspects than the middle and
upper income groups. It is the upper income groups who are less knowledgeable.
A closer view reveals that 27.5% of the lower income group know about
Government policies and only 14% of the upper income group are aware of
this. But among the middle income groups 53.3% women knew that Government
has various measures under old age schemes. Likewise when 92% of the upper
income groups do not know the concept of NGOs only 41.7% of the middle
income groups are not aware of the NGOs and their work in this field.

       However 82.5% of the lower
income groups are also not aware of the work done by voluntary organizations.
The reason for this non-awareness is yet to be found out. Though there
is a strong propaganda through the mass media on Government policies,
the impact of these are seen only among a section of the elderly population.
Vernacular press also gives a wide propaganda on various issues of the
old. This means that even in a state of high literacy, old age issues
are at the backstage and much work is to be done for creating awareness.

       About institutional care, only
the lower income group are less aware than the middle and the upper income
groups. This again shows that the role of family in old age care is slowly
declining and it is slowly replaced by institutional care. In the institutions
the majority are from the upper income brackets as the paid homes are
collecting huge amounts. The tendency to go to the old age homes is mainly
from the security point of view as they feel that they will get psychological

       The traditional living arrangements
of the elderly are breaking down due to modernization and old age care
is taken up by outside institutions. Just like child care, which is weaned
from the families, old age care is also moving to institutions due to
the pressure of moden living. When the population shows a drastic increase
in old people, society is yet to fmd out a means for their peaceful living.
The consolation is that the elderly themselves are doing a purposeful
socialization for themselves through anticipatory preparation. Now the
trend is that the elderly do a lot of mental exercises on various patterns
of living arrangements and then they choose the best according to their
socioeconomic conditions. But this exercise is done only by a small section
of the elderly population. This is to be spread out to the whole elderly
population for their healthy, physical and mental well being.


Dreze, J. “Widows in Rural India”. Mitneograph. The Development
Economic Research Programme, London School of        Economics,

D’Souza, V.S. “Changing Social Scene and its Implication for
the Aged”, in K.G. Desai (ed) Aging in India. New Delhi :        Ashish
Publishing House, 1989.

Dandekar, Kumudini. “The Aged, Their Problems and Social Intervention
in Maharashtra”. Economic and Political Weekly,        26.23.
June 5, 1993.

Gore M. S. “Ageing and the Future of the Human Being” Indian
Journal of Social Policy. Zaid Press, 1992.

lrudaya Rajan S, U.S.Mishra and P.S. Sartna. “An Agenda for National
Policies on Aging in India”. Research and        Development
Journal, (Journal of Helpage India), 1.2. 1995.

Kaur Malkit, R.P. Grover and Kusum Aggarwal. “Socio-Econormc Profile
of the Rural Aged”, in M. L. Shanna and T.M.        Dak
(eds) Aging in India. New Delhi: Ajanta Publicaitons, 1987.

Nayar P. K. B. “Ageing and Sociology: The Case of the Developing
Countries”. Social Welfare 34.2. May 1987.

Registrar General of India. Census of India 1991. Population Projections
for India and States, 1996-2016. Ministry of Home        Affairs,
Govermnent of India, New Delhi: 1996.

Sharma, M.L and T.M.Dak. (eds). Aging in India: Challenge for the Society,
New Delhi: Ajanta Publications, 1987.

Director cum Professor,
Academic Staff College, University of Kerala. Was the president of the
Kerala Sociological Society. Visiting professor at the Morgan State University,
USA in 1987 and Duke University, North Carolina, USA. Attended many international
conferences and workshops. Authored four books, edited three and publishedseveral
research papers. Chief Editor, Kerala Sociologist and Honorary Director
of the Centre for Gerentological Studies, Thiruvananthapuram. The Secretary
of the Indian Sociological Society and Executive Committee Member of the
International Sociological Association.

Lakshmi Lingam

Towards understanding womens health



ABSTRACT---A healthy population is considered to be a national resource. Hence, health is a critical component of planning, policy making and programme formulation in the human resource development of the country. Outside the framework of the State, the provision of health care services to the poor and the needy, has always been a zone for philanthropy and charitable work. It has the quality of being apolitical. The paper examines the contribution of Women's Studies towards an understanding of women's health in India and presents the body of knowledge, information and contestations as women's movement trajectory and research trajectory. The areas neglected by feminist research and gender sensitive initiatives are also listed here. The paper attempts to highlight the importance of viewing women's health from the perspective of "gender and health."

A healthy population is considered to be a national resource. Hence, health is a critical component of planning, policy making and programme formulation in the human resources development of the country. Outside the framework of the State, the provision of health care services to the poor and needy, has always been a zone for philanthropy and charitable work. It has the quality of being apolitical. However, over the decades, it has been observed that regardless of the approach to reaching health care to people it is inevitable to confront questions of the political economy of health (Jesani, 1998). In simple words, the distinction between the ‘right to health’, as opposed to ‘right to health care’, signifies the difference in the scope of the two. The ‘right to health care’ constitutes the duty of the state to allocate to its members an adequate and fair share of its total resources for health related needs, given the competing claims of different health needs. On the other hand, ‘the right to health’ embodies a broad range of entitlements and access to societal resources, within which access to health care is one. If one were to include the gender lens, to examine the issues of health, it unveils how inequalities that arise from belonging to one sex or the other, can create, maintain or exacerbate exposure to risk factors that endanger health. They can also affect the access to and control of resources, including decision-making and education, which protect and promote health.

The limitations of mainstream research that hitherto remained within the parameters of ‘social engineering’, of improving people’s health seeking behavior; bringing about changes in beliefs and practices that are seen as detrimental to good health etc., had become apparent in the 1970s. The emergence of several people’s struggles, health campaigns and the second wave women’s movement has brought into focus issues of equity, rights and justice, as inextricably linked to people’s health and well being. While analysis of the political economy of health existed among researchers (Banerji, 1982) and groups working for health rights, the critical inclusion of gender perspective had unravelled the structural roots of women’s low health status.

‘Towards Equality’, the Report by the Committee on the Status of Women in India (1974) had revealed crucial aspects on women’s status and health. The International Decade for Women (1975-85) had marked the beginning of a shift in perspective in favour of women. The present paper attempts to closely examine the contribution of women’s studies towards an understanding of women’s health in India. For heuristic purposes, research papers emerging from various disciplines and campaign notes/bulletins/reports that emerge from the movements are all considered as contributing to women’s studies. A close analysis of how women’s health has been articulated by researchers and activists over the past two and half decades, demonstrates the convergence of multiple trajectories. The paper presents the body of knowledge, information and contestations as women’s movement trajectory and research trajectory. The areas neglected by feminist research and gender sensitive initiatives are also listed here. In conclusion, the paper attempts to highlight the importance of viewing women’s health from the perspective of ‘gender and health’.

Women’s Movement Trajectory

a. Violence

The mid-seventies had witnessed the resurgence of the women’s movement in India around the issue of rape. The custodial rapes of women in police stations - Mathura in Maharashtra and Ramizabee in Hyderabad - and the court acquittals of the accused police men had led to wide ranging protests all over the country and the formation of autonomous women’s organisations challenging the legal stipulations and various forms of violence against women.

Behind the grim crime statistics, there are real women and young girls who are maimed, traumatised and silenced by a patriarchal culture and social institutions.

The engagement on the issue of violence had not only meant a critical examination of incidents and events of violence, but also a theoretical understanding of the structural roots of women’s subordination and exploitation. The patriarchal values embedded in legislation, the implementing machinery, state policies and programmes have been unmasked. Wide ranging issues of violence starting from rape, dowry deaths/ murder, sati, female infanticide, female feticide, child sex abuse, sex trafficking, invasive contraceptives, coercive population policies, incidents of ‘acid throwing’, sex scandals, honour killings, to name a few, have been scrutinised. Obviously through all this the multiple manifestations, agencies and sites of violence were unveiled. Apart from the physical aspects of violence, the neglect of the girl child, the gender differentials in access to education, food/nutrition, health care, political participation, training and societal resources are also seen as violence, in other words, violation of women’s human rights.

Women’s movement was engaged in a close scrutiny of questions like ‘ Why women are violated or raped?’ ‘What are the different locales of violence?’ ‘Who are the perpetrators of violence?’ ‘How do women perceive violence?’ ‘Why do women endure violence?’ ‘What does violence do to women’s psyche?’ and so on. This has prompted them to examine patriarchal structures, construction of gender, gender relations, social processes and cultural practices. The analysis led the movement to identify the different structures that control women’s bodies, fertility and sexuality. It has become evident that control over women’s bodies, is the bedrock of (a) the caste system - which attempts to regulate sexual relations through marriage practices; and (b) the family - which preserves its honour, izzat, by controlling women’s sexuality.

During the 1980s, some of the women’s groups that campaigned around issues of violence found that support structures were sadly lacking or where they existed, they nurtured patriarchal values. Therefore, they set up alternative shelter homes, provided legal counselling and campaigned for amendments in legislations. Some of the groups conceivably moved on to identify and instill women’s perspective in health issues and campaign against invasive contraceptives and population control policies.

While there are observable changes and increased visibility of women’s issues, the intensity and dimensions of violence against women continue. Women’s groups have recognized the physical, sexual and mental health impacts of violence and incorporated the provision of shelters / short stay homes, counselling and legal aid as part of the services. Systematic research to examine the linkage of gender violence on health is beginning to gain ground.

Studies have established that rapidly growing causes of death such as burns or suicides were not accidents, as officially declared, but domestic violence against women. Physical violence or abuse and the health linkages have attained significance in the recent past, with a WHO report on violence on women as a hidden health burden. The second round of the National Family Health Survey has attempted to capture the quantum of violence that women experience within homes.

A study by Daga, Jejeebhoy, Rajgopal (1998) of Emergency Police Records maintained in a public hospital in Mumbai, strongly argues that more rds than 2/3 of women reporting to Casualty Department may have suffered domestic violence. This may still be the tip of the iceberg. Women approach the health care system with telltale marks of violence. The narrowness of the bio-medical model and the notion that domestic violence is a ‘private’ affair, leave women victims with circumscribed options. The need to modify recording formats, improving the sensitivity of health providers to gender violence has acquired significance in the recent past.

b. Violence, Health & Sexuality
Some of the feminist writings have also attempted to throw light on sexuality and violence. The curious interlocking of love, suspicion, fear and intimate violence, the representation of violence as a marker of love in gender relations, complicate the matter where women are not mere ‘victims’ or ‘survivors’ but also have an agency in a violent relationship.

Violence of various forms and its linkages to various facets of life including health, have often been discussed in the National Conferences of Women’s Movement (Nari Mukti Sangharsh Sammelan). Health sessions are the largest attended and also emerge with fascinating connections that women make. Health sessions discuss range of issues that dwell upon:

• Socio economic conditions that impinge upon livelihood, housing and health

• poor nutrition, working and living conditions and communicable diseases

• access to health services, powerlessness vis-à-vis health professionals and biases in the medical system that
disregard women’s ability to understand

• hazardous contraceptives and coercive family planning programme

• communalism and violence and its effects on the health of women

• increase in inflation or loss of employment for men, increase in alcoholism among men and domestic violence.

The health session in one of the Conferences that was held in Tirupati, Andhra Pradesh, in 1994, had questioned whether heterosexual relations, which are inherently hierarchal, really natural? Women who could identify with terms like ‘lesbians’ and women who preferred to love women but did not identify with these labels, had a separate session in the Conference. The Conferences in the following years have this theme without fail.

Issues of sexual minorities, sexual orientation and sexual rights have come out of the closet in the late 90’s, though still marginalised and criminalised. The controversies surrounding the film “Fire” that explored lesbian relations and series of violent attacks on organisations working on issues of sexual health and rights, have demonstrated the conservative character of the State and the overall environment in society that is intolerant to all minorities be they sexual, religious or even women. The pressure to abide by the “normal” is so great that there seems to be a total shrinking of the space to even assert for basic human and democratic rights.

The term “Gender-based violence” to understand violence against women and girls, is gaining currency in recent times. The unequal power relationships between women and men created and maintained through patriarchal institutions are addressed to bring about changes in gender relations (Lingam, 2001). The entire culture that creates male roles and identities defined as “masculinity” — aggression, dominance, competitiveness and so on, underlie men’s violence. The recognition and focus on masculinity is seen as an important strategy to make men conscious of gender and challenge gender inequalities and violence against women.

Violence places women at a high level of vulnerability to morbidity and mortality. Pregnancy complications, adverse birth outcomes, HIV infection in non-consensual sex, unwanted pregnancy, unsafe abortion/abortion related injury, gynaecological problems, psychological problems/ fear of sex/ loss of pleasure, low levels of immunity due to increased levels of overall neglect and declines in access to nutrition and health care are some of the outcomes of violence. Empirical evidences from India are getting generated steadily. The National Family Health Survey 1998-99 (NFHS — 2) results underscore the widespread prevalence of domestic violence in India, especially violence perpetuated by husbands against wives. Women’s high level of acceptance of wife-beating has also been revealed by the data (IIPS & ORC Macro, 2000).

c. Invasive Contraceptives
The early eighties spurred two major campaigns in opposition to invasive medical technologies. The first is the campaign seeking a thorough review and withdrawal of NET-EN and Depo Provera (injectable contraceptives) and the second seeking a ban on Amniocentesis (sex detection test) (Nadkarni, 1998) In response to a Public Interest Litigation (PIL) filed by a group of women from Hyderabad, who objected to the way injectables were being introduced through a camp approach, the court had clamped a ban and called for a review of these. While, the issue keeps coming up with media reports proclaiming the efficacy of these contraceptives and their introduction into the Family Welfare Programme, in reality the injectables are available in a different combination in the open market. Opposition to invasive contraceptives such as injectables, antifertility vaccines, Norplant and the use of quinacrine as a contraceptive, RU 486-abortion pill, has marked various phases of the movement. The literature covering this issue:

• unravel the mindset that see women’s bodies as expendable

• deride the increasing medicalisation of women’s bodies

• demystify the cafeteria approach of the Family Welfare Programme

• question unethical service delivery practices which violate women’s right to information and informed consent; and
comment on the economics of promoting provider-friendly contraceptives rather than user-friendly contraceptives (Lingam,1998).

The Ministry of Health attempted to introduce Net-en on a pilot basis in some major hospitals in India. The collective opposition of the women’s movement to these moves of the Government had led to a withdrawal by the Government.

d. Population Policy
The state, through various public policies enters the private realm of childbearing by defining desirable family size and the creation of incentives and disincentives to meet the same. Population policies and family planning targets were seen to directly affect women and alienate them from the health care system.

Much of the literature attempts to establish that ‘women are not wombs alone’; that high infant mortality and poverty contribute to population growth; that women’s acceptance of a small family norm is not dependent on receiving information alone, but also on improving her social status, autonomy and decision – making. A close examination of plan period documents, health policies and programmes, has revealed that women are viewed merely as ‘mothers’. The changing rhetoric in policy documents in the late seventies and eighties has not been adequately reflected in the programmes. Efforts to pass a population policy over the past decades by the state, was systematically thwarted by the women’s movement. The National Population Policy was however, passed by the Government in the parliament without any major opposition, either inside or outside the house, in the year 2000. Over the years, the movement seems to have got dissipated and weakened. Further, the language of the new population policy document resembles in many ways the Reproductive Health Approach strategy. Terms like, ‘participation’, ‘decentralised planning’; ‘empowerment of women’ are generously used in the document. Some viewed the document as ‘women-friendly’. During the years 2000 and 2001 several states like Maharashtra, Gujarat and Madhya Pradesh, have also passed state specific population policies. These are found to be far more targeted and coercive compared to the national policy. (See papers in MFC Bulletin Special Issue on Population. July-October, Issue Nos. 286-89, 2001).

e. Sex Selective Abortions
Among the several pre-natal diagnostic techniques (like sonography and chorionic villi biopsy) that are currently being used for sex detection in India, the indiscriminate use of the Amniocentesis test for sex detection followed by sex selective abortions of female fetuses, had led to a major campaign in 1980s seeking a ban of the test. The Maharashtra Regulation of Use of Prenatal Diagnostic Techniques Act was passed in 1988. The mounting pressure for a central legislation led to the passing of Prenatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act in 1994. Obvious shortcomings like punishing the woman who seeks the test, non-implementation of the legislation, the ‘facility’, being still widely available with more sophisticated technologies and lack of civil society response to play the watchdog function, can be stated as reasons for failure of the goals of the campaign.

The issue that requires attention here is the scrambled stand on ‘disability’ in the women’s movement. The legislation purports to regulate the amniocentesis test but not ban it. The Act spells out categories of women who may use the test: (a) those above the age of 35 years could utilize the test to detect Down syndrome, (b)women who have a family history of congenital abnormalities; (c) those who have been exposed to radiation and d) who have experienced repeated abortions. While women’s organisations objected to female fetuses being viewed as ‘unwanted’ ‘ they did not object to genetic analysis, which extends the logic to the disabled as ‘unwanted’. The campaign report of the FASDSP states two unresolved dilemmas: (1) allowing the test for genetic analysis and (2) strengthening the power of the state over people. The report notes
“We have faced the charge of being biased against the disabled–
against those suffering from genetic disorders. We ourselves
questioned at times our justification in taking such a stand. The
fact however remains that in today’s situation of the Indian
society, the burden of childcare as such is so much on the family
mainly on the woman with a handicapped child and no material
resources whatsoever available, the brunt of it all would be faced
by the woman of the family. Hence, until we are at least able to
make a dent in this society, towards taking collective responsibility
of childcare we would have to abide the present stand” (FASDSP,

The issue of disability and women with disabilities has not received adequate attention from the movement. Protests about large-scale hysterectomies on mentally disabled women inmates of a state-run-home in Shirur (Ahmednagar district), Maharashtra, and debate about the right of the state over the bodies of women under its custody, erupted in 1994 (Rao & Pungalia, 1994). This did not get built into a national campaign.

The issue of female foeticide had acquired significance with the release of the 2001 Census provisional population figures. The 2001 Census data indicates an increase in sex ratio from 927 females per 1000 males in 1991 to 933 in 2001. However, the juvenile sex ratio i.e., the number of girls for every 1000 boys under age 6 years, indicates that the sex ratio has gone down from 945 in 1991 to 927 in 2001. This difference is large, and the sharpest declines in sex ratio for the child population are reported from Himachal Pradesh, Punjab, Haryana, Gujarat, Uttaranchal, Maharashtra and Chandigarh, the areas where abortions of female foetuses are known to be widely practiced ( Parasuraman, 2001). This obviously reflects the rampant use of medical diagnostic techniques for sex detection and selective elimination of female foetuses. Amendments to the Pre-natal Diagnostic Techniques Act and strict implementation, vigilance and the misuse of technology have resurfaced all over again, with Public Interest Litigation filed against the State as a defaulter.

Research Trajectory
Research in the recent years has not remained the forte of academics in institutions and universities. Participatory approaches to research and the acknowledgement that research is a powerful tool for advocacy had brought in the NGO and the activist groups into the field of research. Market research groups are also major players in health monitoring and evaluation research. Hence, there are several players and several sources of research data. This section would broadly map the major areas of enquiry and the relevant findings, with reference to women’s health.

a. Household
One of the most significant contributions of Women’s Studies research is the conceptualisation of the household. The household not only as a production, consumption, and a socialisation unit, but one that mediates gender differentials in
access to health goods and services. The close scrutiny of the intra household hierarchy, its organising principles and
functioning has contributed newer dimensions to the understanding of gender division of work, resources, decision-making,
power and autonomy. The intergenerational impact of women’s health and the need to focus on the girl child acquired renewed significance. The evidences point to the following:

• Time allocation studies conclude that women work more than men, their tasks tend to be arduous, and, coupled with low nutritional intake and limited access to health resources, they remain susceptible to illness. Men and male children
receive a larger share of food and other resources, compared to women and girl children

• When unwell, women generally neglect their health, or rely more on home remedies, or purchase medicines over
the counter

• Women’s ill health is attended to earlier in a nuclear family compared to a joint family. The lack of power and the existence
of other women to carry out domestic work explain the neglect in joint households.

• Aged women are neglected in general, but the ones with property are better cared for.

• Most women do not go for all the antenatal checks during pregnancy.

• Infertile women face the threat of desertion.

• Neglect of girl children is linked to the number of girl children.

• Women endure aches and pains.

• Women expend high levels of energy on basic survival tasks like fetching drinking water, firewood in rural areas and
rations in urban areas.

b. Work Related Health
A major contribution of Women’s Studies and the feminist health movement is the recognition that ‘women’s work’ encompasses not only paid work but also unpaid family labour and household chores. The Shram Shakti report (1988) systematically documented the various facets of women’s work, vulnerability, poor implementation of legislations and health hazards. The evidences range on several issues:

At the work place health hazards include exposure to chemical and other polluting elements and physical injuries
caused by the type of work (like lifting heavy loads), work environments (dark, suffocating environments) and work
schedules (long hours without break). The different health hazards associated with different industries have been well

• Attention has also been focused on the health hazards associated with unpaid family labour including domestic work.
Health problems arising from domestic chores like cooking, fetching firewood, and tending to children, which are not considered as “work”, even by women themselves, include body aches and pains, respiratory problems, cuts and
burns and exhaustion.

