A biting cold morning in the winter of 1996 saw a Bhil tribal woman lying naked shivering on the earth floor of her ramshackle hut in village Rajna in Barwah tehsil of Khargone district of Madhya Pradesh. Beside her also shivering, lay a shriveled new born baby. The woman had so lain for the whole night and her ordeal hadn’t ended. There was a twin yet to be born but for the last three hours there had been no movement from within and so the baby was stuck inside the womb. The earth beneath the woman was wet with blood and placental fluid but neither she nor the dai (the traditional birth attendant) seemed to be least bothered. Just then the mobile dispensary of the Kasturba Gandhi National Memorial Trust happened to pass by and was stopped by the people in the village. There were five nurses but they expressed their inability to help as they did not have any instruments. When the villagers beseeched them to take the woman and the baby to the Primary Health Centre (PHC) at Barwah they pleaded their inability saying they were on their way to different villages to administer vaccines under the Pulse Polio immunisation programme. Sometime later a jeep came along with a doctor from the PHC at Barwah. The villagers stopped this jeep too. The doctor also after seeing the woman said that he was helpless as he did not have any instruments with him. He too advanced the responsibilities of supervision of the Pulse Polio programme as an excuse for not taking the woman to Barwah. He even went to the extent of saying that the lives of thousands of children were at stake and he could not put them at risk for the sake of one woman and child. Eventually the husband of the woman had to borrow money from a moneylender at an exorbitant interest rate and hire a jeep to take her to Barwah. The woman just about survived but her twin babies died. Later tests revealed that the woman had a haemoglobin count of just 4 grams per decilitre dangerously below the ideal level of 12 or above. This incident forced a rethinking of the way in which the problems regarding the reproductive health of Bhil tribal women were being addressed by the Kasturba Trust. The mobile clinic of the Kasturba Trust had a qualified doctor and two nurses and a rudimentary dispensary and used to pay a visit to the villages in the area three days a week. In addition it had provided training from time to time to thirteen dais of the area in safe delivery practices and basic medicine and used to give them a monthly stipend of a hundred rupees. The sordid experience of the Bhil woman in Rajna showed that the achievement of health, which according to the World Health Organisation means a state of complete mental, physical and social well being and especially reproductive health for poor adivasi women would require much more than what was being done by the Kasturba Trust. An epochal milestone had been reached just prior to this in the field of women’s reproductive health and rights with the International Conference on Population and Development held in Cairo in 1994. There for the first time the reproductive rights of women were internationally recognised. Thence forward population control policies, which targeted women as objects without any decision-making powers of their own were rejected (Boland et al, 1994). This process was further reinforced at the International Women’s Conference held at Beijing in 1995. There the importance of women enjoying their sexuality for the achievement of complete reproductive and sexual health too got recognition for the first time in an international forum despite some stiff opposition from religious fundamentalists. Thereafter women’s empowerment and the establishment of reproductive and sexual rights became the key issues in the ensuring of reproductive health for women. So much so that the Indian Government too jettisoned its earlier sterilisation target based population control programme in favour of a reproductive health and rights approach. The stress therefore was on organising women to demand their rights as a means to achieving good health. Women’s health, however, is a much more complex issue than just the provision of adequate healthcare services. It has come to be recognised that women’s health, safe motherhood, population control, and poverty alleviation are all dependent on women having reproductive health rights apart from economic and political rights at par with men in a society that is egalitarian in all respects (Correa & Pechinsky, 1994). Thus the basic requirements for improving the health status of women are a direct multi-pronged attack on poverty through the creation of labour intensive work opportunities, removal of social inequalities of all kinds, a campaign against traditional and modern myths and a comprehensive community health care system with primary and referral services (Quadeer, 1995). So any programme aimed at improving the health status of poor adivasi women has to necessarily incorporate both the service delivery and the mass organisational approaches to community work if it has to be successful. The primary cause of ill health in women is their low status in society. Relegated to a position of subordination from the moment of birth, girls eat last and least, are over-worked and under-educated and have to bear children from an early age. They receive inadequate medical treatment when ill and are often passed over for immunisation. Despite the biologically proven fact that women have a longer lifespan than men, in reality, in India the reverse is true in rural areas where more girls are likely to die than boys leading to a sex ratio skewed against women in the population. Adult women lack property rights and