Monday, 25 November 2013

The most important infographic in global health

Find the original source on wired.com here

This is the most important infographic and image in global health right now.

I usually do not write commentary on this blog, preferring to just reblog.  However, this image is hugely important.  Other people have found this image, including Bill Gates's twitter feed.  Which is unlikely to have been sent by him, and largely misses the importance of this image.

The value of DALYs, which this infographic is based on, is that it seeks to measure the loss of life years across all human beings (humanity) due to premature death and morbidity.  It has many controversial aspects that are still open for debate, and it is often used in cost-effective analysis which is also questionable.  However, the really exciting thing about DALYs, and the important aspect of the work of the Institute of Health Metrics at the University of Washington, is that they make concrete the amorphous notion of suffering of the global poor/third world/ global health.  If want to know the GDP of a country, there are measurements that all feed into one number.  If you want to know a nation's debt, there is a number.  But if you wanted to know what a country's health looks like, or the health of all human beings in the world, there was no number, no picture.

This is the first image that I have seen that truly makes concrete how much of human lives are lost because of premature mortality and morbidity.  It also identifies the causes.  And, now, we can start a more informed global public discussion about what are the causes, how much will healthcare solve this problem, and how much do we have to go beyond healthcare and health systems to reduce this loss of human life years.  Once you understand that a preventable loss of a year of life is the preventable loss of one human being's ability to live a life they would like, the question of justice comes to the forefront.

Other people just see a list of diseases and lack of healthcare.  That is a real shame.


Want to Save Lives? You Need a Map of What’s Doing Us In

  • BY LEE SIMMONS
  • 9:30 AM
If sorrow were a landscape, here’s how it would look from a cruising altitude of 30,000 feet. This graphic maps the global cost of early mortality—some 1.7 billionyears of human life forfeited annually—sorted by cause of death. That’s 1.7 billion years of harvests and weddings, of factory work and music lessons and novels and new ideas that were supposed to happen and now won’t.
Infographic by Thomas Porostocky  |  Source: Institute for Health Metrics and Evaluation
And get this: Worldwide, about 40 percent of that toll results from disorders (shown in yellow above) that could be avoided with basic medications, clean water, and neonatal care. As you read this, 3,000 young kids are dying from diarrhea that a few zinc tablets might have stopped. Cost: 38 cents per life.
You might wish you hadn’t read that. But it’s the kind of insight that policymakers and NGOs need in order to focus health resources where they can do the most good. That’s why the Institute for Health Metrics and Evaluation at the Univer­sity of Washington created the massive database on which this graphic is based. Known as the Global Burden of Disease, it quantifies the incidence and impact of every conceiv­able illness and injury. Want to see your own odds of dying from gunshot or animal attack? You can go to the GBD Compare website and find out.
But IHME doesn’t just tally up death rates, it estimates the years of life lost (YLLs) from all those deaths: A fatal pneumonia infection at age 3 erases many more future birthdays than a heart attack at 80. Adding in years lived with disability, the database provides the most comprehensive measure we have of the burden of disease, in terms of lost human potential. It’s not a pretty picture.
Luckily, policymakers are paying attention. Well-targeted campaigns are reducing mortality from infectious diseases and birth complications throughout the world (as shown by the light shading in the picture above). While more than a million people still die of malaria each year, mostly children in sub-Saharan Africa, that number is down more than 20 percent since 2005.
These are just a few of the insights offered by GBD Compare. The interactive
visualization tool lets you drill down on that global map to compare regions and countries, spot trends, or slice the data by demographic groups. And because the data is structured hierarchically, you can set the resolution to zoom in for more detail or zoom out for big-picture comparisons. The basic inter­face is easy to use, but there’s a helpful video tutorial if you want to dig deeper into the toolbox.
Here are are few screenshots from the website itself. Don’t be thrown by the different color scheme; the “tree map” layout is basically the same as in the artist’s rendering above. The labels are a bit cryptic here, but if you visit the site you can run your cursor over the map to see full descriptive info for every tile.