• A five-year prospective epidemiological study (Ray et al, 1995) of chronic obstructive pulmonary disease in rural
Tamil Nadu, observed that prevalence rate was 33/1000 with a significant higher prevalence of 40.8/1000 for males and 25.5/1000 for females. Smoking and exposure to indoor pollution, because of cooking fuels, are seen as major
contributing factors for males and females, respectively. A hospital based prospective study that specifically focused on women exposed to domestic smoke and the various respiratory diseases that they present, observed chronic obstructive pulmonary disease, cor pulmonale, pulmonary tuberculosis and bronchial asthma (Bhat and Sujit, 1997). An urban slum
study by Dutt,(1996) has revealed that women exposed to biofuels were more liable to have increased respiratory illnesses and reduced pulmonary functions than women using kerosene or liquid petroleum gas (LPG). The types of fuel
used and average monthly incomes are closely related. Women from the low-income households are exposed to high
levels of domestic pollution. A study on rura population in Tamil Nadu, observed that majority of the people affected by chronic respiratory diseases belonged to scheduled castes, had low levels of education and income (Karamarkar, 1991). This study obviously indicates the manner in which socio economic conditions mediate vulnerability to infections and
diseases, and affect men and women differentially.

• The relationship between women’s occupation and their reproductive health outcomes has not adequately attracted
the attention of the women’s health movement and feminist researchers. While the association is plausible, in terms of reproductive problems including menstrual disorders, chromosomal and gene defects, abortions, cancer, malformation,
low birth weight, infertility and premature menopause; empirical evidences have not bared out the relationship.

• Work has great impact on the psychology of women. Adverse work conditions lead to depression, anxiety, sleeplessness,
and stress. Sexual abuse at the work place is another cause of mental disorders. Though acknowledged and possibly addressed at a micro level, mental health has gained little focus at the struggle and advocacy level.

• The main problem in dealing with health issues related to domestic work and work in the informal sectors is that laws
addressing issues of occupational health do not include these two sectors, where most women are occupied. The
solution is therefore not a legislative one but one that challenges social, political and economic inequalities.

• Since poverty is linked negatively to several health indicators, women’s employment is assumed to improve the household
and child survival. However, micro level evidences indicate that in the absence of support structures, working women
of the poorer classes neglect their health, show higher levels of nutritional deficiency and drop out of the work force, to recuperate (Shatrugna, 1993; Khan

c. Reproductive Choices
The Earth Summit on Environment, the Cairo Conference on Population and Development, the Beijing Conference on Women, Peace and Development are the milestones in the 1990s, which positioned women’s reproductive rights,
reproductive freedom and empowerment for improvements in several development indicators. Changes in the Family Welfare Programme took place with official announcement of withdrawals of incentives, disincentives and targets, in April 1996, and the heralding of the Reproductive and Child Health Programme. Despite the changes in rhetoric, the ground realities of women’s health inform the following:

From a typical health service delivery perspective, women’s low acceptance of contraception, spacing the first birth and between births, and delay in accepting the small family norm are viewed as a failure of official communication or as women’s ignorance. However, the feminist perspective informs us that women’s procreation is set within the ideological context of patriarchal family, culture and property relations. In a culture, where daughters are given less education, married young, attain status within the marital family only through fertility and male sons, the issues of spacing the first birth between births and
adopting a small family norm, need to be addressed not merely at the level of providing information or services to women.

Research studies observe that women acknowledge the need for contraception and limiting the number of pregnancies. Women are aware of sterilisation in remote tribal and rural villages. However, their utilisation of family planning services (especially those relating to contraception) is low. This will not change quantitatively unless the circumstances within
which fertility decisions are made (or not made) change. Women’s low decision-making power in the early ages of marriage,
their poor health leading to miscarriages, social pressures against contraception before completion of the desired family size, general son-preference, secondary infertility due to reproductive tract infections, and so on, are barriers to the use of contraception or limiting family size (Khan and Singh, 1987; Khan,, 1985; Ravindran, 1993). Therefore, in the Indian context, the concept of ‘choice’ is not limited to availability of contraceptives. The exercise of choices does not emerge from
the control over their fertility alone, but control over their sexuality and life situation (Lingam, 1995).

Studies drive home the point that liberalisation of law has not significantly increased the ratio of legally induced abortions
or reduced abortion-related mortality (Jesani and Iyer, 1993). The use of abortion as a method of family planning, with a high proportion of women seeking abortion in the second trimester, points to women’s lack of decision-making power within sexual relationships and their dissatisfaction with the existing contraceptive choices (Dixon-Mueller, 1993; Karkal,1991). Studies on women’s perceptions of abortion, abortion services and sex selective abortions point to the complex web of pressures from the family, service delivery providers and women’s vulnerability within a context of double standards pertaining to pregnancy ‘outside wedlock’ (Gupte, Bandewar and Pisal, 1997). Studies on gynecological morbidities, reveal that women suffer reproductive tract infections (RTIs) and sexually transmitted infections (STIs) in silence because of the shame, guilt, fear and stigma associated with these illnesses. Due to the high premium on chastity, sexual fidelity, monogamy and the honour of family closely tied to her sexual character, women are reluctant to draw attention to their bodies. Paucity of women doctors in the rural areas compounds the problem. Women endure these infections as ‘part of their lot’. Women’s vulnerability and the lack of power to say ‘no’ to unprotected sex, if her partner is infected, is the hard reality. Heterosexual intercourse appears to be the single most common mode of transmission of HIV. It is predicted that the number of women and children with HIV will outnumber men. The gender concerns of HIV have been taken up by NGOs but the women’s movement has remained largely distanced from this issue.

Several studies have been undertaken both quantitative and qualitative, to understand sexual behaviour of Indian men
and women, adolescents, college going students, truck drivers, etc. The issues of sex education, dealing with male and female sexuality emerge as major areas for intervention. Typically however, interventions underplay the power relations that exist in gender relations and focus on education and condom use. A recent review of studies on sexuality and sexual behaviour
unveil the biases in the conceptualisation of studies on sexuality. The authors point out that only very few studies attempt to connect sexuality with factors other than biology, health and disease (Chandiramani, Kapadia, Khanna & Misra, 2001).

Neglected Areas of Research
A broad list of areas for further enquiry is listed here. The list is obviously not exhaustive.

• The top causes of mortality for women in the reproductive age group from 1981-1994, compiled by the Registrar
General of India places Tuberculosis as the leading cause of death for women in the reproductive ages, though this has
been declining over this period. Subsequently new causes of death such as suicide, heart attack, burns and cancer have emerged and are steadily gaining in incidence. A close examination at the micro level to understand the social
circumstances that contribute to these outcomes is necessary.

• Studies in the field of heart disease, cancers, osteoporosis, diabetes, hypertension, tuberculosis, the domain of research by medical people, are completely left out by women’s studies. A recent review by Gopal & Lingam (2001) of select
research in these fields indicate lower prevalence rates for women for several communicable and noncommunicable
diseases, but however, do not adequately explain whether this is a biological advantage or a methodological problem. Further, answers to the following questions are poorly lacking:

• How does class, caste, and gender variables intervene, interact, and contribute (as risk or protective factors) to morbidities
and differences in prevalence rates?

• What are the intra-class variations in men’s and women’s morbidities?

• What are the inter-class variations in women’s morbidities?

• What are the factors that influence women’s experience of illness, perceptions of disease, and the social etiology of disease
and access to health care?

• Women suffer from a range of gynecological illnesses such as menstrual problems, reproductive tract infections, STDs, etc. Many of these illnesses may have long-term consequences such as infertility or cancer. A recent review by Garimella and Ramanathan (2001) point out that while substantial amount of research covering areas of reproductive morbidity and the
risk factors associated with them are there, gaping holes on a number of issues pertaining to gender power relations that come in the way of spousal communication, decisionmaking, treatment seeking, every day experience of living with the morbiditiesand so on, are evident.

• Risky sexual practices among males contribute to cancer among women. Poor genital hygiene, multiple sex partners
and lack of use of condoms by male partners place women at risk. Breast cancer accounts for 20% of all female
cancers in India. Due to lack of awareness and education, most women present themselves to the medical system with advanced disease.

• A study by Stein et al, (1996) observes that 9% men and 11% women who had low birth weights, short birth lengths, or
small head circumferences at birth, had developed Coronary Heart Disease (CHD) in adulthood. This study subscribes
to the hypothesis that an individual’s health is programmed at the formative stage in the uterus. This reiterates the feminist concern of addressing women’s health from childhood, since it has an intergenerational impact.

• Research in the field of breast feeding and infant feeding practices is dominated by (a) medical researchers interested
in child survival issues and (b) demographers interested in the relationship of breastfeeding to natural infecundity/
post partum amenorrhea (PPA). Studies indicate that the practice of breast-feeding is inversely related to women’s
education and employment. A few papers highlight the need to provide support structures for working women to
facilitate the continuation of breastfeeding. However, women’s studies researchers have not adequately examined this

• Almost a decade of NGO initiatives in building women’s empowerment through various entry points like education, health, income generating programmes, self-help groups and micro-credit, have been witnessed. Attempts have to be made to generate participatory methods and tools to assess the linkages of women’s empowerment to several health and
development indicators at the micro level.

Gender Sensitive Initiatives
The fallout of the discussions on health among women’s groups has led to the development of

• Educational materials about the body in a participatory, culture sensitive idiom. ‘Body mapping’ and ‘body literacy’ in the
way of fertility awareness, male sexuality and reproductive health are now seen as intrinsic parts of empowerment

• Workshops on male sexuality and the construction of male identity are also organised.

• Attempts to document women’s traditional knowledge of home and herbal remedies have been undertaken, as an
alternative to the hegemony of allopathic model. However, these have remained on the periphery.

• Strengthening the health functionaries of the Government and NGO sector through training in gender issues.

• Developing medical kits and formats to facilitate the recording of violence against women.

• Mainstreaming women-centered health care in public hospitals.

• Developing life skills education manuals for women and adolescents.


The present paper has attempted to map the major areas of struggles and research evidences that throw lighton women’s health. The health arena constitutes number of players each engaging at different levels with the ‘system’. The feminist discourse deals with the issue of health within the broader structural roots of patriarchy and patriarchic institutions. It provides a powerful tool to explain women’s health situation. However, from the standpoint of making a difference to women’s health through research and developing programmatic interventions, gender analysis frameworks facilitate a lot of clarity. A critical enquiry of the following areas will provide rich insights into gender differentials in terms of exposure, risk factors, morbidity, outcomes, perceptions and health seeking behaviour:

• Identification of the patterns of illness – who gets ill, when and where?

• What is/are the risk factors that contribute(s) to ill health for different groups of men and women?

• How are men and women’s responses to illness influenced by gender roles, values and norms?

• What are the consequences to everyday life and well-being?

• What are the perceptions of men and women about ill health and morbidity?

• How is their health seeking behaviour shaped by these perceptions and gender roles, values and norms?

Future research with enhanced gender sensitivity only can fill this void and make a difference to women’s health.

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LAKSHMI LINGAM: Reader in the Women’s Studies Unit, Tata Institute of Social Sciences, Mumbai, India.
Co-ordinator, Centre for Health Studies, TISS and the General Secretary for the Indian Association for Women’s
Studies for 2000 - 2002.Her doctoral research, ‘Women’s Roles in the Production and Reproduction Spheres of
Wet and Dry Villages of East Godavari District, Andhra Pradesh’ was at the Indian Institute of Technology, Mumbai.
Published papers on the subjects, women-headed households, girl child, sex-selective abortions, reproductive rights,
occupational health, women’s health, migration and development. She had been widely acclaimed for her book
Understanding Women’s Health Issues : A Reader (1988) published by KALI for women, New Delhi.

Mala Ramanathan

Reproductive and child health issues in kerala



ABSTRACT---Kerala has an impressive record in the area of reproductive and child health when compared to the rest of India. The fertility rate is said to be well below what is needed for replacement and its mortality rates are extremely low. It enjoys low infant mortality rates and also low adult mortality rates. Epidemiological transition is well under way and even if the infectious diseases have not been completely eradicated, chronic diseases do contribute significantly to the total morbidity within the state. The usual parameters of reproductive health like maternal mortality ratio, maternal morbidity, unmet need for family planning, abortion, HIV prevalence, low birth weight babies, and the nutritional status of mothers and children warrant a discussion in the present context.

Kerala has an impressive record in the area of reproductive and child health, when compared to the rest of India. The fertility rate is said to be well below what is needed for replacement, and its mortality rates are extremely low. It enjoys low infant mortality rates and also low adult mortality rates. Epidemiological transition is well under way, and even if the infectious diseases have not been completely eradicated, chronic diseases do contribute significantly to the total morbidity within the state. All this can be very well substantiated through data.

The Reproductive Health Situation
The usual parameters of reproductive health like maternal mortality ratio, maternal morbidity, unmet need for family planning, abortion, HIV-prevalence, low birth weight babies, and the nutritional status of mothers and children, warrant a discussion in the present context.

The fertility levels in Kerala had declined from 3.74 children per women in the early seventies, to 1.73 per women during the early 90s (SRS various volumes). Accompanied with the given fertility transition, Kerala state has attained significant improvement in the mortality situation also. Currently, it depicts a developed country scenario of low mortality combined with high th morbidity (Panickar and Soman, 1984; KSSP, 1991; NSS 28 Round). This is an issue subject to controversy that is still ongoing, but yet this situation is also indicative of the state being ahead in the epidemiological transition.

The maternal Health
The maternal mortality ratio in Kerala varied between 87 to 132 per 100,000 live births as against the same for India being 453-572 in 1993 (Navaneetham, 1999). While it is relatively better when compared with the other states of India, it is reasonably high when compared with the developed country situations. This ratio has actually shown a steady decline from 247 in 1982-86, to 125 in 1993-94. This remarkable decline of 50 per cent in a decade may be partly attributed to decline in fertility. But, even now, hypertensive disorders and haemorrhage account for about forty per cent of the maternal deaths (Sekharan, 1999). The other causes and also maternal factors need to be identified, and some of these are discussed later on in this paper.

With respect to gynaecological morbidity, slightly above 40 per cent of the women were reported to experience any gynaecological morbidity on clinical examination (Shenoy, et. al., 1997). On the family planning front, the state is considered to be a model to be replicated elsewhere with a contraceptive prevalence rate of about 63 per cent, of which 47 per cent is accounted for by sterilisation (PRC, Thiruvananthapuram and IIPS, 1995). But this feature of predominance of sterilisation is not different from other south Indian states. However, follow-up services at home/outside home from health workers after sterilisation, seems to be the poorest in Kerala when compared to other south Indian states (PRC, Thiruvananthapuram and IIPS, 1995). The dominant use of sterilisation in the state could be the reason for the higher unmet need for spacing (7.2 per cent) when compared to that for limiting future births (4.5 per cent). Yet, we can, in general say that the unmet need is not high at all, but it is possible that women have a very limited choice of contraception.

The incidence of abortion is higher among adolescent and young women in the ages 15-19 and 20-24. This indicates that there is a need for other methods of contraception among younger women who resort to abortion to avoid unwanted

We already know that the existing reported measures of abortion are underestimates, and that since other temporary methods are less frequently used, it is possible that women take recourse to induced abortions to control unwanted or ill-timed births and in Kerala, women have declared slightly more than one fifth of the pregnancies to be unwanted or ill-timed (IIPS, 1995).

Kerala enjoys the positive effects of near universal use of ante-natal care and institutional deliveries, which result in low maternal mortality rates and infant mortality rates. But, at times the Government run ante-natal services have been used as a mechanism to bring the women closer to the family planning services (Mishra, Roy and Irudayarajan, 1998).

Kerala is the only state in India where about 95 per cent of the deliveries are institutional. There are, however, variations in this by districts and in Malapuram, Wyanad and Palakkad, this percentage was found to be about 75 per cent. Ante-natal care was also found to be near universal, but the quality of this care needs to be examined.

Kerala has reported a higher prevalence of Caesarean deliveries when compared to the other major states of India (13.94 per cent) with only Goa having a higher prevalence. A C-section rate of about 14 per cent can be considered relatively high, especially in the context of the association with private institutional deliveries in the state (Mishra and Ramanathan, 1999).

The effective reproductive span in Kerala was found to be about five years (Mishra and Irudayarajan, 1997). What does this mean? This means that women complete their reproductive role within this short span leaving very little room for spacing births. The use of temporary methods is quite low and women seem to prefer female sterilisation, with the average age of sterilisation at about 27 years. This has two important implications for reproductive health of women. One is that when sterilisation has become the norm in a society, then women adopt it with very little thought or counselling. This could give rise to future regret of the decision to be sterilised and Kerala did indeed report the highest levels of regret among the south Indian states (Ramanathan and Mishra, 1999) and the major reasons were, the desire for an additional child followed by the issue of after-effects of the surgery that caused regret. This, in a state which experiences one of the lowest levels of infant and child mortality, is reason to pause and think about the implications of promoting female sterilisation, and an easy and one-step procedure to demographic ‘Nirvana’.

It is definitely true that women accept sterilisation voluntarily and would prefer it to the problems of having another child. Yet, it is important, from a quality of service perspective, to ensure that women are well informed about the various choices available, and their relative advantages and disadvantages and then asked to select. However, in the public health services in Kerala, this is not often done (Ramanathan, 1996). Even a request for an abortion, which is legally available, is turned into an opportunity to canvass for concurrent sterilisation without regard for the client’s needs, and in this the service providers are often not guided by the concern for the client’s well-being. By insisting on acceptance of sterilisation, the public service delivery system pushes women towards the more expensive, but anonymous private sector for such services. But, this approach fails to realise that women do not have control over their sexuality or their reproductive capacity, and further disempowers them.

The second issue, is one of the time spent by women during post sterilisation, wherein women are likely to experience the morbidity that is related to the sterilisation procedure itself. A study has indicated that sterilisation is associated with higher chances of menstrual problems with odds ratio of 4 for women who had undergone sterilisation, against women who were non-users of any contraceptive methods (Sowmini, and Sarma, 1999). With women undergoing sterilisation much earlier, the period of exposure to the risk of menstrual problems following the procedure get prolonged. It is possible that the morbidity experienced is a consequence of the relatively low quality of sterilisation services in the state (Ramanathan, Dilip, and Padmadas, 1995; Ramanathan, Mishra and Dilip, 1999).

Child Health and Nutrition
Kerala enjoys one of the lowest infant (IMR) and child mortality rates (CMR) experienced in the country. It is reported to be about 16 per 1000 live births, for the year 1991, when the figure for India was 80 per 1000 live births. By 1997, the IMR had further declined to 13 in Kerala. CMR in Kerala is also low. However, the causes for infant and childhood mortality are not clearly known, but it is expected that deaths due to vaccine preventable diseases, except measles, would be low (Navaneetham and Thankappan, 1999).

Kerala lags behind countries like Sri Lanka and Costa Rica, with which it is compared to usually in the area of low birth weight for babies. A study indicated that in 1996, 13.3 percent of the babies born in rural Kerala were Low Birth Weight (LBW) babies (Kunhikannan and Aravindan, 1999). In comparison, China and Costa Rica, have 6 and 7 per cent LBW babies.

The per capita calorie intake in Kerala was found to be 9 per cent below the standard in 1998-99, and the per capita protein intake was found to be 12 per cent below the standard. Using the weight for age criteria, 29 per cent of children were undernourished and 6 per cent were severely so. Using the weight for height measures, 12 per cent of the children below 4 years of age were considered as under nourished and this indicates the prevalence of acute undernutrition (IIPS, 1995).

Childhood immunisation is quite high, with a coverage evaluation study in 1993 reporting that DPT, Polio, BCG and TT for mothers was over 90 per cent but for measles it was lower, around 75 per cent. Yet, compared to other states in India, the situation is Kerala is one among the best.

Kerala’s relative lower nutrition status for the child is well known and has been documented. However, because of methodological issues and data problems, this has not been resolved conclusively. What is needed is detailed nutrition intake studies to monitor prospectively the nutritional intake of children in Kerala, so as to be able to develop programmes that contribute enhancing this status, should it be necessary.

Is the lower nutritional status reflective of the disadvantage that the infant has during birth in terms of lower birth weight (Kurup, 1997)? The women of Kerala have the lowest effective reproductive span in the country. Combine this with the high age at marriage and we have a picture of potential for short birth intervals (Mishra and Irudayarajan, 1997). This could also independently contribute to low birth weights and the consequent infant disadvantage.

While Kerala enjoys one of the highest levels of immunisation coverage, an analysis of the 1992-93, National Family Health Surveys indicates that there are gender disparities in immunisation coverage, with female infants less likely to have received all the immunisation that is necessary when compared to male children (Elamon, 1998). It becomes important to address this issue of disparities in order to bring about increases in coverage.

What is visible in terms of low Infant Mortality Rates, fertility rates, longevity are reflections of the averages, and there could be wide disparities within the state. It is the outcome of the development process in terms of low fertility and mortality rates, and other similar rates that are taken note of and even celebrated. When such a process has indeed taken place, i.e., mortality and fertility have declined, and when the declines in fertility have been over a short period of thirty years starting from the sixties, the society’s ability to cope with this transition is also brought into question. These are issues related to the transition process itself, and its consequences bear researching especially in the light of their impact on the well being of the population. The concomitant issues of nuclearisation of families, rapid ageing of the population and need for oldage care facilities and other issues, fall beyond the scope of this discussion, even though, these are also part of the consequences of the rapid transition that has occurred. These issues are relevant as they form the wider context for this discussion.

Clearly, not all the segments of the population have benefited equally from this development process. The state is doubly burdened in the sense that while it has not done away entirely with infectious diseases, it is faced with a high chronic disease morbidity, especially among the adult population. In addition, we have to account for diseases that are re-emerging in newer and more virulent forms perhaps, like Malaria in the coastal belt, Japanese encephalitis in Allepey, and more recently Typhoid in Ernakulam.

Future priority areas
The child related issues that need to be prioritised are:

1. Malnutrition of children, especially because the proportions of severe malnutrition are very low, but that of
moderate levels are relevant.
2. Gender differences in immunisation, even though this is not reflected in the chances of child survival
3. Low birth weights of infants - the possible causes.

