Dr Rani Bang, who along with her husband, Dr Abhay Bang, was recently awarded the Padma Shri for her immense contribution to medicine, is known for her stellar work in the rural and tribal belt of the Gadchiroli district of Maharashtra. As co-founders of SEARCH, the doctor couple have changed the face of healthcare in what used to be a backward, Naxal-hit part of the state. In this interview with India Development Review (IDRonline.org), Bang speaks about the state of women’s health…
While working in Gadchiroli three decades ago, what were the health concerns of women then?
When I started working in Gadchiroli, I was the only gynaecologist in the district. I did the first caesarean in the area. I found that very little was known about the issues faced by women here. I did a computerised literature search at the National Library of Medicine and there was not a single community-based study to show the prevalence of gynaecological illness.
All existing studies were clinic and hospital based. I thought it was important to get a deeper understanding of what was happening to the health of women in these communities. So, I decided to do the first-ever research on this.
But before that I wanted to understand what the women themselves felt. I talked to several women from different villages in the district mostly women seen as wise women in the villages. When I asked them about the common health problems among women, they listed many problems. So, I asked them to list these problems in the order of seriousness. To my surprise, all of them put obstructed labour and infertility in the most serious category.
I always believed that only a life-threatening condition could be seen as a serious disease. Thus, while listing obstructed labour as a serious issue was understandable, but I was taken aback to see infertility as a top concern because nobody dies of infertility. So, I asked the reason for putting infertility as a serious disease.
They said that a woman can die of obstructed labour only once, but if she has infertility, she dies every day because everybody blames her. I realised how deep the problem ran. At that instance, it struck me, in Marathi there is a word to describe an infertile woman, but no equivalent for an infertile man.
My study in the region revealed that nearly 92 per cent of the women had gynaecological problems—and these were not just related to pregnancy and childbirth; there were menstrual problems, reproductive tract infections, sexually transmitted diseases (STDs), and so on. Criminal abortions by quacks were rampant, despite India having one of the most progressive laws for medical termination of pregnancy.
A deeper investigation helped me identify the missing links as far as healthcare services for women were concerned. The absence of care for gynaecological problems, reproductive tract infections and STDs; absence of adolescent sex-education; lack of access to safe and low-cost, easily available abortion services; and lack of access to contraception products.
I took the results of the study to global platforms, including the UN, and argued that we should not be limiting our view of women’s health to just maternal and child health (MCH) as was the case then. I said that from the age of menarche up to death, women have so many other problems that need to be considered. Even the ante-natal care, post-natal care and intra-natal care was so poor. I said that we should be concerned with women and child health (WCH) rather than MCH.
How was the study received globally? Did it have an impact on the contemporary discussion on women’s health?
After the study was published by Lancet, it was taken up by many women’s groups around the world. I was invited to conferences and meetings to present the findings.
In 1992, I was invited to the World Health Assembly, which was attended by ministers from various countries and governmental health staff. I was the only non-government worker there. I presented my study and received the appreciation of representatives from all over the world.
I also spoke at the UN assembly in Nairobi, where I said that family planning should be a way to improve the health of women and children, rather than just being linked to population control targets. In 1994, there was a UN meeting in Cairo, where there was a consensus on adopting WCH in place of MCH. Thus, a study conducted in two small villages in a remote district of India changed the level of discussion internationally and that gave me a great sense of satisfaction.
Do you think that the public healthcare system continues to have a fractured view of women’s healthcare needs?
Women’s reproductive health is the most neglected thing in our society. When I started working with the communities, women’s health was equated with only childbirth and family planning. The situation is not very different even today. Gynaecological problems— issues related to antenatal care, pregnancy and childbirth —constitute 92 per cent of the unmet needs of rural Indian women. Our studies show that barely 8 per cent of women seek professional help for these problems.
In the current approach of the government, we see that the birth rate has come down and immunisation coverage has improved. However, the maternal health component of the reproductive and child health (RCH) programme has not succeeded. The programme does not offer the entire gamut of reproductive healthcare services. Moreover, we do not address the key aspect of prevention, which is to improve the health of a woman before she conceives.
What do you see as the more recent and emerging health concerns for women in rural India?
The missing linkages in our healthcare policies, programmes and implementation are still a cause for concern. The lack of affordable and good quality care—secondary and tertiary—undermines our ability to meet emerging health challenges.
For instance, there is an urgent need for awareness and mass screening programmes for early detection of uterine and breast cancers across India. While such services may be available in the urban areas, rural women simply do not have access to these facilities. We need to urgently place these services in rural India through the public health system.
There is also an increase in chronic diseases such as obesity, hypothyroidism, hypertension, diabetes and stroke amongst the rural poor and tribals— both women and men. Alcohol and tobacco consumption is on the rise in rural India, with men, women and even children becoming addicted. While tobacco is responsible for 60 per cent of the cancers, it also exacerbates the problem of low birth weight, a problem that rural areas are already struggling to address. It can also cause stillbirths and miscarriages.
Environmental pollution and the increasing quantities of chemicals in our food chain will also pose new challenges. We need to look at all these trends and find ways to address them.
Has the nature of problems faced by women and youth changed over the years?
Regardless of all the community participation and cooperation received back in the ‘90s, women were still reluctant to get their pelvic examination done as they had many misconceptions about it. So, I had to go to each village and explain why I had to do this examination. Nowadays there is a lot more openness and women are far or less inhibited. While some perceptions have certainly changed, there are still some traditions and beliefs that are hard to challenge.
As far as adolescents are concerned, they have definitely become more open to discussing their problems and asking questions related to their bodies. Today girls want to know about menstruation, while boys are mostly obsessed with masturbation, sex and homosexuality, among others.
A worrying trend, however, is the increase in pre-marital sex. This is worrying not only because of the lack of sex education, but also because of poor awareness of and access to contraception. There is a recent trend of medical abortion using the morning-after emergency contraceptive pill.
Many young girls go to the pharmacy to buy these pills that are available over the counter and consume these without professional medical advice. This has serious repercussions, including incomplete abortion, following which these girls often turn to quacks to undergo criminal abortions.
Because these pills are marketed very well through misleading advertisements that make it all seem so easy, girls do not realise that these pills are to be prescribed by and consumed under the guidance of a doctor. And so many have incomplete abortion and serious medical issues. So, while criminal abortion by quacks has gone down, this kind of unsafe abortion rate is definitely increasing.
Our social outlook towards pre-marital sex and pregnancy has not changed at all. There is still a lot of stigma attached to both. There is also an unwillingness, even in government programmes, to talk about contraception to unmarried girls and boys.
Courtesy: India Development Review (idronline.org)