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Posts Tagged ‘Lancet

Why do educated and well-off Indians kill their girl children?

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Photo: UNICEF/Jason Taylor/2006

Can India balance its distribution of sexes at birth, is the question asked by The Lancet, in its commentary on the findings of a study on female foeticide in India.

“The prospects seem grim,” is the answer. They have been grim from the onset of economic liberalisation, and the links between relative affluence and the demand for sex determination tests and selective abortion has for two decades now been a matter of concern for social and community minded doctors. [See ‘Putting Women First: Women and Health in a Rural Community’]

The counter-intuitive link between two key factors of development – more years of education and households becoming wealthier – and female foeticide have for long been an under-documented subject. This weakness in documentation has been surprising simply because, whether in the mega-metropolises of Delhi and Mumbai or in the cities and towns that are fast-growing, the number of ‘clinics’ providing sex determination tests has also grown. These are often camouflagued within a welter of signs advertising the features of a polyclinic, where the services on offer to middle class Indian families can range from liposuction to cardiac surgery to hip replacement. What else they do is well known, but not spoken about.

That is why The Lancet commentary has said that the demand for sons among wealthy parents is being satisfied by the medical community through the provision of illegal services of fetal sex-determination and sex-selective abortion. “The financial incentive for physicians to undertake this illegal activity seems to be far greater than the penalties associated with breaking the law. The market for sex determination and selective abortion has been estimated to be worth at least US$100 million per year, and the pervasive nature of the low sex ratio at birth suggests that this is not a consequence of a minority of errant physicians in a few states.”

I would say that this is an under-estimate of the size of the sex determination and female foeticide ‘industry’. Since the machinery required is relatively expensive (compared to the needs of a typical public health centre) and the clients are – as this study now helps makes clear – middle class urban Indian households who do not balk at the bill, this figure may under-estimate the true size of this illegal and ghastly business by a large degree. We don’t know how much because it is hidden.

There’s no doubt India’s medical establishment must be held accountable on moral, social, and legal grounds for the staggering imbalance in India’s sex ratio, which the 2011 Census brings out in relief. [See the post on the first set of detailed state-level data is almost complete as a release from the Census of India, 2011 Census and also ‘A population turning point’.]

Of the 623 districts, data were available for 596 in the 2001 census and 588 in the 2011 census. The blue highlighted states are Gujarat, Haryana, Himachal Pradesh, and Punjab, which have shown consistently lower child sex ratios at ages 0–6 years in the last three censuses.

Although there have been efforts to increase the penalty for non-compliance on the part of technicians and physicians, the sluggishness of the Indian judicial system, and the absence of systematic record-keeping of births, will remain a major hurdle for effective implementation of the Pre-Natal Diagnostic Techniques Act. For example, 800 court cases against doctors in 17 states have resulted in only 55 convictions.

In  The Lancet, Prabhat Jha and colleagues have presented a timely analysis of trends in sex ratio at birth in India, and show that the ratio for second-order births, conditional on the first born being a girl, fell from 906 girls per 1000 boys in 1990, to 836 girls per 1000 boys in 2005. On the basis of this finding, the investigators estimate that there have been between 3.1 and 6 million abortions of female foetuses in the past decade. This is an astonishing sum – the upper value indicates a per day countrywide rate of 1,640 abortions!

“In view of the unverifiable assumptions that are needed to derive statistical estimates of sex-selective abortions, the value of the analysis by Jha and colleagues is mainly independent confirmation of two important aspects of the sex ratio in India that have been reported previously with different data,” The Lancet has said. “The first is that sex imbalance at birth seems to be particularly concentrated in households with high education and wealth. This pattern suggests that dominance of the son-preference norm is unlikely to be offset, at least in the short term, by socioeconomic development. Second is that the overall problem of sex imbalance seems to arise throughout India, including in Kerala, which has often been characterised as a model state for social development and gender equality. The problem of sex imbalance seems to be a function of socio-economic status, not geography.”

[The Lancet’s recent coverage of public health and India has been rigorous and exemplary. See this post for its series of papers on India’s path to full health coverage.]

Number of girls per 1000 boys (2011) by per-person availability of prenatal diagnostic facilities (2006) across states in India. Child female-to-male ratio at ages 0–6 years from 2011 Census of India. Prenatal diagnostic facilities calculated as per 100 000 women (age 7 years and older), based on number of facilities registered by state through 2006. Facilities include genetic counselling centres, genetic laboratories, genetic clinics, ultrasound clinics and imaging centres, mobile clinics (vehicles), and in-vitro fertilisation and infertility centres.