The maternal issues that need to be prioritised are:

1. The higher levels of c-section deliveries in the state - are they justified?
2. The possibility of use of abortion as a means of contraception?
3. The high reliance on sterilisation and the possibility of regret, indicates the need for promotion of other methods, especially malebased methods of contraception.
4. The potential for reproductive morbidity associated with sterilisation calls for prioritising quality of services in the RCH programme.

Elamon, Joy. “Gender Differentials in Child Immunisation : A Study based on NFHS data”, The Journal of Family Welfare. Vol.44.(3)1998: 9-17

Health Monitor. Foundation for Research in Health Systems, Ahmedabad. 1997. National Family Health Survey, 1992-93. Mumbai: IIPS. 1995.

Kunnikannan T.P. and K.P.Aravindan. “Changes in the Health Status of Kerala 1987- 1997”. KSSP Report, Kozhikode, Thirvuananthapuram. KRPLLD. 1999.

Kurup R.S.,“ Low Birth Weight and the Need for Nutritional Care for Pregnant Women” in (Eds.) K.C.Zacharaiah and S.Irudayarajan, Kerala’s Demographic Transition: Determinants and Consequences. New Delhi: Sage Publications,

Lal, S.S. “A Study of Gender Related and Rural-Urban Differences in Knowledge and Attitude towards AIDS, Sexuality
and Related Issues Among College Students in Kerala”. Unpublished MPH Dissertation, AMCHSS, SCTIMST, Thiruvananthapuram 1998.

Mishra, U.S. and S. Irudayarajan. “Dynamics of Age at Maternity” in K.C.Zacharaiah and S.Irudayarajan (Eds.). Kerala’s Demographic Transition : Determinants and Consequences, New Delhi: Sage Publications, 1997.

Mishra U.S., T.K.Roy and S.Irudayarajan. “Ante-natal Care and Contraceptive Behaviour in India: Some Evidence from the National Family Health Survey”, The Journal of Family Welfare. 44.2. 1998 : 1-14. Mishra, U.S , Mala Ramanathan,
and S.Irudayarajan. “Induced Abortion Potential among Indian Women”, Social Biology. 45.3-4. 1998: 278-288.
Mishra U.S. and Mala Ramanathan, “Levels and Correlates of Delivery Related Complications and C-Sections among Indian Women”. Trivandrum: Centre for Development Studies. 1999.

Navaneetham K. “Levels and Trends in Maternal Mortality in India”, in Shenoy T.S. et. al., (Eds.) Challenges in Safe Motherhood Initiative in Kerala, India, Medical College, Thiruvananthapuram. 1999.

Navaneetham K. and K.R.Thankappan. “Reproductive and Child Health and Nutrition in Kerala : Achievement and
Challenges”, Paper presented at the UNICEF and ICMR Regional Consultation on Priorities in Research in
Reproduction and Child Health and Nutrition held in Bangalore.” 1999: 11-12 Oct.

Panikar P.G.K. and C.R.Soman. “Health Status of Kerala: Paradox of Economic Backwardness and Health Development”. Thiruvananthapuram. Centre for Development Studies. 1984.

Ramanathan, Mala. T.R.Dilip and Sabu S.Padmadas. “Quality of Care in Laparascopic Sterilisation Camps: Observations
from Kerala, India”, Reproductive Health Matters. 6. 1995: 84-93.

Ramanathan, Mala. “Quality of Care in Family Planning Services in Kerala, India: An Assessment. Using Client-Flow-
Analysis.” Proceedings from the GRHPP Networking Workshop. June 14-18, 1995. Amsterdam: Het Spinhuis Press,

Ramanathan, Mala and U.S.Mishra. “Reproductive Health Services in India: Index of Maternity Care and Contraceptive
Choice, NFHS 1992-93” Paper presented at the workshop on ‘Population Issues of India by the Dawn of the 21 st Century’, conducted by the Department of Demography, University of Kerala and PRC, University of Groningen, Netherlands, 18-19 Dec., 1998.

Ramanathan, Mala and U.S.Mishra. “Correlates of Female Sterilisation Regret in the Southern States of India”, Journal of Biosocial Sciences (forthcoming).

Ramanathan, Mala, U.S.Mishra and T.R.Dilip. Towards Quality of Care in Family Planning Services in Kerala. Amsterdam:
Het Spinhuis Press, 1996.

Sekharan, P.K. et. al. “Maternal Mortality in Medical Colleges of Kerala’, in Shenoy T.S. et. al., (eds.) Challenges in Safe Motherhood Initiative in Kerala, India, Medical College, Thiruvananthapuram. 1999.

Shenoy, K.T. et. al. “Gynacological Morbidity in Thiruvananthapuram District”, Kerala, UNDP Report, Thiruvananthapuram: CDS, 1997.

Shenoy, T.S., K.T. Shenoy and C.G.Chandrika Devi. Challenges in Safe Motherhood Initiative in Kerala, India, Medical College, Thiruvananthapuram. 1999.

Sowmini, C.V. and P.Sankara Sarma. “High Reproductive Morbidity Among Contraceptive Users in Kerala, India:
A Concern for Quality of Services”, (mimeographed), Achutha Menon Centre for Health Science Studies, SCTIMST, Thiruvananthapuram. 1999.

MALA RAMANATHAN : Faculty, Achutha Menon Centre for Health Science Studies and the Sree Chitra Tirunal
Institute of Medical Science and Technology, Thiruvananthapuram. Obtained her M Sc in Statistics from the Madras
University and M.A in Medical Anthropology from the University of Amsterdam. Her M Phil was on Population
Studies. Her PhD on Population Studies was from the International Institute for Population Sciences, Mumbai.

Mridhula Nair B

Analysis of mental health in terms of adjustment of adolescents






ABSTRACT---Adolescence is the years between puberty and entry
into the adult status / adulthood. But the transition from child to adult
takes place more gradually and lasts several years. Adolescence has traditionally
been viewed as beginning with the onset of puberty, with a sudden spurt
of physical growth accompanied by sexual maturity which ends when individuals
assume the responsibilities associated with adult life - marriage, work
and so on. Researchers suggest the role of the effect of this growth spurt
on the adolescents' emotional, cognitive and social development.


       Adolescence is the years between
puberty and entry into the adult status/ adulthood. But the transition
from child to adult takes place more gradually and lasts several years.
Adolescence has traditionally been viewed as beginning with the onset
of puberty, with a sudden spurt of physical growth accompanied by sexual
maturity which end when individuals assume the responsibilities associated
with adult life--marriage, work and so on.(Rice, 1992).

       The beginning of adolescence
is signaled by a sudden increase in the rate of growth which starts earlier
in girls (Stagner, 1998). Researchers suggest the role of the effect of
this growth spurt on the adolescents’ emotional, cognitive and social

       It has now been found that
adolescents were at a great risk with respect to physical and mental health
now- a –days, than at earlier times due to newer and uniquely disturbing
set of problems (Baron 1996). These include the use of alcohol, homicide,
sexually transmitted diseases, suicide and separation from parents. Teenagers
of today face a set of conditions and perils that their earlier generation
were strangers to. According to the journal, The American Psychologist,
the root of all adolescent problems arises at home. Children coming from
divorced parent- absent families develop fear, anxiety and insecurity
(Raphel, 1990). Usually they are the academic underachievers and may develop
a marked tendency for delinquent behavior or have an inability to form
strong relationships. Many teenagers who find themselves in “dysfunctional
families” -- i.e. families that cannot or do not meet the child’s
needs, suffer from anxiety and insecurity. (Kotch, Brown,1991). Children
who had been subject to sexual abuse were found to develop depression,
body complaints and withdrawal symptoms and were found to have greater
adjustment problems (Williams and Finkelhor,1993).

       Adjustment is a dynamic, rather
than a static quality. Well adjusted children make good social adjustments
and have harmonious relationship with people around them. The mental health
of an individual has its base in his ability to adjust.

       While recognizing the role
of mental health in the overall development of the adolescents, it should
be borne in mind that adjustment attains special emphasis as it can either
facilitate or hinder mental health. Sensing the importance attached to
this concept, an attempt is made to analyze the role of adjustment, upon
the mental health of both adolescent boys and girls.


       The hypothesis tested was: “
The pattern of adjustment will be different for adolescent boys and girls”.:


      The sample of the study consists of
200 adolescents-- i.e. 100 boys and 100 girls, from various colleges in
Thiruvananthapuram. The sample was selected at random, but given equal
representation on the basis of age, religion and

socio-economic status.

Tools Used in the Study:

       1. Mathen Maladjustment Inventory

       2. Personal Data Sheet

       The inventory measures five
major aspects of maladjustment and also gives an index of general maladjustment.
The variables are:

       1. Anxiety: which leads to
fear, worry, being upset etc.

       2. Depression: which leads to
suicidal thoughts, feelings of guilt, disinterest.

       3. Mania: which is indicated
by lack of social control, over activity and quick temper.

       4. Inferiority: which leads
to sensitiveness, shyness and lack of self confidence.

       5. Paranoia: which includes
suspiciousness, not trusting others and getting into quarrels.

       6. Total Maladjustment: consists
of anxiety, mania, depression, inferiority, phobias and nightmares.

Analysis of Data:

       The data pertaining to the variables
of the study were analyzed with test.

Table. I

Means, S.D and T value showing the significance of the difference in the
5 Variables of Adjustment for Boys and Girls



T Value
Significant at 5 % level
Total mal



       From the table it may be noted
that the t value are significant at 5% level in the case of maladjustment
variable, depression and inferiority. The values are not significant for
mania and paranoia, which might be because of the fact that the sample
of the present study comes under the normal category.

       Detailed scrutiny of the result
reveals that girls have more depression and inferiority, compared to the
boys. The higher incidence of depression in girls might be because of
her realization that society has double standards for boys and girls regarding
the same issue. She has to be submissive and less assertive in order to
get male approval. During adolescent years, this difference becomes clearer
and can cause depression. Moreover the hormonal change and a distorted
body image also result in girls experiencing depression (Nolan Hokesoma,
1994). No less a person than E. Barbara has pointed out that estrogen
can increase depression during periods of menstruation. The show conducted
by Oprah Winfrey also ascertained that girls experience more depression
than boys (2000, Star World).

       The prevalence of inferiority
among the girls may be due to society’s expectation of a certain
kind of behavior from them. Girls are expected to be docile and submissive,
whereas boys are expected to be aggressive. The girl may be educated,
or may enjoy the privilege of wealth and high society, but she is expected
to be shy and sensitive.

       The variable anxiety is somewhat
the same for both sexes and this is indicative of the modern trend of
parents to treat boys and girls in the same way. Practically, there are
only slight differences in their experiences.

       With regard to the manifestation
of total maladjustment, girls are found to have more variable. This might
be because, unlike the earlier generation, a higher percentage of women
work both outside and inside homes. Thus, she has to have a dual role--the
hitherto masculine role of working in offices or work places, and also
follow the feminine role model inside the home,as expected by society.
The adolescent is literally crushed by the double standards of society.


       The study proves that the pattern
of adjustment is different for adolescent boys and girls. Mental health
and adjustment pattern of an individual are interdependent, and so it
is necessary to take preventive, remedial measures to lower the amount
of depression and inferiority in girls. Otherwise, we are in danger of
rearing the mothers of tomorrow, in such a way, that they can never cope
with life’s experiences.

Barbara, E. Effect of Menstruation on Academic Performance
among College Students. 6.4. 1979: 289-296.

Baron, R. A. Psychology ; Chapter IX : 1996: 339-342. Kotch, J .B; Browne,
D.H. “Correlation of Dysfunctional Parenting        Attitudes
among Low Income Adolescent Mothers”, Journal of Adolescent Research,
6.1991: 212 – 214.

Slagner, J. M. “Menarche and Exercise” Medical Aspects of Human
22. 1988: 118-133.

Mathew, G. V. Mathew Maladjustment Inventory , University of Kerala.
1962. Nolen Hokesma & Girgus,J .S. The        Emergence
of Gender difference in Depression during Adolescence: Psychological Bulletin,
115. 1994: 424 - 443 .

Oprah- Winfrey. Show conducted by Oprah Winfrey on a Survey on Depression

among Children in America 2000. Williams, L .M & Finkelher, D. Impact
of Sexual Abuse on Children: A Review &        Synthesis
of Recent Empirical Studies, Psychological Bulletin. 113. 1993: 164-180.


Teaches Psychology at the M.G.College, Thiruvananthapuram.
Her doctoral thesis is entitled ‘The Effect of Change in Medium of
Instruction on Sex, Personality and Adjustment’. She is interested
in adolescent mental health and has conducted pre- marital counselling
sessions for undergraduate students.

Ramakrishnan Nair Jayasree, Nair Hema

Engendering health-a brief history of involvement in health issues



ABSTRACT ---The question of entitlement - the question of who gets what, why and how of the available resources of the society at any given point of time is at the base of the gender justice and equity issue. The interlinked and interwoven nature of these entitlements with the entire gamut of structurally determined gender relations makes the analysis of the relationship between feminism, health problems, political rights, social issues and economic issues very difficult. This paper traces the history of women's involvement in health issues from the 1 850s to the present day. Many women's organizations were involved in identifying core issues of health and struggling to establish the basic rights of women.

Women and Rights
The question of entitlement - i.e. the question of who gets what, why and how much of the available resources of the society at any given point of time is at the base of the gender justice and equity issue. The interlinked and interwoven nature of these entitlements with the entire gamut of structurally determined gender positions makes the analysis of the relationship between feminism, health problems, political rights, social and economic issues very difficult. The most problematic of these eras was the latter half of the nineteenth century when women shook off the shackles of centuries of oppression.

The awareness of the discrimination against women in various fields caused them to protest against the oppression. The fight for political equality was one of the areas that women concentrated on. The first treatise in defense of the rights of the women, Mary Wollstonecraft’s A Vindication of the Rights of Women, inspired by the French Revolution, was published as early as 1792 but had to wait for more than five decades to gain prevalence and adequate supporters in the western world. By the 1850s, the word “feminism” had gained universal acceptance and was included in the Oxford English Dictionary.

The women’s agitation to get their right to vote surfaced in Britain as the Suffragette Movement that began in the 1860s and developed into the National Union of Women’s Suffrage Societies in 1872 nearly a century after the Wollstonecraft treatise. The overwhelming attention to political rights subsumed the awakening interest of the feminists in the representation of women’s bodies. Yet the politics of body coverings-- the clothing, is an ironic subtext in many a writing by women. The clearer gender distinction between men’s and women’s dress in the 17th, 18th and 19th centuries led to a total inundation of the women in yards of fabric. Scientific sexism and racism sought to keep under wraps the rights of the marginalized, underprivileged women. One of the key concepts in feminist theory, one that underpins the Women’s Movement’s analysis of the subordinate status assigned to the women in the phallocentric culture, is the distinction between biological sex on the one hand and socially constructed gender on the other. This concept involves the recognition that while the sex of the individual depends upon the anatomy, gender is a culturally constructed artifact. As gender is the outcome of cultural and social artifacts, it conditioned responses to the body. Just as the body was kept “under wraps”, the problems of the body too were kept under wraps and could only be whispered behind closed doors.

Social Medicine
All 19th century texts of health have a section called Diseases of Women-- diseases that are related to reproductive health that is prioritized over other health related issues. Any study of anatomy or dissection focused more on the woman’s sexual parts and only skimmed her brain. The equation of womannature- body as opposed to man- nurture- culture sought to discriminate and confine the woman. This led to the woman’s sense of dissatisfaction and hatred of her body, an area that women writers of the age investigated. The instances of mental illness, the taboos that prevailed and the harsh treatment meted out to women, who were victims, were subjects explored by many women writers of the time-- examples: Charlotte Bronte, Charlotte Perkins Gilman and others. Institutions like St. Mary of Bethlehem Hospital for the insane in London were established as early as 1247 and were incorporated as a Royal Foundation in 1547. The doctors were all male till the 19th century after which women began to join the profession. Mental depression ranging from post partum depression to ante natal depression that raged among women added to problems related to repeated pregnancies and childbirth. The taboos related to contraception and abortion further clouded the issues.

Apart from quinine discovered by the Spaniards in America, iron and digitalis that were specific for diseases like malaria, anemia and heart diseases, medical drugs were not disease- specific. But the dream of medical men to use drugs like magic bullets aimed at the specific cause of the disease was finally a reality only by 1928 when Fleming discovered penicillin at St. Mary’s Hospital, Paddington. Other antibiotics like streptomycin, tetracycline, erythromycin and many others followed. Though antibiotics made a late appearance, England did have an established health service manned by the male doctors with a fair sprinkling of nurses after Florence Nightingale’s intervention in the Crimean War (1853- 56).

By 1842, an attempt had already been made in the field of social medicine, by Edwin Chadwick who first thought in terms of social control of diseases by dealing with their causes so that they were prevented from rising at all. His argument that it was necessary to provide clean drinking water to eliminate typhoid and cholera found favor with the legislators who took several measures for this, including framing laws. Chadwick helped to found the Poor Law Commission that produced a report in 1842, the principal suggestions of which were (a) a municipal water supply for all towns (b) a scientific drainage both in town and country (c) an independent health service with large powers for dealing with those who endangered the lives of others by polluting water and causing other inconveniences and (d) a national service for the internment of the dead for in those days bodies often remained for days without burial. Chadwick’s proposals were the earliest efforts to prevent bad health and had later been complemented by many efforts to maintain good health or rather the idea of positive health which led to the formation of the National Health Service which attempted to take care of the health needs of both the men and the women.

Medical Education for Women
If the idea of having a male doctor to attend or take over the service of the mid--wife was revolutionary in England in the 19th Century, the idea was outrageous to India, Britain’s colony. Indian families did not relish the idea of having male doctors to attend on women because of segregation. Dr. Ida Scudder of Vellore was inspired to go in for a medical education when she saw two young women dying within 24 hours of each other because their families did not allow male doctors to attend on them. Medical education for Indian women came about when medical missions from abroad observed the plight of Indian women. English education was introduced in India as early as 1813 but the education of the Indian women was largely ignored until 1840 when girls’ schools began to function. By the mid century, however, many girls were sent to schools-- especially after Lord Dalhousie, the Governor- General of India issued an education despatch in 1854 detailing the need for female education in India. Higher education, especially medical education remained a dream till 1883 when the Universities of Madras, Bombay, Calcutta and Lahore opened their doors to women for medical studies. Western medical training had long been available to Indian males but it was not until 1885 that Lady Dufferin, wife of the Viceroy, established the National Association for supplying Female Medical Aid to the Women of India— otherwise known as the Dufferin Fund. This association provided financial assistance to women willing to be trained as doctors, hospital assistants, nurses and midwives, aided in establishing medical training programs for women and encouraged construction of hospitals and dispensaries. Miss Anne Walker, a domiciled English woman was the first to qualify as doctor from the Mumbai University. Dr. Anandibai Joshi who studied at the Women’s Medical College at Philadelphia was the first Indian woman to qualify in medicine. Kerala was not far behind in women’s education. Mary Poonen Lukose, born in 1886 graduated in medicine in 1915 and was appointed superintendent of the newly constructed 100 bed women’s hospital in Trivandrum in 1916. In 1924, she achieved distinction as the first woman to be made Acting Head of the Medical Department of Travancore State controlling 32 government hospitals, 40 government dispensaries and 20 grant-in-aid private institutions. 95% of the medical corps of the state was then constituted by men. What has to be noted is that the small State of Travancore had by 1915 more than 30 hospitals but even more importantly had introduced allopathic medicine and vaccination in the beginning of the 19th century itself. The indigenous medical systems like Ayurveda, Sidha and Unani flourished, for many people were interested in those systems of medicine.

Growth of Women’s Organizations
Practice of allopathic medicine and more concern with woman’s health that emerged by the end of the second and third decade of the 20th century coincided with the establishment of women’s organizations. But foregrounding this was the publication of Bankim Chandra’s Ananda Math (1882) that portrayed revolutionaries sacrificing their lives for the motherland. Bankim’s emotional hymn “Bande Matharam” served to link idealized womanhood with nationalism— thus attempting to place the body in political role. The women however, viewed this representation of the motherland as a call to women to join the political movement— something they desisted.

Between 1917 and 1927 three major organizations emerged in India-- the Women’s Indian Association, the National Council of Women in India and the All India Women’s Conference. The more important of the women’s organizations and the most truly Indian of the three was also the last to be formed. The AIWC-- All India Women’s Conference met in Poona in January 1927. Delegates to the Conference included a large number of professional educationalists as well as social reformers, women associated with the nationalist movement, the wealthy and the titled. Their specific resolutions stressed the importance of moral and physical education, deplored child marriage and urged special arrangements for educating women doomed to wear purdah. They believed that education should complement gender roles. By 1929 AIWC widened its scope to include all questions of social welfare. They opted to remain apolitical in order to preserve their identity. They traced the role of women historically and maintained that in ancient India, women had equal access to education, political power and wealth.

Child marriage had long been a thorny topic in British India. In 1860, the criminal code set the age of consent for both married and unmarried girls at ten years. The issue reappeared in 1880s and in 1891 the criminal code was amended to raise the age of consent to 12 years. A revival of interest in the age of marriage that happened in the 1920s can be traced to discussions in the League of Nations. In the wake of such interest, the new Sarada bill was to be implemented after the establishment of a select committee. The committee, in order to access public attitude sent out 8000 questionnaires. The women’s organizations promoted the legislation at every stage. They generated propaganda against child marriage, commented on proposed bills, petitioned, met with Joshi committee and lobbied to secure the passing of the Bill. Throughout the country AIWC branches organized meetings at which women’s opinion could be expressed. In their speeches women refused to confine their remarks to child marriage. Many women expressed the view that this was only one of the many customs that crushed their individuality and denied them opportunities for education of mind and body. Enforcing the act was an uphill task for many who practised child marriage. It was difficult to make a change and difficult to obtain a guilty verdict.

