The undying Malthusian arithmetic

From Population Control to Reproductive Health: Malthusian Arithmetic by Mohan Rao; Sage Publications, New Delhi; pages 287.

THIS is not a book about the orchestrated fears of population boom and demographic explosion. Anyone who expects such a perspective from the book will be disappointed. But for those who are interested in the debates on population boom theories and critical of policy approaches that are far removed from realities, Mohan Rao does justice. As a medical doctor by training with specialisation in public health and as an activist of the People's Health Movement a broad alliance of community initiatives, he is on a familiar terrain when he discusses the politics of population policies. The book is also important and relevant as it has come out on the 10th anniversary of the International Conference on Population and Development (ICPD) held in Cairo, which marked a paradigm shift in a context of entrenched neo-liberalism.

Mohan Rao emphasises is that despite overt or covert shifts in policy and despite the ICPD, the neo-Malthusian sway continues. The history of the Indian family planning programme, he argues, has been fraught with contradictions. But one strain that has been common to the entire programme and that which appears repeatedly in new "avatars" is the policy makers' obsession with stopping the "cascading numbers" at any cost. What is more insidious is the inculcation of this "problem" in the middle class consciousness in a massive way. Therefore, with this Central or State preoccupation with controlling the numbers, especially those of the numbers of the poor, it is little wonder that Mohan Rao, who teaches at the New Delhi-based Centre of Social Medicine and Community Health, finds medical students in his post-graduate classes identify with much conviction, "population explosion, Acquired Immune Deficiency Syndrome and cancer" as the major health problems in India.

The author traces the "national consensus" on the population "problem" to state policy as embodied in the Five Year Plans up to the Fourth Plan. It was from this Plan that a mild change in policy direction took place. He quotes from the First Five Year Plan (1951-56): "The pressure of population is already so high that a reduction in the rate of growth must be regarded as a major desideratum." Such sentiments are repeatedly articulated in the subsequent Plans. There were slight modifications but the thrust remained the same.

Mohan Rao's primary purpose in the book, in his words, "has been to locate and critique the family planning programme in India, its assumptions, unstated biases and implications".

The entire public health infrastructure, he notes, has been "suborned for family planning". This situation has not come about owing to the myopia of planners alone but is an outcome of the conscious intervention of international finance institutions, the World Bank in particular.

The first chapter exposes the government's biases regarding population control. The second and the third chapters titled "Red Herrings: Malthusianism and Neo-Malthusianism" and "Beyond Malthusian Arithmetic" examine what the author calls the ideological underpinnings of population control. These chapters are a reminder that we live in "shamelessly ahistorical times", as the notions of eugenics and racial purity appear to be staging a come back.

The dominant thread of the population policy had always been one of disdain for and fear of breeding by the poor. This idea was pervasive not only within the country but internationally too. Whatever little change has taken place is the result of international lobbying. However, even now, when concepts such as reproductive rights, sexuality and control by women over their bodies are talked about the issue of primary health care is sidelined.

The Plans gave different rationales for strengthening the population control methods. The Third Plan accorded very high priority to family planning, drawing inspiration as it did from the Bhore Committee, which recommended that family planning should be in the nature of a mass movement. The Fourth Plan observed that in order to make economic development yield tangible benefits for the ordinary people, it was necessary that the birth rate be brought down substantially as early as possible. It also had a proposal to step up targets for sterilisations and Intra Uterine Contraceptive Device (IUCD) insertions and to widen the acceptance of oral and injectable contraceptives. Vasectomy, says Mohan Rao, received great official impetus, especially in the context of the failure of the IUCD programme. In fact, when the Collector of Ernakulam, S.S. Krishnakumar, organised a historic vasectomy camp in December 1970, 15,000 vasectomies were performed in a single month in an almost "festive atmosphere" replete with incentives. But despite this, there was an overall sense of despondency regarding the progress in population control. There was some acknowledgement that the problem could have been owing to the move to seek advice from foreign advisers. The Estimates Committee of the Lok Sabha, in its 13th Report on the Family Planning Programme (1971-72), observed: "The Committee regrets to note that the IUCD programme was formulated and implemented on the advice of foreign advisers, without analysing its pros and cons and without exercising an independent judgment on its suitability in Indian conditions and without establishing any proper infrastructure for the same...." This was the period, Mohan Rao says, of "the greatest, most obvious involvement of foreign donors and international experts". But the more significant observation that he makes is that although the proportion of finances from international donors has never been significant - they have exerted a disproportionate share of influence.

