May You Be the Mother of a Hundred Sons (46 page)

IN A PARCHED CORNER OF WESTERN GUJARAT, ALONG AN EMPTY ROAD
that disappeared into the brown, scrubby plains, there stood a local government health center, nothing more than a drab, single-story cement building, where for twenty minutes one November afternoon I observed what India’s population-control establishment bureaucratically, and somewhat inappropriately, referred to as a “laparoscopy camp.” When I arrived for the “camp,” shortly before two in the afternoon, I found four peasant women—Januben, Taraben, Nortiben and Manjuben, ranging in age from thirty to twenty-two, all mothers of two or three—squatting barefoot and huddled together with their backs against a wall in a small holding room, as frightened and wide-eyed as cornered small animals. The government nurses had removed the women’s saris but had tied the waists of the women’s full-length petticoats up over their breasts to create make-do surgical gowns, all soiled and greasy from cooking smoke and field work. Each of the women had come to the health center under pressure from local
government health workers, whose pay would be docked if they did not meet strict annual quotas of sterilization cases. The health workers knew that the women, illiterate, poor and leading hand-to-mouth existences after another summer of drought had scorched the fields, desperately needed the twenty-four-dollar payment promised by the government to those who had the operation.

When the doctor was ready, three of the women were led into the “operation theater,” a dark, dank, sour-smelling room with stained, peeling walls. There were three low operating tables, and to raise them up higher, the hospital staff had precariously stacked red bricks under each of the legs. The nurses instructed the women to climb up on the tables, which they did, as awkward in their petticoats as toddlers climbing stairs. Once the women had settled, the nurses flipped the petticoats up over their faces, spread the women’s legs, then waited for the doctor in a far corner of the room. He was R. P. Raol, a laparoscopy specialist who was known for his fast work. He could usually sterilize twenty women in an hour and had once sterilized one hundred women in a single session at a “prestige camp,” attended by a government minister. Today’s small workload would be accomplished in no time. Dr. Raol gave the first woman, the one on the operating table the farthest from the holding room, an injection of local anesthesia in her stomach. With a small knife, he made a slit just below her navel, then inserted a thin tube that blew in carbon dioxide. This procedure pumped up her abdomen and pushed the large intestine away from the uterus to make his field of vision clear. Dr. Raol took the laparoscope, a shiny metal rod about an inch in circumference, inserted it into the slit, looked through a small magnifying lens at the top, and found one of the patient’s fallopian tubes. He then pulled a triggerlike mechanism on the side of the laparoscope, releasing a tiny ring that wrapped around and tied up the woman’s fallopian tube. Dr. Raol repeated the procedure on the other tube, instructed an assistant to stitch up the slit, then rapidly moved on to the other two women.

By twenty past two, all four women were sterilized and the “camp” was over. The speed of the operation explained why laparoscopies had become such a popular method of sterilization in India. The conventional method for a tubal ligation, or tubectomy, as the Indians called it, normally required a larger abdominal incision under general anesthesia and six days of hospitalization. But with the laparoscopy, these women were expected to feel only mild pain in their stomachs, and it was presumed they would be able to start normal activities after only
twenty-four hours of rest at home. Dr. Raol quickly departed—he normally worked two camps a day—leaving the medical officer who ran the day-to-day activities of the health center, a polite, nervous bureaucrat named Dr. S. G. Gharia, in a sullen mood. He, too, was feeling pressure from his superiors to meet the annual sterilization targets sent down from Delhi. “This was a small camp,” he said, annoyed and embarrassed by the low turnout. “We had an insufficient number of cases.” The term “camp” more accurately applied to the weeks-long sterilization sessions in remote areas of India, where thousands of men and women journeyed to be sterilized by government doctors. But India’s family-planning establishment also used the term for the smaller group sterilization operations at the permanent government health centers scattered in thousands of towns and villages across the country. Dr. Gharia normally held his camps twice a month, sometimes attracting dozens of patients by advertising with leaflets and passing the word through his nurses and midwives. “I am not satisfied with my workers,” he complained. I asked him what he intended to do. “I will scold them,” he said, explaining that he was trying to finish half of his yearly quota of sterilizations within the next few weeks. “I will say, you must achieve 50 percent target by the end of this month. Why are you not working?”

