Make me a takeaway baby

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The booming ‘business’ of renting wombs to produce babies will drive a beautiful alternative like adoption underground which instead we ought to encourage seeing the need of thousands of abandoned and orphaned children that crave for parental care

A recent Internet advertisement posted by a Medical Tourism Corporation made me fume. It brazenly advertised surrogate motherhood options available in India, bellowing that it costs “a fourth of what it would cost in the United States”. It slobbered over the fact that “surrogacy in India has few legal hassles and India’s laws allow the surrogate mother to sign away her rights as soon as the baby is delivered”.

The patronisation of India as a cheap place to get ‘takeaway’ babies sounded abhorrent and ethically questionable. I consulted two protagonists representing differing points of view. The first, Prof Uma Chakravarti, a historian and an academic doyen among women activists; the second Dr RS Sharma, Deputy Director-General in the Reproductive Health and Nutrition Division in ICMR who was actively involved with assembling the 2005 guidelines for Assisted Reproductive Technology clinics and later the draft ART Regulation Bill and Rules, 2008.

Let us hear what Ms Chakravarti had to say. She basically raised four issues: First, we in India staunchly protect our national identity and take umbrage at the first signs of exploitation by the white man. We bristle at a whiff of racism or veiled dominance and are quick to lash out on grounds of sovereignty, independence and freedom. Why then do we allow commercial exploitation of Third World women’s wombs by baby seekers from the first world?

Second the surrogate mother is expected to enter into an agreement which is contractual and legally enforceable. While the law gives her the normal right to terminate the pregnancy and refund all the expenses incurred by the biological parents, this is easier said than done: In the case of illiterate and uneducated women with no economic independence reneging on the contract would be next to impossible.

Third, dangling Rs 100,000 before a poor family would lead to women getting coerced into unwanted pregnancies for money. The plethora of consent forms and protective clauses cannot belie the fact that poor women are already exploited in umpteen ways and thumbing or signing a piece of paper does not constitute the exercise of independent choice. Oversight committees cannot get inside male dominated homes where the woman has no choice but to acquiesce to patriarchal diktats.

Finally, the whole business of surrogacy will drive a beautiful alternative like adoption underground which instead we ought to encourage seeing the need of thousands of abandoned and orphaned children that crave for parental care. Counselling about the goodness of adoption is unlikely to appeal to ART seekers once the road-map is clear before them.

Dr Sharma did not directly allay these doubts but gave convincing justification for regulating the whole business of ART. This is what he explained: Infertility can be placed at 10 to 15 per cent among the reproductive health seekers in hospital settings. Most of them approach infertility clinics that lack technological expertise and infrastructure. The clinics exploit anxious couples by charging exorbitant rates for even inexpensive procedures. In order to regulate and supervise the existing clinics and contain the mushroom growth of substandard infertility clinics ICMR issued the 2005 guidelines.

Several countries in Europe and West Asia had issued ART guidelines. So had Japan and USA done so. ICMR’s guidelines aimed at filling the lacuna that existed in India. Publicised widely they were discussed in six major cities where over 4,000 participants including doctors, scientists, public servants, legal experts and infertile couples voiced their opinions. Both the National Human Rights Commission and the National Commission for Women had reviewed these guidelines before they were notified.

In 2008 a draft Bill was formulated on which public comments have again been sought before taking it to the Law Ministry and Parliament. The Bill sets out a national framework for the regulation and supervision of ART. The process for registration of ART clinics, their standards and duties have been laid out explicitly. A National Advisory Board and similar set ups in each State would exercise the powers of a civil court to extend supervision and oversight over implementation. The system for sourcing and storage of gametes and embryos, the regulation of research, the rights and duties of donors and patients and the determination of the status of the child have been detailed comprehensively. Most couples using the ART clinics would not be foreigners but millions of Indians. The accompanying Rules spell out detailed requirements of infrastructure, staff, counseling, donation and cryopreservation.

Medical specialists that service an unregistered ART facility or contravene the provisions of the Act would be punishable with three years imprisonment. More importantly the offences are all cognisable, non-bailable and non-compoundable. The outcries about the non-bailable provisions have already created enough of a flurry among practitioners-a pointer to the Bill’s potency in preventing medical malpractice, Sharma added.