Mohan Rao quotes Nicholas Demerath, who had worked as an expert in the Indian family planning programme in the 1960s, as saying that the first reason why family planning fails is the obsession of the experts with the techniques of contraception. "The belief that just about any problem can and will be fixed by some new tool or technique is as Anglo-American as apple-pie", says Demerath. In fact, Mohan Rao says that the Indian family planning programme is a history of monumental failures.

It was only after the Fifth Plan that this trend was somewhat reversed but the underlying ethos remained the same. While the Plan emphasised on enhancing the development outlay for the health sector and integrating family planning services with those of health, maternal and child health and nutrition, it set a target of 18 million sterilisations, 5.9 million IUCD insertions and 8.8 million conventional contraceptive users. And while the integration of programmes was the guiding philosophy, separate allocations for family planning continued to be the norm, says Mohan Rao. The understanding of why the poor procreate more, even if they do and that population control could never be independent of other social and economic objectives, did not become part of the policy framework. The neo-Malthusian refrain continued in subsequent policies, including the National Health Policy 2002.

According to Mohan Rao, it was in the course of the Fifth Five Year Plan that some of the excesses were committed in the name of family planning. He says it would not be an exaggeration to state that the scars of the family planning programme of the Emergency period still rankle as they gave a bludgeon blow to the credibility of the health care system. It was "undoubtedly the largest ever loss of lives in the history of a welfare programme". This was a period of harsh incentives and disincentives. Government of Maharashtra suggested compulsory sterilisation.

But towards 1980, the shift began. As sterilising men proved to be "politically costly", as Mohan Rao puts it, government policy turned to the silent half of the population, women. A working group on population policy set up by the Planning Commission asserted that "population policy and general development strategy are two sides of the same coin", but recommended that the programme "for the immediate future be increasingly centred around women" since they were "the best votaries of the programme". This approach towards women and the concept of the "unmet needs" still prevails.

In Chapter 2, which deals primarily with the ideological underpinnings of population control theories, Mohan Rao argues the concepts of Malthusianism and neo-Malthusianism are not conceptually or methodologically distinct. "They differ insofar as the victims of their ideas or methods are concerned," he observes. While Malthusians were concerned with the poor of their respective countries, neo-Malthusians looked at the poor in developing countries. While Malthusians spoke of moral restraint, the latter came equipped with contraceptive technology. The difference, it would seem, was only of technology while the basic perception remained constant.

As the jargon changed under new pressures from outside, attention shifted more and more from primary health care to "reproductive rights". While there was nothing wrong with the notion of reproductive rights per se, the focus was confined to the question of meeting the "unmet needs" of women, that is, contraceptive needs. It lacked the understanding that there just might be other needs for women as well, including those of comprehensive primary health care.

Mohan Rao believes that the "largely American, bourgeoisie feminist agenda was what shaped the consensus at Cairo, if indeed consensus it was". The agenda included "rechristening family planning programmes as reproductive health programmes, and population control programmes as gender equity programmes," and providing "a politically correct rationale, a new lease of life" to discredited programmes. "It was indeed a case of new wine in old bottles."

It would not be incorrect to say that the trend continues even now. It is incomprehensible why the "number" obsession continues despite overwhelming and overarching evidence pointing out to the dictum "development is the best pill" - a sentiment articulated by none other than the Indian Minister of Health and Family Planning in 1974 at the Bucharest World Population Conference.