We recently interviewed Dr. Saroj Pachauri, a community health physician who has been extensively engaged with research on reproductive health. Dr. Pachauri was the Regional Director for the Population Council-South and East Asia till 2012 and continues to serve as a Population Council, Distinguished Scholar.
Prior to joining the Population Council, Dr. Pachauri worked for the Ford Foundation, where she developed the Foundation’s child survival and reproductive health programs. She also initiated work on HIV and AIDS when there was no national program in India. She has published extensively on policy and implementation issues related to family planning, maternal and child health, HIV/AIDS, reproductive health and has given presentations at conferences and workshops around the world.
Here are some of her thought provoking responses to our questions:
- Corruption is pervasive and every day we hear new stories of corrupt practices in all fields. It has permeated within the corporate, government, medical health sectors and in the NGO sector too. I am very saddened that the money has corrupted the Indian youth
- There was the long struggle that took place for more than a decade to make a paradigm shift from thinking about ‘population control’ to thinking about ‘reproductive health’ .I think that the proudest moment in time was when this change was made by the Government of India.
- If you look at the social and demographic indicators of India, it is a crying shame that our neighbours who are poorer economically, are handling health problems better than us. Right next door we have Bangladesh and Nepal, which are poorer countries that are doing better than us.
- One lesson that we should learn from China (and this is not to do with family planning) is that they made sure that their entire population receives health care. They have also ensured education for all, so if you look at the indicators of China and India, there is a huge difference.
- Sex selective abortion is the symptom of a larger problem of a patriarchal society. This is the underlying pathology and it is pervasive across class, cast, and social strata in urban and rural areas. Son preference will not go away unless you address the larger issue.
- Gender discrimination is pervasive across the world. It is not unique to India. But this killing of foetuses is unique to India and a few other countries.
- A generational change has to take place. In other words, the current generation has to somehow show over its lifetime to the younger generation that women should be valued equally.
A. The following questions are related to your views on the status of health in India.
1. According to you, what should be the top three health priorities in India?
India is facing a double burden of disease right now. While on one hand it has not resolved its communicable disease problems, which continue, it has also been hit by a rising non- communicable disease burden. Therefore, we need an approach that can effectively deal with both. This is one major challenge that India needs to address now.
The second priority issue in India is the paucity of health professionals of all kinds and the dispersion of health professionals, which is currently very skewed. In the public health sphere, there is an urgent need to address the issue of inadequately trained human resources in all areas of health care.
Our third priority should be to address issues concerning the growing private sector – it is growing in a very unregulated and unethical manner and is mostly catering to a higher socio- economic group. We have a growing middle class which of course needs health care but we also have to address the needs of the poor and make sure that private- public sector partnerships are formulated. Unethical issues that take place within the private sector are mind-boggling. There is an urgent need to ensure that this sector is well regulated.
2.What makes you proud about health in India?
What makes me proud is that India is trying to address the issues of Maternal and Child Health (MCH). Serious efforts have been made in recent years. There is a decline in maternal mortality which for me is a dream come true. We are not reaching the MDG 5 goal even now, but there is a significant continuing decline in maternal mortality all over the country and that is very encouraging. The percentage of decline is higher in states where the rates were very high (as there is more scope in the earlier stages) and less in states where the rates were lower. Therefore, there are a lot of disparities but it is still a major achievement.
I am also very happy that there is now an understanding that we need to integrate the MCH and the family planning programmes. While this may seem obvious, the reality has been different, as we have always had vertical programmes for family planning, MCH and HIV. Now, this has changed partly due to a lot of advocacy by NGOs and pressure from donors to achieve the MDGs.
3.Are there examples where other fast-growing economies are handling health problems better than India?
If you look at the social and demographic indicators of India, it is a crying shame that our neighbours who are poorer economically, are handling health problems better than us. Right next door we have Bangladesh and Nepal, which are poorer countries that are doing better than us. Sri Lanka has done better than us for years ; that is nothing new but, if you look at any social or health indicator in Bangladesh and Nepal, you will find that they are doing better than India.