No doubt the debate will go on .This is not a perfect world but considering everything on balance, much more will be gained than lost by supporting the Bill to make it law.

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Missing the wood

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In a bid to show how high its reach is, the media prods a Minister with loaded questions whenever there is an outbreak of some disease or an epidemic, realising little that it’s not a Minister but a municipal health official who is supposed to have the answers

The National Health Policy was announced in 2002 — 19 years after it was first formulated. While its aspirations and prescriptions make a strong case for reducing regional iniquities and enhancing funding for health, it was only three years later in 2005 that the National Rural Health Mission attempted a gigantic leap forward in rejuvenating the primary health set up with funding and systems that could make paper orders spring to life.

Neither Health Policy, 2002, nor the National Rural Health Mission, however, addresses the specific subjects and situations that occupy the front pages of national dailies and television screens. Organ transplantation rackets, hazards of junk food, the net worth of anti-smoking fiats, seasonal diseases and cyclic outbreaks of dengue, malaria and sundry fevers are what constitutes the bulk of health coverage by the media. The reports are undoubtedly useful as they serve as news as well as warning cum health bulletins alerting people to be prepared and know what to do.

But preoccupation with localised news to the exclusion of the bigger picture is fraught with two dangers — first, the stories demand reactions from top health functionaries, thereby distracting attention from those directly answerable for the mess; second, they overlook the need for reporting about massive health programmes which affect millions of citizens and ultimately the well-being of the country.

In the present scheme of things, the media hardly reports on the success or failure in attaining health and family planning goals which are vital for improving overall health indices and without which sustainable development cannot take place.

Strictly speaking, the role of the Central Government under the Union List of the Constitution is limited to promoting medical research, setting standards for medical education and administering special Central institutions. Drugs, cosmetics, food adulteration, population control, family planning, are on the Concurrent List with shared responsibilities between the Centre and the States.

In contrast, public health and sanitation, hospitals and dispensaries are wholly on the State List of the Constitution but one hardly sees a Health Minister or Director General of Health Services in any State questioned for failure to control epidemics, equip health facilities adequately or get doctors to report for duty in primary health centres.

Likewise, we never see heads of sanitation and conservancy in the Municipal Corporation asked to explain their failure to perform direct obligatory functions. In the zeal to target the top, the mike is usually thrust before Ministers and senior functionaries of the Delhi Government when the prevention and control of malaria, dengue, cholera and gastroenteritis is directly a Municipal responsibility. The Delhi Government has little supervisory authority over the Municipal Corporation, which owes allegiance to the Central Government under a 1957 Act. So, why not ask the people who are directly responsible?

Why are public health doctors and engineers responsible for ensuring that sewage does not get mixed up with drinking water questioned why they remained unaware of the contamination? Did the Jal Board take sufficient samples and have them tested for purity as often as needed? Supervised by whom? Did they file for criminal action against known culprits who tampered with the water pipelines (since that is the usual excuse)? Why not? Was preventive action against mosquito breeding adequate? By what measure? Did the sanitary officers supervise the daily clearance of 2000 dhalaos and dustbins cascading with garbage and filth? Who inspected them and how often? Such questions are never asked from the real actors. Instead, sound-bytes spouting “everything under control” platitudes are what we get from senior functionaries while the real actors remain safe and dry.

It is time the people directly responsible are held accountable as generally happens when a building collapses or electricity fails. It is time that the functions and responsibilities of different echelons of the public health, drinking water, food hygiene and the mosquito control hierarchy are set forth on websites listing people responsible for prevention and control of health hazards, area-wise.

Equally, if extraordinary work has been done, nothing would boost the morale of workers more than giving a real performer a place in the sun while ignoring the vacuous worthies that mouth the “we are doing our best” baloney. Confronting the real culprits on camera or lauding their efforts, will heighten public awareness and the wrath and laurels will be directed where deserved, instead of giving free publicity to higher-ups having little direct responsibility.

On a wider scale, media should provide the lay reader an independent State-wise update on the final destination of thousands of crores of rupees spent on improving the condition of health care. Instead of recounting what World Bank and CAG enquiries reveal many years later, State Health Ministers and their battery of professionals should be made to respond to much larger current issues.

