By Shahina KK
JANAKI KNOWS well that it is hard for her to rear more than four children. Yet she is not willing to go to the sterilisation camp. Her husband would be of no help in taking such a decision. “He drinks heavily, beats me up every day,” she says. Janaki is not able to express her fears in clear terms, but it is difficult to imagine her summoning up the courage or the strength to go to the camp voluntarily.
Janaki belongs to one of the most primitive tribes in Wayanad, a district in Kerala’s largest tribal belt. Tribals constitute 17 percent of the total population of the district, and are vulnerable to various health problems that scale up infant mortality, maternal mortality and communicable diseases, including sexually transmitted ones.
Adivasis in Wayanad are brought to sterilisation camps in large numbers by health workers. “We have sterilisation camps every week at block level,” says Dr Kunjikkannan, who is in charge of conducting camps in the district. “It is a fact that the majority brought to the camps are tribals.” Apart from the weekly camps, there are district-level camps every year if possible. The last camp was on 26 November 2010 in which 42 men underwent nonscalpel vasectomy (NSV) — 32 were from tribal communities. Government officials deny coercion or compulsion, but the boundary between the two is narrow.
“Official figures indicate that the number of tribals in Kerala is diminishing,” says CK Janu of the Adivasi Gothra Maha Sabha, a prominent tribal movement. “Yet the sterilisation programme is in full swing. It has to be viewed in connection with the issue of land alienation and the ongoing land struggles by Adivasis. The government does not want to give the alienated land back to tribals.” However, it would be difficult to establish ‘ethnic cleansing’ as the intent of the government, as she alleges.
Wayanad district has the largest infant mortality and maternal death rates in Kerala. The state average of infant mortality is 13 per 1,000 but here it is 50 per 1,000. Last year, 86 infant deaths were reported of which 46 were from tribal communities. Similarly, of the eight maternal deaths reported, six were of Adivasi mothers.
Again, Kerala may record highest life expectancy for both men and women in India, but the average life expectancy of tribals in Wayanad is merely 45 years, equivalent to that of the poorest countries of the world. The prevalence of communicable diseases, malnutrition and anaemia is considerably high, as is the practice of giving birth at home. According to recent figures, Adivasi women in Wayanad constitute 85.1 percent of the total number of ‘home deliveries’ recorded.
“The prevalence of anaemia among mothers and expectant women is very alarming. In many cases, the haemoglobin count is below four. When you see the poor health of pregnant women and mothers among the tribals, the current rate of maternal mortality is in fact low,” says Dr Santhosh Kumar, a pediatrician at the government hospital in Mananthavady.
Recent figures set off yet another alarming signal. The prevalence of Hepatitis B is disproportionately high among tribals in Wayanad. In 2009, 13 cases were identified in the district hospital alone, with 11 being tribals. In 2010, the number of cases of Hepatitis B was 81, for tribals 47. “No study has been done with regard to this,” says Dr Santhosh. “Men and women are being taken to estates in Karnataka as contract labour. I assume this is the reason for Hepatitis B being rampant.”
DR GEETHA Vijayan, Wayanad’s District Medical Officer (DMO) says, “It is true that the tribal communities in Wayanad are highly vulnerable. We do understand their problems. “We have a target-free approach, we don’t force anybody,” she adds. “The junior public health nurses and Accredited Social Health Activists (ASHA) go to the field and bring them to sterilisation camps, but we have given strict instruction not to force anybody.”
“Coercion need not be very direct,” counters Dr Kumar. He may be right, for the performance of ASHA workers, who do not get salary, is assessed in the monthly review meeting conducted at district level. They work on commission basis. “One ASHA worker gets Rs. 50-100 when she/he brings a person for sterilisation. Obviously, they make the effort to bring as many people as possible,” says Dr Kumar.
Meenakshi, belonging to the Kattunaikkar colony in Batheri, has decided to undergo sterilisation, though her knowledge of the procedure, its side effects and its consequences is sketchy. “She (the promoter of the family welfare programme in her colony) comes frequently, she is asking me to do this operation.” That’s all Meenakshi knows. It is difficult to persuade such women to go in for intra-uterine devices, which work for five years, as they would have to maintain certain hygiene standards and then come back after five years for a fresh insertion.
Lakshmikutty, 65, a retired Anganwadi teacher who worked in family welfare over a couple of decades but is now an open critic, says, “We used all kinds of tactics, from appeasement to intimidation, to meet the target.” Health workers even mislead Adivasis by warning that they might not get the benefits and welfare schemes for tribals if they have more than two children.
A practising gynaecologist in a government hospital discloses that Adivasi women are sent back home as soon as possible after delivery to avoid the death of either the mother or the child in the hospital. The possibility is high because the women are severely anaemic.
Official records seem to corroborate this: post-partum sterilisation, the surgery conducted soon after delivery, is avoided on tribal woman. In 2008, this procedure was performed on 2,535 women, but only 322 were tribals. Instead, Adivasi women are usually brought to sterilisation camps after three or four months.
In contrast to their keenness to promote permanent sterilisation, the authorities display little interest in promoting temporary measures for birth control. “It is practically impossible,” says Dr Vijayan, expressing helplessness.
Field workers in the villages of Wayanad more or less share this view. They think that it is impractical to think of teaching the use of condoms in these areas due to social inhibitions among the populace.
Health activists, however, refute the claim that there are any such constraints. “The authorities are highly pre-occupied,” says Dr Prakash, an activist of the Kerala Sasthra Sahitya Parishad, working at a rural hospital in Wayanad. “If they can mobilise people for permanent sterilisation, why can’t they do it for temporary birth control measures that are relatively less harmful?” The question that Dr Prakash raises remains unanswered.
Permanent methods are keenly promoted by health workers but not temporary birth control measures
The targeted tribals face other complications for which there is no accountability. Ponni’s fourth pregnancy was an accident, the result of failure of her husband Maniyan’s vasectomy. He had undergone the procedure after the birth of their third child. Six years after the surgery, Ponni gave birth to a baby girl. Suspecting Ponni’s fidelity, Maniyan left home, leaving his wife and children in abject poverty.
Kerala is the top-ranked state in terms of meeting the objectives of the national family welfare programme that dates back to 1951. But it smacks of discrimination if the state manages to achieve this status by sterilising the most vulnerable and marginalised people regardless of their other health problems.