RainuGupta knows exactly where she’s going on one sunny September afternoon. Small and sprite, she bolts out of the Umrain PrimaryHealthcare Centerwhere she spends most of her mornings and weaves her way down the uneven pathof the adjacent village. She skips a fewpaces until she arrives at her destined location. “Santosh!” she yells. Her voice raises anoctave as she steps into the family’s open-air wooden enclave, “Oh, Santosh!” Rainu casually pushes a grazing Rajasthaniwater buffalo out of her way as she steps up to the front entrance of the smallone room, un-electrified house. “Santosh?” she asks to an older woman lying onthe family’s woven rope bed. The womanturns over and sighs, “She’s upstairs.” Rainu leaps outside to the bamboo ladder leaning precariously againstthe roof. She climbs up the first tworungs, as the woman who is assumingly Santosh begins to climb down. “Santosh,aap parso ka nasbandhi shivr aaogi kya?” (Santosh, are you attending theday after tomorrow’s sterilization camp) Rainu asks briskly. Santosh, a frail woman whose face is coveredby a blue sari shifts the basket of rice she had been carrying to her left hipnervously. “I can’t,” she muttersquietly. “I’m not feeling well.” “Meri ko chakra a rahay hain (I’m feelingdizzy). The woman who had been lyingdown inside comes out and emphatically nods in agreement. “She hasn’t been feeling well for a very longtime.” Rainu looks crestfallen andleaves abruptly.
Unfortunately,the type of conversation between Rainu and Santosh is still commonplace in ruralRajasthan, a desert state in Western India. Rainu is an Auxiliary Nurse Midwife (ANM), apublic health nurse appointed by the Government of India. She often remains the only source ofhealthcare for the 5000 villagers whom she serves. In addition to doling out the occasionalparacetamol and doxcycycline tablets, she is also under intense pressure tokeep India’sgrowing population at bay at the most micro of levels- by promoting familyplanning methods to families door-to-door.
Although,after the International Conference on Population and Development in 1994, India adopted its own policies in accordancewith the agreements from Cairo,the ambitious transition to a family planning program that emphasized reproductiveand child health has been lacking. Widelyscorned for its history of coercive mass sterilization campaigns, India quicklyimplemented measures such as the two “Reproductive Child Health Approach” (RCH)programs and what is known as the “Participatory Planning Approach,” an attemptto make family planning programs under more local control. For obvious reasons then, the shift put newdemands on the nurse midwife to analyze the “unmet needs” of thecommunity. Nurses now conduct surveysevery year of the couples and families that live in the villages that theyserve. The nurses ask what sort of birthcontrol they use. Families that havemore than two children and those automatically become candidates forsterilization or IUDs. They then come upwith estimates of how many condoms they will need to dole out, how many howmany IUDs they will need to insert, how many sterilizations should beconducted. They then submit the resultsand estimates from their surveys to the Deputy Chief Medical Health Officer whooften slashes their estimates and raises them by a few more cases.
Throughoutthe year then, meeting these “targets” (an eerie use of an English word bymonolingual Hindi speakers) is a perennial concern for the ANMs. At monthly meetings with the Chief MedicalHealth Officers (CMHO), they are often scolded for not encouraging enoughcandidates to attend the bi-monthly sterilization camps. Many nurses testify that they spend a greatdeal of their day talking to women about their responsibility to becomesterilized. “In the street, in thefield, in their homes, at lunch.” Rainulaments. “I ask them how many childrenthey have and whether they can feed them, and they rarely understand that theycan’t.” “Even if they say they will goto the camp, they decide not to later.”
Thewomen in Rainu’s village are also often under intense pressure by theirfamilies to have more children, particularly sons. Throughout India,particularly in Rajasthan, traditional customs of dowry remain standard. Families have to pay a “minimum of one lakhRupees,” (100,000 Rupees or about 2500 dollars) in order to ensure that theirdaughter is married into suitable and safe environment. With many families making less than threedollars a day, the birth of a daughter is often a promise of virtuallyinsurmountable debt and difficulty. Theonly way to compensate for this disparity is to give birth to a son whosefuture wife may offset the debt.
As aresult, nurses like Rainu Gupta stand at the intersection of three competingforces from both her local community, the greater national community and abroad. The first comes from the population controlmovements. Western scholars likeJonathan Sachs and Thomas Friedman often bemoan the high birth rates in thedeveloping world and the potential toll that population growth may have on theenvironment. The rhetorical influence ofthese arguments is great on the subcontinent. Further, many Indian officialssee the “population problem” as one that is rudimentarily steeped in poverty-mainly families having more children than they can afford to support. Nurses also face the well-intentioned influencefrom some abortion-focused Western feminist activists who often emphasize theimportance of access to a variety of contraception methods, but often neglectsocial factors that disempower women such as low literacy levels and maternalhealth. Even in the final agreements at Cairo, the emphasis onhealthcare was framed as a means to curb population (future blog entry on thisforthcoming). The nurses must thenmediate between these influences that support a fervent dissemination ofcontraception and the traditional customs of the villagers whom have veryspecific and meaningful intentions for their own families. Although all of these forces aremulti-farious and consist of a diverse set of well-reasoned arguments, ruralnurses are both requested to “motivate” the residents of their village toemploy specific contraceptive tactics while still preserving their agency.