To start with to account for State-wise progress on achieving the specific numerical goals of the Population Policy 2000 and the Health Policy 2002.These questions can only be responded to by those at the very top, particularly in the low performing northern states, but unfortunately they are never asked.

Assault on innocence

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A recent report reveals that 66 per cent of the poorest children in the country receive little or no healthcare. Worse, rural population in the poorest States continue to have more children. Will the Government wake up to the reality?
Statistics, according to many, are damned lies. That is the most comfortable way of dismissing uncomfortable facts. There is, therefore little concern about the recent ‘Save the Children’ report, which tells us that 66 per cent of the poorest children in the country received little or no healthcare. Even our home-grown statistics told us that in 2003 a fifth of the total deaths in the country were of under-five children.

Upbeat as we are about India’s growth, we have no time to check whether things are any better now. Articles about children dying, wasting, stunting and succumbing to disease can be easily dismissed as a failure of Governments and health authorities (which indeed they are).

But what is not understood is how this phenomenon is already reflecting upon development which will ultimately affect every one of us. Poor people continue to have more children to compensate for the ones they lose. In Bihar and Uttar Pradesh, the “wanted” fertility exceed the replacement fertility levels of the National Population Policy. In other words, even if all the facilities in the world are made available, at a certain stage of (under)development, rural people in the poorest States will continue to have more children and this cannot be reduced through conventional approaches.

All States, regardless of age transition, target couples who have two or more children by advocating sterilisation as an end in itself. Hardly any State targets young couples who should not have been married before the legal age of marriage, leave alone be begetting children. The percentage of women and men married before the legal age of marriage in rural areas shows that this is a huge factor.

When the latest National Family Health Survey-III was conducted:

* 12 per cent of women between the age of 15 and 19 were already mothers

* Four per cent of women between the age of 15 and 19 were pregnant with their first child

* In total, 16 per cent women between the age of 15 and 19 had begun childbearing.

Epidemiological evidence as well as common sense tells us that adolescent mothers give birth to underweight children. Low birth weight babies are prone to remain underdeveloped. It is no wonder that 50 per cent of children under five are stunted, 40 per cent are underweight and 23 per cent are wasted. Child mortality is as high as 25 per cent in Uttar Pradesh and Madhya Pradesh.

Behind family planning approaches is the belief that the demand for family planning is high and a substantially proportion of this demand is unmet. What is not understood is that unless there is a certain minimum threshold of social and economic development, families will not adopt the small family norm. State Governments do not think of the implications of the age structure when children are born. The 15 to 19 age group is far from ideal to start procreation, but it is treated as business as usual.

Knowing this entire story, how can sterilisation operations alone make a dent on population stabilisation? By the time sterilisation is undergone, millions of children would have been born and will encounter serious handicaps unable to derive the benefit of a plethora of development schemes. Unless people and particularly parents of girls have an inducement to get them educated, let them acquire skills and become empowered, there will be no incentive to reduce fertility.

Also, if the wanted fertility is not accompanied by commensurate child care (witness the shortfall in immunisation coverage particularly in the northern States), death and disability of children will continue. ‘Save the Children’ resear-chers will have their hands full for the next 20 years.

A resultant phenomenon is the exponential increase in urban population caused by migration. This has already affected mega-cities to breaking point. The slum population of greater Mumbai, Delhi and Kolkata today accounts for more than 55 per cent of the total slum population of the million plus cities in India. This in-migration, although it fills a void in providing urban services, has become a major headache for city infrastructure. Today, the main destination of migration is from Uttar Pradesh into Delhi, Haryana and Maharashtra. Migrants from Bihar largely go to West Bengal followed by Delhi, Haryana and Uttar Pradesh. This leads to polarisation of cultural and political identities and a dangerous growth of regionalism witnessed recently in Mumbai. The net effect of migration will affect population growth in our immediate surroundings. This must be forecast well in advance to deal with the influx before it creates havoc.

Committees, task forces and think tanks will not suffice. It needs an entire Ministry of Population Planning devoted to understanding the implications of population growth and dispersal as a part of overall planning. Unless there is a holistic approach to evaluate the final outcomes of literacy, education, and skill building, supplementary feeding, employment generation to name only a few, departmental silos will continue to judge outcomes by their own standards of achievement. The result will be that the wrong kind of population will get born, will expand and the quality of people’s lives will not improve.

