MANUFACTURING CONSENT

MANUFACTURING CONSENT: IMPACT OF DONOR AGENDA ON THE WOMEN'S HEALTH MOVEMENT

Newsletter Sept-Dec 2005

The Indian women’s movement has been a part of the international women’s movement with a focus on India-specific issues all along. Women’s health was not one of the first issues addressed by the Indian women’s movement but the primary concern was violence against women - rape, dowry related violence and domestic violence, and a nationwide mass mobilisation of women occurred around the ‘Mathura rape case’. Women’s health as an issue for the women’s movement emerged in the early 1980s. Protests and court cases against hazardous injectable contraceptives was the beginning of the women’s health movement in India. These protests were against either the utter neglect of the women from the health delivery systems and/or the coercive State policies. The ‘State’ was thus the first target of the women’s health movement. As the women’s movement gained focus, stability and ‘status’ it caught attention of the international funding agencies such as the Ford Foundation, MacArthur Foundation, Population Council, United Nations Fund for Population Activities [UNFPA] etc. Funding started as a trickle but soon became a flood.

Impact of Donor Funding on Different Issues of the Movement

Looking back over the 20-25 year period provides an interesting angle to the funding priorities of the donor agencies. If a comparison is made between the impact of donor funding on the ‘violence against women’ versus ‘women’s health’ as campaign issues a very different picture emerges. As long as violence against women is being dealt within the personal domain such as rape or domestic violence, there is ample donor funding but its impact on the nature of activism or campaign strategies appears minimal. Exception to this is violence associated with ‘trafficking’, which does not fall into the category of domestic violence. Trafficking tends to receive larger assistance because it has an impact on the notions of nationhood, cross-border migration, international trade compulsions, etc.

On the other hand, in the context of women’s health the nature of activism has been deeply influenced by the donor assistance. The stress on population control as well as large financial interests of the pharmaceutical industries have a deep impact on donor assistance. Some of the ‘advisors’ on boards of donor agencies are/were directly or indirectly associated with pharmaceutical industries. This kind of nexus is seen in other fields too - a well-known example is of arms dealers sitting as advisors on security measures for a country! Internationally, stabilizing population growth of a developing country like India is deemed important to promote sustainable development, to improve trade, to mitigate illegal immigration, and ease potential conflicts. Controlling population of certain sections of the society is also considered crucial at the national level especially when the question revolves around politics and Panchayat level elections. Donor assistance has certainly played a role in determining priorities of the governments and priorities of NGOs working on health.

Changing Trends in Donor Assistance

The State-sponsored Indian family planning programs launched in the 1950s from the very beginning were coercive, with notions of incentives and disincentives. As early as in 1961, the Mudaliar Committee recommended disincentives. Donor agencies, particularly the Ford Foundation, had started funding various programmes since the early 60s. The funding was either directly channelised for family planning or was indirectly used to ‘develop’ scientific expertise and political leadership, which in return would help in the perpetuation of the myth of ‘over’ population. The grip of various funding agencies such as World Bank and USAID became firmer when they got opportunities to provide major financial help following droughts and economic crises of 1966. At no point in history did the funding provided by the international donor agencies exceed a tenth of the total Indian health budget, however, the donor agencies exerted a disproportionate share of influence on the State health policies.

Cairo was considered as a landmark conference by many, as there seemed to be a ‘consensus’ about reproductive rights and the notion of a ‘feminist’ population policy at the end of the conference. However this ‘consensus’ failed to provide any context for the majority of women in countries like India. Political, economic, cultural and social factors which influence women’s health and determine understanding of fertility, sexuality, reproduction and gender roles for Indian women were not seriously taken into account. The narrow emphasis on ‘reproductive freedom’ is not meaningful for many urban Indian women and it leaves the majority of the poor, rural Indian woman completely untouched. In order to assert social, economic and political rights, a major change in the framework is necessary. It consists of challenging the macro economic policies such as structural adjustment and neo-liberalisation which are pushed by the same international donor agencies which advocate population control. In addition, there must be a demand for other rights – to life, to work, to property, since ‘reproductive rights’ alone cannot be the answer. Further, this push has to extend to land reform, expansion of social services, and more even-handed distribution of resources. Indian women’s movement has to strive for this shift in paradigm which will ensure equitable development and bring down the birth rates.

Further Retreat of the State as a Healthcare Provider

In a variety of ways macroeconomic policies of liberalisation have had an adverse impact on women’s health. In India the expenditure on health was poor to begin with. The State was failing to provide comprehensive healthcare to most of its citizens. Now, there is a further retreat by the State from the realm of welfare and social entitlement. While appearing to be concerned to provide an increase in the contraceptive choices, giving woman a choice for regulating her fertility, the State has relinquished its responsibilities to be an active partner in reproductive health programmes. Worse still, the State has formulated an official policy for giving a formal status to the NGOs as providers of health care. Most of the NGOs working in the health sector are being funded by the international donor agencies. Thus, directly and indirectly the donor agencies are regulating the status of health care programme in the country.