There is already coverage of the study and some analysis in the news media. Here is a selection:

Reuters has reported – Up to 12 million girls were aborted over the last three decades in India by parents that tended to be richer and more educated, a large study in India found, and researchers warned that the figure could rise with falling fertility rates. The missing daughters occurred mostly in families which already had a first born daughter. Although the preference for boys runs across Indian society, the abortions were more likely to be carried out by educated parents who were aware of ultrasound technology and who could afford abortions.

“The number of girls being aborted is increasing and may have reached 12 million with the lower estimate of 4 million over the last three decades,” said lead author Professor Prabhat Jha at the Center for Global Health Research in Toronto, Canada. “The logic is families are saying if Nature gives us a first boy, then we don’t do anything. But if Nature gives a first girl then perhaps we would consider ultrasound testing and selective abortion for the subsequent children,” he told Reuters in a telephone interview on Tuesday.

The Indian Express has reported – They analysed census data and 2.5 lakh birth histories from national surveys to estimate differences in girl-boy ratio for second births in families where the first-born child had been a girl. They found that this girl-boy ratio fell from 906 girls per 1000 boys in 1990 to 836 in 2005. “Declines were much greater in mothers with 10 or more years of education than those with no education and in wealthier households. But if the first child had been a boy, there was no fall in the girl-boy ratio for second child over the study period,” Jha said. The article authors said this suggests that selective abortion of female foetuses, usually after a first-born girl, had been more common in richer and educated families.

The Washington Post has reported – The study found that, from 1990 to 2005, the “sex ratio” of first-born female children in India did not change significantly nor differ from what was biologically expected. (In 1990, it was 943 girls per 1,000 boys, and in 2005 it was 966). However, in families whose first-born was a girl, the incidence of the second-born being a girl fell almost steadily over that period, from 906 per 1,000 boys in 1990 to 836 in 2005. During the period, the trend increased among families in which the mother had 10 or more years of education but did not change in families in which the mother had no education. The sex ratio fell especially sharply in the richest 20 percent of households, Jha and his colleagues found. The findings were the same in both Hindu and Muslim households.

The most extreme decline in the probability of having a girl occurred in families in which the first two children were girls. In that case, the ratio of girls to boys in the third-born child was 768 to 1,000 in 2006. This came at a time when the average family size in India was 2.6 children — a huge reduction from earlier generations. The overall phenomenon of many more boys than girls among children under age 6 was once limited to northern and western India. Now it has spread throughout the country, Jha said. In 1991, about 10 percent of India’s population lived in states where the sex ratio for girls was below 915. Today, 56 percent of the population does.

[The paper is: ‘Trends in selective abortions of girls in India: analysis of nationally representative birth histories from 1990 to 2005 and census data from 1991 to 2011’ by Prabhat Jha, Maya A Kesler, Rajesh Kumar, Faujdar Ram, Usha Ram, Lukasz Aleksandrowicz, Diego G Bassani, Shailaja Chandra, Jayant K Banthia and is published in The Lancet, 24 May 2011.]

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Universal health coverage in India, economic growth, and social justice

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The Lancet, 08-14 January 2011 issue, India health coverageThe Lancet has published, in its 08-14 January 2011 issue, a series of papers on India’s path to full health coverage. Taken together, the papers and comments show that a failing health system is perhaps India’s greatest predicament. The papers (pay only, the comments are free to read) reveal the full extent of opportunities and difficulties in Indian healthcare, by examining infectious and chronic diseases, availability of treatments and doctors, and the infrastructure to bring about universal health care by 2020. This Lancet issue with the India health coverage special brings together a rapidly growing body of evidence to show that Indian health is in grave crisis. As the country with the largest democracy in the world, India is well positioned to put health high on the political agenda.

Introduction to the Lancet Series – Indian health: the path from crisis to progress – Can India’s vibrant political process and civil society create the public demand for health reform? Do Indian health institutions — the Ministry of Health and Family Welfare and the health professions, for example — have the capacity to lead reform? In India, community identity rivals individual identity in importance. How do community identities shape attitudes and policies towards health? – Richard Horton, Pam Das (The Lancet)

The Lancet, 08-14 January 2011 issue, India health coverageUniversal health care in India: the time is right – India’s record in expanding social opportunities has been uneven. The health and nutritional status of children and women remains poor, and India is routinely ranked among countries performing weakly on overall health performance. But there is good reason for hope. The country has withstood the recent global financial crisis and quickly returned to rapid economic growth. There is a refreshing openness to participation by civil society and to the power of ideas to improve performance and governance. We are enthused by India’s recent commitments to invigorate the public health-care system to address health disparities. – Vikram Patel, A K Shiva Kumar, Vinod K Paul, Krishna D Rao, K Srinath Reddy (London School of Hygiene and Tropical Medicine, London, UK and Sangath Centre, Goa, India; UNICEF India; All India Institute of Medical Sciences; Public Health Foundation of India)