Today, more slums next door are a joy for slum lords and vote-seekers. Tomorrow the children of slum dwellers will rebel against their deprivation and walk into our homes for water and shelter. Numbers will be on their side. The law will have no place.

Too young to be mother

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In India, there is little access to information or counselling about the risks of early pregnancy and contraception. No wonder teenage pregnancies and childbirth complications are among the leading causes of death among young women
Teenage pregnancies and childbirth complications are among the leading causes of death among female between 15 and 19 years of age. The same age group also contributes 19 per cent of the total rural fertility in India. This phenomenon is at its peak in Jharkhand (28 per cent), West Bengal (25 per cent) and Bihar (25 per cent), all in the eastern region. The level of teenage mothering is lowest (less than five per cent) in Himachal Pradesh, Goa and Jammu & Kashmir.

In several States like Bihar, Rajasthan, West Bengal, Jharkhand and Madhya Pradesh, almost half the girls are married before 18, foregoing educational and employment opportunities. A high percentage of teenage mothers begin child bearing immediately after marriage and contribute to higher fertility levels long thereafter. Young mothers being physically immature, often experience obstructed labour, pre-eclampsia (hypertension), eclampsia, leading to death or disability. They are also prone to deliver premature or low birth weight babies. The conclusion that women aged 15 to 19 years have higher maternal death rates compared to those aged between 20 and 24 is stating the obvious.

No wonder children born to minus 20 mothers have a 50 per cent higher risk of dying by the first birthday than those born to older mothers. Child mortality is as high as 25 per cent in Uttar Pradesh and Madhya Pradesh. In the worst league stand three States — Madhya Pradesh, Jharkhand and Bihar — which jointly account for producing more than 58 per cent of India’s scrawny offspring, contributing to India’s shameful record of supplying 40 per cent of the world’s underweight children. That 38 per cent of the less than three-year-old children are stunted, is just another sad statistic (Too much to take in and hence best disregarded).

Almost universally young women do not have access to information or counselling about the risks of early pregnancy and contraception. When 20 per cent pregnancies are unplanned, much greater attention needs to be paid to this sub-sector of adolescent pregnancies. The move to include pregnancy testing kits in the repertoire of the village ASHA is a step in the right direction as is the easier availability of the ‘morning after pill’. The challenge still lies in making these options available incognito and also to enable women to have safe abortions in secrecy. Neither is feasible today as privacy and secrecy are virtually unattainable in rural settings.

The illegality about sex determination has frightened people which is good. But it has also confused couples about the legitimacy of first trimester abortions, which are perfectly legal and absolutely necessary when the woman does not want a child and a pregnancy has been thrust on her. More so when the woman has little or no access to family planning and is incapable of negotiating condom use with her husband.

The population momentum is on us and cannot be stalled now. But the deluge of teenage pregnancies can be slowed down by pushing up the age of marriage, not by law but by attempting to change social custom. The National Population Policy 2000 recommends cash incentives and rewards for couples who marry after the legal age of marriage, register the marriage, have the first child after the mother is 21 and adopt a terminal method after the birth of the second child. The logic behind this is that babies born to very young mothers are much more likely to be below par physically and mentally. Since the woman’s body needs about two years to recover fully from pregnancy and childbirth, an additional incentive should be given for 36 months spacing between the first and second child. Linking the child’s health with the mother’s health should be an important focus of adult literacy messaging, instead of harping on age-old ‘chota parivar’ dictums.

Indian Railways deserves to be complimented for displaying 19 posters on their website highlighting responsible parenthood and in particular appealing to newly married couples not to be pressurised by aspiring grandparents and sundry relatives impatient to cuddle the newborn; or to display one’s mardanagi by taking bets to announce a pregnancy in the very first year of marriage. With slogans like ‘agar ma banegi bacchi tow neev rahegi kacchi’ and ‘baccho ko paida karna baccho ka khel nahi’ the messages target the responsibility cast by parenthood without hectoring about family planning per se.

If Indian Railways can do this on its website one can only hope that it will not be long before it displays the posters at railway stations where millions of people congregate throughout the day and most of the night. The strategy can become an example for other public and private sector giants, particularly those with a massive presence (and enormous goodwill) in rural areas.