Under pressure from the market forces the State is further distancing itself from even the regulatory aspects of the healthcare delivery. One way in which this distancing is manifested is by lowering safety standards for various drugs and devices. The drug for Emergency Contraception [EC] is one such case. EC is a method for prevention of undesired, unplanned potential pregnancy. Drug for EC was introduced for the first time as a prescription drug in the year 2002-2003. The reason for introducing it as a prescription drug was to do with the side effects, about which the woman should be warned. The drug used for EC has not changed in the last 2-3 years, neither has revolutionary new information become available about it which would make the it particularly safe and without any side effects. However, in September 2005, it was declared over the counter (OTC) drug thereby implying that it can be used without any kind of advice or supervision from the expert! This change in practice to make drugs readily available to increase their sale is an unethical trend. From other examples it appears as if the trend is likely to become more common as exemplified by another drug called RU486.

RU486 is a drug recommended for inducing early medical abortion under medical supervision by the US Food and Drug Administration [USFDA], an autonomous body which monitors, regulates and licenses various drugs for specific use in the United States. The USFDA recommends that RU486 may be used under medical supervision which extends to 3 visits because there are many side effects of RU486 which can be dangerous to the woman’s health if they go unnoticed, e.g. 5-10% women do not abort their foetus completely and need further medical intervention to ensure complete abortion. In 2003, WHO and Ministry of Health and Family Welfare [MoHFW] organised a national consensus building exercise and came up with extensive guidelines for the use of RU486. These guidelines are elaborate and do take a note of USFDA warnings about its use. What are the chances that the State will buckle under pressure about RU486 too and allow its use as a readily available drug for medical abortion without doctor’s prescription or supervision?

Role of NGOs as Healthcare Provider vs Healthcare Vigilantes

As mentioned earlier, the State is actively encouraging the participation of NGOs in healthcare delivery. In fact, the National Population Policy 2000 lists partnership with NGOs as one of the strategic themes. Further, the 2003 guidelines issued by MoHFW, for NGO involvement in ‘family welfare’, were prepared with ‘generous technical and financial support’ from the UNFPA. This document states that NGOs are supplementary and complementary in nature to that of the government and thus have comparative advantage of flexibility in procedures, and a rapport with the local population. While highlighting their role and flexibility the document still insists that the grants given to NGOs are dependent on their ‘performance’. Thus, not only does the State adhere to its emphasis on incentives but it also insists that NGOs follow the suit and adhere to the target oriented approach!

Unfortunately, a significant proportion of this work in the health sector is executed by the same NGOs which get funding from the international donor agencies for achieving the targets set by the State, thus completely jeopardising their ‘non-government’ status! These contradictions in the workings of the NGOs, donor agencies and the government together is obvious in an extreme case of coercive population policy measure such as chemical sterilisation with Quinacrine. Use of Quinacrine in India is chequered with unregulated, illegal ‘clinical trials’ by NGOs in collaboration with anti-immigration NGOs in the US, and vested corporate interests.

So the question often arises as to what is the role of NGOs and what is the role of the movement?

Illustrating the dilemma with a concrete example would be useful here. Parivar Seva Sanstha [PSS] is an NGO which has been working in this country for more than 20 years. Its role over the years has included distribution, Post Marketing Surveillance and building a body of information in favour of injectable contraceptives, despite well-known concerns of the women’s movement. In October 2004, PSS organised a meeting in Manesar, supported by MOHFW, Packard Foundation, UNFPA. Senior managers of Pfizer, which manufactures Depo Provera, the hormonal injectable contraceptive, were also present at the meeting. The organisers and funders of the meeting were of the opinion that injectable contraceptives positively enhance women’s ‘basket of choices’. The primary aim of the meeting was under the pretext of ‘dialogue’ with groups and people from all walks of life to evolve a ‘national consensus’ and a roadmap for their introduction in the national family planning programme. This would, of course, ensure a huge market for the Pfizer product! Along with a few other groups who have been active, vocal opponents of this idea, we were invited for the meeting. Instead of providing legitimacy to the decision which this meeting was hoping to achieve, we declined. Instead, we, along with 63 groups from all over the country signed a petition resisting the introduction of injectables. This pressure compelled the government to say it was not going to introduce injectables at this point of time.

