Relying on Hard and Soft Sells, India Pushes Sterilization

Yoshie Furuhashi furuhashi.1 at osu.edu
Sun Jun 24 15:18:57 PDT 2001


The New York Times June 22, 2001, Friday, Late Edition - Final SECTION: Section A; Page 1; Column 2; Foreign Desk HEADLINE: Relying on Hard and Soft Sells, India Pushes Sterilization BYLINE: By CELIA W. DUGGER DATELINE: BOLLARUM, India

Like a preacher at a tent revival, Chandrababu Naidu, one of India's most powerful politicians, summoned parents with big families to the front of the crowd so he could publicly scold them and urge them along the road to sterilization.

Nara Singh, a father of four with a fifth on the way, picked his way through the thousands of villagers sitting in a parched field. He took the microphone and stoutly insisted he needed more children eventually to help him work his small farm.

But Mr. Naidu sternly told him he would never be able to care properly for so many offspring -- and then turned to the throng, tittering uneasily on a recent, sweaty afternoon, and demanded in a booming voice, "Is this man on the right path?" Only a few raised their hands.

"Nobody is supporting you," proclaimed Mr. Naidu, who governs the state of Andhra Pradesh, "Immediately go for the operation."

Mr. Naidu's population policies, held up by state officials as a model for developing countries and condemned by critics as coercive, have dramatically increased the number of sterilizations in the state over the past five years to 814,061 a year from 513,726. More than half of married women have had their tubes tied, the highest rate in India, and one of the highest in the world.

Population remains a pivotal issue for the world's largest democracy, which has added 181 million people over the past decade and passed the one billion mark. India expects to overtake China as the world's most populous nation by the middle of the century.

But India and Andhra Pradesh, its fifth largest state, have taken profoundly divergent paths to control population.

Following the consensus on population adopted at a United Nations conference in Cairo in 1994, India's Parliament last year abandoned numerical targets for sterilizations. Instead, it set an agenda for improving health and education for women and children, while offering couples a range of purely voluntary contraceptive choices.

But the central government -- struggling to provide for more than 250 million desperately poor citizens -- has let the states go their own way.

Andhra Pradesh, with financial support from the World Bank, is actively trying to better conditions for women. But its population strategy is relentlessly driven by specific targets for the sterilization of couples with two or more children, backed by the entire machinery of the government. Poor people in the state who are sterilized after one or two children receive priority for anti-poverty benefits: houses, plots of land, wells and loans, among many other things.

"If you get operated quickly, you get goodies quickly," said Debabrata Kantha, who carried out the policy in the state's Karimnagar district over the past three years. "That quickened the pace of sterilizations. It was a gold rush."

These clashing approaches to controlling population mirror a larger debate that is especially persistent in South Asia: Is social progress for women the best way to reduce the number of children they will bear? Or should governments aggressively seek to reduce fertility with incentives and targets even before social progress is achieved?

In Andhra Pradesh, declines in fertility clearly started before Mr. Naidu's four-year-old population program. The question is whether his approach has accelerated the reductions.

India's 2001 census found that Andhra Pradesh had the sharpest slowdown in the rate of population growth among India's large states, while Uttar Pradesh and Bihar, the hugely populous states in the north, registered a slight rise in the growth rate.

In those two northern states -- home to a quarter of India's population -- women are still bearing four or more children each, while demographers believe Andhra Pradesh has neared or hit the point where population stabilizes and women are having an average of 2.1 children each.

That would make it the third southern state to achieve that milestone, after Kerala in the late 1980's and Tamil Nadu in the mid-1990's. And the success of these different states indicates that there are different ways of reaching the same goal. Kerala, for example, is often cited as a model of what high rates of female literacy and good health care can accomplish in lowering fertility.

But the explanation is necessarily different for Andhra Pradesh, where half the women are still illiterate and married before the age of 15.

In the 1990's, fertility rates have declined across India, largely because the poor and illiterate are themselves choosing smaller families, said Mari Bhat, a demographer at the government-supported Institute of Economic Growth in New Delhi. The number of children an Indian woman bears has fallen to around 3.0 now, down from 3.78 in 1990 and around 6.0 in 1950.

The declines in family size that began among the educated in India have now spread to people with no education at all, a common pattern in many societies, demographers say.

Experts in India offer various explanations: That the growing reach of radio, television and movies in rural areas where most Indians live has helped popularize the idea that small families are better; that higher survival rates for children have reduced the pressure to have more children as insurance; and that government propaganda and services have also played a role.

What's clear is that many poor couples want fewer children.

Govinda Rao, an illiterate farm worker who earns about 50 cents a day, had a sterilization operation a year ago when she was just 21. At the time, the state paid her 500 rupees, or about $11 -- as it does to all poor people who are sterilized -- to cover her lost wages. She and her husband, G. Ramanamma, who live in the village of Puriti Penta in northern Andhra Pradesh, had decided two children were enough.

"If we have more children, our problems will also multiply," he said. "We cannot afford to educate more than two. I do not want my children to grow up to be farm laborers like us. I want them to get jobs."

Andhra Pradesh's program to convince other couples to make the same choice is built on a high-pressure huckstering that would be the envy of any door-to-door salesman.

In Karimnagar, where every arm of the government had its own target, the animal husbandry staff recruited 3,000 people for sterilization camps over the past three years and transported them to the camps in departmental jeeps. Every time a milkman brought in a sick cow or a herder got his sheep vaccinated, veterinarians talked up vasectomy.

