Moving beyond the beneficiaries of technology

MADHU BALA NATH

ACCORDING to the ninth five year plan, India had set ambitious goals for the year 2000, with clearly articulated indicators to measure these goals. As the plan period comes to an end, the scores on the ‘National health report card’ as Menon-Sen and Shiva Kumar1 put it, are as yet very low.

Why has this happened? The last three decades of the 20th century had witnessed great advances in medical technology, raising hope that the universal goal of health for all would be achieved to a large extent, if not completely. These advances pertained not only to technological discoveries but their extensive use by clients. Appropriate, affordable and accessible technology remained the watchword for development workers as they went from one international conference to another – from Rio to Cairo to Beijing to Copenhagen. These three A’s appeared in all intergovernmental plans of action that emerged in the decade of norm and standard setting – the 1990s. The figures below indicate that these norms and commitments, however, did not translate into real gains in the lives of men and women.

 

 

To take the case of contraceptive technology as an example, in India, currently less than half of the couples in the reproductive age group use any kind of contraceptive technology.2 In the highly populated and poorer states like Uttar Pradesh and Bihar the percentage is much lower – a mere 30%.3 Access to technology seems to be least where it is most needed. The states where contraceptive use is the lowest, where it is justified to assume that women’s need for safe abortion services is the greatest, have in fact the lowest share of approved centres for the medical termination of pregnancy. In Uttar Pradesh and Bihar there are less than five centres for a population of a million people.4

 

Illustrative Goals for Health and Family Welfare by the year 2000

 

Indicator

Most recent estimate

Goal for 2000

Infant mortality rate

70 (1999)

Below 60

Perinatal mortality rate

42.0 (1998)

30-35

Crude death rate

8.7 (1999)

9

Maternal mortality rate

4.07 (1997)

Below 2.00

Life expectancy at birth (years)

Male

Female

 

63.0 (1996-2001)

63.4 (1996-2001)

 

64

64

Babies with birth weight below 2000 grams (%)

30 (1993)

10

Crude birth rate

26.1 (1999)

21

Effective couple protection rate (%)

45.4 (1998)

60

Total fertility rate

2.85 (1996-98)

2.2

Pregnant mothers receiving antenatal care (%)

65.1 (1998-99)

100

Deliveries by trained birth attendants (%)

76.7 (1998-99)

100

Immunization status (%)

42 (1998-99)

100

 

These figures point to the reality that we do not have the infrastructure to take technology to the masses. A gender analysis of this scenario reveals that only a very limited number of women in India have the opportunity to use medical technology to choose whether or not to have a child.

Technology demands a good infrastructure as well as a harmonised policy environment. This again remains a gap in India. The public health system emphasises permanent methods like sterilisation or long term methods like intra uterine devices (IUDs). As a result sterilisation accounts for more than 75% of total contraception, with female sterilisations accounting for 95% of all sterilisations.5 These kinds of gender unfriendly approaches to reach technology to the masses have resulted in reduced interest to access health technology. Added to this are factors like embarrassment of consulting a male doctor or the lack of privacy in the health centres that contribute to widening the ‘beneficiary access gap’.

 

 

Given this background, the onslaught of the HIV/AIDS epidemic has only worsened the situation. The epidemic in India is in its second decade and unfortunately the disease has emerged as a disease of social exclusion and disempowerment. The prevention options today, i.e. male condoms, mutual monogamy and treatment for sexually transmitted diseases are not feasible for millions of women in the country. Today 25% of the four million people living with HIV/AIDS in India are women and these numbers are growing. Yet, ironically, there is now little doubt that technology can prove to be an empowering tool, not only for prevention but also for the care of those infected and affected by the mutating virus.

Peeping into the future, the potential of the technology in reducing vulnerabilities is emerging in the discourse around the development of microbicides, the effective use of the female condom and the development of the vaccine. None of these are as yet available for users in a safe and user friendly form, but even when all these preventive technologies are in place and available to large masses of the population, it is the strategic decision to position HIV preventive technology as a means of protection against HIV and not dilute this message with other potential benefits, e.g. contraception, that will decide whether men and women use it to increase their negotiating power to reduce their vulnerability to the epidemic.

 

 

Let us take care not to go the ‘condom way’. The images of the epidemic throw up a disturbing collage – a collage of young boys and girls being sexually abused and placed at risk with little or no access to the well-known source of dual protection – the simple condom. Images of women faced with dilemmas and at times raising pertinent posers: Can a woman really be sexually assertive? Can she even think of differing from the concept of mutual fidelity when she has been socialised and brought up on the principle that her husband is God?

Can a woman ensure safe sex by suggesting that her sexual partner wear a condom, when the very suggestion of condom use carries with it an indication of infidelity that could threaten her personal security and destroy the relationship? Furthermore, if the woman did have sex using a condom, how would she be able to prove that she is fertile to a society where her status is dependent on her being able to bear a son? These are some of the dilemmas that women are confronted with as medical technology marches ahead. The HIV virus can be prevented only when such conflicts and contradictions are addressed.

Then there are images of young men and women living with the HIV virus, unable to ward off recurrent opportunistic infections as they may or may not be close enough to a medical service provider who could prescribe and provide the necessary palliatives, ORT packets or ointments and bandages. These images get further entangled to blur the collage. It is these young men and women who at times have heard of the great advances made in medical technology – the discovery of AZT, the drug cocktail, the nevirapine – cocktails and concoctions that can make their lives more meaningful. Yet, they tell us that they are starved as access has been difficult. The costs are formidable, there is no infrastructure to monitor the effect of these drugs on the body – it is like seeing food on the table when you are hungry, but are unable to eat it!