control over economic resources, which contributes to the general preference for a male offspring as an insurance against old age incapability. This in turn results in women having to go through the rigours of repeated pregnancies and childbirths to produce sufficient male children that can survive through to adulthood overcoming the uncertainties of an insecure childhood. Malnutrition, lack of sexual hygiene, repeated pregnancies and overwork lead to most rural women being anaemic and so prone to other diseases in general (Mehta & Abouzahr, 1993) The prevailing pattern of development has been particularly harsh on women. Destruction of resource bases has led to the workload increasing with a corresponding decrease in nutritional levels of the food intake. The introduction of artificial input mechanised agriculture has deprived women of the little control that they had over production processes in traditional agriculture and further reinforced patriarchal power relations. Forced migration either temporary or permanent has exposed women to sexual violence in unfamiliar surroundings. The loss of traditional livelihoods has been accompanied by the induction of women into low-paid jobs in the informal sector where the work environment is unhealthy and the workload high. The general level of violence in society has gone up, to further sequester women in their homes thus reducing employment opportunities. All this has had a negative impact on the health of these women (Duvvury, 1994). Last but in no way the least harmful have been the government’s health and population control policies. Primary health care has received short shrift both in terms of financial outlays and in terms of the introduction of participative health care systems. Thus apart from the foreign funded immunisation campaigns like the Pulse Polio programme mentioned above, rural populations rarely ever receive any effective healthcare from government health services (Bose & Desai, 1983). Consequently for the poor infant mortality levels are still dangerously high as are maternal mortality and morbidity levels (IIPS, 2007). Again spurred on by the neo-Malthusian myth that population growth is responsible for poverty the government had launched an aggressive population control programme in the 1970s, which targeted women for sterilisations and the use of various unsafe and unhealthy contraception measures (Mamdani, 1973). Even though with the introduction of the sterilisation target free reproductive health approach from 1996 onwards there had ostensibly been a so called paradigm shift at the policy level in population control and maternal and child health care, the ground reality in rural areas had remained much the same as before (Rahul, 1997c). Thus the achievement of health, like any other social attribute, is primarily dependent on the urgency with which people seek it. The Bhil adivasi women are too burdened by the multiple oppressions enumerated above to be able to seek anything at all let alone health. Thus the focus of the reproductive health programme of the Trust too shifted towards the organisation of women from just the provision of health services. The main problem with organising women is that the deep-rooted patriarchy in rural societies prevents women from coming out of their homes. In most cases patriarchy has been internalised by the women themselves thus making it difficult to make a beginning in organising them by focussing on patriarchal oppression alone. Specifically in the sphere of reproductive health, moreover, there exists an intimidating culture of silence (Dixon-Mueller & Wasserheit, 1991). Nevertheless, the health of women being an issue that affects everyone it is relatively easier to get the acquiescence of the men to let their women do something about improving it. Thus both felt-need wise and strategically health provides an ideal entry point for organising poor adivasi women and helping them create a space of their own in society. So an attempt was made to start the organisation process in Barwah tehsil with an effort at opening up this dark and forbidden area. Weeks were spent in visiting the villages and going from house to house to talk to the women. A whole day was spent in Chainpura village going to the houses and the fields where they were working to talk to the women and call them to the meeting to be held in the evening. Only five women came to attend. The women listened silently as the conversation was directed gradually towards reproductive health. Initially this did not draw much of a response. Then when specific problems like white discharge from the vagina, leucorrhea, were mentioned, one woman said that she was suffering from it as well as back pain. Another revealed that she had a slight prolapse of the uterus at times when she did hard work. It was decided to hold a bigger meeting on a later occasion. The village Golanpati, which is about six kilometres away, is picturesquesly set on the banks of the Kanar river in a depression surrounded by hills at the foot of the escarpment of the Vindhya hills descending from the Malwa Plateau. It is unfortunately without any electricity. Consequently most of the men and the young unmarried women were away labouring on the fields of rich farmers atop the Malwa plateau to earn the money needed to buy diesel for running their engine driven pumps with which to irrigate their winter crops. A death of a close relative had taken place in a village some distance away from where most of the young wives of Golanpati hailed and so they too were absent. So time was spent in desultory conversation about various things and after some time some of the women decided to go fishing in the Kanar