Were rural post offices, petrol stations, banks and the FMCG players to target a mindset change in favour of later marriages and support delayed child births, they can instill enormous credibility to important social messages. They can help rescue hapless adolescents from a premature generational cycle propelled by societal pressure to prove fertility. They could also dispel the all-pervading ‘munna ho gaya’ obsession which has precipitated a fast worsening gender ratio.

Coping with death

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High-tech hospital care must include mandatory counselling by advisers, independent of the medical management. This will enable us to take rational decisions in time. If we don’t, we will end up spending most of our money on healthcare in the last years of our lives

Quite unlike the ‘developed’ world, India does not have an ageing problem. With an overwhelming number of young people, its population will remain youthful for at least two decades more. While the grey may never show, the addition of 90 million elderly in the next 20 years will increasingly make hospitalisation a longevity hazard. A couple of decades ago, 80 was considered a ripe old age. Nowadays people live into their nineties and the chances of confronting serious medical problems swell.

In recent months, I have witnessed three old men in the 80 plus age group getting hospitalised post a sudden stroke. The first stop is naturally the ICU, entailing a battery of investigations, followed by ventilators, tracheotomies, oxygen masks, feeding tubes and day and night nursing. The family does not have a clue about where this is leading, but cannot bear to see the old man go. They plead with the doctor to tell them what his chances are.

The doctor does not have an answer, but he abstains from giving false hope, while trying not to upset the stricken. He also cannot predict things, but stands to lose clients by seeming hopeless or helpless. Looking at the patient’s age and general health, he knows that the old man should survive in an unconscious state – maybe a month or two, on ICU support systems which cost a whopping Rs 10,000 to Rs 15,000 a day. He elects to tell the anxious relatives, “The old man can pull through if he shows will power. We will do our best of course. The rest is in god’s hands.” The family huddles together observing the old man breathing heavily through masks and tubes, his eyes closed to the world.

Meanwhile, distraught children (now in their forties and fifties) fly in from the US or Europe, balancing last minute tickets and hard to get leave. Thoughts of unsupervised teenage children, wrecked official commitments, and a home devoid of domestic support, loom large on the flight. Every day spent in India is an extension of that anguish, but any mention of returning meets with dismay and disapproval from resentful siblings who have tended the old man for the past 20 years. Throwing money at the problem only generates bitterness and the charge of callousness. Yet, visiting an unconscious parent in the ICU at the appointed hour, twice a day, becomes a painful and meaningless chore, followed by pointless family conclaves in crowded hospital lobbies.

Only when the costs of ICU become unmanageable, does pragmatism overcome emotion and impart courage enough to demand a step down to less intensive care. Legal and medical advice cautions that the ventilator would have to be removed and the old man may succumb on the spot. “We are prepared,” says the family in unison, confronted with soaring ICU bills and demands for instant payment. The old man remains unconscious but does not collapse. He adjusts well to his step down status, but remains near comatose and dependent on props.

But costs in the private ward too become prohibitive, eventually making yet another step-down unavoidable. “Can we remove him to a smaller hospital, doctor?” “By all means,” says the doctor, “but wherever you take him, the new hospital will insist on putting him back in the ICU and will re-run all the investigations from scratch, I warn you. All hospitals are bound to do that.” A parley with smaller hospitals confirms this statement. The new management scans through the case papers and flatly refuses to handle the patient unless he comes as a “new case”.

The last resort is to nurse the old man at home. As usual, it becomes the responsibility of the harassed spouse or the non-NRI progeny, to engage nurses, attendants and physiotherapy services that constitute the gruelling job of providing home care. The beleaguered offspring returns home to the US after spending a miserable fortnight in India, dejected, remorseful, but hugely relieved to get away. Those left to care for the old man feel forsaken at such cavalier neglect of filial responsibility. They curse the cult of self-centredness that comes from living in the new world.

The old man lingers on. Domestic management of apathetic paramedics, attendants and physiotherapists becomes a nightmare. There is little sadness when the end comes. Indeed, it comes as a relief.

Increase in life expectancy is good news but alongside the likelihood of critical conditions developing at an older age will increase. Scores of multi-specialty hospitals already vie for national accreditation and international recognition. As more Indians live to see what the French call the quatrieme age, some are fated to spend their last days and lifetime savings on dying under ISO 9001:2000 care.