Before I saw Dr. Gharia’s laparoscopy camp, it was easy for me to sit in New Delhi and think that part of the answer to India’s population problem was simply to sterilize more people. But once I saw the operation for myself, my reaction was that treating women as if they were cattle could not possibly be the most humane or even the most effective method of population control. In 1988,
The Telegraph
, the Calcutta-based daily, reported that forty-four women had died during sterilization operations in Rajasthan during the preceding two years. The newspaper described the camp conditions as “unhygienic and filthy,” which I readily believed, and reported that laparoscopes were used over and over without sterilization. In one camp the reporter discovered that a bicycle pump was used to pump ordinary air into the women’s stomachs instead of carbon dioxide, which dissolves easily in the blood. Ordinary air bubbles in the arteries can block the heart or damage the brain.

And yet I also knew it was too easy to simply deplore the excesses and mistakes of programs like the laparoscopy camps. The truth was that something urgently had to be done to prevent India from over-populating itself toward self-destruction. At the very least, Dr. Gharia’s
laparoscopy camp introduced me to the dilemmas of population control in India. I also realized, after seeing how the population-control program worked—and did not work—in villages in Gujarat and other parts of India, that there could be no success without a significant improvement in the lives of India’s women.

The nation’s population statistics were well known, even to those who only casually followed the problem. At independence in 1947, the population of the country stood at 342 million; by 1988, that number had more than doubled to 800 million. Paradoxically, overpopulation was a result of progress and development. India’s population had been virtually stationary at the beginning of the century, before the spread of penicillin and vaccines, because people died routinely from infections, plagues, cholera and malaria. Medical advances since the 1920s had succeeded in substantially lowering the death rate, but there had been no corresponding drop in the birth rate. Sometime in the next century, India is expected to surpass China as the most populated country in the world. (No one is quite sure about this; a number of experts think that China is underreporting its own population growth.) In any case, China’s one billion people live in a territory three times the size of India. In 1988 one out of every six people in the world was an Indian, and every year the country grows by fifteen million people—the equivalent of the population of Australia.

It did not take a trained demographer to see that the country was already staggering through a nightmare. All you had to do was watch the commuters clinging to the outside of a packed bus as it groaned across a New Delhi intersection, or look at the masses of shacks in the streets, or gaze at the miles of northern Indian hillsides denuded of the trees and grasses that millions of villagers cut down for firewood and cattle feed. Such deforestation caused the soil erosion and floods that were destroying agricultural land faster than the government could reclaim new land by building expensive irrigation systems. Despite steady national economic growth, overpopulation helped to keep more than half of all Indians in a state of miserable poverty. In fact, nearly every major problem that India faced—from unemployment in the cities to scarce drinking water in the villages to violence among religious and ethnic groups—had its roots in the strains caused by overpopulation.

The government is hardly blind to the dilemma. Reducing fertility became part of the Indian government’s official policy in 1951, and since then the country’s population-control program has grown to
become one of the largest and most complex in the world. Over the years, India relied on an array of nonterminal family-planning methods—intrauterine devices, the pill, condoms—but the core of the program was always the sterilization of men and women. It was chiefly sterilization, for example, that succeeded in bringing down the birth rate from 47.1 live births per 1,000 people in the 1960s to around 34 per 1,000 in the 1970s. At that point, Sanjay Gandhi, Mrs. Gandhi’s younger son, began to assume increasing control of the Indian government and took on population problems as a personal project. But he used aggressive and coercive methods that everyone now agrees backfired disastrously. Particularly devastating were the widespread reports of forced vasectomies, a procedure many village men equated with castration. The issue led to the popular revolt that helped defeat Mrs. Gandhi in 1977 and also derailed any further effective program to control the country’s population. Vasectomies are much simpler procedures than laparoscopies, but they became so unpopular in subsequent years that most of the sterilizations in India have been performed on women. Governments after the Sanjay debacle were forced to play down what was already a sensitive political issue. India, for example, always referred to population control by the more euphemistic term “family planning” and was critical of China, which had used coercion to greatly reduce its birth rate in a remarkably short period of time. As a result, by the early 1980s, India’s birth rate was stagnating at around 33 per 1,000. (As a way of comparison, the U.S. birth rate hit a record high of 26.5 per 1,000 during the height of the postwar baby boom in 1947; in 1985, it was 15.7 per thousand.)