river with small nets called “dahwalia”. The people of the area are able to supplement their normal simple diet with such occasional infusions of rich fish protein. The village Akya too was without electricity at that time though later efforts have brought it onto the electrification map. It is situated on the banks of the Sukhri stream. Here the people had already arranged for the diesel and were busy in the fields irrigating the standing crop of wheat and gram. Once again the day was spent visiting the women in their houses and fields. The houses here are all on the farms of the respective people and so scattered over a distance of some three kilometres. In the evening upwards of thirty women attended the meeting. The meeting went off well. As many as twenty-three women reported various kinds of reproductive health problems and demanded that something be done to relieve their sufferings. The women complained that local quacks only gave them injections, which did not relieve their pains or suggested that they get their uteruses removed. The government health worker rarely visited the village. The villages Okhla and Chandupura are adjacent and for all practical purposes are like two hamlets of the same village. The district administration, however, displaying typical bureaucratic perversity has put the two villages in two separate panchayat clusters. These villages are lucky to have electricity because there is a Hanuman temple in Okhla where the epic Ramayan has been recited day and night continuously for the past twenty-five years. Even though the adivasis and their Gods hold no value for the government the same is obviously not true when it comes to Hindu Gods and their devotees. The people here too were busy with their agricultural operations. The people here have been enterprising enough to draw water over great lengths from the river Kanad using electric pumps and PVC pipes. Here during the initial house visits one woman in Chandupura said she could get all the women together in a jiffy if she was given a share of the pickings from the project being planned for them! Here for the first time women brought up the behaviour and attitudes of their men for discussion. The lust and violence of their men fuelled by alcoholism they felt was the main deterrent to achieving a healthy status. A health clinic in which specialist doctors could diagnose their problems would be immensely beneficial they felt. There are in these two villages, in addition to adivasis, dalits also. The next set of villages has mixed populations and is dominated by upper caste people. Limbi is a village of Jats. These are a farmer caste, which had come here originally from the state of Rajasthan. They owned most of the land in the village on which the dalit and adivasi people worked as labourers. Here there was a pretty good meeting among the poorer people where most of the problems identified in the earlier villages came to the fore once again. The Jat women were prepared to talk individually but none of them came to a meeting, which was organised separately for them. There was one Jat woman who had lost her mental balance because she could not bear the mounting pressure on her to produce a male child after repeated births of girls. There is another woman who was tricked into marrying a doddering old Jat in his seventies. The old man had died later and she had been left to make a living on her own with a small girl of five and some land. Mundla is another village dominated this time by a different farmer caste, the Dangis. These people too own most of the land in the village and make the adivasis and dalit people work for paltry wages as low as Rupees twenty a day which is less than half the statutory minimum wage. Here the men instead of the women attended the evening meeting. The men listened and went on saying “Ha bahenji, Sach Bahenji” – yes sister, true sister, but did not make any comments of their own when they were told that they should be more considerate of the health of their women. Even though they promised to send their women to the repeat meeting to be held in the morning no one came then either. The village of Palsud is situated between these two villages and the villagers there, some dalits and some adivasis, are continually troubled by the Jats and the Dangis. There have been murderous fights and two dalits from Palsud are serving a life sentence in Indore jail for having murdered a Jat from Limbi. The women in this village enthusiastically took part in the meeting and talked about their reproductive health problems quite freely. There are two other villages Bargana and Barkhera nearby but in both of these the meetings drew only four or five women each. One of these women a Jat went around wearing a cloth belt around her loins to prevent her uterus from coming out. She would have liked to have a hysterectomy but did not trust the private doctors in Sanawad where most of the other women had got themselves operated. In the local dialect this is referred to as the “burra operation” to distinguish it from the sterilisation operation which is called just “operation” and is done free by the government doctors as part of the family planning programme. Another phenomenon was that of women’s vaginal opening having become so extended from repeated childbirths that when they get up from a squatting position air is sucked into the vagina and then ejected with an embarrassingly loud sound when they sit down again. The last set of villages is in a cluster on the banks of the Choral river. The villages of Aronda and Kundia lie to the west of the river while the villages of Sendhwa and Karondia lie to the east. In Sendhwa village the Brahmins and