A representative image of a government hospital. Photo: PTI
The orientation of medical science is such that cisgender heterosexual men are taken as the default bodies. The focus for women’s health thus remains on what is seen as the “differences”: uteruses, pregnancies, contraception, hormones, vulva and so on. This is problematic on several levels. First, it ignores the existence of different types of women. Transwomen, women without uteruses, women who don’t seek to get pregnant and queer women are all excluded from the ambit through such approaches. Moreover, this approach marginalises all women and cannot cater to all the needs of even cis-heterosexual women, who are supposedly normalised.
A WHO report on gender and health in India demonstrates how women have unequal access to the determinants of health, that is the socioeconomic factors that determine health. The report also shows that reproductive health issues are only one of the many causes of poor health in women – with communicable diseases, cardiovascular diseases and chronic obstructive pulmonary disease, diarrhoeal diseases featuring in the top ten causes of mortality in women. The top ten causes also feature diabetes and falls as causes of death in women, but not men. Women also suffer disproportionately from anaemia and injury due to intimate partner violence. Thus, it is evident that we must see women’s health and illness in the context of their lives and livelihood.
Access to medical care
Within the realm of medical care, women are less likely to be able to access medical care. This is evident in the late diagnosis and poor follow-up seen in diabetes and hypertension. Moreover, women are not only less likely to be able to access formal care but also receive less informal care. This is a result of the existing gender norms which make caregivers out of women but don’t ensure care for them. Poverty, food and income insecurity reinforce these norms thus worsening health outcomes.
Even as the country struggles with issues of livelihood and food security, women bear the brunt of this dearth. A recent visible example of this would be the women workers that thronged the national capital protesting the budget cuts, poor wages, lack of jobs and introduction of an ill-considered NMMS app for MNREGA workers. The MNREGS by official estimates employs more women than men. Yet, in reality, women are struggling to make ends meet despite being eligible for jobs. In a world where women work several times more than men within the household, such weakening of schemes only further the heteronormative patriarchal division of labour. The lack of work opportunities thus forces women back into the household and keeps them dependent on their male counterparts. According to the press releases of NREGA Sangharsh Morcha, several women haven’t received their wages due to tussles between the Union and state governments as well as inappropriate technology. The women who take up different jobs are often exploited and paid poorer wages. This not only violates their right to work but also affects their health by affecting their diet, nutrition and access to care.
The food security schemes, too, target women during their pregnancy. According to the National Food Security Act 2013, pregnant women should receive Rs 6,000 to ensure better nutrition during pregnancy. The current schemes carry this out through the Janani Suraksha Yojana and Pradhan Mantri Matru Vandana Yojana. These schemes almost incentivise this provision to ensure Ante Natal Checkups. Given the state of primary health care in the country, this adds a barrier even to pregnant women who may then not receive adequate nutrition. Meanwhile, the changes in provisioning of ration, too, affect women. Recently, the government cut back food entitlements to 5 kg (albeit for free instead of the subsidised rates). Packaged as a gift to the people, the government has masked the cancelling of the extra provisioning of ration in the garb of “free ration”. To buy the extra ration, families would need to pay far more. Within the household, women bear the impact of this. We see this in the latest NFHS data where malnutrition continues to plague women and children. In the midst of this, band-aid solutions targeting specific micronutrient deficiencies are inadequate. What is the use of IFA tablets for six months of pregnancy if women are to remain deficient for the rest of their lives?
The lack of food security combined with income insecurity makes women vulnerable in several other ways. It makes them more vulnerable to intimate partner violence, child marriage and less likely to be able to escape abusive situations. For context, 29% of married women face gender-based violence in India according to NFHS-5. Food insecurity also forces several women to engage in unsafe sexual practices – both within relationships and in sex work. This leads to increased rates of sexually transmitted infections in women, especially transwomen. The focus of most schemes is on reducing transmission rates, not the health of the women themselves. This makes it difficult to address the social determinants that are making women vulnerable in the first place. This is not to say that medicines and condoms should not be distributed, they should. But it is necessary to address the factors that lead to such vulnerabilities.
It is obvious that the rights to livelihood and food are essential to improve the health of women. There is a need to strengthen the existing social security schemes and enhance their provisions over time. We need to refocus women’s health in a way that centres on the health condition of the woman and her context. First, we need to start thinking of women as whole people existing beyond the function of reproduction. The health of women is not just a means to improve society, reduce infant mortality, reduce population, etc. The improvement of women’s health is a complete goal in and of itself.
Shivangi Shankar is a medical doctor currently pursuing her Master’s in Public Health at the Centre of Social Medicine and Community Health, JNU.