Monday, 11 November 2013

A Dream Deferred: The Right to Food in America

Original link to Huffington post can be found here


A Dream Deferred: The Right to Food in America

Posted: 10/30/2013 5:03 pm


This year our nation commemorated the fiftieth anniversary of the March on Washington and Dr. Martin Luther King Jr.'s "I Have a Dream" speech, giving us all occasion to reflect on his civil rights aspirations and the extent to which they have been fulfilled. But the persistence of hunger in America today brings to mind Dr. King's other dream -- that of ending poverty and realizing the full spectrum of human rights, including the right to food.
Dr. King understood that social justice cannot be achieved without economic justice. In March 1965 he declared: "Let us march on poverty until no American parent has to skip a meal so that their children may eat." In the months before his assassination, Dr. King spearheaded nationwide efforts to launch a multiracial Poor People's Campaign. "We are coming to Washington," he said. "We are coming to demand that the government address itself to the problem of poverty."
Although he did not live to see the Campaign, those of us who believed in his dream carried it forward. In May 1968 thousands of people occupied the National Mall and demanded economic justice in the form of fair wages, decent housing, quality health care and education, and access to adequate food. Nearly fifty years later, this dream remains deferred for far too many Americans. Most starkly, we continue to treat access to food as a privilege, instead of as a fundamental human right.
The world over, freedom from hunger and access to sufficient, nutritious food are recognized as human rights. These ideas are not foreign to the United States; they were inspired by our government's commitment to ensuring "freedom from want" in the wake of the Great Depression. Now, more than ever, we must reclaim these values and ensure the right to food for all Americans.
Last month, the USDA reported that 49 million Americans live in "food insecure" households, meaning they cannot afford adequate food for themselves or their families. In other words, nearly one in six individuals in the richest country in the world is struggling to put food on the table. Hunger in the United States is not the result of a shortage of food or resources -- it is the direct result of poverty perpetuated through policies that fail to prioritize Americans' fundamental needs.
On the heels of the USDA report, the House voted to cut $40 billion over the next ten years from the Supplemental Nutrition Assistance Program (SNAP) -- the nation's largest anti-poverty program. Under the House version of the farm bill, 3.8 million individuals would lose their SNAP benefits in 2014 alone, and an estimated 210,000 children would be kicked off of free school lunch programs. On November 1, SNAP recipients will see an automatic decline in their benefits when a temporary boost to the program (voted in as part of the 2009 Recovery Act) ends.
The impact of these assaults on our nutrition assistance programs will be felt over a generation and possibly beyond. Children who do not receive adequate nutrition -- including prenatally -- are at risk of serious health and developmental problems. Hungry children struggle to learn in school and, according to a report by Feeding America, are far more likely to experience behavioral problems, increasing the chance that they will drop out of school and decreasing their lifetime earning potential. By failing to adequately feed our children, we are setting them up to fail.
This is a moral failing. It is also a violation of human rights.
As the House and Senate enter negotiations over the farm bill, we must call upon them to strengthen -- not undermine -- our food safety net. A recent study by the International Human Rights Clinic at NYU School of Law found that many food insecure households do not receive SNAP benefits because the program's eligibility requirements are drawn too narrowly. For households that do qualify, the benefits are simply insufficient to meet their food-related needs. On average, families on SNAP receive under $1.50 per person per meal.
We need to fortify SNAP, ensuring that it reaches all food insecure households and enables families to afford sufficient, nutritious food. In addition, we need to adopt and implement a national strategy to tackle the root causes of hunger in America today. At minimum, we must ensure a living wage so that individuals and families can provide for themselves.
Five years from now, when we commemorate the fiftieth anniversary of the Poor People's Campaign, we will inevitably ask ourselves: How far have we come in fulfilling Dr. King's other dream?
Let us act now to end hunger and ensure the right to food for all.
Rev. Jesse L. Jackson Sr., a former aide to the Rev. Dr. Martin Luther King Jr., is the president and founder of the RainbowPUSH Coalition.
Smita Narula is a human rights lawyer and professor and co-author of the studyNourishing Change: Fulfilling the Right to Food in the United States.

Thursday, 31 October 2013

Who care about human rights anyway? Richard Horton's offline column.

Original link here.


The Lancet
Volume 382, Issue 9902, 26 October–1 November 2013, Pages 1390
Comment

Offline: Who cares about human rights anyway?