Likewise, the wardens and matrons of state boarding schools for poor children in the district lobbied parents. "If the person in charge tells the parents, 'You should get operated,' they are more likely to listen," explained Mr. Kantha, the district collector.

In the Vizianagaram district, Mr. Naidu, who monitors sterilization numbers on his laptop, noticed the district was lagging as the fiscal year neared its end this spring -- and pointedly asked why. District officials then scrambled to get Lions and Rotary clubs to donate wall clocks and steel pots, gifts for those who agree to be sterilized. The district's target for the year was 25,000 sterilizations. It just made it, with 25,019. "These extra incentives came to our rescue," said S. Perumal, the district medical officer.

At the state level, there is a lottery for sterilized couples. Three winners from each of the state's 23 districts are rewarded with 10,000 rupees (about $220) and a free trip to the state capital, Hyderabad, where Mr. Naidu, who himself had a vasectomy after fathering one son, personally congratulates them.

Some nonprofit groups, feminists and academics regard the state's policies as appallingly intrusive and coercive to women and the poor. Mohan Rao, a public health expert at Jawaharlal Nehru University in New Delhi, called the drawing "a macabre metaphor of the lottery that is the life of the poor."

And Saroj Pachauri, regional director of the Population Council's South Asia office in New Delhi, said the pressure to be sterilized is overwhelmingly directed at women, for whom sterilization is serious abdominal surgery.

"I've met people who work in villages there who tell me women were offered gold chains to get their tubes tied," she said. "If that isn't coercion, what is?"

Critics also raise the troubling history of sterilization camps in the mid-1970's, when Indira Gandhi, who was then prime minister, suspended democracy. Many Indians believe local officials, under pressure to achieve sterilization targets in those years, forced men to have vasectomies -- and that these abuses led to Mrs. Gandhi's resounding electoral defeat when democracy was restored.

But Mr. Naidu, who won a second term as the state's chief minister two years ago, makes no apologies for his approach. As he hopped from mass meeting to mass meeting in a six-seater helicopter, he explained over the drone of the engine that he believes having lots of children impoverishes families -- and that rapidly growing populations make it hard for government to provide enough schools, hospitals and roads.

He said his program uses no force and has won wide acceptance. And he defended the policy of giving scarce anti-poverty benefits to sterilized couples as an effort "to help those who are disciplined and have some social commitment."

At the end of a huge public meeting here, Mr. Naidu asked the people what they needed. Mr. Singh -- the same farmer Mr. Naidu had earlier chastised -- rose up to demand that the state build his growing family a house.

"I will only give you a house if you have the operation," the chief minister bluntly told him. And the farmer quickly promised, "I will definitely have it done."

Mr. Naidu has frequently used his bully pulpit to argue for small families as he has traveled to each of the state's 23 districts dozens of times over the past few years. His policies are now playing out in thousands of villages.

The story of Muhammad Anwar, an illiterate fruit peddler and father of two, is a case in point.

Two years ago, he was the last holdout in his village of Rangampalli in the Karimnagar district. Soon, four village women he had known since childhood came knocking at his door over several months, pressing him to get a vasectomy. The four were among the millions of women who have joined microcredit groups that receive some state support and that the state has sought to mobilize to push for the two-child family.

They told him he was a poor man and his children would have a better chance at a good education and life if he had a vasectomy. They told him the operation was a simple procedure. They told him they would use their influence with district officials to see he got a loan if he was sterilized.

At first, Mr. Anwar refused. His mother still wanted another grandson. Once at his home, the old woman ran them off, shouting, "He won't go!"

But Mr. Anwar found that he was having a conversation with himself. "Sometimes, I would think my mother was right," he said. "But then I would think, 'I have a small business. I am a man of little means. These women are advising what is best for me and my children.' "

Twice he agreed to go to sterilization camps. Twice he was a no-show. "I gave them the slip," he confessed.

But soon, the women went to his house looking for him again. He was not there. They strode purposefully to fields where they thought he was laboring. No Mr. Anwar. They found him in the market selling fruit from his pushcart. And finally, he went with them to the camp. The operation was over in a couple of minutes.

The village target was achieved. The last holdout had come into the fold.

GRAPHIC: Photos: Govinda Rao, with her 3-year-old son in the courtyard of their home, is among many Indian women who have undergone sterilization. (Celia W. Dugger/The New York Times)(pg. A1); Above: Sari Gouri -- with her husband, S. Gauri Naidi, and their 7-month-old daughter Lakshmi -- is counseled by the surgeon, Dr. S. R. Murthy, who operated on her. Dr. Murthy performs about 2,000 of the 25,000 sterilizations done in the Vizianagaram district of Andhra Pradesh each year. Right: Muhammad Anwar, a fruit peddler and father of two, with the four women who persuaded him to have a vasectomy. "These women are advising what is best for me and my children," he said. (Photographs by Celia W. Dugger/The New York Time)(pg. A10)

Chart: "A CLOSER LOOK: Uneven Growth" India's population grew by 181 million in the last decade, but the rates of growth varied greatly from state to state.

Map of India highlighting the percentage increase in population, 1991-2001.

+Census data does not include area controlled by Pakistan. (Source: Census of India, 2001)(pg. A10)



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