Securing the right to health for all in India – The health status of people transcends the health-care sector, and the social determinants of health, such as food, water, sewerage, and shelter, still elude large numbers of the poorest citizens in India. Inequity in social determinants of health and health care in a market-based system itself becomes a pathogenic factor that drives the engine of deprivation. These inequities are set to increase even further in the near future even as major investments are being projected and planned in the health sector from 0·9% to 3·0% of the gross domestic product. The stunted public health system is hardly geared up to absorb this increased allocation; already state governments are returning allocated money because of the inability to absorb increased allocations. – Binayak Sen (Christian Medical College, Tamil Nadu, India) (The Lancet writes: “One notable absentee from the launch of the Series on Jan 11, 2011 is paediatrician and Comment author Binayak Sen. He remains in prison, an appalling situation discussed in an Editorial in the Jan 8-14 issue of The Lancet.”)

Gender equity and universal health coverage in India – The findings presented on health-care coverage in India emphasise that maternal health concerns, such as fertility and maternal mortality, continue to affect large numbers of women and girls in India. Although these concerns are diminishing, present trends indicate that India is not on target to reach national and Millennium Development Goals. Too many Indian women and girls are unnecessarily affected by gender-based violence and inequities in health-care access and use. – Anita Raj (Department of Social and Behavioral Sciences, Boston University School of Public Health)

The Lancet, 08-14 January 2011 issue, India health coverageIndia: access to affordable drugs and the right to health – Competition from generic companies is the key to affordable drugs. Generic companies in India can therefore produce drugs at prices that are among the lowest in the world. This cost advantage means more than 89% of the adult antiretroviral drugs purchased for donor-funded programmes in the developing world are supplied by companies in India. The European Union and India free-trade agreement seeks to introduce TRIPS-plus and other measures, such as patent term-extensions, data exclusivity, increased border and enforcement measures, and investment protection agreements, all of which would impede generic competition. – Anand Grover, Brian Citro (Lawyers Collective HIV/AIDS Unit, Mumbai)

Good governance in health care: the Karnataka experience – The health sector, with high public interaction and large societal impact affecting almost the entire population, was the second most corrupt sector in India. Bribes related to health care comprised the highest portion of all bribes paid in the state of Karnataka in 2008, at 40%. More than 150,000 estimated households below the poverty line paid bribes for seeking basic health care in 2005 in the state. In 2008, 64% of all bribes paid in the state for basic services was by people living below the poverty line and amounted to INR650 million. – Hanumappa Sudarshan, N S Prashanth (Karuna Trust, Karnataka, India; Institute of Public Health, Bangalore, Karnataka, India)

Research to achieve health care for all in India – Many of the leading causes of disease burden across communicable diseases, non-communicable diseases, and injuries continue to be under-represented in this published research output, indicating that even among the limited papers on public health research, a large proportion do not address public health priority conditions in India. Distinct from published papers, an analysis of public health research reports produced in India also showed that the leading chronic non-communicable diseases and injuries were under-represented between 2001 and 2008. – Lalit Dandona, V M Katoch, Rakhi Dandona (Public Health Foundation of India, New Delhi, India; Institute for Health Metrics and Evaluation, University of Washington; Department of Health Research and Indian Council of Medical Research, Ministry of Health and Family Welfare, Government of India)

The Lancet, 08-14 January 2011 issue, India health coverageUniversal health care in India: missing core determinants – India’s growing economic strength is based on an economic model that has enhanced the very disparities that the call is concerned about. Promotion of medical tourism at the cost of universal primary health care has not been accidental, but the result of a policy that places the market above people’s basic needs. All health-care reforms have to respond to this political dichotomy in the economy of health. Any health-care reforms, including the national health bill and integrated national health system suggested, have to be placed within a national effort to provide food, water, shelter, sanitation, education, and other basic needs. – Ravi Narayan (Centre for Public Health and Equity, Society for Community Health, Awareness, Research and Action, Bangalore, India)

Towards a truly universal Indian health system – The current framework of economic growth is not designed to address the concerns of very large sections of the population, for whom it has directly perpetuated the situation of ill health and inadequate health care. This position is not one of mere semantics, since any sustainable recommendation needs to be set in an honest and robust analysis of the causes of ill health in India. Little mention is made of the severe, persistent, and near ubiquitous poverty that has characterised this era of so-called economic growth, in which 77% of Indians live on less than INR20 a day. – Amit Sengupta, Vandana Prasad (People’s Health Movement-India [Jan Swasthya Abhiyan], Uttar Pradesh, India)

Please see this page on the Lancet series for longer summaries of the comments.