Sridhar Venkatapuram surprised, even shocked, his audience at this month's Global Health Lab, hosted by the London School of Hygiene and Tropical Medicine and The Lancet. The question he was asked seemed straightforward enough: what is the contribution of human rights to global health? To many engaged in global health, the right to the highest attainable standard of health is a sacred principle. But Sridhar, a lecturer in global health at King's College London, argued that human rights have very little to do with global health today. Human rights might be talked about, often with great rhetorical energy, but few in global health seriously believe in, let alone understand, what human rights mean. The problem lies with those who lead global health: “I have given up on this particular generation running global health.” The only coherent rights global health leaders truly believe in are civil and political rights. All other rights, including the right to health, are seen as “unAmerican” and “bad philosophy”. Sridhar looked to Isaiah Berlin's two concepts of liberty to understand why this is so. Berlin distinguished between negative and positive liberties. Negative liberty means freedom from interference. Positive liberty suggests mastery over one's environment. Good government, so those running global health today argue, is about leaving people alone. Human rights should be about protecting negative freedoms. They should be about defending us from interference. Right? Wrong. We need new leadership in global health, leadership that is willing to defend positive liberties. The right to health is a positive liberty. It means working to ensure people are given the possibility of leading flourishing lives. A generational change is coming.
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Gorik Ooms, a human rights lawyer based at the Institute of Tropical Medicine in Antwerp, drew a different distinction. He noted that rights-based advocacy had been a powerful means to secure access to financing for AIDS through the Global Fund and PEPFAR. But why have rights-based arguments not succeeded in winning wider provision for other aspects of global health, such as emergency obstetric care? Partly because the maternal health community is divided as to the best approach to take (facility-based deliveries or community platforms for care?). The result is that the maternal health community, despite adoption of rights-based arguments, seems unable to make a clear or specific demand. They are unable to show that intervening to save the lives of pregnant women is a global public good. And, of course, maternal health has no Global Fund. So although human rights arguments might be important, they are not sufficient to trigger political change. The lessons for universal health coverage (UHC) are clear. UHC certainly should use rights-based advocacy. It has a specific demand and it is manifestly a global public good. But there is no equivalent of a Global Fund. Without a financing mechanism, can universal health coverage succeed?
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“Human rights do exist!”, proclaimed John Tasioulas, Quain Professor of Jurisprudence at University College London. Indeed, they have “profound implications” for global health. But something is wrong with the way we use human rights arguments in health. Is it correct to say that human rights should be the predominant basis for global health advocacy and policy making? And if rights arguments are used, is the right to health really the most important right we should be considering? The answer to both questions is no. There is much more to global health than human rights. Other rights beyond health matter as much, if not more, than health. Health is only one aspect of what we might call a “good life”. Consider this: imagine the right to health was fully satisfied. Would the world's health problems disappear? Of course not. So why are human rights important? Not because they are the predominant means to improved health and wellbeing, but because they bring a moral dimension to our discussions about the suffering of others and because of the duties they impose on each of us. In sum, what is the contribution of human rights to global health? This perhaps. Human rights arguments have important work to do in global health. But we are still only beginning to discover what that work is. There was one more lesson from this Global Health Lab. We should embrace our philosophers. Philosophers may not have perfect answers, but they ask more precise and disturbing questions than many of us are prepared (or feel comfortable) to ask.
With thanks to Martin McKee, Erika Richardson, and Bayard Roberts.
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Monday, 28 October 2013

Videos from Vanderbilt Univ's Politics of Health conference.

Video from Politics of Health Conference at Vanderbilt University 3-4 October 2013
Vanderbilt University’s Center for Medicine, Health & Society hosts "The Politics of Health," a two-day conference which explores the political exigencies of health and illness. The conference, held October 3 and 4, in Nashville, Tennessee, invites participants and attendees with a range of experiences, priorities, and backgrounds, to a conversation about the paradoxes and the promises of health.
The Politics of Health was held at Vanderbilt University on October 3-4 2013. Videos from the conference are available from the media page or through the links below:
·         Conference Opening Opening Remarks: Dean Carolyn Dever, Intro Remarks: Jonathan Metzl, Opening Address: Emilie Townes
·         Panel I: Health and Social Justice Chairs: Jonathan Metzl and Laura Stark, Discussants: André Churchwell, Manesh Sethi, Christopher Coleman, Melinda Buntin, and Arthur Sutherland III
·         Plenary Address, Day 1 Intro: Linda Norman, Speaker: Sue Siegel
·         Panel II: Health Infrastructure  Chair: Ken MacLeish, Respondents: Susan Cahn, Aimi Hamraie, Jay Clayton, Julia Landstreet, Kitt Carpenter
·         Panel III: Social Foundations of Health  Chairs: Derek Griffith and Dominique Behague, Keynote: Tyrone Forman, Respondents:Monique Lyle, Reavis L. Mitchell Jr., Lindsey Andrews, Arleen Tuchman, and Amy Non