5.If you think about India in 20 years time, what will the citizens of 2034 wish that we had done in 2014? (Why?)
If we really address the three issues that we discussed in the first question then, the citizens of 2034 might that we say that we took some good initiatives in 2014. I think there is also a need for more resources. India is very poor in its resource allocations, so the citizens of 2034 might wish that we had invested more in 2014. At the same time, this is a tough question to answer, as we do not know what the situation is going to be in the future – in 2034. If you know what the progress is or the lack thereof, then you can say “this is what should have been done in 2014”.
6.Which new technology do you think will make a difference to health outcomes in India over the next 20 years?
Well, in my field the technologies that have really made a difference are the family planning technologies. There are a lot of new contraceptive methods and are constant improvements. For example, the method that I am more familiar with is the progesterone vaginal ring, which is currently under field trials here in India in collaboration with ICMR and the Population Council. It is a fertility control method that can be used by women who are breastfeeding. There are some methods that are able to address the issues of both STDs and family planning. These methods should be promoted.
However, I have a concern about technologies as well. My view is that a new technology is often seen as a panacea or a magic bullet. But if you really look at the history of family planning technologies in India, you will see that it is a very turbulent one. In India, there are many technological issues that they have not dealt with in the social context – which is where these technologies are to be embedded. For example, angry feminist voices against contraception have been a huge set back for the programme. Feminists have been upset because of the misuse and even the abuse of technologies.
The misuse of a technology is a huge concern. Laparoscopic sterilisation as a method of family planning is an example. I worked on it personally as I did the clinical trials in the 70’s and 80’s when laparoscopic techniques were very new and needed to be field tested for their safety and effectiveness. They were seen rightly so as a simplification of the abdominal surgery method. Major surgical methods were used for sterilising women. Laparoscopy was a much simpler process as it could be done as an outpatient procedure. It was cheaper, more cost-effective and safer, which is why it was adopted by our government. But then it was taken up on a large scale and problems arose. Around the early 80’s, there was a lot of coercion since the contraceptive target system was in place and sadly many women were coerced to undergo sterilisation. There was a misuse of technology. Camps were set up to use this laparoscopic procedure on thousands. With those numbers even if there was a great surgeon, the quality of care was going to suffer. The technology has huge advantages but its misuse created serious issues . Hence, technologies are a double-edged sword and we need to be careful about how we use them.
B. These next few questions are on prevention and family planning.
1. Many say that India will face a wave of non- communicable diseases. What can the country do to prevent this?
There are a lot of lessons to learn from the West. We have recently started getting an onslaught of the non-communicable diseases. The same very diseases are the causes of mortality in the USA and other western countries. There has been a tremendous amount of research on communicable diseases so we know the answers. For example, heart disease is one of the leading causes of death in the USA and we know its causes, the underlying conditions, prevention and treatment. We can learn lessons from the West and apply them here.
2.Will prevention be led by government, the voluntary sector or the private sector?
For prevention of heart disease, obesity, diabetes, cancer and other non-communicable diseases, which are currently afflicting the population in epidemic proportions, we need to work at multifarious levels. I think we need to begin at the school level. Education of school children is so important as healthy habits and lifestyles develop in childhood. We know there is huge childhood obesity in this country. Therefore, I think it is a task for everybody and it needs to begin early.
3. Why has Bangladesh done so well on child survival and family planning in comparison to India?
It is difficult to compare India to a country, which is half the size of one of its states. But, yes, Bangladesh also had very serious social and health problems. There are a couple of reasons why they have done so well. Firstly, they have a very strong civil society in Bangladesh. In India, it is fragmented across the land. In Bangladesh, the NGOs are all over and are a very powerful constituency in the social developmental sector. They have played a major role.
Secondly, there has been a very strong effort to address the gender issues in Bangladesh. In my views, maternal health and child survival have a very strong gender base. So, if you can address gender issues and ensure that women are empowered to understand their health problems, recognise their right to services and are able to seek services, it makes all the difference.