 

 

The collage has not yet ended and the faces of women, young and old, loom large. These are women facing the dual brunt of the HIV/AIDS epidemic – as those living with the virus and as those caring for people living with the HIV virus. These are women who are riddled with a host of ethical dilemmas. Should I conceive a child? Will I be able to terminate my pregnancy, if I so decide? Or will I have access to the short regimen of AZT so that I can bring into the world a child free from the HIV infection? But what, once the child is born? Will I get this child into the world only to be orphaned as service providers, in keeping with the government’s policy, stop the supply of AZT for my treatment and care once the child is born. The list of questions goes on.

 

 

The collage also captures a dream. It is these very women, who are dreaming a dream as they live and cope with the epidemic in India, at a time when new and emerging technologies are offering new hope and opening new vistas.

The turn of the century is witness to collaboration between Hindustan Latex and the Female Health Company in the UK to develop the female condom. This joint project was launched in February 2002 and HLL has sought the permission of the Drug Controller General of India to produce the female condom in India from locally sourced materials. Social acceptability studies on the female condom have already been launched in Andhra Pradesh, Maharashtra and Kerala.

The turn of the century also saw some technology studies in the development of microbicides, another female initiated if not a female controlled method for HIV prevention. Scientists are pursuing 60 product leads. Some candidates are in the safety trial stage while a couple of these candidates are been tried for their efficacy. At the same time, the country has entered into a dynamic collaboration with the International AIDS Vaccine Initiative to launch a programme for the development of a preventive vaccine for the HIV/AIDS virus in India, a vaccine that is envisaged to stop the spread of the HIV-2 clade C virus that is predominant in India.

Will this dream, this hope, get transformed into reality? It remains to be seen. Female controlled preventive technology is on the anvil as these options do not essentially require the cooperation of the male partner. They have the potential to place the power to protect squarely in the hands of women. This, therefore, can not only empower, it can emancipate them. But the challenges before this utopia can materialise are many. Access to preventive technology for HIV/AIDS has to be envisioned and implemented as part of a larger programme of health care that aims at ensuring safety and quality services so that technology can not only be accessed but monitored as well. This client-friendly, gender-sensitive programme will need to be implemented as a package of reproductive and child health services that includes services of HIV prevention, HIV management and HIV care and support.

 

 

Special components of this programme will need to include a micro credit fund to enable access to technology, especially for women in resource poor settings as well as ongoing engagements of the society in questioning and challenging gender inequalities and gender norms. This is critical. This kind of integrated approach to technology development and dissemination will reduce stigma and discrimination against the beneficiaries of medical technology who are living with, or are at risk of, the HIV virus.

As reduction of stigma and discrimination is central to any effort aimed at HIV prevention, the programme would essentially need to be developed within a rights based approach. For this a categorical sensitisation to gender and human rights issues for the service providers will be necessary. As India witnesses the entry of the largest ever generation of adolescents (the 10-19 years represent one fifth of India’s population), we are faced with the ever compelling need to target programmes centred on preventive technology for HIV/AIDS on this group. They will need to be seen as the ‘real’ recipients and beneficiaries of technology.

Needless to add, the course charted above cannot be successful without ensuring that technology is embedded within a framework accommodating the social, cultural and political context in which HIV has arisen and is perpetuated. It is the adolescents who can be the force for change to evaluate these contexts and engage the community to re-examine and reframe them. Of special importance is the reframing of the gender context. The female condom presents an excellent example to illustrate this point.

 

 

In 1993, Ford and Mathie reported an overall shift from a pre-use ‘neutral attitude’ of couples to the female condom to a diversity of ‘positive’ and ‘negative’ attitudes over three months of use. They noted that after three months, 52% of the 67 couples generally felt positive about the use of the female condom. In the same study however, 36% of them felt negative and the remaining 12% were cases that responded with a ‘no or don’t know’.6 Besides reasons like high cost and lack of availability, the female condom was perceived by some men to have the potential to change existing social and gender relations.

Whereas some partners resisted the use of the female condom fearing that their wives might become promiscuous and thus change the existing social balance in which only men are allowed to be promiscuous, other men felt that introducing the female condom in a relationship provided an opening for communication on sexual matters otherwise not discussed. A study in Senegal also pointed out that the female condom increased women’s knowledge about their bodies and gave rise to discussion between men and women on sexual and reproductive health, at times reinforcing women’s bargaining power.

 

 

What is interesting is that this preventive technology has been the key to triggering these changes in gender relations. This change has come about without violence, which has often been the bane in programmes on women’s empowerment. Empirical data has shown that whereas women reported ‘fear’ of violence by their partners as a barrier to negotiating the use of the female condom, in Kenya, violence took place in only one of the 96 sexual encounters.

In a study in Papua New Guinea, where the prevalence of violence against women is high, only four cases of violence occurred among the 224 women asking their partners to use the female condom. In fact in Zambia men are now purchasing female condoms more often than women! I am reminded of the women who protested in Rio de Janeiro during the Earth Summit in 1992 against technology that was polluting women’s lives. They marched with banners that read: ‘If it is not appropriate for women it is not appropriate!’

We have come a long way from that state of affairs as the experience with the female condom has shown. Let us hope that the launch of the microbicide and the preventive vaccine brings with it similar outcomes. Outcomes that move beyond access and use by beneficiaries of technology, to outcomes that change the way societies think and act for the better; outcomes that can bring solidarity with issues of justice, of equality, of equity and above all of respect and dignity for all.

 

Footnotes:

1. Women in India – How Free? How Equal? Report commissioned by the office of the United Nations Resident Coordinator in India, 2001.

2. Ibid.

3. Ibid.

4. Ibid.

5. Ibid.

6. Madhu Bala Nath, How to Empower Women to negotiate Safe Sex – A Resource Guide for NGOs.

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