·         Plenary Address, Day 2 Intro: Frank Dobson, Speaker: Priscilla Wald


Health is a political object par excellence: everyone agrees on its fundamental importance. Yet there is widespread disagreement about what health consists of, who needs it, and how we can equitably share its benefits. American politicians and communities spent the last two years arguing over whether a national healthcare system was a moral necessity or an egregious governmental overreach. The business of health has made a dizzying array of technologies and treatments available across the globe, but as a result health has also morphed into a commodity available only to some. Political, social and environmental issues—war, gun control, climate change, food security, discrimination—are increasingly understood in terms of their health effects, but their practical and social dimensions remain no less complex. Health is not just a state to strive for or a quantity we can posses, but a lens that reveals contention, suffering, and the possibility of better lives. Health, that is to say, is political.
The conference is organized around a series of interlinked themes that speak to the scale, urgency and intimacy of health as a political problem: inequality, infrastructure, justice, and aesthetics. A panel on justice and activism will consider the possibilities for health justice in settings of scarce money, time and attention. A panel on aesthetics and infrastructures will examine how seemingly distant economic and legal decisions about health are materialized in our everyday physical, social, and natural environments. And a panel on the social foundations of health will take on the persistent causes and consequences of health disparities. By opening the discussion to practitioners, scholars, activists, students, and community members, we aim to address health issues as they are now understood by a wide variety of stakeholders: not as a condition or an abstract object, but as an ongoing political project.

Thursday, 26 September 2013

Global Report on health and access to care by minorities and indigenous people

Find the original website here.

Minorities and indigenous peoples suffer more ill-health and poorer quality of care, new global report launched as UN meets to follow up on MDGs

25 September 2013

Minorities and indigenous peoples suffer more ill-health and receive poorer quality of care, says an international rights organization in a new global report.
Minority Rights Group International's (MRG) flagship report, State of the World's Minorities and Indigenous Peoples 2013, presents a global picture of the health inequalities experienced by minorities and indigenous communities.
The report is launched to coincide with a United Nations General Assembly meeting to follow up on efforts made towards achieving the Millennium Development Goals (MDGs), and says that ill-health and poor healthcare are often consequences of discrimination.
‘Indigenous peoples and minorities are often marginalized in all aspects of life, such as access to water and sanitation, education and employment. But the marginalization and inequalities experienced by these groups in relation to health outcomes are particularly stark,' says Carl Soderbergh, MRG's Director of Policy and Communications.
‘MRG believes that everyone - regardless of their ethnic, religious, linguistic or cultural background - should have the right to access appropriate care and to lead healthy lives. After all, the right to health is the most fundamental right - the right to survive,' he adds.
In Africa, Asia and the Americas the report says that the maternal mortality rate - a key area of concern for the MDGs - is generally much higher among indigenous and minority communities, particularly those in remote areas.
For instance, in Pakistan, the maternal mortality ratio for Baluchistan - largely inhabited by the Baluch minority - stands at nearly three times the national average. Women and girls from marginalized communities in Kenya and across East Africa, who are subjected to harmful cultural practices such as female genital mutilation and early marriage, are at high risk from obstetric fistula, a hole in the birth canal caused by prolonged or obstructed pregnancy.
Other key MDGs include reducing child mortality and combating HIV/AIDS, malaria and other diseases.
The report finds that in Guatemala, indigenous children experience 20 per cent higher malnutrition than their Ladino counterparts, whilst in Europe Roma children have less access to vaccines and have higher infant mortality rates.
Meanwhile in Tanzania, national HIV/AIDS prevention campaigns were issued only in the dominant language of Swahili. Anti-retrovirals, although free, were not easily accessible in districts where pastoralists predominantly live.
The report makes key recommendations for ensuring that minorities and indigenous people have access to life-saving healthcare, such as the training of minority or indigenous staff and increased community involvement in local healthcare initiatives.
The UN General Assembly must take into consideration the perspectives of minorities and indigenous communities, the factors that they identify as priorities for delivery of healthcare, and the problems and structural barriers that exist, in the formulation of a new generation of development goals after 2015, says MRG.
A case study in the report shows that involving Adivasi women in the planning and evaluating of health care has significantly reduced deaths and empowered women among Adivasi communities in Jharkhand and Odisha. Over 84 million Adivasis (original inhabitants) from more than 500 tribal groups live in western, central, eastern and north-eastern India.
‘The report, with its focus on health inequalities, clearly shows that any post-MDGs framework is doomed to fail unless discrimination towards minorities and indigenous peoples is urgently addressed,' says Carl Soderbergh. ‘Critical to this is the involvement of community representatives in the UN discussions.'
According to UN estimates, there are some 370 million individuals belonging to indigenous peoples in the world, and a much greater number of persons belonging to ethnic, religious and linguistic minorities. Over 900 million people, or, some one in seven of the world's population, belong to groups that experience disadvantage as a result of their identity.

