On a recent trip to I finally got around to reading P. Sainath's Everybody Loves A Good Drought, considered somewhat of a classic in the development sector. Between 1993 and 1995, Sainath spent months in India's poorest districts researching this book. In one of the few optimistic articles in the book, Sainath celebrates a social movement in Pudukottai district, Tamil Nadu state, that in 18 months saw over one-fourth of the rural women in the district learning to cycle.
In contrast, in his section on health Sainath describes a government system that is corrupt, lacks resources, and, in many cases, just does not function. Doctors take bribes from patients, or withhold services in the government clinics, to usher patients into their private practices. Medicine is either not available in government clinics at all, or it has been diverted to private pharmacies, again often owned by or linked to the government doctors. Doctors aside, Sainath documents a severe shortage of nurses and health workers. And in the worst cases, Primary Health Centers have been turned into cowsheds, private residences, or have just been looted for every door, frame and fitting.
The alternatives to the government system that Sainath encounters range from quacks to dissaris. At one end, many quacks have few qualifications other than a board saying 'doctor,' and are accountable to no-one. At the other end are dissaris, hereditary practitioners of traditional systems of medicine in the state of Orissa, who are a mine of knowledge on the use of local herbs and roots for some ailments, but do not have cures for others.
Reading Sainath's book reminded me of a post I had written earlier, in which I had talked about a study published in the Lancet, that found that there has been a significant drop worldwide in the number of women dying each year from pregnancy and childbirth. However, some advocates for women's health were reluctant to have the study released for fear it would reduce foreign aid for maternal health at meetings to be held in June and December. In my post I used a painting of women on bicycles by Tejuben to argue for an approach to development that does not treat women as patients or problems, but rather empowers them to lead lives that are physically active, independent and free. While an empowerment approach to development is applicable to poor men as well, I'll stick to women here.
The meeting referred to in June was most likely the G8 Summit held in Muskoka, Canada. Its Muskoka Initiative for Maternal and Child Health is a $7.3 billion package that can fund a laundry list of programs: pre-natal care; attended childbirth; postpartum care; sexual and reproductive health care and services; health education; treatment and prevention of diseases; prevention of mother-to-child transmission of HIV; immunizations; basic nutrition and relevant actions in the field of safe drinking water and sanitation. While the $7.3 billion fell short of what aid experts and NGOs were calling for, it seems that the global recession was a bigger consideration for donors than the positive news in the Lancet study. As of now, it looks like each contributing country will be able to decide on how it wants to spend its funds and there will be no coordination between them.
While a painting of women riding on bicycles can be symbolic of an empowerment approach to development, what does this mean in practice? If the $7.3 billion was to be spent using an empowerment approach, how would it be spent?
I was stimulated in my thinking by this article in Canada's Globe and Mail. The article is on a drug called misoprostol. With the exception of its use as an ulcer medicine, misoprostol is highly controversial.
When a woman delivers, if all goes well her uterus will naturally contract to close around her blood vessels. But in up to 15% of cases, the uterus can fail to contract and the woman can bleed to death within an hour. In the industrialized world, the drug oxytocin is considered the best to stop postpartum bleeding, but crucially it requires refrigeration and injection. In the developing world women have a one-in-100 chance of dying in childbirth because of postpartum bleeding.
Misoprostol can stop postpartum bleeding, and needs no cold storage or special services to deliver. Misoprostol can also be used for abortion and to induce labor. However, if misused, misoprostol can rupture the uterus, killing mother and baby.
The WHO (World Health Organization)'s position is that misoprostol can be administered by properly trained health workers, but cannot be administered locally. Yet the matter does not end there. There is a debate over who qualifies as a trained health worker, when birth attendants in poor settings tend to be relatives and neighbors of the pregnant woman. And several aid organizations have disregarded the WHO's recommendations altogether, and distribute misoprostol to women delivering.
Venture Strategies for Health and Development, founded by two physicians at the University of California at Berkeley and a health policy specialist, is one such aid organization. Dr. Potts of Venture Strategies calls the WHO's goals, of training health workers and getting more women to go to hospitals, unachievable because doctors don't want to work in rural areas. Instead, his organization gives misoprostol, with instructions, to pregnant women directly at their eight-month checkup.
Does giving misoprostol directly to pregnant women empower them? Dr. Potts seems to think so. He suggests that doctors are reluctant to have women medicate themselves because they are threatened by the notion that people can do for themselves things only doctors have done. Reading between the lines, doctors fear the loss of power in allowing women to medicate themselves. So by administering misoprostol themselves, women should gain power, which is really the meaning of empower.
However, I'm not so sure. According to this article on the Lancet study, one of the main reasons that the number of women dying from pregnancy and childbirth per year has dropped significantly in developing countries is because women are giving birth in the presence of either a doctor or trained health worker (however that may be defined).
In Orissa, for example, the same state in which Sainath documented the poor condition of the government health system, women are now given a monetary incentive to deliver children in hospitals rather than in their villages. While delivering their children in the kinds of hospitals Sainath describes is not likely to improve their chances of survival, this push by the government is being accompanied by funds through the National Rural Health Mission. There has also been discussion in the news about launching a new category of medical degree that will only allow doctors to practice in rural areas. It is hoped that this will address the shortage of doctors.
In Tamil Nadu, the fact that women are choosing to give birth in government rather than private clinics is being trumpeted loudly. Why is this something we should all celebrate? Because government clinics are, at least in theory, accountable to the people they serve. In my first job in the development sector, I was lucky enough to be exposed to an initiative to empower rural women to hold government health clinics accountable to them. Women both led their village health committees, which monitored Primary Health Centers and their sub-centers, and gained entry into committees at higher levels that oversaw these facilities. An empowerment approach to preventing maternal and child mortality to me is one that enables women to both use and, crucially, hold accountable, the government health system.
I'll end by returning to the misoprostol debate. I don't doubt that, with proper counselling, pregnant women can be trusted to use the drug safely, as they have been doing. Yet the arguments that Dr. Potts and his colleague Dr. Prata put forward for giving misoprostol directly to pregnant women are dangerous ones. If Venture Strategies is able to reach pregnant women for an eighth-month checkup, might it be possible to reach them at the time of delivery as well? I think there are better solutions to the problems of access to health facilities, whether because the facilities are not there or the women reluctant to go, than abandoning the idea altogether.