The Manesar meeting ‘roadmap’ is another way of ‘manufacturing consent’. During this meeting the ‘Forum for Expanding Contraceptive Choices’ was renamed ‘Advocating Reproductive Choices’ (ARC) and many NGOs were reportedly joining the forum with its Secretariat at PSS. This incarnation as ARC with representatives of health professionals, service delivery organisations, manufacturers and suppliers of contraceptives, international reproductive health experts, is calling on the Government of India to ‘strengthen the availability of injectables’, deemed to be a safe method. Despite these contraceptives being hazardous and unacceptable to the women’s movement, groups like PSS, bodies like the UNFPA, Population Services and MOHFW are working very hard to evolve a national consensus! We do not have to pause and ask what is the priority of the State, but if we have to visualise the role of NGOs in women’s movement we certainly need to ask - what is the priority of the participating NGOs - Population control over women’s health? Contraceptive cover over safety?

From the very start, the Indian women’s health movement has struggled against the power of State propaganda. Behind seemingly harmless slogans of a ‘Small Family Being a Happy Family’ were the history of coercion, violence and utter disregard for women’s health and well-being. The State continues in its efforts to build a ‘national consensus’ for its repressive programmes. Yet today, when funding agencies and NGOs are themselves using the language of ‘evolving consensus’ it is necessary to ask: for whose agenda is consent being manufactured? We have to strive to maintain the autonomy of the women’s health movement despite the dialogues, consortiums, networking and working only towards agendas set by international or UN kind of bodies.

Manufacturing Consent: Steady Onslaught

Donor agencies have been steadily working their way towards manufacturing of consent. Preceding direct intervention in population related activities, Ford Foundation, since 1952 has spent millions of dollars on biomedical research, training and research in demography, with a neo-Malthusian tilt. They have achieved this by funding for the Population Reference Bureau, providing Population Council fellowships, funding United Nations Demographic Centres and through Universities, including London School of Economics and Johns Hopkins Institute. The products of these efforts are well-moulded in the ideology voiced by the donor agencies. A few examples would help illustrate the point.

UNFPA, provides support to more than 140 countries and manages the majority of the world’s multilateral population assistance. Since 1969, UNFPA has provided more than $6 billion for voluntary family planning and related health care in developing countries. They also work with the countries to track and analyse the distribution, structure, size and dynamics of populations, to help develop the International Migration Policy Programme. Despite the euphemism about ‘freedom of choice’ and ‘reproductive rights’ UNFPA ‘constructively engages with’ though ‘not supporting’ China’s coercive population policy! This is no different from the United States saying “In areas of economic liberalization and human rights, the United States has adopted a policy of engagement”. In one of the rare instances of frank admissions of intent Carmen Borroso, from MacArthur says: “For many foundations, the basic motivation is to curb the rate of growth. I would say that, for all foundations, this motivation plays some role, in one way or another. The question before us then is: does it matter?”

The notion of ‘evolving’ consensus or ‘manufacturing’ consent is not restricted to any single field. Telling historical lies to school children repeatedly as textbook information, without providing access to factual information is sufficient to create opinions that are considered ‘desirable’ and/or ‘beneficial’ to a given country. There are examples of this kind which are familiar to many. Similar tactics can be used by donor agencies too! Another example is the Public Service Broadcasting Trust [PBST], an autonomous body working in collaboration with the State-run Prasar Bharati Corporation. PBST’s mission statement was, “To create and sustain an independent, participatory, pluralistic and democratic space in the non-print media, distanced from commercial imperatives and state / political imperatives.” It was to provide for a minimum of 52 documentary films a year, which will help widen the public discourse on a range of issues by creating programming for the national, state-run television broadcaster, Doordarshan. Since its inception PBST has worked to protect ‘freedom of speech’ of the filmmaker by taking on the role of the negotiator and mediator – minimising interference and pressure of State agenda. In the year 2005, UNFPA and MacArthur together plan to fund upto 26 films on India’s population & reproductive health through PBST, focussing on issues defined by them. These issues may be as politically correct as ‘sex determination’, however, they are still framed by a ‘population stabilization’ agenda. Their commissioning brief seeks work to be created in collaboration with ‘their experts’, and based on research to be whetted by them! This new situation will certainly translate as reduced autonomy of film-makers/opinion-makers, it is likely to renew propaganda of the population control agenda, albeit in a more sophisticated language. This is an example of virtual control of all the ‘space for gender-related programming’ by UNFPA and MacArthur on the national television!

Thus, if the State and the donor agencies are permeating the space which was carved out by the women’s movement, how do we see this as a challenge and what steps do we need to take to have it back before it is gone for ever! Whether the groups working in the women’s health movement are funded by the donor agencies or not, the existence of a vibrant movement is of paramount importance, we need to reclaim the crucial element of criticality and resistance.