In the 1920s and 1930s, women’s organizations demanded educational and medical services for females. Separate institutions were required to deliver these services, for sex segregation norms prevented women from using institutions designed for men. Women leaders wanted new institutions to be staffed by female professionals. As is already stated, medicine was one of the new careers opened to Indian women in the late 19th century. In the early decades of the 20th century demand for women medical professionals grew. The demand came from middle class Indian women who regarded western medicine as modern and scientific. This led to the establishment of a new sector which was mandated to provide medical services for the government employees and the public and to establish clinics, hospitals, dispensaries. Most middle class women sought the services of women doctors. The supply of trained medical women did not equal the demand in those times. By 1929 however 19 men’s medical colleges and schools admitted women and there was one medical college and four medical schools for women alone. Attending men’s medical colleges presented a distinct set of challenges for young women. They faced a number of challenges as they embarked on their careers.

(a) It was difficult for them to combine family life with professional demands. Society had little tolerance for the
single woman.
(b) They had to contend with sexual harassment in work places. A case in point is the widely reported case of Dr (Miss) Ahalyabai Samant, the director of the municipal dispensary of Nadiad who was abducted and assaulted by
Dr Balabai Harisankar Bhatt ended with Dr Bhatt getting off with a mere fine.
(c) The female doctor received less pay and had to contend with racial and gender discrimination.

Abortion and Social Issues.
The women however prevailed and by sheer grit and determination made themselves a powerful force in the sphere of health. The major problems women and by extension women doctors the world over faced were in the field of contraception and abortion. These issues were moreover part of a wide range of social issues ranging from perspective of social order, concern with overpopulation, solution to social problems, attitude to the concept of family, sexual freedom, sex equality, sexual deviation and/or abstinence, right of fertility control and the overwhelming question of abortion.

In Britain before the 19th century, it was only the middle class who had conservative sexual attitudes, who often attacked the upper class for its behavior. Amongst peasant groups, the young were allowed to express sexual feelings but premarital pregnancy was not encouraged. Contraception of a sort was therefore practised. Chastity was neither the dominant practice nor the ideology. The change in perspective is linked to the social and economic changes that occurred in the early part of the 19th century and influenced life considerably during the middle of the 19th century. This included:

(a) The worsening Economic situation of the working class which resulted in lower standards of morality among working
(b) The changing position of the middle classes which attempted to restrict women. Women were placed on a pedestal
and were supposed to embody the virtues of the home and not soil their hands with the evils of the world-- an idealization which led to chastity being greatly valued,
(c) Myths about sexuality; and
(d) Education and middle class virtues which led to the strengthening of conservative attitudes.

The fight for sex equality was thus part of an overall struggle for a changed society. Women argued that restrictions on women’s behavior were designed to support the patriarchal family and ensure safe transfer of property to the next generation. To counteract women’s oppression, they had to make marriage and divorce, personal decisions, while abortion and contraception had to be made available on demand. Although the supporters of Malthus were radical on contraception, they were totally opposed to abortion, while the medical profession was totally opposed both to contraception and abortion in the latter half of the 19th century. However the medical profession did take a more sympathetic view to the plight of women. Most doctors of 1890s were of the view that while illegal abortion was wrong, it was unfair that women should have to shoulder the blame. The church was opposed to birth control as surprisingly were the socialists too.

By the 1920s people became increasingly concerned with the change in sexual morality which had shown definite changes even before the war. However, it was only during the 1920s that the new attitudes became widely discussed. One focal point was the behavior of young people and the growth of a new youth culture with a distinctive style of dress. A new term “flappers” was coined in England to describe those who were assertive, independent and granted “permissive favors” to young men. Sex was no longer a sin to the young. For the first time the problems of sexually transmitted diseases and the need for birth control were hotly debated. By the 1930s the Malthusians had become respectable but the Catholic Church was their major enemy. Moreover some supporters of birth control like Mary Stopes, a member of Malthusian league in the war years, opposed abortion and even feared that the issue might harm her fight for birth control.

The first known call for a change in British abortion laws was from Stella Browne. She proposed a number of reasons for liberalization in 1915. She argued that:

(a) A reliable contraceptive had not been discovered; so pregnancy might occur even when the greatest care is taken;
(b) The education of young people in sexual matters was only beginning and it was grossly unwise to penalize ignorance;
(c) The laws left people open to blackmail because of the need for secrecy and the fact that abortion had mainly fallen
into the hands of the criminal class.

Women’s groups were the most forthright in the matter of birth control. Radical women were also prime movers of the pressure group for the reform of the abortion law. In 1936, the Abortion Law Reform Association (ALRA) was set up. The greatest victory of ALRA in the 1930s was the trial of Aleck Bourne for it extended the law to cover rape and other factors related to the health of women. The medical profession extended the grounds for therapeutic abortion in suitable cases and hence the abortion laws had to be modified.

The Second World War produced deep-seated social changes in British Society and did much to reduce the social class difference. The position of women in society improved. But in the case of sexual morality it appears that the closing distance between the classes meant that chastity became an ideal pattern of behavior.

Attitudes in western Europe changed in the 1960s with the growth of permissive ideology. By 1962, nearly a third of people were married by civil ceremony. The decline in the practice of religion and change in emphasis meant that the conservative influence of the Church had declined in the 1960s. The change in the nature of the education system, the growth of new radical groups within the middle class, the radical youth, and the development of the “pill” and the strength of the women pressure groups in the political arena led to the passing of the British Abortion Act (1967)

Change in Attitudes: The Interface of Psychoanalysis, Women and the Body
The idea of the mind was a familiar concept to the average European because of transcendental phenomenology. Europe nourished the idea that no object was understandable unless converted to a phenomenon. The idea of the mind as something transcendental was challenged by hermeneutical phenomenology that stated that the mind is contextual. It comes into being in relation to others. The relatedness and the distinction between subject and object inaugurated a new era of the science of the mind. Robert Carter had published in 1843, a theory of hysteria in terms of the unconscious and repressed sexual impulses but was largely ignored. When Freud expressed similar ideas approximately forty years later, he too was ignored for the idea was too conservative for a vast majority of people. Gradually Freud abandoned the popular hypnosis in the treatment of hysteria and developed a talking therapy that he called psychoanalysis. Psychoanalysis became popular with the series of lectures Freud gave at Clark’s University, Massachussetts. Psychoanalysis became a dominant school of thought in both American psychology and psychiatry during the period 1920 to 1950.

Psychoanalysis focuses on the irrational, the functioning of desire, on contradictory ways of experiencing oneself as a subject and behaving as a person. The focus on the unconscious immediately undercuts both the unitary subject and the simple reflectionist view of the essentialist construction of the individual in relation to the social. Freud posited that instincts are sources of continual psychic energy that seeks to discharge and affect mental life and that they have a source, an object and an aim. The source is the body, the aim is to remove bodily excitation and the object is the means by which bodily excitation is removed. Psychoanalytic theory assumes the occurrence of a natural progression through five phases of psychosexual development. This view of a pervasive influence of sexual motivation has been a point of contention since Freud proposed it and it is possible to distinguish at least three groups of critics. One group of critics proposed modifications in Freud’s theory of sexual energy. They suggested other drives as having a pervasive influence on mental life. Jung and Adler were the two major figures of this group of critics. Another group of critics concluded that Freud’s hypothesis of identity motivation needed to be complemented with a theory of ego motivation. This movement began in the late 1930s and some of its major figures were Anna Freud, Hartmann, Erickson, Horney, Sullivan and White. A third group of critics challenged Freud’s theory of sexuality on the grounds of inadequate evidence. This position has been typically those of the theorists unsympathetic to psychoanalysis, such as early feminist critics like Millet, Beauvoir, Freidan and Greer.

In his early work The Interpretation of Dreams, Freud does not remark on the difference in the oedipalization of the little boy and the little girl. However his cultural norm of subjectivity is centered on the male. By 1925, he argued that feminine sexuality is related to masculine sexuality in terms of negative absence. The obvious problems for feminism in this theory are those of sexist bias, universalism, biological determinism, a historicity and the privileging of the visible. Another problem was the impossibility of a woman in the context to have a satisfactory organization-- the necessary adjustment between the individual and the society--which then leads to questions of adjustment and health. Psychoanalysis sought to present women as seeking men to fulfill and complete them, which according to Erickson was a consequence of their anatomy, their need to protect the unique inner space of the womb which had to be protected and made safe by the male through the institution of the family.

A woman’s different characteristics are produced by her innate narcissism or masochism, a consequence of her anatomy, as most post-Freudian psychoanalytic theory would have it. A reading of Freud would tell her that she has little sense of justice, less capacity for sublimating her instincts and is weaker in her social interests— all of this is no doubt related to the pre-dominance of envy in her mental life. (Freud, 1974.134) If she attempts to resist such a definition and pursue a masculine trajectory, she is perceived as unfeminine and hence unnatural. A woman who refused to conform to social and familial expectations was labeled deviant, abnormal or mentally ill and was prevailed upon by force to fit in with the behavior and attitudes deemed suitable for women. Normality for women was madness.

The readings of Millet and other feminists of Freud’s theory that reduces all behavior to sexual characteristics and the theories of penis envy, narcissism and masochism has been challenged by later feminists like Juliet Mitchell and Jacqueline Ross who argue that Freud does not take sexual identity to be an inborn, biological state and that Freudian psychoanalysis sees sexual identity as an unstable subject position that is culturally and socially constructed in the process of the child’s insertion into human society. Narcissism has been seen by Sara Koffman and Ulrike Prokop, in different contexts, as a representation of female power. Janine Chasseguet Smirgel has argued a cogent case for seeing penis envy as a manifestation of the little girl’s need to establish a sense of her own identity as separate from the mother— a process which for Chasseguet Smirgel is crucial for the later development of the woman’s personality.

In the 1960s, feminism fostered and set the tone for many reforms in relation to health-- especially in the sphere of health and education for women. It was from this time that women’s vital role as providers of health care both inside and outside the home was recognized. An appropriate understanding of women’s health presupposed a change in attitudes and values that were discriminatory to women’s health. Women began to have more involvement in the formulation and the planning of their health and health educational needs. Women had more access to and control over income to provide adequate nutrition for themselves and their children and were able to make some headway in this by reducing prevalence of nutritional disorders like anemia. Women’s organizations took more interest and participated more in primary health care activities including traditional medicine. The modern perception that the onus must be on preventive rather than curative measures dates back to the ancient Indian Ayurvedic concepts of maintaining good health.

The establishment of the WHO and the interest shown in the sphere of women’s medical health-- especially the appropriate gender-specific indicators for monitoring women’s health could lead, if utilized, to reduction of high morbidity among women, particularly when illnesses are psychosomatic or social or cultural in nature. Occupational health and safety and a focus on risks endangering women’s reproductive capabilities and unborn children were other areas of health explored by the WHO. The impact of new technology on the health and the welfare of the woman were also first explored in the late 1960s.

The new psychology of women that emerged in the late seventies and the early eighties of the 20th century meant, in general, a development that took as its base the psychological characteristics that had been fostered in women while they were subordinates. It built on this base, a set of strengths formerly categorized as weaknesses that grew out of women’s new aspiration to be equals. Concepts like autonomy, power, authenticity and self determination were reexamined and re-defined by women. Dichotomies like aggressiveness vs. passivity, leadership vs. affiliativeness and power vs. powerlessness were resolved and transcended. The implication of the arguments raised by Anne Koedt, Mary Jane Sherfy and others was that one could begin to consider the possibility of femaleness as normative while maleness was a derivation. By the mid 1970s many female theoreticians promoted the concept of a woman centered analysis and the view that female experience ought to be the major focus of study and the source of dominant value of culture as a whole.

Women and Their Bodies
The Women’s Health Movement has its origin with the reawakening of feminism in the 1960’s and the 1970’s. Those involved in the movement developed a deeper awareness regarding central issues related to women. Health was identified as one of the core areas demanding urgent and minute attention. Consequently the female body and its care earned prime importance. Those women who were alerted to the necessity of understanding their bodies took up the challenge of spreading the seed of this awakening among others. The year 1969 was important with regard to the Women’s Health Movement. In the U.S.A., Boston area was one of the centers of activity. During a liberation conference twelve women met and talked about their personal experiences with doctors and shared their knowledge about their bodies in a workshop on “Women and their Bodies”. This small group was called “The Doctors’ Group” in the beginning. Their main criticism was leveled at the “condescending, paternalistic, judgmental and non-informative medical system”(Vintage Book of Feminism. 353). The important principles which spurred this movement included the concept of women as informed health consumers who will be instrumental in social change and the idea that women can turn out as their own health experts by discussing health and sexuality with each other, and sharing knowledge. This was imperative because for centuries the medical field had been monopolized by men, women ending up either little informed or misinformed on their own body and its well-being.

The irony inherent in this is that women are truly the health care providers but are refused the information necessary for healthcare. The lack of knowledge regarding health, acts as an impediment, rendering women unable to decide on the correct course of treatment. The Doctors’ Group, which had been formed with the express intention of popularizing health information, paved the way for the renowned Boston Women’s Health Book Collective which began in 1970. They brought out a comprehensive course booklet “Women and their Bodies” in 1970. This publication set the issue of women’s health in a new political and social context. This booklet was renamed as Our Bodies Ourselves and published in 1972, while the 1973 edition quickly earned widespread acclaim

Female Sexuality and Lesbianism
Any discussion of the body should deal with sexuality. The 1960’s had been a period of sexual liberation in the West, “ … the rules of sexual relationships were being rewritten …. The Pill had just begun to be widely available, and widely discussed, and thus to a young cosmopolitan cohort of students, it really did appear as if sexual intercourse, together with the Beatles, had been invented in 1964.”(Mary Evans 5) The period was one demanding sexual liberation; sexual restrictions and other taboos associated with women came to an end. Feminism in the 1960’s and the 1970’s was accentuated by the new enthusiasm. Some revolutionary books that appeared during this period were Betty Friedan’s The Feminine Mystique( 1963), Kate Millett’s Sexual Politics (1970) and Germaine Greer’s The Female Eunuch( 1970). While Greer was an advocate of heterosexuality and demanded more equality between the perceived experiences of the sexes, Millett was “advocating a more cautious attitude to heterosexuality, an attitude that was eventually to emerge as explicit lesbianism.” (Mary Evans 10) The new demand was for a female sexual liberation. This direction of contemporary thought gave rise to what was popularly known as the “sisterhood” mentality, calling on women to organize and work together and claim their rights.

In connection with the increasing discussions on female sexuality, lesbianism came to be debated on. Though in the early years, lesbianism was regarded as abnormal behaviour, slowly it came to be understood as a variant form of sexual behaviour. Groups like the Radicalesbians emerged in 1970 and The Furies in 1971. Groups such as these fought to establish Lesbian rights. In countries like the U.S., the lesbian community has contributed towards the advancement of feminism. An article “Compulsory Heterosexuality and Lesbian Existence” by Adrienne Rich advocated resistance against male control and popularized the idea of a “lesbian continuum to include a range of woman identified experience.” This could facilitate greater bonding between women and enable them to comprehend and find solutions to common problems.

The impact of Foucault in feminist sexual politics
The theoretical insights provided by Michel Foucault were central to redefining the feminised central politics. In his book The History of Sexuality Foucault elaborates on sexual identity. He debates on the regulatory and productive potential of power at the level of the body. He concentrates on the effects of power in treating sexuality as the essence of subjective being. His observation that the creation of sexual difference is a mechanism of power where subjects are divided between “the good and the bad, citizens and criminals, the normal and the deviant”( Deborah Kerfoot and David Knights.“ Into the Realm of the Fearful: Power, Identity and the Gender Problematic” Power / Gender 83) is of great significance in feminist studies. Subjects are differentiated as men and women, masculine and feminine. The power play and connected discourses arise out of the efforts to safeguard individual sexual identities. In the light of Foucault’s arguments it is easy to understand why the masculine negates the feminine and the normal negates the deviant. Significantly, Foucault exposed the hypocrisy of the Victorian society which sought to repress the biological body.

Foucault’s theory served to empower the feminist sexual politics in the 1980’s. His effort was to bring to the forefront the fallacy of theorizing about ‘good’ or ‘bad’ sex. The suggestions he put forth inspired thoughts regarding the importance of subjective experiences. In the feminist scenario, women started discussing the experiences and sexual desires of women themselves rather than envisioning these aspects from the point of view of men. Individual preferences mattered more than any conventional ideology. Foucault is important in feminist studies since his idea of power and of sexual identity could facilitate the possibility of a feminist politics that avoids the binary notions of sexuality of gender essentialism, and the disembodied discourse of deconstruction theory.

Mental Health
While lesbianism which was a very powerful sexual variant came to be accepted in the U.S., other issues related to the sexual and reproductive health of women were given closer attention. Contrary to the traditional medical practice, “feminists redefined women’s health through a holistic model which acknowledged the personal experiences of women and the social, historical, political, cultural, economic, emotional as well as physical determinants of health. This social perspective of health argues that women’s health needs and concerns are entirely incompatible with the conventional medical model which ignores widespread inequalities in society and depends simplistically on morbidity and mortality statistics.”(Feminist Activism in the 1990’s) Women were exhorted to secure control over their bodies. With the increasing consciousness of the female body, sexuality or body politics became the epicenter of discussion and debates in the 1970’s and the ‘80’s. This brought to the forefront thoughts regarding health issues. Organizations were founded to guide women regarding these issues. Centuries of negation and suppression had caused women to pay little, if no attention at all, to their physical and mental health. For a woman to focus on her physical health, it is necessary that she has the proper emotional conditioning. Self-esteem plays a key role in this and “a woman’s sense of self esteem and how she feels about her body, are largely shaped by her personal and family histories -- whether as a child and young woman she learned to respect herself and was comfortable with how her body grew and matured or whether she was taunted, humiliated and abused.”(Marion Crook vii) Thus any physical problem can be negotiated only after addressing the emotional problem. Consequently, mental health attains prime importance in any feminist critique. ‘Mental illness’ is very often a product of emotional suppression. Emotional imbalances create a sense of alienation and sadness. The popular psychological standards assigned normalcy to masculine characteristics and an aura of “unpredictable” ness and “mystery” to the feminine. “Femininity is both socially devalued and representative of actual oppression. Women’s lack of assertiveness characterized by this traditional stereotypical femininity coincides with a high state of anxiety and feelings of low self-worth and thus ill health.”(The Psychology of Women’s Health Care 14)

One of the factors that triggers mental instability in women is the abusive relationship they find themselves in. Bonnie Burstow in her book Radical Feminist Therapy, quotes L. Walker’s “Cycle of Violence”: “ In the cycle, tension building leads to violence; the ‘violence phase’ is followed by ‘a honeymoon period’ in which the man is mortified, apologizes, promises to do better, and ostensibly is believed and forgiven. The honeymoon phase is followed by a further tension building phase and that phase by further violence. And so the cycle continues, with the honeymoon periods characteristically becoming progressively shorter and the violence and the tension building phases becoming progressively larger.” (Burstow 149). Due to a variety of personal and social pressures, very often the woman continues in the abusive relationship, deliberately hoodwinking herself and others. It is however, imperative that in such cases, the woman is made aware of her position and given professional advice. Suppression of the extremities of an abusive relationship results in acute mental stress and trauma. In countries like India, economic dependency along with social and familial pressures trap women in abusive relationships, both physical and mental, forcing them to hide their anguish.

Mental health is also influenced by stress. Significant sources of stress include major life events -- break up of marriage, death of one’s spouse, diseases in the family and such other instances. These events might destroy a person’s ability to cope with and function effectively. Women who face financial hardship experience tremendous stress. At the same time traumatic events such as rape might also spark off tension and anxiety at a dangerous level. Male violence towards women is an important issue that demands public attention – women organize against this internationally. In many cases, women who undergo extreme sexual violence experience a loss of self and self-esteem following the shock inflicted on them. When there is a continuous period of traumatic stress, it becomes chronic, lessening the individual’s ability to do any kind of constructive work. Such cases require careful counselling so that the victim can be gently brought back to a normal level of existence. There are numerous crisis centers and support groups all over the world which extend valuable help to such victims. Mental health centres had assumed importance during the 1960’s and ‘70’s; consequently Women and Psychiatry groups came to be formed in the early 1970’s. The journal Feminism and Psychology was begun in 1992. The focus during this period was on violence. In the 1980’s health promotion was identified as an important factor to be put into actual practice. Close studies of the issues related to health revealed that the causes of ill health include poverty, poor housing, unemployment and social disadvantages. Feminist therapy or counselling has been suggested as an ideal solution for the innate feeling of unhappiness in women. Feminist therapy emerged in the wake of the women’s movement. The mental health establishment which was viewed as patriarchal was deemed unable to impart the required counselling. The prevalent mental health system came under acerbic attack for being “a particularly misogynous and oppressive substructure.”(Burstow. ix) The research carried out by Inge Broverman “indicated that both male and female clinicians identify ‘socially competent adult’ with ‘socially competent man’ and see women as socially competent only when not acting like a competent adult.” (Burstow. ix)

Phyllis Chessler’s study of women and madness successfully established how the patriarchally structured psychiatric system subjugated women. She accused the existing trends of psychiatry for creating sex role stereotypes and exposed the actual danger which awaited women whose efforts to stay feminine would jeopardize their well-being and destroy their identity. Chessler’s and Broverman’s studies spurred new feminist approaches regarding therapy. Counselling ought to make women more aware of their problems and the oppressions they faced. Therapy can provide alternatives to deal with health issues.