Our Man in New York - tweets from Richard Horton

I thought these tweets from Richard Horton, Editor of the Lancet were so fantastic that I am collecting them and putting them here. If you do not know, this week is UN week in New York City where the General Assembly, Social Good Summit, and Clinton Global Initiative among other meetings are all happening. It is where the powerful, wealth, and famous are all converging to talk about how to improve global health. Richard has an insider view.


10 lessons from the UNGA. 1. The voice of civil society is shut out of serious discussion, and when present is only lip gloss. 2. Nobody here takes equity seriously. 3. The scientific community has made a massive, and largely unrecognised, contribution to global health policymaking. 4. Innovation, innovation, innovation, innovation, innovation...the most meaningless word in the lexicon of global health. 5. Nobody wants to talk about the 22 million women who have to endure an unsafe abortion every year. 6. Too many people on panels want to flirt with fame or superficially amuse rather than offer serious proposals for advancing health. 7. When people talk about greater private sector engagement they are warmly applauded, but nobody really knows what they mean. 8. You will never hear these two words: sexual rights. 9. Everybody wants "quick wins" and "low-hanging fruit": which shows how short-term thinking will never solve the deep inequities that kill. 10. Global health is paralysed by its silos: NCDs, RMNCH, HIV, NTDs, TB, malaria—they live in serene and deliberate ignorance of one another Two favourite UNGA quotes. 1. Joy Phumaphi: "The biggest gaps in global health are those between intent and action, and action and results." 2. Michel Sidibé: "The global health architecture is obsolete."

Wednesday, 25 September 2013

India's Women: The mixed truth. - Amartya Sen

Originally posted by New York Review of Books.  Find the original here.

India’s Women: The Mixed Truth


“I am not a boy, I am a girl,” wrote a twenty-one-year-old woman in Delhi, called Jyoti, who was studying at a medical college to be a physiotherapist. This was in a text message sent in December 2010 to a twenty-six-year-old man who worked in information technology and who had initially taken Jyoti to be a man. They met, and what began as a casual communication became a close friendship.
Two years later, on December 16, 2012, after they had seen a film, The Life of Pi, Jyoti was gang-raped with extreme brutality, and the man was severely beaten as he tried to protect her. They had been tricked into boarding a bus that seemed to be going their way and that had offered them a ride. It was a closed bus with darkened windows in which five determined rapists were waiting for their prey, with their impatience heightened, it is alleged, by the drugs they had taken. The battered bodies of the abused pair were dropped off on a lonely street, and by the time Jyoti received medical attention, she was on her way to death from the injuries, despite specialized medical care in Delhi, and later in Singapore.
The gang rape, including the violence accompanying it, not only got headlines in every serious Indian newspaper, it received continuous coverage around the clock on radio, television, and cable channels. It also led to large-scale public protests and demonstrations that continued for many days in Delhi as well as in other Indian cities, with agitated crowds—men and women—much larger than any seen before in protests of this kind. The insecurity of women, including their vulnerability to rape and abuse, became overnight a national issue in a way it had never been.
Public anger at gender inequality in India must be seen as an important—and long-overdue—social development, and it can certainly help in remedying the persistent inequalities from which Indian women suffer. It is, however, very important to understand the nature of female disadvantage in India, which can take many different forms. If the lack of safety of women is one aspect of it, the old phenomenon of “boy preference” in family decisions is surely another. Boy preference relates closely to the deep-rooted problem of what has been called “missing women,” which refers to the shortfall of the actual number of women from the number we would expect to see, given the size of the male population, and the female–male ratios that could be expected if there were symmetry in the treatment of women and men. There is, moreover, strong evidence that the economic and social options open to women are significantly fewer than those available to men; and going beyond women’s well-being, we have reason to ask also about women’s limited role in society and their ability to act independently, and how their initiatives and actions influence the lives of men as well as women, and boys as well as girls.