It is time that high-tech hospital care includes mandatory counselling by advisers, independent of the medical management, but competent enough to give meaningful counsel. This will enable the family to understand what is going on and take rational decisions in time. Lest like America, we too end up spending ninety per cent of our lifetime expenditure on health, in the last year of life.

Senselessly going green

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In New York, confused consumers buy paint brushes with plastic handles because they are forest-friendly. Alternately, they buy wooden-handled paint brushes because they are not made of non-degradable plastic. One can imagine the dilemma of consumers in India
Eco-narcissism is the new name for the game the rich and guilty play in the name of saving the environment. As they sleep in organic payjamas on organic bedsheets, their roof-top generators run half a dozen air-conditioners, to keep the house cold enough to snuggle under blankets through the night.

While the green brigades ban plastic bags, their writ runs no further than the Mother Dairy outlets in Delhi where sporadic attempts fail to change bad habits. In New York, the confused consumer buys paint brushes with plastic handles because they are forest-friendly (not being made of wood) and conversely wooden-handled paint brushes, because they are not made of non-degradable plastic!

Such is the power of massaging, absurd as it is. In the same league we delude ourselves that CFL bulbs are eco-friendly (which no doubt they are), but not if they are accompanied by halogen lamps to give the special glow that the much maligned incandescent bulbs can’t match. This is akin to the hypocrisy of wearing organic cotton shirts while driving a fuel guzzling Merc.

The green movement having reached somewhat ridiculous proportions in rich countries is slowly catching up with us though a few right thinkers have begun exposing how telling half-truths, if not complete lies, is nothing short of “voodoo marketing”.

A columnist in the US has questioned the proliferation of green but environmentally expensive consumer goods in the name of what he calls “eco narcissism”. In psychology and psychiatry excessive narcissism is recognised as a personality dysfunction and is seen as a manifestation of egotism and selfishness. Applied to a social group, it denotes elitism and indifference to the plight of others.

Out-of-season fruit transported thousands of kilometres by fuel-guzzling jet planes from the southern hemisphere is an example of madness, especially when it is devoured in the name of organic cultivation. The delicacy is environmentally damaging if one considers the enormous fossil fuels burnt to bring Chilean summer raspberries to snow-bound American consumers.

Then there is the snobbery about bottled water. Not even a dhaba will today dare offer plain water for fear of putting off the client. Either it will be bottled water with the stamp of known and unknown companies, or it will be dispensed through an expensive reverse osmosis apparatus “so sweetly” promoted by the Hema Malini and daughter duo. That the contraption requires rejection of three litres of water to give one litre to drink hardly bothers the environmentalists.

No conference or board meeting looks complete without the ubiquitous plastic bottles hiding the chairman and others on the dais. In restaurants, snobbish waiters ask from their lofty heights whether you want mineral water or ordinary water. The guest is made to feel that much more important if mineral water is ordered ordinary water being considered too plebian. In the snootiest hotels they produce Perrier from France (unasked for) at Rs 400 a bottle, knowing full well that the person who foots the bill would not dare send it back. In the market a chilled bottle of water costs as much as a soft drink.

We in India might soon have to face what is happening in America where restaurants buy water for a dollar and resell it for as much as eight dollars or more, making it the highest mark up on any item on the menu. No wonder some restaurants in San Francisco’s Bay area have decided not to serve bottled water at all, as a part of an environmentally sustainable campaign.

Meanwhile the present generation of baby boomers has its own take on giving an eco-friendly upbringing. While swearing that they will not put their baba log through the trials and tribulations of competitive schools, they choose schools with air-conditioned buses and classrooms and ensure that their offspring return to the environment of an air-conditioned house, albeit to eat organic atta chappatis and organically fed chicken.

The argument here is not that we should give up environment-friendly measures and efforts to recycle waste. The solution lies not in deluding oneself that the organic label can buy peace with nature, but by changing lifestyles that waste energy. Should people who adopt unsustainable lifestyles and waste electricity, petrol and diesel (directly or indirectly) become trail-blazers just because they profess green tokenism?

What we need are awareness campaigns that tot up how much we ruin the environment, while deluding ourselves that we are saving the planet. We also need to set our own Indian standards for what is considered environmentally-friendly, safe and sustainable instead of blindly aping Western ideas and practices that have created the impending eco-catastrophe for life on earth.