The Focus on the Body
The socially accepted notions of femininity thus function as a snare since these prove to be hostile to women’s health and related concerns. “Femininity has a social meaning which transcends simply being a woman …. Women need to be feminine and have feminine qualities in order to avoid being pathologised, and paradoxically femininity itself is a pathologised concept.” (The Psychology of Women’s Health Care. 10) This is borne out by the fact that all physical changes of a woman from the period of puberty to menopause are considered pathological. Women’s bodies have become sites for medical experimentation. An aura of sickness has come to be associated with the woman’s body. Technological intervention had shorn the female body of individuality.A new awareness had to be instilled in women regarding their body behavior. Menstruation, pregnancy, childbirth, menopause, ageing were all to be regarded as natural phenomena rather than instances of ill health. Pre-Menstrual Syndrome is now considered as one of the debilitating factors as far as women are concerned. There are many explanations for this phenomenon. Coming under one of the new reproductive illnesses, medical experts and researchers have offered a variety of explanations for this so-called disease. It is true that many women experience premenstrual discomfort, which is characterized by headaches, irritability, nervousness, fatigue, crying spells, and depression with no logical reason. Menstrual cramps are also experienced. Although premenstrual symptoms and discomfort during menstruation were once thought to be of psychological origin, research now indicates that hormonal and chemical changes are responsible. However, the hormone responsible for the disorders has so far not been identified but a wide range of drugs are prescribed to treat the syndrome. This cannot be justified because there is no conclusive proof that pre-menstrual behavior patterns have any influence over the performance of women or their psychology. Jane Ussher argues convincingly that PMS is a political category that ties women to their biology and provides reductionist and reactionary explanations for women’s discontent or distress. She says that the feelings of women who suffer from PMS are not necessarily rooted in biology. She adds that the negative framing and defamation of the female body which links it with unhappiness, does not allow women to express discontent except through the body. Biology should not be elevated to the status of the sole site of misery, turning unhappiness into illness. Thus a natural body phenomenon has come to be treated as a disease and the woman becomes a victim of her own biological self which overpowers her and weakens her.

Similarly pregnancy and childbirth are also viewed as states of ill health in need of medical intervention. Feminists have been constantly fighting against the medicalization of the natural phenomena of pregnancy and childbirth. The exit of the traditional midwife and the entry of the male physician has in a way snatched the reins from the hands of women, regarding their individual freedom and private experiences. Women are demanding more choices and cooperation from the medical professionals and this has become an area where women can hope to stay in control of their health. It is true that some deliveries may become emergencies, but this does not justify the fact that normal deliveries should also be considered as cases demanding the interference of medical personnel. When a woman faces the event of childbirth all by herself with none other than the doctor beside her, she might be consumed by a feeling of depression and anxiety. Therefore this mental condition of women should not be seen as pathological.

Menopause is another stage a woman has to pass through – a stage which also has drawn attention to the female body. The medical field views this as a period when women suffer a general deterioration of health and complain of various physical and mental disorders. Menopausal complaints, like PMS and PND, cannot be regarded as a general complaint, applicable to all women. The psychological complaints during this period, if any, can be attributed to the behavior of society and the treatment meted out to women. A community which pathologises menopause as well as the negative ideas associated with ageing contributes towards the depression experienced by women during this period. Negative effects of menopause can be reduced by maintaining a healthy diet, eliminating caffeine and alcohol, reducing sugar and salt intake, stopping smoking and taking vitamin supplements. Exercise helps increase conversion of androgens to estrogens and can help relieve menopausal symptoms. How women view menopause may also affect symptoms. Traditionally in our culture, menopause has been viewed negatively, as a period of fluctuating hormones that weakens women. For many women, there is only a fractional discomfort during menopause, and some find renewed energy and enthusiasm after menopause.

Reproductive Rights
Women’s efforts to control their own reproductive systems have been an important part of the Women’s Rights Movement since the mid-19th century. The right to use contraceptives, the decision to plan their family and the choice of abortion had to be necessarily provided for women. Women must be provided the option to select the time to become mothers. The greatest controversy in this respect has been regarding the legality of abortions, whether a woman can be given the right to terminate her pregnancy or not. Abortion was illegal in the United States until 1973. Abortion has become one of the most intense and antagonistic moral and philosophical issues of the late 20th century. Modern medical techniques have made induced abortions simpler and less dangerous. But in the United States, the debate over abortion has led to legal battles in the courts, in the Congress of the United States and state legislatures.

On one side are individuals who favor a woman’s reproductive rights, including the right to choose to have an abortion. On the other side are those who oppose abortion except in extreme circumstances, as when the mother’s life would be threatened by carrying a pregnancy to the full term. The former group holds that the foetus is not yet a human being and thus has no legal rights. The woman bearing the foetus can decide whether to continue her pregnancy or abort it. The other group believes that the foetus is a living thing and hence deserves legal rights.

Considerable hostility surrounds the abortion debate due to medical vagueness regarding the status of the foetus, as well as social, political and religious reasons. Many women are worried about allowing the government to decide the options open to them – they fear this might lead to interference in their reproductive rights. Many religions forbid or restrict this practice. Abortion was considered illegal in most countries until the 19th century. In the 20th century, however, many nations began to relax their laws against abortion. The former Union of Soviet Socialist Republics (USSR) legalized abortion in 1920, followed by Japan in 1948, and several Eastern European countries in the 1950s. In the 1960s and 1970s, much of Europe and Asia, along with Canada and the United States, legalized abortion. In India family planning programmes have legalized abortions and in 1971 the Parliament passed the Medical Termination of Pregnancy Act to make abortions legal. In 1975 the Indian Government made rules and regulations regarding abortions so that abortions would be done only legally. Abortion facilities are available everywhere in India now. However, the problem in India is the increasing case of female feticide which is still prevalent. The introduction of amniocentesis has made it easy for identifying the foetus and eliminating it in case it is a female. This is largely triggered by other social evils like dowry which make the girl child a burden and hence unwanted.

In the United States, the legalization of abortion began in 1966 when the state of Mississippi passed a law permitting abortion in cases of rape. In the following four years, other states allowed abortion when for instance a pregnancy threatens a woman’s health, the foetus has serious abnormalities, or the pregnancy is the result of incest. In 1976 the Supreme Court recognized the right of pregnant girls under the age of 18, known as mature minors, to have abortions. There are other restrictions regulating who pays for abortions, where abortions are performed, and what information is provided to women seeking abortions. In the year 1977, the Supreme Court allowed the states to limit the government assistance for health care in cases where the abortions were elective. Funding for abortions, considered medically necessary, was also restricted by the Supreme Court . There were many cases related to abortion fought in the courts of the United States of America. In 1996 the Congress of the United States enacted a bill banning the practice of abortions. President Clinton vetoed the law because it failed to permit use of the procedure when a foetus displays severe abnormalities or when a pregnancy threatened a woman’s health or her life. Many states have since passed laws banning use of the procedure.

Since the Supreme Court ruling that legalized abortion in 1973, the antiabortion campaigners have worked continuously to reverse the decision. They have consistently requested state and federal officials to place restrictions on women seeking abortions or on individuals providing abortions. They have also held protests directed at clinics that perform abortions, and, in some cases, have protested against and obstructed patients at such clinics. In May 1994 the Freedom of Access to Clinic Entrances Act was passed, which made it a federal crime to use force , or physical obstruction to injure, intimidate or interfere with reproductive health care providers and their patients.

More than two decades since the Supreme Court first upheld a woman’s right to abortion, the debate whether abortion is ethical and legal, continues in the United States. Although supporters of abortion and those against it still are at war, a growing number of individuals expect that discussing the issue taking into consideration other related aspects might put an end to the debate. In Britain, the National Abortion Campaign is the largest and most successful organization in favour of abortion. It was founded in 1975 and works tirelessly to spread awareness among women regarding health and related matters topics. When there are pro-choice centres on the one hand, there are anti-abortion groups which function to protect the rights of the unborn child. The NAC’s objective is to provide women, irrespective of their social, economic and cultural background, access to safe and free abortion on request .

The Euro-centered perspective of women’s movements which was followed by the women’s movements in India underwent drastic changes as time went on. For a long time the women’s movements stood for the interests of the intellectual, upper-middle class Indian womanhood. It was only by the 1990’s that the movement became a strongly felt presence among those whose lot required betterment. The movement then became truly of the people. Such people’s movements like the visible and very vocal eco-movement are undoubtedly for the betterment of the country. The health movement too is beginning to gain momentum. Women were traditionally accepted as health care providers. Their involvement with health issues can lead to the betterment of health in home and in society. When rural women who are often distanced both physically and financially from the best of hospitals are educated, they can even save lives. A case in point is the decrease in the number of deaths caused by diahorrea, one of the major causes of infant mortality. The education women were given about the need to provide fluids with the appropriate ratio of sugar and salt considerably reduced the high incidence of death. The health education of women will thus lead to better health for all.

It has now been accepted that women’s health can be an index for the measurement of the overall progress that has been brought about by the health services of a country. This is because of the extra burden that women carry in health and development matters. Although women experience the same pressing problems like, lack of access to resources, underemployment or unemployment, lack of training opportunities, they are almost always the most severely affected. They are the last to be given resources, to be listened to and consulted about their own needs, to be beneficiaries of health and development schemes. The fact that women’s well-being has a powerful impact on society is now being recognized as an important index to measuring a people’s state of health

Support groups and Health Centers for Women:
Looking at the world scenario in general, the ‘70’s, ‘80’s and ‘90’s saw the mushrooming of a number of centers and support groups for women all over the world. Important among these are the National Women’s Health Network which began work in 1976, the Combahee River Collective, a black feminist group founded in Boston in 1974 and, ROW (Rights of Women) established in 1975. Women-controlled health centers emerged as alternatives to conventional medical centers and there emerged many self help groups who taught cervical self exam, and provided abortion services. These centers gave prime importance to the client and her needs. There were also various support groups dealing with infertility, menopause, pre-menstrual problems and such aspects. The new womencentred organizations were insistent that whatever be the issue, the primary importance was to be given to the client and her well-being.

Life Style Issues
The choices made by individual persons about their lifestyles determine the nature of their diseases. Smoking, too much alcohol, too little exercise and using drugs combined with dietary and other factors put people at the risk of poor health and premature death. A number of countries have attempted to regulate alcohol and tobacco promotion by issuing statutory warning and by levying high taxes on these products. Educational campaigns against the use of tobacco and alcohol have helped the cause of health care. There are evident connections between improving lifestyle of the people and the number of noncommunicable diseases they seem to face. If infections and parasitic diseases and malnutrition plague developing countries, lung cancer, heart diseases and cirrhosis of the liver are diseases that haunt developed countries. These trends have great significance for women’s health.

Earlier, women had lagged behind men in alcohol consumption and smoking. Studies have revealed that only 5 to 7 percent of the women smoke in developed countries. However in certain developing countries like Swaziland, 72 % of adult woman smoke. There is an alarming increase in the percentage of young women who smoke. The need for educating young women to avoid health destroying addictive behavior is the need of the hour. If cardiovascular diseases and lung cancer had at one time never claimed female victims, with the increase of women who smoke, the statistics show an alarming increase in the death toll due to tobacco use. The scale of the threat that smoking poses to women’s health has received surprisingly little attention. A recent study revealed that women smokers have higher rates of cervical cancer. A comprehensive culture specific programme tailored to meet the local situation, containing three key elements of protection, education and support may go a long way to slow down the enthusiasm of young women for tobacco consumption.

Research has confirmed that women are more sensitive than men to alcohol effects. Due to a biochemical difference in the stomach lining, women absorb more of the alcohol she drinks into her blood stream. This greater psychological vulnerability added to socio- economic changes and the increasing stress on women accounts partly for the increasing number of women who are addicted to alcohol. Society is harder on women who are addicted to alcohol and this results in their being totally isolated while guilt may result in a total loss of respect. Women drinkers are less likely than men to seek treatment or get into a self-help group. Family life and marriage become casualties in this context, for the husband of a woman drinker is more likely to leave her. Alcoholism in women is a problem that could be aggravated by urbanization for fewer social controls operate in an urban scenario. Even if women themselves do not drink, women are affected by the increasing consumption of alcohol as much violence against women is associated with alcohol.

Though drugs have the power to reduce pain and treat diseases, they are also used by people to experience pleasure. The escape offered by the psychotropic or mood altering drugs treads the fine line of drug abuse or addiction. As this fine line is not always clear, there are particular consequences for women’s health. Psychotropic drugs that are the main concern of the medical companies that sponsor campaigns are minor tranquilizers that have sedative effect on the brain. A study in Europe in the 70s found that the proportion of women who used anti- anxiety sedative drugs far outstripped men. The minor tranquilizers prescribed or those that women used, could produce severe effects when compared with alcohol, to pregnant women particularly. The tranquillizers prevent women from solving problems that make them turn to drugs in the first place, for drugs help them to mask the misery and prevent expression of misery that would have a psychotherapeutic effect. The reaction of women while coping with anxiety, stress and anger are not welcomed by society for they are not expected to express their emotions at all. Instead, their problems are medicalized and soon they begin to feel that they cannot cope without drugs. Dependence on drugs is the result.

The various preventive measures suggested by health personnel include calling the attention of the public to drug abuse, providing information about the problem, approaching policy-makers and politicians and encouraging publicity about the extent of the problem and the need for appropriate services.

Disease and Disability:
“While for both the sexes, coping with disabilities can be difficult, to be female and disabled in our society is a double drawback” (Jo Campling, 1979.2). Statistics reveal that one person in every 10 has a significant disability. Probably more than half of them are women. This is because women live longer and experience the disabilities associated with old age. Certain disabling diseases like multiple sclerosis and anemia strike women more often than men. Several of the causes of disability are because of nutritional deficiencies. Accidents in the house or at the workplace or on the road are major causes of disabilities as are preventable childhood diseases such as poliomyelitis and measles. The impact of disability on women range from total isolation and abandonment to the limited opportunities available for girls with disabilities. Many disabled women feel that while disabled men are taught to fend for themselves, women are not encouraged to do so. A woman with a disability has to be twice as qualified to get employment. Disabled women are frequently victims of rape and violence. Disability causes a poor self-image for the woman. Multiplication of self-help initiatives, the establishment of the Disabled People International and the setting up of developmental training programmes for disabled women may help them to acquire greater self esteem.

Just as the disabled among women suffer more both physically and psychologically than men, women struck with diseases suffer more than their male counterparts. Often, women do not enjoy the same medical care that the male members of the family do. This may be determined by their economic status too, for the kind of attention that the wage earner claims in matters medical is not available to the home maker. Screening techniques ranging from mobile X-ray units to C.T.scanners are now available on request. Yet, it is a fact that even educated women often hesitate to make use of these facilities. They would rather wait and see if the symptoms would disappear. Choices regarding treatments too rest on the authoritative figure of the family, thereby considerably lessening the power of the woman to determine the kind of treatment she would like to follow. In certain kinds of diseases women are at the mercy of social and religious beliefs.

Despite the social and economic aspects of women’s health, their reproductive function continues to be a major issue. The World Development Report of 1993 proposed a new composite measure called the Disability Adjusted Life Year or DALY as a generic indicator usable everywhere to help set up health policy priorities. This would facilitate comparison between countries and standardize the way decisions are made in the health sector. The leading causes of DALYs lost among women aged between 15 and 44 in developing countries were found to be related to childbirth, tuberculosis and sexually transmitted diseases. It was found that the leading cause of death among women in developing countries is cancer of the uterine cervix. According to a recent study, cervical cancer can be caused by infection with certain strains of human papilloma virus, a sexually transmitted pathogen. Genetic causes have also been established. All these affect the reproductive status of women.

The incidence of breast cancer is something that women dread because of medical, social and psychological reasons. In the mid 1970s, women were educated to detect the presence of lumps in breasts, a possible indication of breast cancer. The issues surrounding the treatment of breast cancer were addressed by a number of feminists activists, particularly the journalist, Rose Kusher. The preponderance of surgery for all who approached a medical doctor, following minimal indication, was opposed by Kusher who argued that breast surgeries should be performed as a two step procedure. One positive result that emerged was the increased awareness of the existence of non-surgical treatments. Yet, more than the availability of medical treatment is the feeling of loss and bewilderment that seem to plague the sufferers. The very medical treatment that would cure them also brings into focus various taboos and social barriers that women are subconsciously aware of. The trauma associated with breast cancer is clearly influenced by the cultural emphasis on breasts as objects of male sexual interest and pleasure, one of the major reasons why women tend to shy away from surgery. Surgical treatment could also lead to the society’s negation and cruelty. The feeling of being out of control of one’s life when subsumed by intense competition, one of the direct results of the market economy brought in by globalization, is further heightened by the loss of the support systems that women had hitherto enjoyed. An even more distressing aspect is the attitude of society. On auspicious occasions, such women get the short shrift from even their closest relatives. In India, in conservative circles, persons afflicted with diseases are kept under wraps and not permitted to take part in rituals. It is important to educate people to give up such outdated attitudes and practises, and provide those striken by diseases with support as part of a comprehensive health care system. The existence of support groups will certainly help to reinforce the woman’s decision to get professional health care and minimize the trauma of affliction. The support group system can bolster the will power of the patient and equip her to face the disease and ultimately to conquer it. It will also help her to overcome the morbid curiosity of society and the taboos enforced by it.

Amongst many sexually transmitted diseases, the incidence of the AIDS epidemic could erase whatever progress made in women’s health over the past decade. Statistics reveal that the number of HIV positive women will soon surpass that of men. It is clear that AIDS is putting additional burden on women in their role as health care providers. STDs can contribute to blindness, brain damage, pelvic inflammations, spontaneous abortions, ectopic pregnancies and cervical cancer. Like all other health issues, the drawing up of an education and prevention programme that is appropriate to the public is as important as providing information, support and counselling to the infected.

Women and Nutrition
Even granted the severe limitation of low income, many groups fare far worse than they should because of culturally determined practices, particularly regarding diet. It is impossible to chronicle the many permutations of counter productive food taboos which fall most heavily on those least likely to tolerate them- i.e. children, women and lactating mothers. In countries like Peru, Indonesia and Malaysia, fish is withheld from children for fear that it may make them sick. Eggs are linked with illness in India, Lebanon and Syria. It is linked with mental retardation in East Africa, with late speech development in Korea and licentiousness in various countries. In West Africa, eggs are kept away from children on the grounds that they will come to expect luxuries and grow up to be thieves. In some tropical countries, papaya and similar fruits are thought to cause worms in children. The children may develop xerophthalmia and suffer permanent blindness from the resultant avitaminosis A.

Apart from these taboos, nutritional deficiency underlies women’s deaths to a greater extent than male deaths. The lower nutritional status among women is, according to a recent study conducted in India, due to greater morbidity. When clearly analyzed, it was further discovered that nutritional deficiency was one of the most important among the health problems of women. Though milk intake was high even among low income groups, the intake of milk and milk products by women was less than 20 grams per day. Women’s consumption of green vegetables was much less than that of cereals and pulses. The quality and the quantity of food women consumed were comparatively inferior and lesser than that of the male members of the household. In the case of families without adequate income or larger landholdings the food intake of women was extremely poor. Women were, moreover, culturally bound to eat only after the men had had their food. Often they had to be content with leftovers. The case of old women was even worse for their nutrition was hardly ever taken into account. Far from being given vitamin and nutritional supplements, they were often denied a balanced diet under the erroneous belief that they do not require any further nutrition.

Nutritional deficiency among women include also anemia owing to iron deficiency and calcium deficiency that manifests itself as osteoporosis among older women. Among young adults nutritional deficiency may well be the result of self induced starvation with a view to remain slender. Extreme dietary restrictions may lead to anorexia nervosa or bulimia, which were basically ‘culture bound’ syndromes in the West. With globalization and the expansion of the beauty industry, these hitherto culture bound syndromes occur in urban areas all over the world.

Increase in per capita income and a greater amount of money spend on food may at times lead to impoverishment rather than improvement of nutrition. In India, food preference has gone from home polished rice and wheat to commercially polished grains or flour. A great deal of vitamins and protein may be lost by these refinements of the natural food grains. The “Coco Colonization” of the world shows how rapidly cultural changes can occur. In India, more costly but less nutritious substitutes have replaced the abundant greens, fruits and legumes. In virtually all countries, there is a rapid increase of consumption of sweets, soft drinks and other junk.

With the advent of the 90’s women are seen to be given enough exposure to health related issues so that they are educated on their bodies, illnesses and treatments available. They have been sufficiently warned against the indiscrete prescription of drugs by physicians and given available information regarding alternative medicine. Among the organizations formed in recent years the Universal Health Care Action Network (UHCAN) formed in 1992 is significant. It brings together diverse groups and activists working for comprehensive healthcare. NAWHO founded in 1993 aimed at eliminating health disparities for Asian women and families in America. The new demands of women’s organizations are that reproductive health care must include maternity care, family planning, abortion facilities, infertility treatment, care for sexually transmitted diseases, and such others. Education has contributed a great deal towards empowering women and making them aware of their rights. The presentday concerns of women are gathering information regarding diseases such as breast cancer, reproductive and sexual health, mental health, osteoporosis, smoking, immunization and sexual violence. In the United States, there are many organizations providing information regarding specific women’s diseases. The organizations have also expressed genuine concern over the immense influx of women-targeted health and medical technologies.

Towards a Health Policy for Women
If women’s health issues are to be treated fairly and effectively, one has to stress the necessity of a practical health policy. What is most important is that the policy makers should realize that the health problems of women cannot be uniform. The various health issues identified have differing dimensions in different countries. A certain issue has to be dealt with in its particular context. In India, the National Health Policy 2001 recognizes the catalytic role of empowered women in improving the overall health standards of the community. This underscores the fact that women are the actual health care providers. Proper practical education is imperative in this regard. It is important that the government take steps to prevent infanticide, pre-natal sex selection and immoral trafficking of girls. In developing countries, easy access to basic health care facilities should be made available. Ensuring proper nutrition and health care is a major responsibility of the government since in countries like India the girl child is the subject of neglect and disregard. Meeting a number of necessities like the adequate provision of clean drinking water, sanitation and ensuring the systematic performance of the public distribution system must rank high in the government agenda. Given the right choices and in the presence of an ideal infrastructure, women will surely make the right decisions for themselves and their families. If sufficiently educated in matters of health and hygiene, women can bring about substantial improvement in the community health standards.