Patidars who are higher up in the caste order do not let the dalits draw water from the public hand pump and the latter have to drink water from the Choral River. Consequently during the monsoons there is an annual epidemic of waterborne diseases among these people and in 1995 there were three deaths due to gastro-enteritis. Here too the meetings were sparsely attended but the women who did come all complained of reproductive health problems and of the the insensitivity of their men. The upsarpanch was a Muslim who as a community are notorious for their anti-women attitudes. The upsarpanch’s wife herself suffered from anaemia with a haemoglobin count as low as 6 grams per decilitre despite their being quite well off economically. She spoke about her problems individually but did not come to the meeting. Katkut village is located roughly at the geographical centre of this area and by virtue of being the weekly marketplace and also having a civil dispensary, banks, the forest range office and a police outpost it is also the commercial and administrative centre. It is a peculiar village. It is dominated by the Jats and the sarpanch at that time in 1996 was a Jat woman. The husband of the woman operated in her name. The Jats of Katkut are held in low esteem by their caste men from other villages because of their arrogant and boorish behaviour and the men find it difficult to get brides. One young Jat woman complained that she repeatedly aborted and would like to know whether there was any solution. She was the only daughter-in-law in a house of four sons. There was no father-in-law who had died very early. The mother-in-law Karmabai fought a long legal battle with her brothers and gained possession of her share of her father’s land. She was a panch in the panchayat. She said that the Jat women were extremely oppressed and it was not possible to get anything done in their interest given the attitude of the men. This area is just fifty kilometers away from the city of Indore. Yet the women here regardless of whether they are from relatively well off households or from the extremely poor adivasi and dalit ones, are uniformly oppressed by various forms of patriarchal oppression. The general reluctance of women to talk about their reproductive health problems in a women’s group was initially very puzzling. Finally Ramanbai of Chandupura provided the answer. She said that in her village there was tremendous infighting among the different families over various issues. There was a lot of backbiting. So, women did not want to reveal their illnesses, the public knowledge of which could be used against them. Consequently, even if individually they would talk freely about their problems, often women refused to come to the meetings. So getting women to come together to discuss health problems turned out to be a tough nut to crack. But the women that did come insistently demanded that arrangements should be made for proper medical attention to their reproductive health problems by gynaecologists as the gynaecologist in the PHC in Barwah had never set foot in these remote adivasi areas. So, a few reproductive health camps were organised in which gynaecologists from Indore attended to the women. A major revelation after these camps was that many women do not take the medicines prescribed to them. Some women had orally taken the vaginal tablets for curing leucorrhea given to them for insertion in their vagina. Another woman had kept the vaginal tablets safely wrapped up in cloth in her private box because the doctor had just told her to keep it ‘inside’ without mentioning the Hindi word for vagina. So the woman had assumed that the tablets were some kind of totem and kept them in her box instead of inserting them into her vagina. Inquiries revealed that this carelessness or reluctance in taking medicines regularly was quite common. Many of the women came to the camps with the expectation that the big doctors from Indore would give them injections of special miraculous medicines which would immediately cure them of their problems. One woman in Okhla, Suraj, even went to the extent of saying that she did not trust the medicines and the workers of the Trust. She had gone for the check-up to see what kind of treatment was being given. She was extremely upset when the workers repeatedly went to her house every week to see whether she was taking the medicines. “Mujhe aise lafde nahin chahiye, mere naam tumhari chopdi se kat do”(I do not want to get into such trouble so please remove my name from your register) she said irascibly. Thus despite all the rhetoric and policies of women’s empowerment and the hype around the Janani Suraksha Yojana and National Rural Health Mission in recent years there is still a deep lack of appreciation in the public health system of the tremendous socio-cultural barriers to ensuring the overall reproductive health of poor women. The focus is solely on safe motherhood and the more persistent gynaecological problems that women suffer as manifestations of patriarchal oppression are not addressed at all. Consequently the stark reality that prevails even today in Bhil tribal areas in western Madhya Pradesh is that the women suffer from severe neglect both from their families and from the society and government. Truly these women are the neglected of the earth. References Boland, R et al (1994): Honouring Human Rights in Population Policies: From Declaration to Action in Sen et al eds op cit. 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Quadeer, I (1995): Women and Health: A Third World Perspective, Lokayan Bulletin, Vol. 12 Nos. 1& 2 Rahul (1997): Target Free but not Oppression Free, Free Press Daily 24th March, Indore.