Speaking Her Mind

Lying on her back on a mud floor, Mallai looks nervous as a nurse bends down to examine her. After losing two children at their birth, the 27-year-old farmer’s wife is frightened for the baby that is due soon. Nirmala Palsamy, the nurse who is visiting this makeshift clinic in the southern Indian state of Tamil Nadu, is also worried. This fetus is in an incorrect position. “You know that you might need an operation, don’t you?” she asks her patient. Mallai bursts into tears. Nirmala patiently explains that a caesarean surgery will help the baby. Then she makes a little joke and asks after the rest of the family. Mallai begins to smile again. “The doctor amma [mother] is wonderful,” she declares as soon as the nurse leaves.

Just a decade ago, if an Indian nurse told a woman about to give birth that she should have an operation, it might have meant something else altogether. It might have been surgery to have her Fallopian tubes cut so she could never have another child. Even though family planning had a bad reputation after the abandonment of the Gandhi government’s coercive vasectomy program in the 1970s, states like Tamil Nadu still set birthrate targets and quietly instructed health-care workers to urge patients to be sterilized. The policy was often aimed at women rather than men. In fact, nurses earned bonuses based on how many sterilizations they encouraged. But this more subtle tactic never really worked. Patients balked, and the bonuses led more often to falsification of records than to a lower birthrate.

In 1992 Tamil Nadu finally started dropping its by-the-numbers policy, setting an example that was later adopted by India as a whole. The change paralleled the consensus reached at the U.N.’s 1994 population conference in Cairo, which rejected target-based birth control in favor of giving women better health care and more family-planning choices.

If India finally has a more humane–and effective–population policy, much of the credit goes to people like Nirmala, 32, who heads the Village Health Nurse Association in Tamil Nadu. The typical nurse in the group zips around on a moped to visit 5,000 or more people under her care. Treating all sorts of ills and offering contraceptive tips, she leaves smiles on the faces of patients like Mallai.

Long before the Cairo conference, Nirmala complained about the birth-control numbers game, but superiors told her she would be “suspended” if she challenged policy. Only in 1992 did she get a real hearing, when S. Ramasundaram took over Tamil Nadu’s family-welfare program. Nirmala told him that birth-control targets made mothers distrust nurses and resist the policy. Later, she said nurses would forgo the sterilization bonuses if allowed to do their jobs without so much government interference.

When Ramasundaram followed the nurses’ advice, the results were dramatic. The state’s population growth rate has dropped from 1.5% in 1991 to 1% in 1999, compared with 1.8% for India as a whole. “You don’t need draconian measures for family planning,” Ramasundaram says. “Simply remove the shackles and let people do what they were supposed to do.”

Nirmala still has complaints about India’s population situation–particularly that men don’t concern themselves with birth control. “Family planning is a social responsibility,” she says, “but everything is targeted to women.” You can’t call it family planning, she feels, until the whole family is involved. –By Meenakshi Ganguly/Tamil Nadu