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JAYASREE RAMAKRISHNAN NAIR : Freelance writer and translator. Has published many articles and translated many works including four plays of Shakespeare into Malayalam. Interested in Shakespeare Studies, Translation Studies and
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Shalmalee Palekar

V Suja

Epidemiology of HIV-AIDS-womens perspective


Author:V. SUJA

ABSTRACT---HIV infections including AIDS have now become an almost developmental and security problem in most developing countries, in addition to its medical, social and economic consequences affecting the individual, home, society and country. AIDS, first reported in women in 1981, is a major concern for women and girls affecting their motherhood also. Globally, to date 48% of people living with HIV are women and this rate is gradually going up Biologically women are more susceptible to get the infection, even though not much difference is seen in the progression of the disease.

HIV infections including AIDS are one of the pandemics affecting the st world in the 21 century. It had its origin in early 1980’s. No other disease has gained so much “popularity” within this short period. It is even threatening the security of countries especially the underdeveloped and developing ones which have more than 95 % of this infective disease. It is worth quoting here the words of Peter Piot, Executive Director of the Joint United Nations Programme on HIV /AIDS (UNAIDS),“ We do not have a cure; we do not have a vaccine. The primary strategy to reduce the spread of HIV is behavior change. And it is much harder to change an adult’s behavior than it is to help young people adopt safer behavior from the very start of their sexual lives”. The UN secretary general has called the HIV /AIDS epidemic “The most formidable development challenge of our time which needs a global commitment for intensified and coordinated action”. “You can’t get AIDS by kissing, hugging or holding hands. We are normal human beings. We can walk, we can talk, we are all the same. When I have an open wound, that is the only time people need to be afraid of me”. These are the words of the 11year old Nkosi Johnson at the opening ceremony of the International AIDS Conference in the city of Durban in the year 2000. This was the poor young South African boy who got infected at birth. What he said is true also.

Eventhough much awareness has occurred in this field , the problem of HIV /AIDS is growing in magnitude worldwide and the cost in human life and suffering is staggering. HIV /AIDS which was regarded primarily as a serious health crisis, a decade ago, is now clearly a development crisis and in some parts of the world is becoming a security crisis too. This will have a profound impact on infant, child and maternal mortalities , life expectancy and economic growth. Raising public awareness on change in moral behavior is the key factor in prevention programmes. HIV / AIDS epidemic affects and kills people in their more productive years ( 20-45 yrs ). HIV infection leads to increased morbidity and mortality in their most reproductive ages and it will have serious economic consequences on the family, the community and the nation. There will be a drop in life expectancy and a loss of skilled forces across all levels. The catastrophe of HIV /AIDS can undermine the achievements we have gained in the health field, like increase in life expectancy, decrease in infant and maternal mortality rates etc. Even the 4 million people currently living with HIV /AIDS in India will be in an extra burden on the already over stretched health care system.

The AIDS epidemic has a profound impact on growth, income and poverty. It is estimated that the annual per capita growth in half the countries of sub-Saharan Africa is falling by 0.5– 1.2% as a direct result of AIDS. By 2010, per capita GDP in some of the hardest hit countries may drop by 8% and per capita consumption may fall even farther. Calculations show that heavily affected countries could lose more than 20% of GDP by 2020. People at all income levels are vulnerable to the economic impact of HIV/AIDS, but the poor suffer most acutely. One quarter of households in Botswana, where adult HIV prevalence is over 35%, can expect to lose an income earner within the next 10 years. A rapid increase in the number of very poor and destitute families is anticipated. Per capita household income for the poorest quarter of households is expected to fall by 13%, while every income earner in this category can expect to take on four more dependents as a result of HIV/AIDS. In the worstaffected countries, steep drops in life expectancies are beginning to occur, most drastically in sub-Saharan Africa, where four countries (Botswana, Malawi, Mozambique and Swaziland) now have a life expectancy of less than 40 years. Were it not for HIV/AIDS, average life expectancy in sub-Saharan Africa would be approximately 62 years. In South Africa, it is estimated that average life expectancy is only 47 years, instead of 66, if AIDS were not a factor (see Figure 2). And, in Haiti, it has dropped to 53 years as opposed to 59. The number of African children who had lost their mother or both parents to the epidemic by the end of 2000— 12.1 million— is forecast to more than double over the next decade. These orphans are especially vulnerable to the epidemic, and the impoverishment and precariousness it brings.As more infants are born HIV-positive in badly affected countries, child mortality rates are also rising. Unequal access to affordable treatment and adequate health services are some of the main factors accounting for drastically different survival rates among those living with HIV/AIDS in rich and poor countries and communities. This holds good for our country also.

What is HIV / AIDS ?
The Human Immunodeficiency Virus (HIV ) causes a chronic infection that leads to profound immunosuppression. The course of the infection may vary somewhat, with some individuals developing immunosuppression within 2-3yrs and others remaining free of immunosuppression for 10-15 yrs. Eventually the infected individual develops early symptomatic HIV, which progresses to AIDS.AIDS is the acronym for Acquired Immune Deficiency Syndrome which forms one fatal end stage in the natural progression of HIV infection. HIV infection means any individual harbouring the organism, who may or may not have any disease manifestation ,which includes AIDS also. But at the same time they can transmit the infection to others in certain peculiar circumstances which we will discuss later. So the outward appearance of an individual need not tell us whether he is harbouring the virus or not. After acquiring the virus, the mean duration by which it progress to AIDS is 10 yrs.

Origin of the Disease :
The medical community was surprised in the early 1980’s, by reports of a particular type of pneumonia caused by Pneumocystis carini in 5 otherwise healthy young men from Los Angeles between October 1980 and May 1981 and a series of other 26 cases of a particular skin cancer called Kaposi’s sarcoma, again in healthy young men. Prior to these reports these diseases were seen in elderly persons with immunosuppression and that also equally in males and females. Further it was found that all these young otherwise healthy were homosexuals, thus attributing something related to sexual activity as the cause. Later it was also detected in those who received blood transfusions, and in intravenous drug abusers (IVDU). Research work later identified a peculiar type of virus belonging to the group of retroviruses as the cause by Montagnier and Galo. In 1983 the virus was isolated from a patient with lymph node enlargement. In 1984 it was confirmed to be the cause of AIDS.

When and how the disease originated is controversial. Retrospective analysis done on stored blood showed that the earliest case identified dates back to 1959. Eventhough various theories of origin of the disease are there,the most reliable is that the virus was present in certain chimpanzees in Africa ( Pan troglodytus troglodytus ) from ancient times without producing disease in them but getting transmitted among them from generation to generation – leading to mutations making them pathogenic. In certain African forest areas these animals were slaughtered for food purpose and, by injuries in hand the organism might have entered the human being and from that individual to his sexual partner. When both of them die the virus also gets arrested there. But due to the behavioral th pattern of man in the latter half of 20 century, with much travel for education and job and due to increasing promiscuous sexual behavior, the virus might have spread first among homosexuals and gradually to bisexuals. The virus might have moved from forest to cities.Now it has become a heterosexual disease causing concern for all group of individuals irrespective of age or sex or race. So it is the behavior of the human population which paved the way for its spread. In New York, in the Stonewall Inn , by the gay revolution it spread among homosexuals.So initially it was thought that homosexuals are more affected by the disease. Now it is seen equally in homo and heterosexuals world wide, but in the US even now the main mode of transmission is homosexual contact and intravenous drug abuse (IVDU).

Virus and the Disease :
HIV is a retro virus belonging to lentivirus family and is icosahedral in shape. It consists of RNA and a peculiar enzyme called reverse transcriptase. This is covered by an inner protein and an outer lipoprotein membranes, in which are seen the important antigenic determinants — gp-120 and gp –41 in the outer cover and p18 & p24 in the inner cover. There are two types of HIV ie HIV –1 & HIV –2. HIV –1 is more common in the US. After it enters human body,the ideal site in which it likes to reside, host cell is a peculiar type of lymphocytes, one type of white blood cells, called CD 4 T cells with CD 4 molecule on its surface. These lymphocytes are important in preventing infections and in immune surveillance and tumor prevention normally. This primary infection occurs by entry of organism through sexual / other routes. Gradually the virus increases in number in the body and leads to an “ acute HIV syndrome” simulating a viral fever. In this stage the patient is highly infectious because of high levels of virus in blood, but at the same time the disease cannot be detected by blood tests. Then gradually immune response occurs against the virus and the virus gets trapped in lymph nodes and viremia and the acute symptoms stop and patient goes into a latency stage, on the average of 10yrs. Gradually the metabolism of the virus inside these cells leads to progressive quantitative and qualitative deficiency of CD 4 cells.Then slowly CD4 cells decrease and when it reaches a particular level the patient develops various infections and cancers. Initially these may not be life threatening, but when the CD4 count drops to very low levels, the patient develops serious infections and malignancies and succumbs to that. This fatal stage is called AIDS. Even though various groups of drugs are there to decrease viral multiplication, drug treatment is costly and is with various side effects, needing constant supervision of a specialist.

The main modes of transmission of HIV are:

1. Sexual contact – homosexual,heterosexual &bisexual
2. Blood & blood products transfusion and organ transplantation
3. Intravenous injections and drug abuse
4. Mother to foetus
5. Occupational exposure

More than 80 % of HIV cases are transmitted by sexual contact. Intimate body contact during the sexual act leads to minute abrasions and injuries in the skin and mucosa.Through these injuries the body fluids of one partner can enter the other and the virus can enter the body.Semen and vaginal fluids contain plenty of organisms. Also if there is an ulcer in the genitalia or urethral discharge the chance for transission of the infection increases. That is why the presence of other sexually transmitted infections as syphilis, herpes genitalis and gonorrhea is said to increase the chance of tranmission. Through vaginal mucosa it can be transmitted especially if traumatized. So there is 20 times more chance of HIV transmission from man to woman than from woman to man by vaginal intercourse. This is because in females there is increased exposure of vaginal and cervical mucosa as well as endometrium of uterus to infected semen. In males the penis and urethral orifice are exposed only to a brief period to the infected vaginal fluid. Persistent and proper use of condoms can significantly reduce this mode of transmission. In receptive anal intercourse due to increased trauma and due to some other reasons the chance of transmission is increased more than that by vaginal intercourse. Vaginal mucosa is several layers thicker than rectal mucosa. The chance of transmission by oral sex is less but the disease can occur and cases have been reported. Behaviors that bring the highest risk of infection in Asia and the Pacific are unprotected sex between clients and sex workers, needle sharing and unprotected sex between homosexual men. But infections does not remain confined to those with higher-risk behaviour. Many countries have seen major epidemics grow out of initially relatively contained rates of infection in these populations. Northern Thailand’s epidemic in the late 1980s and early 1990s was primed in this way. Over 10% of young men became infected before strong national and local prevention efforts, including the ‘100% condom programme’, reduced high-risk behaviour, encouraged safer sex and lowered HIV prevalence. Few countries are acting vigorously enough to protect sex workers and clients from the HIV virus. Yet, it is from the comparatively small pool of sex workers first infected by their clients that HIV steadily enters the larger pool of still-uninfected clients who eventually transmit the virus to their wives and partners. Although recent behaviour surveillance surveys show that in 11 out of 15 Asian countries and Indian states, over two-thirds of sex workers report using a condom with their last client, the need to boost condom use remains. In Bangladesh, Indonesia, Nepal and the Philippines, for instance, fewer than half of sex workers report using condoms with every client.

The best way to prevent transmission by sexual means is to follow certain principles in life. These are – never have sex before marriage and be faithful to the spouse after marriage. These should be stressed especially in early adolescence ie. before starting any sexual activity. It is seen that sexual activity before marriage is more common and begins more early in boys. ie, between the ages of 10 and 15. If one cannot follow these things, advise about safer sex, as proper and consistent use of condoms. Also try to avoid contact with promiscuous individuals, commercial sex workers and unknown persons. Semen during artificial insemination can also transmit infection.

Blood and blood product transfusions and organ transplants, if infected, can transmit the disease by direct entry of organism into the body. The chance of transmission by transfusion of one bottle of infected blood is nearly 90 100%. The chance of transmission by an unprotected sexual contact from an infected individual is 1in 1000. But more than 80 % of HIV cases are sexually transmitted. Blood transfusions leading to transmission are becoming rare because of proper screening of blood before transfusions. Also blood from high risk individuals should be avoided. Intravenous injections using infected syringes and needles also can transmit the infection. Government has put forward various directions to prevent these modes of transmission. By using properly sterilized glass syringes and needles, cleaned and sterilized in boiling water for 30 minutes or by using reliably new disposable syringes and needles this can be averted. HIV virus can be killed by one minute boiling, but Hepatitis organism is killed only by 10 minutes and various spores can be killed only by 20 –30 minutes boiling. The disease can also be spread through the skin or mucosa of an individual coming in contact with infected material from another individual as blood, semen, vaginal secretions, other body fluids as urine, feces etc contaminated with blood. Even though the organism won’t enter through intact skin or mucosa, care should be taken to handle these materials because minute injuries in the skin or mucosa are usually not visible to naked eye. Usually tears are noninfectious, but in the case of saliva it is controversial. So proper care should be taken, as using gloves, in handling open wounds in any situation. Also it is advisable, as far as possible, not to come in direct skin contact with any body secretions or excretions of another individual.

Using of improperly sterilised needles and syringes or sharing of these equipments among intravenous drug abusers is another important cause of transmission. Sharing injecting equipments is a very efficient way of spreading HIV, making prevention programmes among injecting drug user populations another top priority. Upwards of 50% of injecting drug users have acquired the virus in Manipur in India, Myanmar, Nepal, Thailand and China’s Yunnan Province. Extensive harm reduction programmes can and do work. By the late 1980s, Australia had prevented a major epidemic from occurring among injecting drug users and, quite likely, from spreading beyond them. Such examples are being followed by several other countries but in an isolated fashion. The SHAKTI Project in Dhaka, Bangladesh, offers injecting drug users needle exchange, safer injecting options and safer sex education, as well as condoms.

Transmission of the infection from mother to the child can occur in utero, more commonly during vaginal delivery due to trauma in vagina and coming in contact with cervical and vaginal secretions, and after delivery. The chance of materno fetal transmission is 20 –30 % for each pregnancy. Breast feeding by an infected mother can transmit the disease to a baby through breast milk, if it is already not infected. So in developed countries they advise an infected mother not to breast feed and to give completely artificial feeding. But in developing countries like India where artificial feeding is not feasible always, and improper feeds can lead to malnutrition and progression of AIDS more rapidly in the child, this is debatable. Another point to remember is that a pregnant lady if HIV positive has to take drugs which decrease transmission of the virus to the fetus, under supervision. Most often such a child will invariably become an orphan within a few years because the father and mother might be infected in such cases.

To our knowledge till now, HIV is not transmitted by casual body contact as shaking hands or by insect bites or mosquito bites.

High Risk Groups :

The following are the high risk individuals in society who should be monitored.

1. Patients with other sexually transmitted disease as syphilis, herpes genitalis, gonorrhoea which can produce
genital ulcers /or urethral symptoms
2. Individuals in the high risk category - Intravenous drug abusers, homosexual and bisexual males, those undergoing
regular blood transfusions, regular sexual partners of such high risk individuals, sexual partners of a known HIV
patient, commercial sex workers and their sexual partners, heterosexual persons with multiple sexual partners or unprotected intercourse.
3. Persons who consider themselves at risk
4. Health care workers who perform invasive procedures
5. Donors of blood, semen and organ. 6. History of transfusion after 1985 of unscreened blood or blood products. It is advisable to screen these individuals.

How to detect HIV infection ?

1. Enzyme Linked Immuno Sorbent Assays - the commonly called ELISA test – are widely used to screen the presence of HIV infection. In this the test detects presence of antibodies in the blood of a patient harbouring HIV. This is important because clinically the patient may not have any symptoms/signs to diagnose HIV and so the infection goes unnoticed . But such an individual can spread the infection in certain particular risk behaviors as discussed above .But in the initial 3-4 weeks of infection it may not produce a positive result because for development of HIV specific antibodies, it takes about 3-4 weeks after acute infection. Also conditions other than HIV infections can lead to a false positive result. So any individual who is undergoing an ELISA check up for HIV is advised to have a pretest and post test counselling by a trained counsellor. In the pretest counselling patients should be made aware of the ‘ window period ‘ for the HIV test - that a period of 12 weeks since the last possible exposure to HIV should have elapsed by the time of the test or otherwise it may be a false negative one.

2. Western Blot tests : This is used to confirm an ELISA reactive serum as a true positive or not. It detects antibodies and the specific HIV proteins against which it is directed. It also may not be positive in the initial 3 to 4 weeks of infection.

3. Other tests which can be done include: antigen detection ( p24 assays), CD4 counts to assay the level of immunosuppression to decide on treatment and Polymerase Chain Reaction (PCR ) for measuring the amount of viral particles and rarely viral culture.

Manifestations :

Most often an individual harbouring the virus doesn’t have any initial manifestations and go on transmitting the disease under the high risk behavior states previously discussed, if proper protective measures are not taken. Only years after acquiring the infection, a majority will show symptoms and will be diagnosed. After a prolonged period of asymptomatic stage the patient develops various infections and malignancies and finally AIDS. The important symptoms include loss of 10 % body weight, chronic diarrhea of one month duration, some types of tuberculosis, a ‘thrush ‘like fungal infection in the oral cavity and oesophagus, certain neurologic manifestations and some peculiar types of skin diseases.

Burden of the Problem :

Global burden : Twenty years after the first clinical evidence of acquired immuno deficiency syndrome was reported, AIDS has become the most devastating disease mankind has ever faced. Since the epidemic began, more than 60 million people have been infected with the virus. HIV/AIDS is now the leading cause of death in sub-Saharan Africa. Worldwide, it is the fourth-biggest killer. The diversity of HIV’s spread worldwide is striking. But in many regions of the world, the HIV/AIDS epidemic is still in its early stages. While 16 subSaharan African countries reported overall adult HIV prevalence of more than 10% by the end of 1999, there remained 119 countries of the world where adult HIV prevalence was less than 1%.UNAIDS latest statistics shows that globally 40 million adults and children were living with HIV / AIDS at the end of 2001. Of infected adults, 48 % were women. In 2001, the global adult HIV prevalence rate was 1.2 %. During2001, 5 million people were newly infected. There were 3 million adult and child deaths due to HIV /AIDs in 2001. Since the beginning of the epidemic, there have been 25 million AIDS deaths.

The Sub- Saharan Africa has the maximum number of HIV positives 28.1 million with a percentage prevalence of 8.8 in adults. In this area 55% of infected adults are women. HIV prevalence rates have risen to alarming levels in parts of southern Africa, where the most recent antenatal clinic data reveal levels of more than 30% in several areas. In Swaziland, HIV prevalence among pregnant women attending antenatal clinics in 2000 ranged from 32.2% in urban areas to 34.5% in rural areas; in Botswana, the corresponding figures were 43.9% and 35.5%. In South Africa’s KwaZulu-Natal Province, the figure stood at 36.2% in 2000. This notwithstanding, in some of the most heavily affected countries there is growing evidence that prevention efforts are bearing fruit. One new study in Zambia shows urban men and women reporting less sexual activity, fewer multiple partners and more consistent use of condoms. This is in line with earlier indications that HIV prevalence is declining among urban residents in Zambia, especially among young women aged 15– 24. Progress is also being made on the treatment and care front. In the southern African region, relatively prosperous Botswana has become the first country to begin providing antiretroviral drugs through its public health system, thanks to a bigger health budget and drug price reductions negotiated with pharmaceutical companies.

In Australia, Canada, the United States of America and countries of Western Europe, a pronounced rise in unsafe sex is triggering higher rates of sexually transmitted infections and, in some cases, higher levels of HIV incidence among men who have sex with men. The prospect of rebounding HIV/AIDS epidemics looms as a result of widespread public complacency and stalled, sometimes inappropriate, prevention efforts that do not reflect changes in the epidemic. In Japan, meanwhile, HIV infections are also on the rise.

The rise in new HIV infections among men who have sex with men is striking. In Vancouver, Canada, HIV incidence among young men who have sex with men rose from an average of 0.6% in 1995– 1999 to 3.7% in 2000. In London, reported HIV infections among gay men are also on the rise. Rising incidence of other sexually transmitted infections among men who have sex with men in places like London confirms that more widespread risk-taking is eclipsing the safer-sex ethic promoted so effectively for much of the 1980s and 1990s. Similar trends are being detected among the heterosexual populations of some countries, especially among young people. Diagnoses of gonorrhoea and syphilis among men and women have hit their highest levels for 13 years in England and Wales, for instance. But in high income countries since 1996 the life saving anteretroviral drugs which are costly are in use.Deaths attributed to HIV in the USA, for instance, fell by a remarkable 42% in 1996– 97, since when the decline has levelled off.

However, this wide access to antiretroviral therapy has encouraged misperceptions that there is now a cure for AIDS and that unprotected sex poses a less daunting risk. High-risk behaviour is increasing, as a result. In high- income countries there is evidence that HIV is moving into poorer and more deprived communities, with women at particular risk of infection. Young adults belonging to ethnic minorities,including men who have sex with men, face considerably greater risks of infection than they did five years ago in the USA. African-Americans, for instance, make up only 12% of the population of the USA, but constituted 47% of AIDS cases reported in 2000. As elsewhere in the world, young disadvantaged women, especially African-American and Hispanic women, in the USA are being infected with HIV at higher rates and at younger ages than their male counterparts. In USA, sex among males is still the main mode of transmission accounting for some 53% of new HIV infections in 2000. But almost one-third of new HIV-positive diagnoses were among women in 2000. In this latter group, an overlap of injecting drug use and heterosexual intercourse appears to be driving the epidemic. Indeed, injecting drug use has become a more prominent route of HIV infection in the USA, where an estimated 30% of new reported AIDS cases are related to this mode of transmission. In Canada, women now represent 24% of new HIV infections, compared to 8.5% in 1995.