Nepal is also doing better than India. In the case of Nepal, less has been written and analysed. I think we need to do more research about the work in Nepal. It is a very poor country with very difficult terrain. Health efforts have focused largely on the public sector to strengthen its capacity. Nepal has acknowledged its difficulties and problems and has established the required networks, human resources and mechanisms so that even the poor in the remote areas are able to access services. But as I mentioned, much more needs to be understood.
4. India and China share some similar population dilemmas but have different approaches toward family planning. Are there places where India was wrong and China was right?
I certainly do not feel we should have gone the China way. In the 80’s, India was also implementing coercive family planning programmes and violating human rights of women, which was a huge concern. There is a total denial of the fact by the government that there is any coercion today. Of course, a lot has changed after the implementation of the reproductive health agenda. It has taken many years. I may be wrong, but I do feel that in some places there is still some level of coercion happening because change takes time. But on the whole, the policies and programmes for family planning are not meant to be coercive.
As for the China policy on population, I don’t know how well it has worked for them because they are reversing their one-child policy. Socially and culturally they are similar to India and their population like ours is aging. Now they are trying to deal with the long-term consequences, as there aren’t the children to look after the elderly. They too are very “family- oriented” and so now they are having a very hard time. I think we will also face the very same issues as we have a huge aging population. But as far as family planning is concerned, we are moving in the right direction.
One lesson that we should learn from China (and this is not to do with family planning) is that they made sure that their entire population receives healthcare. They have also ensured education for all, so if you look at the indicators of China and India, there is a huge difference. This is a major reason for China’s economic success as well. To ensure that such a large population receives health care and education is a big achievement.
5. Are you still worried about sex selection even though it is illegal in India?
I think it continues. I don’t think that simply creating awareness and putting up billboards is going to do it. There have been advocacy efforts by many NGOs and I applaud them, but I don’t know if this is going to have the impact that is hoped.
The reason is that sex selective abortion is the symptom of a larger problem of a patriarchal society. This is the underlying pathology and it is pervasive across class, cast, and social strata in urban and rural areas. Son preference will not go away unless you address the larger issue.
We know what is causing sex selective abortion. We have done a lot of research on how the sex ratios are skewed because of son preference. We also know that now most people do not want large families- (not more than 2 or 3 children) .We don’t need to convince people that they should opt for small families. But at the same time they want their sons.
I am an optimist. I’m not saying that this change in society won’t happen. I am saying that it is not going to happen with the way we are trying to address the problem today. A generational change has to take place. In other words, the current generation has to somehow show over its lifetime to the younger generation that women should be valued equally. Of course, we also know no matter which country you look at, there is gender discrimination and it takes different forms .In America, for example, you won’t find many women working in higher positions . Gender discrimination is pervasive across the world. It is not unique to India. But this killing of foetuses is unique to India and a few other countries.
6. As you mentioned earlier, India has had a troubled history with long acting methods of sterilisation. Where do we stand today? What advice do you have for family planners?
Well, I think that there is much less coercion now but there are a couple of issues that need to be addressed. We have several technologies available even in the current basket of services that the government provides. But, the reality is that women are not given a choice. In the public sector, female sterilisation is still the most common method used.
In India, we have a growing young population with many young adults including those in their late teens getting married and having children early. Most of India’s fertility is occurring in this young age group, wherein, many have not completed their family size and want more children. They need non-terminal methods such as the condom, pill and IUD to help them delay their first child and space the birth of their second child. But, the government still doesn’t provide a choice of methods. So in theory, there is a basket of services available, but in reality the method provided is sterilisation, which is not appropriate for young people.
According to the latest National Family Health Survey, there are very few people using spacing methods. Those who are doing so are getting contraceptives from the private sector. But the number of poor people who can afford to go to the private sector is low. There is no reason why the government, which is supposed to serve the needs of the poor and has a basket of family planning services, cannot operationalise what I call “informed contraceptive choice”.
The government is now making an effort towards an integrated approach to deal with MCH and family planning and to enhance the use of spacing methods such as the pill, condom and the IUD. Efforts underway are very nascent at the moment. I don’t think we are going to see an impact immediately.