When Rajiv Gandhi became prime minister in 1984, India’s population was growing by an estimated 2.1 percent annually, a rate at which it would double every thirty-five years. Fresh, impatient and confident that he would not repeat the mistakes of his brash younger brother, Gandhi was willing to declare, although not too loudly, that overpopulation was the most serious problem facing India. In the fall of 1986, after a long period of preparation, his government announced a five-year, three-billion-dollar “revised strategy” to promote the goal of a two-child family by doubling the money spent on health and family planning, and using television, radio and posters in an extensive advertising campaign. To improve literacy and health care for women, the program envisioned a “Women’s Volunteer Corps” of two million members, to be selected from India’s villages at the rate of one for every sixty families and then trained by the government to provide
rural women with information about health care, immunizations, nutrition and birth control. The “revised strategy” was largely the work of Krishna Kumar, a highly respected and successful family-planning specialist. (In 1971, he had organized a “sterilization festival” in which more than 63,000 vasectomies were performed in a single month.) The overall strategy was praised by population experts at the United Nations as an intelligent, promising program, but as always, coordinating a master plan from Delhi through myriad ministries and state governments, each with its own intractable bureaucracy, was an onerous job—especially when Kumar, the person who might have had the skill, influence and determination to do so, was transferred to another job, apparently for political reasons, just as the new program was announced. Two years later, much of the program had not been implemented, and the “Women’s Volunteer Corps” existed only on paper.

A more fundamental obstacle to population control was, as it had always been, the Indian family’s overwhelming desire for sons. Surveys in the 1980s showed that 90 percent of the population was aware of the family-planning program, and that as many as 65 percent thought it was a good idea to limit the size of families. But the truth was that most couples preferred to have at least two sons, no matter what encouraging statements they might have made to a questioner hired from New Delhi. In the absence of a social security system, parents felt they needed someone to provide for them in old age—ideally an heir and a spare. In pursuit of those sons, parents often had five or six children. Bilquish Jahan, the woman who ran the government health program and was the chief advocate for population control near the village of Khajuron, where Steve and I had lived, told me that she herself had given birth to five children—first a son, then three daughters, and finally a second son. She admitted that she was not a good example in her efforts to encourage people to practice birth control. “Those who have only daughters—I never try to persuade them to adopt family planning,” she said.

One of the main misconceptions of India’s approach to population control had been the family-planning message “A Small Family Is a Happy Family,” which was plastered on billboards and buses and in health centers and offices across the country. In fact, the slogan made sense only to the kind of people in Delhi who had devised it. Urban, educated families knew what it cost to raise, educate and find jobs for more than two children, but throughout the rest of the country, it was still the large family that was the happy one. For most families in India,
more children meant more hands to help in the fields, and therefore more income. This attitude was changing among some of the poor families in the cities, who had no opportunity for field work, but in rural areas, experts such as Rami Chhabra, the media adviser to the Health and Family Welfare Ministry, told me that most families still thought the economic benefits of their children’s labor outweighed the burden of feeding them. “Where there is work, two hands do amount to more than one mouth,” she said. Another specialist, George Walms-ley, who worked at the United Nations Fund for Population Activities in New Delhi, said that in some cases families did see that having six children was not to their benefit. “But that has been translated down to having four kids, not two,” he said. India’s family planners had learned these lessons too, and readily admitted that their “small family, happy family” message had failed. The government’s revised strategy abandoned the whole approach and instead focused on improving the health of women and children. A barrage of new advertisements told women that it was medically risky to give birth as a teenager, or to have a fourth child, or to have one child right after the other. “We’ve shifted the communication,” Chhabra said. “Now the approach is ‘This is what’s good for you.’ ”