The HIV epidemic in western and central Europe is the result of a multitude of epidemics that differ in terms of their timing, their scale and the population they affect. Portugal faces a serious epidemic among injecting drug users. Of the 3733 new HIV infections reported there in 2000, more than half were caused by injecting drugs and just under a third occurred via heterosexual intercourse. Reports of new HIV infections also indicate that sex between men is an important transmission route in several countries, including Germany, Greece and the United Kingdom. Unfortunately, HIV reporting data are uneven in several of the more affected countries, including some of those believed to be most affected by the epidemic among injecting drug users. In Japan, Germany and United Kingdom, the number of HIV infections detected in men who have sex with men has risen sharply in recent years, with male-male sex now accounting for more than twice as many infections in men as heterosexual sex. This is a major departure from past patterns: until two years ago, the number of new infections reported in both groups was roughly equal. Eastern Europe— especially the Russian Federation— continues to experience the fastest-growing epidemic in the world, with the number of new HIV infections rising steeply with increase in other sexually transmitted diseases and increased rate of IV drug abuse.

Developing Countries :

More than 95 % HIV infections are now in the developing countries. In many parts of the developing world, the majority of new infections occur in young adults, with young women especially vulnerable. About one-third of those currently living with HIV/AIDS are aged 15– 24. Most of them do not know they carry the virus. Many millions more know nothing or too little about HIV to protect themselves against it. In Asia and the Pacific, an estimated 7.1 million people are now living with HIV/AIDS. The epidemic claimed the lives of 435,000 people in this region in 2001. The apparently low national prevalence rates in many countries in this region are dangerously deceptive. They hide localized epidemics in different areas, including some of the world’s most populous countries. There is a serious threat of major, generalized epidemics. But, Cambodia and Thailand have shown that prompt, large-scale prevention programmes can hold the epidemic at bay. In Cambodia, concerted efforts, driven by strong political leadership and public commitment, lowered HIV prevalence among pregnant women to 2.3% at the end of 2000— down by almost a third from 1997.

In Asia & India :

The heavily populated countries in the world such as India, China and Indonesia registered a marked increase in HIV cases, eventhough HIV/AIDS had a late arrival to Asia. Until the late 1980s, no country in the region had experienced a major epidemic. This situation is now rapidly changing. In 2001, 1.07 million adults and children were newly infected with HIV in Asia and the Pacific. At the end of 2000, the national adult HIV prevalence rate in India was under 1%, yet this meant that an estimated 3.86 million Indians were living with HIV/AIDS— more than in any other country besides South Africa. Indeed, median HIV prevalence among women attending antenatal clinics was higher than 2% in Andhra Pradesh and exceeded 1% in five other states– Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu– and in several major cities including Bangalore, Chennai, Hyderabad and Mumbai. India’s epidemic is also strikingly diverse, both among and within states.

In India with more than 1 billion population, national prevalence loses its meaning. In India it is in the rising or trajectory stage with many case hidden under the iceberg with the estimated ones forming only a part of the cases.India has several HIV epidemics with different patterns and prevalence. The epidemics vary significantly from state to state. Heterosexual transmission is more in Maharashtra and Tamil Nadu, whereas those associated with injecting drug use is most common in Manipur. In general, there is a comparatively high HIV prevalence in western and southern India and low in the eastern and northern parts.This heterogeneity together with big differences in social structures and the enormous size and population of India, make it difficult to monitor the various epidemics and institute effective interventions. This has probably contributed to the rapid and continuing spread of HIV in India despite the ten year grace period India experienced from the start of the epidemic in western countries and in Africa in the early 80’s until the prevalence rose abruptly in India.The Indian states of Maharashtra, Andhra Pradesh and Tamil Nadu,each with at least 55 million inhabitants, have registered HIV prevalence rates of over 2% among pregnant women in one or two sentinel sites and over 10% among sexually transmitted infection patients— rates far higher than the national average of less than 1%. In the absence of vigorous prevention efforts, there is considerable scope for further HIV spread. Even HIV prevalence rates as low as 1% or 2% across Asia and the Pacific,which is home to about 60% of the world’s population, would cause the number of people living with HIV/AIDS to soar.


In India due to the diversity in social and cultural factors the state of HIV also differs. States as Arunachal Pradesh has reported almost no HIV infection, and in general other states have reached an adult HIV prevalence rates of 2% or more. In most of our states and in Kerala often it is seen that the infection in females including pregnant women is from husbands who had been infected in turn by sex workers, and these are more in those who travel much for job purposes. NACO estimates that in Kerala 70,000 to 1 lakh people are living with HIV. Patients having an STD has 10 % more risk. In Maharashtra, Karnataka, Andhra Pradesh, Tamil Nadu & Manipur the antenatal rate is greater than 1 %. In Kerala , in antenatals the rate is less than 0.2%, but in STD cases it is greater than 5%. In Kerala most of the cases are from outside, because at least in 40 % of families in kerala atleast one member is living outside. The other peculiarities seen is that most often ladies get infection from their husbands and the male female ratio is 3:1. In other parts of India it is more seen in urban places but in Kerala it is prevalent equally in urban and rural areas.

In India 50 % of the cases are seen in those less than 25 yrs of age but in Kerala infection in those aged less than 25 yrs is less. More than 70% of HIV infections world wide are estimated to result from sex between men and women. Nearly 80% of cases in India and 95% of cases in Kerala are reported to be caused by heterosexual transmission. According to sentinel surveillance Kerala comes in group 3 in which HIV infection in any of the high risk groups is still less than5% and less than 1% in antenatal women. Now HIV infection is percolating from very high risk to low risk groups.In the Indian context due to varied cultural characteristics, traditions and values with special reference to sex related risk behaviour, infection shifts from high risk population to general population over a period of time.

HIV and Women :

HIV affects both women and men. AIDS was first reported in women in1981. World wide, more men are living with AIDS, but women are contracting HIVat a faster rate. Women are biologically more vulnerable to transmission. Of the total 40 million affected in the world,48 % are now women. Women are more susceptible to HIV because of the behaviour of men especially in sexual life . On the average, men have more sex partners than women either male or female and so more oppurtunity to contract and transmit the disasese. Also men have more influence over whether or not to have safer sex. Gender inequalities are important. In most societies women have less access to health care, education and employment. Their unequal situation is reinforced in many societies by the double standards of sexual morality . When women are subjected to violence or sexual abuse, it is conveniently said that women ‘get what they deserve.’ In certain societies the double stand is that women are expected to preserve their virginity until marriage, but young men, on the other hand , are encouraged to gain sexual experience and indeed having many sexual relationships may make a man popular in the eyes of his peers. In some societies having sex with a young girl is believed to increase virility and is seen as a risk minimization strategy by older men or is thought to cure HIV . Yet older, sexually active men are more likely to be HIV infected. While trying to decrease their risk of ‘ becoming HIV infected, they are in fact putting young girls at risk of HIV, other sexually transmitted diseases and unwanted pregancies. Many women who test positive for HIV face the twin prospects of coping with their diagnosis and finding a way of informing their husbands or male partner. In such situations men and their family members may accuse the woman of bringing HIV into the house hold – even though it is much more likely that the man is responsible. In extreme cases, women with HIV may be ejected from their home by their husbands or by the husband’s family after his death. Now the male female ratio is nearly becoming equal with a rapid increase in female cases. An estimated 13.2 million children have been orphaned due to AIDS till now.

Gender Issues in HIV /AIDS :

1. Male violence against women – In most societies there is a double standard of sexual morality, which ensures that women can be viewed as creatures that lead men ‘astray ’. Sometimes, dressing and appearing attractive suffices to earn a woman the label of ‘sexual promiscuousness’. When women are subjected to violence or sexual abuse , it is conveniently said that women ‘ get what they deserve ’.

2. Women’s economic dependency on men – In many societies women have less access to health care, education and employment. Women are also likely to have less formal education, less knowledge of HIV, language barriers and financial issues. In most societies they are dependent on males economically and socially, in their health seeking behaviour.

3. Ideologies of motherhood. In most parts of India especially North India and other developing countries, early pregnancy and delivery are very common, at an age in which the girl is not mentally and physically prepared for motherhood

4. Traditional norms which make it difficult for women to seek treatment and information about sex –In many societies, cultural barriers can inhibit public discussions of sexuality and therefore prevent a better understanding of women’s needs.

5. Forces which dictate that good women should be ignorant about sex: In many societies the belief is that women shouldn’t take any decision on sexual activities, and most often the males dominate in taking decisions.

6. The culture of silence that surrounds sex – In many societies , women are at incrased risk of HIV because lower social or economic status renders them dependent on their husband or male partner or places them in a diminished position to request that a husband or male partner be faithful or use condom, to prevent HIV transmission.

The above forces render women susceptible to HIV /AIDS.Eventhough it was seen early that women appear to progress to AIDS and die faster than men, it is not true. However their deaths are due to unequal access to care and treatment. Cumulative evidence indicates that women are about four times as susceptible to HIV infection as heterosexual men, based on biological / anatomical factors.

The leading cause of death in NewYork city for women aged 25-44 is HIV. The stigma surrounding HIV is very tragic. Even now people appear afraid to reveal their sero status . For women the effect of AIDS stigma is usually very severe that relatives usually force women to leave their marital home after the death of a husband with a history of AIDS. One important effect of HIV/AIDS in the demographics is that, it produces a “population chimney”, with young people including women dying or becoming infertile, and so less babies, and one third of infants born to HIV positive mothers will succumb to infection. Infection is usually acquired by children of the age group 10 to 15 years who develop AIDS within 10 years. So the population of women above 20 and men above 30 decrease radically and the total population gradually decrease. HIV is highly stigmatized in India. In many countries the association between HIV and “promiscuous “ sexual behaviour has created a belief that people who are infected with HIV somehow “deserve” their fate. Paradoxically, a recent study of attitudes shows that women – who are often monogamous wives infected by their husband – are especially stigmatised. They are frequently blamed by their infected spouse, even in cases when they themselves are not infected. If a man dies of AIDS, his wife risks being thrown out of home by their in-laws.

Preventive Measures:

From the previous discussions it is clear that the only way of keeping away from HIV / AIDS is to prevent it by avoiding certain risk behaviors. Sex education delays first sex and decrease risk taking behaviour in both men and women. So young people both men and women should be given proper sex education as early as possible. It is most effective when given before the young begin their sexual lives. Well planned sex education can help reduce the risk of contracting sexually transmitted diseses, including HIV and unwanted pregnancy.So motivate men and women to talk openly about sex, sexuality , drug use and HIV/AIDS. Parents should talk to their children. Pressured to have sex , most are poorly informed about sexuality and reproduction. Parents need to talk more with their children abut sex, sexuality and gender roles. Boys need to be taught that responsible sexual behaviour is a positive aspect of masculinity and both boys and girls should be offered the chance to acquire the life-skills needed to refuse sex or negotiate safer sex. AIDS prevention and care programmes are widespread but often promote broad messages that are not rooted within the context of of men’s and women’s life. While abstinence and mutual fidelity are effective ways of preventing HIV infection , not every one can, or wants to adopt these options. Even the consistent use of condoms is difficult for many men and women. So messages must reflect the realities in men’s and women’s lives. To be successful, prevention programmes must respond to realities in life. Women and men should be addressed separately and messages should be delivered to the young, the old, the rich, the poor, the urban and the rural. In some societies young women exchange sex for urgent needs for money or gifts offered to them in exchange for sex for clothing, to attend school or for food. Young girls need to be taught skills to help them reject sexual advances from men or at least to negotiate the use of condoms.

United Nations General Assembly Special Session on HIV/AIDS in June 2001 set in place a framework for national and international accountability in the struggle against the epidemic. Each government pledged to pursue a series of many benchmark targets relating to prevention, care, support and treatment, impact alleviation, and children orphaned and made vulnerable by HIV/AIDS, as part of a comprehensive AIDS response. One of the target aimed is to have by 2003,strategies that begin to address the factors that make individuals particularly vulnerable to HIV infection, including under-development, economic insecurity, poverty, lack of empowerment of women, lack of education, social exclusion, illiteracy, discrimination, lack of information and/ or commodities for self-protection, and all types of sexual exploitation of women, girls and boys. Young people and women are a priority on this front. Twenty years into the epidemic, millions of young people know little, if anything, about HIV/AIDS. According to UNICEF, over 50% of young people (aged 15– 24) in more than a dozen countries have never heard of AIDS or harbour serious misconceptions about how HIV is transmitted. Vigorous prevention efforts are needed to equip young people with the knowledge and services such as HIV/ AIDS information, condom promotion, life-skills training they need to protect themselves against the virus. Given that young people especially women are bearing the brunt of the economic transitions in the region, socio-economic programmes that can reduce the vulnerability of young men and women are also vital.

Special steps are needed to include HIV-related life-skills education in school curricula and to extend peer education to vulnerable young people who are in institutions or out of school and employment and among housewives. Much more comprehensive efforts are needed to address the complex issues related to HIV and injecting drug use among young people. Prevention is the best to avert the future cost of treating and caring the HIV affected ones. A particularly effective intervention is the prevention of mother to child transmission which is the most significant source of HIV infection in children below 10 years. This can be achieved by the primary prevention of HIV infection in parents, the prevention of unwanted pregnancies in HIV infected women and by preventing HIV transmisssion from HIV infected women to their infants. HIV infected women should have access to information, follow up clinical care and support, including family planning services and nutritional support. These can be achieved by educating and giving information and support to develop life skills to each and every girl and woman at an early age in their life that is before sexually active stage.

There is ample evidence that early, large-scale and focused prevention programmes, which include efforts directed at both those with higher-risk behaviour and the broader population, can keep infection rates lower in specific groups and reduce the risk of extensive HIV spread among the wider population. Cambodia’s prevention measures, which began in earnest in 1994– 95, saw highrisk behaviour among men fall and condom use rise consistently in the late 1990s. As a consequence, HIV prevalence among pregnant women declined from 3.2% in 1997 to 2.3% at the end of 2000, suggesting that the country is beginning to bring its epidemic under control.

In developing countries, which cannot afford antiretroviral therapy, the following are the preventive measures :

1. Access to condoms for all groups of high risk individuals.

2. Prophylaxis and treatment of infections including STD s and Tuberculosis.

3. Sex education at school and beyond.

4. Access to voluntary counselling and testing.

5. Counselling and support for pregnant women and efforts to prevent mother to child transmission.

6. Blood saftey and safe injection practices.

Why women centered preventive programmes?

Compared to men, women are likely to have less formal education, less knowledge of HIV, language barriers and financial issues. Women are less likely to have a regular source of health care and are frequently unaware that they have any risk factors. Women account for a higher proportion of marginalised people with HIV, such as homeless. Also women must contend with social barrier of sexism and often dual barriers of sexism and racism.Access to treatment also is less especially to those with lower socio economic status. Women tend to have more depression. Clinical depression in HIV positive women drastically affects quality of life and greatly increases the chance of nonadherence to medications. In many societies women are at increased risk because lower socio-economic status renders them dependent upon a husband or male partner or places them in a diminished position to request that a husband or male partner be faithful or use condom, the most widely available method to prevent HIV transmission during intercourse. Many studies show that a majority of women get the infection from their sole sex partners, usually their husbands. Often women with more than one partner include those who are driven by economic necessity into sex work and they are at risk for acquisition of HIV through multiple, often unprotected, sexual exposures. So there should be an effective female controlled method so that women may protect themselves.

Future :

Ultimately the most important long term goal on HIV education and prevention involves the prevention of infection. The strategies in trial include vaccines and microbicides. Female condoms has been marketed for several years, but it is expensive for most women. Vaginal microbicides are still under research; they are extremely promising. Their advantages include non delectability including lack of smell and taste, safety and efficacy, antimicrobial properties against HIV and other STDs, and as spermicide. This may be a cream, gel, film suppository, vaginal ring or diaphragm. But all these are in the experimental field only.

Around half of the people who acquire HIV become infected before they turn 25 and typically die of the life threatening illness called AIDS before th their 35 birthday. This age factor makes AIDS uniquely threatening to children. The number of AIDS orphans are gradually increasing in the world AIDS orphans means those who have lost their mother before reaching 15. Stigma is there in the provision of health care also. A majority of hospitals are reported either to turn away HIV infected patients or refuse to serve their needs. In a study of discrimination, in the health system, many health workers are of the opinion that treating patients with HIV was a waste of time and money because the patients are destined to die anyway. In this climate of irrational fear and discrimination prevention work is difficult. For prevention to be effective, culturally sensitive issues as extramarital sex and condom use must be tackled head on. Promotion of responsible reproductive health behaviour among the youth is very important. Adolescent ignorance about the sexual behaviour is compounded by the reluctance among parents and teachers to impart relevant information. Mothers expect their adolescent children, particularly daughters to remain uninformed about sex and reproduction. Sex and puberty were considered to be embarressing and dirty subjects not to be discussed with their adolescent children. The education system is also important in sex education. Teachers also usually by and large find the topic embarrassing and try to avoid it. As a result of the reluctance on the part of parents and teachers the main source of such information is from peers and mass media. These always need not give correct information. So education becomes important in imparting knowledge on reproductive health, STDs, HIV /AIDs , moralities and principles to be adopted in life which helps to prevent transmission of HIV. If not the youth should be given information about the ways of safe sex especially the consistent use of condoms .

The objective of an AIDS control Progamme should be :

1. to bring about change in behavioural practices ( unsafe sex, sharing of needles)

2. to persuade people to take action which will sfeguard them from getting infected

3. to care for the already infected without creating panic.

UNAIDS Statistics 2001

UNAIDS Aids Update 1999

AIDS News.


V. SUJA Associate Professor, Department of Dermatology & Venereology and faculty, Regional Clinical Epidemiology and Resource Training Centre, Medical College, Thiruvananthapuram. Has taken M Phil in Clinical Epidemiology and M.D. in Dermatology & Venereology. Has organized various conferences. Has conducted many research projects and published papers.

Vijaya V

Towards a health agenda for women in sex work



ABSTRACT---The article reviews the experiences and approaches generated by the programmes that determine the health agenda for women in sex work in the context of the prevalent discourses and health policies with reference to the particular programmes in Kerala State. It was the threat of the HIV/AIDS epidemic that forced the Government to look beyond the conventional approaches to women's health based on the mother and child welfare paradigm. The issues thrown up by the HIV/AIDS "throw the canvas open in ways which go far beyond the current paternalistic approach to monitoring the health of pregnant women and infants as passive agents of a family planning oriented development strategy." The only way in which the harms and abuses in sex work, the problems of trafficking and of HIV can be addressed is through the active participation and leadership by sex workers. To support the rights of women in the sex industry is to support the rights of all women.

The focus of this article is on the programmes that determine the health agenda for women in sex work in the context of the prevalent discourses and health policies with reference to the particular programmes in Kerala State. It reviews the experiences and approaches generated.

It was the threat of the HIV/AIDS epidemic that forced the Government to look beyond the conventional approaches to women’s health based on the mother and child welfare paradigm. The issues thrown up by the HIV/AIDS “throw the canvas open in ways which go far beyond the current paternalistic approach to monitoring the health of pregnant women and infants as passive agents of a family planning oriented development strategy. They raise questions about sex and sexuality, socialisation and self worth, gender relations, family structure and female autonomy. They bring women to center stage, not as passive bodies and minds to be steered by a patriarchal social and political structure; rather the prevention and control of HIV hinges crucially on women as active and autonomous agents of their bodies and social relations”. (Ramasubhan, 213)

This then is the context in which women in sex work were catapulted from a position of invisibility and indifference to being the focus of targeted interventions. The interventions were therefore focussed on sexual health and sexual behavior that figured in the national agenda for the first time. It was the perception that women in sex work were the carriers of HIV/AIDS that shaped the policies and programming in sexual health vis-à-vis the women. As the National Commission for Women report states, The women in sex work are traditionally depicted as “reservoirs” of infection, epicenters of epidemics and a public health hazard.”( National Commission Report, 23)

The programmes, it is important to note, draw upon massive funding support and the expertise offered by bilateral and multilateral donor agencies. The policies are based on the identification of High Risk Groups and are followed by targeted interventions. The major component in the sexual health-project that speaks of the programming is Targeted Interventions (TI). The multilateral agencies have identified certain groups as High Risk Groups – these include sex workers, truck drivers and street children. It may be noted that identification of the High Risk Groups has been questioned by activists & organisations as being arbitrary & unscientific – for example the Joint Action Council, Kannur in their web site & through media, public meetings etc.

Notwithstanding the redefinition of ‘prostitution’ as ‘sex work’, the women involved suffer from multiple disadvantages that need to be taken into account while formulating health intervention strategies. They are relegated to the lowest rungs in society and suffer social stigma and exclusion, have a history of sexual abuse, are exposed to unsafe and often violent sex and related risks of RTI/STDs/HIV transmission, repeated unsafe abortions, unhygienic conditions, sexual abuse at the hands of the police, pimps etc. They are often deeply in debt and struggle to raise children singlehandedly. A significant number are also addicted to drugs/alcohol.