C. We would like to know about your work:
1. Could you tell us a bit about the current work or research that you are doing? How did you first get involved in this field?
I started my career teaching community medicine in medical schools. The theses for my MD as well as my PhD were focussed on the causes of low birth weight because it was the leading cause of infant mortality in India. I believed that if we understood the causes, we could address them. The sad thing is there has not been much improvement since then. The prevalence of low birth weight was of the order of about 30 % in the sixties and is the same today. My concern with low birth weight led me to an understanding and an interest in maternal health. I have always been very interested in research, I started working in 1972 with Family Health International (FHI) and conducted research on international health issues. I undertook clinical trials globally to evaluate the safety and effectiveness of contraceptives technologies.
So that was a long period of work that propelled me into the family planning and MCH arena, and since then I have never looked back. There has been a tremendous learning, and it is an area that I am deeply committed to.
2. What excited you about working with The Population Council?
Prior to joining the Population Council, I worked with the Ford Foundation on issues of child survival, women and reproductive health and on the ICPD agenda. This agenda addresses the problems of the top down population control approach and the coercion that we spoke about. The reproductive health approach addresses the multiple reproductive needs of the people. These include not only the need for family planning but also maternal and child health, reproductive health and gender.
At the Ford Foundation, I worked with organisations such as the Population Council, which is the largest and oldest, non-profit global NGO that undertakes research. It is headquartered in New York and had, at that time. regional offices including one in Bangkok. The Population Council was looking to move its South and East Asia Regional office to India and asked me to set it up.
To address your question, I wasn’t very sure at that time of its agenda .It had traditionally been a population agenda and I was totally committed to the reproductive health agenda. I took up the job as Regional Director once I was sure that I could work on a reproductive health agenda.
3.What has surprised you most about working in this field that you are currently working in? What do you find most challenging?
What I have enjoyed and has been very gratifying is that I have been in a position where I could make a difference to national policies. Policy change is a long process. Many changes and significant shifts have occurred over the years. That I could make a contribution to policy change has been very gratifying.
What I have not enjoyed is the growing corruption that has permeated the NGO sector. There were many times, when I would fight with the government, backing NGOs with glowing reports of how wonderful they were. I don’t know if I can do that today.
Corruption is pervasive and every day we hear new stories of corrupt practices in all fields. It has permeated within the corporate, government, medical health sectors and in the NGO sector too. I am very saddened that the money has corrupted the Indian youth.
4. What’s the best thing to happen to you since you started working in this field?
There was the long struggle that took place for more than a decade to make a paradigm shift from thinking about ‘population control’ to thinking about ‘reproductive health’ .I think that the proudest moment in time was when this change was made by the Government of India. A team of people worked on facilitating this policy change and I was a part of the team.
5. What might someone be surprised to know about you?
I think it will surprise people to know that I really did not want to be a career woman. My mother was a doctor and my role model but I saw her working 24/7. We could not have a meal during which she was not called off for an emergency. We could never go to the movies —either she could not go or she was called away. I did not like this while I was growing up. I really did not want to be a career woman.
Studying medicine was really a decision that my father made for me. He was the most loving father that anybody could have. When he was a young, he had decided that he was going to get married to a doctor. There were very few female doctors in the1920’s. However, he did get married to a doctor. He had also decided that he would have one daughter and that she would be a doctor as well. It was all predestined. I tried to fight it but I did not succeed.
Once I got into medicine, I have to admit that the study absolutely fascinated me. And to date, it still fascinates me. What I didn’t like was having to treat patients. I wanted to understand what went wrong, the pathology. But, I did not want to be a practicing physician, so I decided to go into academics. Research has always fascinated me and the rest as they say is history.
6. What do you do when you aren’t working?
I paint and it is a big de-stressor. I love to read. But, for the last few decades, I have read only technical and research – related books. I love literary works. I can read more of that now as I have the time. I love music. I love creative writing; I wanted to do more but I ended up writing research publications and books. Anyway, even that was fun. When I am not working, I greatly enjoy spending time with friends and family.
**end of interview**