This is an account as much about the lives and times of the people of India as it is about the practice of and awareness about social medicine… The clinic Dr Rani Bang runs with Dr Abhay Bang, her husband, is a fount of ideas and wisdom, research and practice, in health and medicine. The work done at the Society for Education, Action and Research in Community Health (SEARCH) by the Bangs and their team has critically questioned, challenged, and fundametally altered many key ways in which health policy and planning in India examines its most pressing issues.
This book… is a commentary of the chronic myopia of policy-makers who all too often fail to see the state of many millions of Indians and the ways in which it could be improved. It is an essay on contemporary sociology, concerning a tribal society that is being buffeted by modernity and whose traditional kinship and ecological systems are being sorely stressed. It is a logbook of case medicine, for Rani Bang has skillfully woven into her book the major ailments and complaints in evidence among the people of rural India, and the minutely recorded data on every case registered at her clinic, explaining the malady and its cure in a manner that always educates and never overwhelms.
A thread of humility runs through the narrative from the very outset. A sense of bristling outrage at some of the more upsetting incidents in her life as a doctor in Gadchiroli becomes apparent only rarely. She is angry about sex determination tests, selective abortion and dowry. She is caustic about the commercial sex industry and more so about men destroying their families. She is astonished time and again to find that while education has given literacy of a sort to its beneficiaries, the so-called literates often lack comprehension and understanding… That understanding must perforce, and now especially with the agents of globalization so active in our country, include the mechanics of policy-making too. As Chapter 3 on health services emphasizes, gynaecological problems and issues related to pregnancy and childbirth constitute 92% of women's unmet needs in rural India. SEARCH's studies in Gadchiroli show that barely 8% of women seek help for these problems, an alarmingly low fraction that can be remedied through access to primary health centres that offer safe maternal, gynaecological and abortion services… and reproductive health education for couples and adolescents, issues that are simply not being addressed.
“The health system must make an effort to know what influences the health-seeking behaviour of rural Indian women. This means understanding the cultural perceptions of what are normal and abnormal in a patient's mind, where and why they go for treatment.”
The differential that SEARCH grapples with routinely are daunting. The very premise of girls' education, especially of poor girls, is based on an understanding that education is critical to social development; that it leads to lower fertility rates and better child-rearing practices, for example. Though the benefits of women's education are compelling, all too often the struggle for the right of girls and women to education gets reduced to issues of access alone. It has been easier for women's and voluntary groups to work with girls outside the system of formal education, especially the government system of education that is notoriously inflexible.
Within a 50 km circle around the SEARCH campus, one would see… the assembly-line blocks that in rural India purport to be schools. What does it mean to be “schooled” in one of these miserable containers? Conditions in these schools are hardly conducive to meaningful learning. None possesses the very basic set of facilities such as adequare classrooms, toilets and drinking water, teaching–learning materials and libraries. As is the case elsewhere in India, physical inaccessibility, irrelevance of curricula, repeated “failure” and harsh treatment in schools contribute to children dropping out or never enrolling…
It is firm adherence to what is practical, immediate and relevant to the needs of her patients that characterizes Rani's case notes…. In contrast is the state's current engagement with the health needs of our varied populace; a scenario dramatically different from that of the first phase of independent India's health system (roughly 1947–1983) when health policy was assumed to be based on two principles: that none should be denied care for not being able to pay for it; and that the state is responsible for providing health care to its people. Despite the meagre resources, during this period malaria and cholera were effectively contained, smallpox and plague eradicated, maternal mortality was brought down by 50%, infant mortality reduced drastically, and longevity increased. These gains were in no small measure thanks to the professional cadre of public health specialists.
Today, while there is undoubtedly an infusion of capital (mostly private) in the health sector, this is unlikely to give the “disadvantaged” citizens greater access to health care. The disintegration of primary health services continues. Besides, evidently, India is bearing a double burden of communicable as well as non-communicable illnesses, now termed “lifestyle-related”. It is a growing impasse that has been recognized, and the Report of the National Commission on Macroeconomics and Health warns:
“Despite states attempting several innovations, the health system continues to be unaccountable, disconnected to public health goals, inadequately equipped to address people's expectations and fails to provide financial risk protection to those unable to access care for want of ability to pay. Despite huge investments in expanding access, a villager needs to travel over 2 km to reach the first health post for getting a tablet of paracetamol; 6 km for a blood test and nearly 20 km for hospital care.” (Government of India. Ministry of Health and Family Welfare, 2005)
“No doctor reaches them. These newborn dead constitute 75% of the infant mortality rate in India. While current medical guidelines insist on hospitalization to avert neonatal morbidity and mortality, India is in no position to bear the total burden of 13 million babies who need hospitalizing every year.” (Abhay Bang)
This account, however, shines for its embrace of the sweep of community and social, maternal, infant, adolescent and family needs and concerns… It lists first-hand accounts of the effects of child abuse, alcohol abuse and mental health-related problems on the family. It offers penetrating insights into what the rural populace thinks of sex determination, infertility and perceptions about contraception. We learn of the insidiousness of the industry that is unregulated and the ill effects of seeking treatment from unqualified quacks and of the unseen stresses and pressures that families face in society.
At another level the book is a sociological tour de force, containing the myriad exchanges Dr Bang has had with her patients, their spouses, families and friends. This account works both as a reader-friendly medical casebook and a sociological primer: a model for any rural medical practitioner, both incumbent and intending…
Health services… previously determined by a responsible state are now in the hands of an influential private sector… Today most states provide only selective services in rural areas and some curative treatment in urban areas when it comes to health care. On the other hand, the private sector has grown impressively. Such a pattern of growth in the larger context of poverty is plainly unacceptable, notwithstanding the self-congratulatory noises that our central and state governments regularly make about India's newfound economic prowess and strength. This so-called economic growth has marginalized huge sections of our society.
As several of Rani's many case descriptions show, privatization in highly iniquitous societies like ours leaves out the lower-middle and poorer classes, 30–60% of the population, of the ambit of its benefits. Studies of the utilization of services in India show that it is the poor who use public services more than say the middle class. The indirect costs for even publicly provided services are increasing and getting beyond the reach of certain sections of the population. Equity concerns are very important for health policy: since the middle classes are not accessing the public facilities any more, the principles of universality are weakened. Therefore, the concern for public health is impacted by both the excessive growth of for-profit, market-based health care, as well as the state of public provisioning.
These are concerns shared by those who have collaborated to work on this volume. Rupa Chinai, the co-author of this book who documented the cases presented here, is also an accomplished journalist who has written and commented extensively and authoritatively on health issues in the country… Sunanda Khorgde… stewards the women's health programme at SEARCH and trains dais (traditional birth attendants) at the campus. She has also become a part of the SEARCH adolescent sexual health education programme. Her ability to look beyond what is evidence and identify social, economic and community reasons at the root of many of the complaints registered at Dr Bang's clinic have impacted the understanding of social medicine in Gadchiroli, and by extension, rural India.
This is a work whose need has long been felt by our planners and policy-makers and by the public in whose name such planning is done… As a citizen of India, journalist and fellow traveller, I am deeply honoured to be associated with the writing of Putting Women First.
Goa, July 2010
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