Plan the Indian family

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If Iran has been able to bring down its fertility rate from 5.6 births per woman in 1985 to 2 by 2000, India can definitely do the same, if not better. What is needed is political will, apart from better planning and coordination
In January this year, an All Party Parliamentary Group of the UK’s House of Commons published a report on Population, Development and Reproductive Health. The forecast: The Millennium Development Goals espoused by 189 Govern-ments in the year 2000 are practically unachievable, given the current levels of population growth.

The report assumes significance because the evidence of all population stalwarts the world over was recorded before releasing the findings. “Population issues have lost priority,” says the report and “funding has stagnated or decreased at a time when unmet need for family planning information and services is increasing.” Women in developing countries are dying for lack of access to family planning services and having to confront unwanted pregnancies and forced abortions even when options are available.

Ironically, if there is any concern about population it is related only to the extremely low fertility of European countries and Japan. The End of World Population Growth in the 21st Century, a book, which is considered a must for policy-makers, simply overlooked that in the country like India, 17 million more births than deaths take place every year. Western thinking about global warming has overtaken even the Indian psyche, despite the fact that India emits less than half the carbon dioxide of Brazil, only a third of China and a not even a fifth of the European Union, leave aside the United States.

The fact that population pressure is eating into agricultural land, forest, water, and biodiversity is never even mentioned. In countless meetings about ecology, climate change, deforestation, urban migration, demographers are notably absent or unheard.

It was in the late 1980s that the subject of population growth began to be swept away from policy agenda. The 1994 Cairo Conference on Population and Development successfully muffled it behind the nebulous nomenclature of reproductive and child health (RCH). Any mention of numbers and sankhya still draws the wrath of activists, who in their zeal to end coercion and sub-standard family planning services have unwittingly helped to overturn the family planning programme.

India’s discreditable memories of 8.3 million sterilisations, performed in a single year 1976-77 – four times higher as compared to the year before – have sealed the lips of politicians of all hues forever and drawn stony silence from the media.

The RCH alternative has not provided the synergy that was expected observes a paper by Srinivasan et al (IIPS Mumbai). They found no co-relation between per-capita expenditure incurred on RCH and the level or pace of change of indicators. The National Commission on Population charts display decline in sterilisations and IUD insertions – attributable largely to the low performance of Bihar, Rajasthan, Assam and Uttar Pradesh. The IIPS study ends on the unhappy note, “The RCH umbrella seems to be leaking.”

Against this backdrop the story of Iran bears telling. There the equivalent of the Planning Commission painted such a grim picture of the country’s economy and how the nation’s resources simply could not support the services stipulated under its Constitution, that all Government departments were directed to review the population growth rate impact.

The Iranian media disseminated how the country’s population growth was too high and if left unchecked, would have serious negative impact on the national economy and the welfare of the people. Iran’s Health Ministry and its Judicial Council then declared that there is no Islamic barrier to family planning.

Families were encouraged to delay the first pregnancy, and space out subsequent births, to discourage women to become pregnant younger than 18 and older than 35; to limit family size to three children (not even two). Resources were poured into family planning services and to help couples prevent unplanned pregnancies.

The village health workers (two instead of our one ASHA) put up charts of the age and sex profile of each village at a central place, which were updated each month. The data showed the number of children who had been born since the beginning of the year, the number of children vaccinated, the number who died and the cause of death. The data also showed the number of married women, their age and the contraceptive method used.

Contraceptive pills became the most popular method. Population education remains an integral part of the curriculum at all educational levels; university students must take two credit courses on population and family planning. Couples planning marriage have to participate in a family planning class before receiving a marriage license and these pre-nuptial classes are mandatory for both the bride and groom-(to-be). Women’s average age of marriage had crossed 22 years by 1996.

The result of all this has been astounding. From a total fertility rate of 5.6 births per woman in 1985, Iran brought total fertility down to 2.0 by 2000. Infant Mortality, Maternal Mortality, Under 5 Mortality, have all reduced; literacy has gone up, and now more women than men have entered Universities.

What we need is less looking the other way; less emotional outbursts in donor-driven seminars and much more by way of sustained family planning services. And an effective leadership in the northern States which are disproportionately delaying India’s population stabilisation.