In Kerala, a major Governmental and Voluntary organisations (nongovernmental organisations) partnership has emerged (PSH) and has generated a whole range of programmes spanning the state. A state level nodal agency has been constituted for this purpose. The project “manages and facilitates a focussed initiative for prevention and control of HIV/AIDS. The project is implemented by partner organisations comprising non governmental organisations, community organisations, private sector and local government. It aims at ‘AIDS FREE Kerala’ through the prevention and control of HIV/ AIDS and STDs by facilitating better sexual health among the vulnerable population, particularly among the poor. The agency fulfils this mission through Targeted Interventions, Networking, Cross border initiatives and Soft support programmes. A Project Steering Committee headed by the Health Secretary, Government of Kerala and a Core Group Committee headed by the Special Secretary, Health, monitors the overall programmes of HIV/AIDS prevention at the state level. Over 40 projects exist at present, comprising interventions among female sex workers, men who have sex with men, prisoners, migrant population, coastal population, tribal population, street children etc. Many of the interventions address various target groups in different micro sites, as the size of the target group is limited.”

With reference to women in sex work, largely street based sex workers, the projects purport to improve the health seeking behavior of the women, provision of referrals, counseling and organising drop in centres. The targeted interventions mainly involve condom usage and enhancing the sex workers’ bargaining skills in this regard and information on STD/HIV/AIDS through innovative IEC (Information Education Communication) and BCC (Behavior Change Communication) materials. The strategy is to work with the sex workers, a majority of them, street based sex workers, through peer educators. In Kerala, there are no red light areas or brothels

Each project has a major component of enhancing the skills and the negotiating power of the peer educators and the women. Women are trained in the use of condoms with clients even in difficult situations and to work out strategies to protect themselves. It is important to realise that women are much more at risk than transmitting risk. “ What makes women particularly vulnerable in the context of the growing possibility of an HIV epidemic, is the state of their sexual and reproductive health. There is a range of biological and social factors at work here. Since infected semen remains in the vagina for a while penetrative, sexual contact is a critical route for the transmission of the HIV virus. Men therefore can infect women more effectively than vice versa.” (Ramasubhan, 214) The prevalence of STDs facilitates infection with HIV. There is also a clearly established link between prevalence of RTIs and HIV.

Health issues affecting sex workers are quite intimately linked to other and major concerns. The issues centered around health education through peer educators were brought to the fore in a unique sharing experience in the recent past. On the initiative of a PSH project in Kerala at Calicut, a national level Peer Educators’ Meet was organised in October 1998. This forum brought together peer educators for learning through sharing experience. The women from various states had common experiences like discrimination in health care and police brutality.

A woman from Ernakulam district had this to say: “

I have never attended a meeting like this one. I am uneducated. However, in the course of my work, I have met many women, distributed condoms to them as you have taught us to do. We now have something to say to you respected ‘sirs’. So please listen to us. We face a lot of harassment and torture at the hands of the police. This is particularly brutal and severe at the end of the month. The police use our “services” at other times. When it comes to their targets they beat us most inhumanly. Anyway it is clear that our efforts to build a ‘rapport’ with the police has not worked. ..They are really not concerned about us. What they are really concerned about is the threat of the killer diseaseAIDS.. and so they fear us..and therefore you take interest in our “welfare”..You then acknowledge us, make us feel important.

The police have no scruples about extorting money from us, supposedly for the wrongs we do. Have they ever stopped to consider where this money comes from?

You the police represent the hypocrisy of our society. You can control your wives, but not “women like us”, and that is why you fear us, and try to set us right.. ..

No one sanctions such treatment, certainly no law does. We are aware of our basic rights by now, thanks to AIDS and the attention given to us. Well, so if you do not change your ways, we will continue to fight.. Can you from the office safeguard us? You can get funds for your project, but can you protect us from the goondas? Are you really concerned about us? Or is it that as women, we can be subjected to anything? Whatever men do is fine..but we are women and therefore can be harassed; we all know what goes on, but only we are caught. Why?

However there was also a perception of a slow degree of change among authorities because of the project interventions. Another group of peer educators from Kerala shared that “goondas’ harassment has increased since we started this work of peer education. They poke fun at us. At least we have an office. Though many of us are fortunate enough to have a roof over our heads, the situation of those who do not, is really bad. The drop-in centre is useful, at least in the daytime.

The attitude of doctors is also gradually changing. When we show them our project ID card, they are impressed. It has accorded us a status. As such the attitude with regard to the other women is still to change. Recently one street-based sex worker was seriously ill and was taken to the Government Hospital. The hospital functionaries covered their faces and looked totally repelled. We came to know and intervened. It took a lot of convincing for them to examine her… generally with regard to women in prostitution, their life is placed at a very low premium…

Anyway we are convinced about the purpose of our work and we carry on ..”

Women are most concerned about the police problems. The police pick them up not while soliciting, but when they go out to the doctor or to buy provisions or drop their child to school. Women have shared in personal communication how they are arrested and detained illegally and charged cases they never get to know what these were about. They are then subjected to torture, which impedes their physical and mental health. A sex worker who was also a peer educator was assaulted violently and her breast severely injured (a human rights case with photographic evidence was filed but she withdrew later). Sometimes their clothes are taken off, the feet tied together and they are beaten up severely.

The attitude of the health care personnel is also discriminatory. Women speak of needing repeated abortions and D&Cs at times. The nurses and doctors do not even bother to give them local anesthesia in this process. The PSH projects have taken up sensitisation projects for both the police and the health care personnel.

In their “trade” they experience the most intense health risks and physical violence. They suffer from itching of the skin, minor bruises and cuts in the skin because they operate in unhygienic surroundings. They operate on highly risky ground; all instincts sharp for unwelcome customers, for police, pimps etc. from whom they are poised to run away. In the course of such escapes they may sustain injuries which they take in their stride.

Though most have a regular clientele they are often forced by pimps to entertain others. While on the street they are also quite helpless and have no choice to choose clients. The rapes they suffer cannot be reported or action taken.

Women speak about their helplessness in gang rape, in the various perverse acts of sex that they are subjected to. It is debatable how far such individual and groups centered capacity building programmes help in making a dent in the already unbalanced power equations. Again it is highly debatable whether NGOs are competent to undertake capacity building for such women who have highly developed street smartness.

The street based sex workers are more conscious of their health statics and associated risks than any other group of women. I have observed from the field that women have devised their own crude methods of protecting themselves e.g. washing with saline water after intercourse. With the project interventions, there has been much awareness building around the risks involved and the sex workers one spoke to, shared that the clients were definitely more conscious than before about the need to practice safe sex, but they are also not always in a position to insist that the client use condoms.. According to them there has been no change in the violence that they experience from clients, police and pimps.

The bottom line is that the projects have been responsive and sensitive to their practical needs such as drop-in centres, organising referrals etc. A case in point is the strategy used by a project in Calicut district to promote sexual health by arranging legal aid for women detained by police. This is helpful to the women and simultaneously enables the project functionaries to reach out to more sex workers. However the strategic gender interests remain to be addressed as the interventions are unfortunately based on the premise that practice of safe sex revolves entirely around the woman.

What this does is to place the entire onus for safe sexual health behavior on the women in sex work. This gives credence to the view expressed by the sex workers that what masquerades as a “concern “ to improve their “health seeking behavior” may be interpreted as an agenda to protect the rest of the society from infection.

Whatever be the strengths and limitations of the project approaches, there has been an intense debate on this subject .Two major responses have emerged. One led by the feminist groups, staunchly oppose the interventions as reinforcing the oppression of the women and encouraging sex work for the tourist industry and calls for economic rehabilitation instead. They perceive women in sex work as victims in need of rehabilitation. This infuses a moral dimension which obscures the harassment and stigmatisation the women face. Many women street sex workers have internalised the larger value system that perceives them as “fallen women” and suffer from low self esteem as a result and this approach only reinforces this perception. Further, though there is suggestion for economic rehabilitation, there has been no articulation of a well thought-out process of social rehabilitation and skill building. Observations that have emerged through discussions with Paulson Raphal , one of the first activists to raise the issue of the rights of women, street based sex workers in Kerala and based on discussions with women street sex workers. Another approach has gone beyond the project agenda to look at sex work, with a labour rights perspective and attempted to unionise the sex workers for their rights. This perspective argues that sex work should be seen as any other work and that women in sex work like workers in the informal and unorganised sector need to be organised on issues affecting them and fight for better working conditions.

Their vulnerability in health derives from their vulnerability to human rights violations. This is reinforced by the stigma and criminal charges associated with sex work.

The violence that this category of women experiences cannot be isolated from that experienced by women at large. A socio-economic dimension to be appreciated is that these women are mostly from the Scheduled Castes.

Larger systemic issues of patriarchy and human rights have to be addressed in the context of social dynamics at large instead of placing the entire responsibility on specific groups as the makers of their own destiny.

To quote from a report that appeared on the internet of the First International Sex Workers Millenium Mela held at Calcutta in March 2001, “The only way in which the harms and abuses in sex work, the problems of trafficking and of HIV can be addressed is through the active participation and leadership by sex workers. To support the rights of women in the sex industry is to support the rights of all women. Once sex workers are treated with respect and equality, are given rights to housing, health care and safe working conditions, no other woman will be entitled to anything less. The sex workers mela marked an important moment for all progressive movements - the human rights movement, the workers movement and the feminist movement - providing them with an exciting new direction in which to take these struggles. As one T-shirt slogan read, “Roadside women - Show us the way!”

The article is mostly based on experiences in working with street sex workers and informal interactions with them.

Ramasubban, Radhika, “Patriarchy And The Risks Of STD And HIV Transmission To Women”, Dasgupta, Monica., Chen Lincoln C. and T N Krishnan. eds. Women’s Health in India- Risk & Vulnerability. New Delhi: Oxford University
Press. 1998: 213.

Societal Violence on Women and Children in Prostitution – Report of the National Commission 1995-96, Government of India. 23.

Report on Social Development Initiatives in PSH Project , Kerala, 1999-2000, prepared by the State Management Agency, Thiruvananthapuram.

Ramasubban, Radhika, “ Patriarchy and the risks of STD and HIV transmission to women”, Dasgupta, Monica.,
Chen Lincoln C. and T N Krishnan. eds. Women’s Health in India. Risk & Vulnerability. New Delhi: Oxford University Press. 1998: 214.

Newsletter on the Internet entitled ‘A Rally for Rights and Roses’ prepared by Ratna Kapur, Director, Centre for Feminist Legal Research.

V. VIJAYA : Junior Programme Officer with an NGO, Socio-Economic Unit Foundation based in Kerala and supported by the World Bank, Royal Netherlands Embassy, UNICEF, and the Government of India. Has worked as Project Officer,Project co-ordinator, Programme Officer, Investigator and Consultant in many projects. Her M.A in Social Work with specialization in Urban and Rural Community Development was from the Tata Institute of Social Sciences, Mumbai.

Wildburger Eleonore

Diversity in otherness-identity formations in intercultural encounters



ABSTRACT---Awareness of cultural differences mostly exists in the context of tourism, where stereotypical representations of the "Other" are taken for authentic cultural "knowledge". The "Other" is held at bay or expected to stay with her/his own kin. However, the profitable "Other", albeit the tourist or the skilled professional or the prosperous investor, is welcomed and invited to stay if s/he is profitable. Marcial Langton argues that any representation of the "Other" is an imagined construct, that is why identity formations need to be examined- and, if necessary, adapted to changes - in ongoing intersubjective, intercultural dialogues.

Modern lifestyle and contemporary job strategies increasingly imply concepts of globalisation, profit, efficiency, new technologies and more. Cultural awareness hardly exists in this scenario any more. Awareness of cultural differences mostly exists in the context of tourism, or to be more precise, in the context of mass tourism, where stereotypical representations of the “Other” are taken for authentic cultural “knowledge”. I am speaking out of my own experiences. I am living in the very centre of a rapidly and fundamentally changing Europe, in an area where three cultures meet and where mass tourism contributes a considerable share to my home country´s revenue. I argue that tourism also relates to a multi-layered phenomenon: the interrelationship with the “Other”, or rather, with stereotypical representations of the “Other”. Generally speaking, I argue that stereotypical representations of the “Other” keep forming the mindset of political leaders and people in various speaking positions, and recent history shows that this tendency is still going strong. The “Other” is held at bay or expected to stay with her/his own kin. Yet there is an exception to the rule: the profitable “Other”, albeit the tourist or the skilled professional or the prosperous investor, is welcome and invited to stay under certain conditions. This suggests a controversial strategy: acknowledgement of the “Other”, if s/he is profitable, denial of the “Other”, if s/he is not. This is relevant for both the “Other” from another country and/or from another cultural background. I argue that encounters with the “Other” are processes of identification or exclusion that happen according to fundamentally similar patterns of behaviour. This phenomenon accounts for the fact that culture studies and, by the same token, intercultural research fulfil an important task, or to say it with the words of the American film expert E. Ann Kaplan:

...we must address other cultures, since we increasingly live in a
world where we will rely on one another, where not to know will
be dangerous. We need to contribute to the decentering of
Western culture, and it helps for us to focus on other cultures.
Our own paradigms are further opened up, changed in beneficial
ways, through the challenges that other cultures offer. Yet we
can only enter from where we stand, unless we want simply to
mimic those we aim to know about. not knowledge.
Knowledge can only happen as we enter into a dialogue with the
other culture, as we dare to look at it within frameworks we bring
with us rather than trying to get inside ´their ´frameworks, and
losing ourselves in the process. (Kaplan, 1989: 13)

In accordance with this perspective, I will investigate processes of intercultural encounters in a socio-political context, and I will draw attention to unbalanced power strategies and their relevance for ethnic minorities in this respect.

Intercultural encounters are indeed encounters with the “Other”, where identification processes draw borderlines between the “Other” and the “self”. Deirde Jordan (1988) defines identity as a social process in which individuals construct their identity within their particular world of meaning, and they can only build up a stable identity according to their ability to apply their “model” world to an objective, symbolic universe. On the one hand, difference can be marked by marginalizing or excluding the “Other”, on the other hand, it can be construed as source of enriching plurality (Woodward, 1997: 35). This is also relevant for identity formations in the socio-political field. Thus a main issue in current identity politics, understood as “politics of recognition”, is the question of identity formations of minorities. As identity politics is based on collective representations of identity and their recognition or resistance, serious political problems arise with unbridgeable, dogmatic differences between groups claiming particular identities.

Consequently the question arises, how identification processes develop. The answer to this question will have to analyse how established identity positions are constantly challenged to allow for shifting identity formations, whereas, by the same token, fixed identity paradigms need to be taken into account. Any process of negotiation (on identity positions) necessarily requires ildburger leonore W Identity Formations in Intercultural Encounters some negotiable ´essences´ to draw upon.

This means that identity discourse takes place where essentialist concepts compete with concepts of flexibility and transformation, which has turned out to be one of the core problems of intercultural research processes. On one hand, identity can relate to historical, socio-political or other factors, on the other hand, it can be defined as temporary position that undergoes constant changes and adaptation. In the first case, the problem lies in the “politically correct” identification paradigms, or to say it in other words, in the above mentioned, (un)bridgeable, dogmatic differences between particular identities. The other case raises the question how change and transformation may be defined as such.

The recognition of socio-political identity constructions varies between the view that national identities are purely political inventions and the belief that such identities ´grow out of the existing, living memories and beliefs of the people´ (Stokes, 1997: 10). If history is conceived as a construction rather than an invention, identities are founded ´upon different measures of authentic inheritance ... judicious interpretation, and unconscious selection´ (Stokes, 1997: 10).

Lattas (1992) is critical of theories which define identity as socially and culturally produced, because they deny people the ´myths of their own autonomous being´ and disempower them. He agrees with Beckett´s (1988) notion of an imaginary past, but he adds that the past is a necessary fiction where the meaning of present existence is defined through being differentiated and related to a past. It is a question of seeing the past as a necessary imaginary condition for living in the present. (Lattas, 1992: 163)

This means that the imagined, primordial past serves many indigenous people not as ´an essentializing prison controlled by whites´, but rather as an ´uncolonized space...from which to reflect upon the terms of present existence´ (Lattas,1993: 254). Lattas understands the critique of essentialism as a fear of difference and a fear of some essential Otherness, and he calls for an academic practice which is sympathetic to deconstructing dominating political power structures. By the same token, M. Dodson (1994) argues that it is important to resist a fixed, unchangeable essentialism. Dodson says,
But resistance to imposed categories is very different from
forbidding us to represent our cultures and peoples in terms of
our past, or our distinct ways of being and seeing the world. The
recent trend to charge self-representations by Indigenous peoples
with the politically incorrect crime of ´essentialism´ is little more
than a modern extension of the politics of control over knowledge
that has been going on since colonisation... (M. Dodson,
1994: 10)

Contemporary cultural theorists have increasingly focussed on this tension between essentialist and unfixed identity concepts. Stuart Hall conceptualises cultural identity as a matter of ´becoming´ as well as of ´being´ (1990). He admits the existence of the past, but he argues that we reconstruct it and transform it constantly in the identification processes. Consequently, the question arises, if there is any fixed positioning in identity formations. Stuart Hall´s (1990) view of identification processes offers a viable model. He argues that
[c]ultural identities are the points of identification or suture, which
are made, within discourses of history and culture. Not an essence,
but a positioning. Hence, there is always a politics of identity, a
politics of position, which has no absolute guarantee in an
unproblematic, transcendental ´law of origin´. .... [I]dentity does
not proceed, in a straight, unbroken line, from some origin,....
Difference, therefore, persists - in and alongside continuity.
(quoted in Woodward, 1997: 53)

I am well aware that Stuart Hall´s concept has been widely accepted by researchers, yet I argue that it favours established, socio-political power positions of majorities in their flexibility, without providing enough space for points of identification to ethnic minorities. The question of political correctness of identification processes in the context of a cultural “past” has gained global relevance in times of worldwide migration and ethnic minority policies. The concept of multiculturalism as a putative well-balanced system of equal opportunities for those involved seems to be politically correct at first sight. Yet I hold a different view. I argue that multiculturalism is based on unfixed, ever changing, open identity concepts that are supposed to relate to the mainstream identity paradigms, which do not adequately take into account the innate differences of concepts of “the past” as points of identification. I hold the view that minorities are disadvantaged within socio-political, mainstream power strategies, if they are granted equal rights within patterns of shifting identities, without taking into account the essentialist concern of these minorities. I argue that identification processes within multiculturalism happen at the expense of well-balanced diversity, as they favour assimilation to mainstream paradigms.

Consequently, I argue that identification processes need to take the ´risk Identity Formations in Intercultural Encounters of essence´, a phrase associated with Gayatri Spivak, who advocates a strategic essentialism as a method of asserting differences within a strategy of constant change. Going along with Spivak´s point, I understand essence as a kind of content, yet admitting that not all content is essence (Spivak, 1993: 18). Identity formations need a ´minimalizable essence´ in the bonding process, because ´[d]ifference articulates these negotiable essences´ (ibid). As a consequence, this means that participants in anti-colonial encounters need ´to think through the limits of one´s own power´ (Spivak, 1993: 19), thereby realising that ´knowledge is never adequate to its object´ (Spivak,1993: 8), but always open to negotiation. But in order to enter a process of negotiation, one needs to know some negotiable ´essences´ to draw upon. There is little doubt that identity formations remain ambiguous, as the ability to perform change necessarily requires a coherent entity to reflect upon: a phenomenon which Ian Anderson calls ´one of the fundamental paradoxes of human being´ (Anderson, 1995: 39).

It has become obvious so far that knowledge of the “Other” is generated in political acts. Unbalanced political power strategies are the ground where stereotypical representations of the “Other” justify political mainstream decisions that enforce further constructions of these imagined, stereotypical “Other” identities. I argue that there is a close interrelation between political power, epistemological processes and representations of the “Other”. By the same token, Andrew Lattas argues that constructions of the (post)colonial “Other” must be seen within colonial power relations, where lack is deliberately created as a function of the market economy of the dominating class. He concludes,
The secret truth is delivered to us through a hermeneutic process,
controlled by certain privileged groups of intellectuals who
appropriate the construction of our identities in the process of
asking us to confess the secrets they read into our existence. It is
time for us to stop treating the artist, the writer, the historian, the
priest and the explorer as outside of the power structures of our
society. .. It is time to recognize that these figures ... are authorising
certain images of ourselves. (Lattas, 1997: 255)

To say it in different words, language creates “truth” which justifies imagined models of this very “truth”. Concluding, I hold the view that representations of culturally determined identity patterns are of socio-political relevance. That´s why cutural theorists are called upon to generate knowledge in interculturally adequate, epistemological processes. The Australian Indigenous anthropologist Marcia Langton (1993) has established such an interculturally adequate epistemological model. She argues that any representation of the “Other” is an imagined construct, that´s why identity formations need to be examined - and, if necessary, adapted to changes – in ongoing intersubjective, intercultural dialogues. In these dialogues all participants need to act as subjects, not as subjects and object. The participants need to be constantly aware of their speaking positions and they need to focus on the interrelations between epistemological processes and shifting patterns in identity formations. These dialogues constitute encounters where identity concepts that relate to paradigms like “race” will not be mystified any more. Unbalanced power positions within the dialogue will be transformed, if each participant, being aware of his own identification paradigms, is ready to question her/his concepts in intersubjective processes. Thus the ground is prepared for establishing, within balanced power zones, a variety of different speaking positions that generate knowledge of identity formations which is constantly examined, adapted and updated. Thus intercultural borderlines become transparent and reveal stereotypes as imagined constructions. As a consequence, the “Other” is recognised as an equal member of a transparent diversity that dissolves prejudiced stereotypes per se. Or to say it in different words, finally the “Other” will not be the “Other” any more.

ELEANORE WILDBURGER Part-time lecturer at the University of Klagenfurt, Austria. Earlier this year she finished her Ph D thesis on ‘Indigenous Identity Formations in Black Australian Poetry’. She is currently preparing a post-doctoral project in Cultural/Aboriginal Studies