Numbers and Insecurity

One of the positive consequences of the agitation following the barbaric incident of December 16 has been to draw attention both to the prevalence of sexual brutality and rape in India, and to the failure of the media to report on it seriously, thereby limiting public discussion and the likelihood of social change. Even though Indians buy more newspapers every day than any other nation, the reporting of sexual assaults and sexual harassment had been quite rare in the widely circulated papers. It is, therefore, impressive and encouraging that newspapers in India, smarting from intense criticism of the negligence in their coverage, rapidly reinvented themselves as rape-reporting journals, and many of them have been devoting several pages every day to reports of rapes gathered together from all the different parts of India. This dramatic change is certainly a welcome development, but it can be asked whether the ongoing news reporting is well aimed and as helpful for public discussion as it could be.
How frequent is rape in India? If there are pages and pages of reports of rapes from across the country in the newspapers, the incidence must be high. There are, in fact, good reasons to believe that the majority of rapes go unreported in India, and the actual incidence of rape may be much higher (some estimates suggest that it is larger by a factor of five or more) than what gets recorded by the police. Based on the news coverage of rape across India, it has been argued, with some plausibility, that India has an extraordinarily high frequency of rape. To what extent is this the right way of thinking about India’s problem? Rape and brutality against women are not exactly unknown around the world. One question is whether rape is relatively more common in India than elsewhere, despite the increased attention it is now getting in Indian news reports.
In fact, if we go by the comparative statistics of reported rape, India has one of the lowest levels of rape in the world. The United Nations Office on Drugs and Crime found the incidence of rape in India for 2010 to be 1.8 per 100,000 people, compared with, for example, 27.3 in the US, 28.8 in the UK, 63.5 in Sweden, and 120.0 in South Africa. The number of recorded rapes in India is certainly a substantial underestimate, but even if we take five times—or ten times—that figure, the corrected and enlarged estimates of rapes would still be substantially lower in India than in the US, the UK, Sweden, or South Africa (even with the assumption that there is no underreporting in these other countries).
High frequency of rape may not be the real issue in India, but all the evidence suggests that India has a huge problem in seriously monitoring rape and taking steps to reduce it. The failure of the police to help rape victims and to ensure the safety of women is particularly lamentable. Following the December incident there were large clashes with the police by protesting crowds, not only because of the attempts by the police to break them up, but also because the demonstrators frequently confronted the police for their very poor record in dealing with this problem.
Even though the alleged rapists in the particular case on December 16 were picked up by the police quite quickly and promptly charged in court, the police were criticized for acting too slowly in giving emergency care when the raped victim and her beaten male friend were found lying on the street. Even in dealing with another terrible aspect of the December incident, the failure of people in passing cars to stop to help the victims (even though some of them did call the police), it was claimed that many passersby are afraid to get involved in a scene of criminal activity because of the fear that the police can—and often do—harass the good Samaritans who are found near the victims of crime, rather than searching diligently for the criminals who have fled the scene.
There was discussion also of the large number of cases in which the police seemed to doubt the credibility of a rape victim on the ground that the suspected rapist told a different story that seemed “equally credible” to the authorities. The Indian judicial system is itself extremely slow, and has not typically been able to rise to the challenge of bringing about speedy convictions of rapists and assaulters on the basis of the information provided by the victims. But the courts are certainly not well served by the unclear information provided by police reports on what exactly happened. From what we know, India’s problem may well lie not so much in a particularly high incidence of rapes, but in its inefficient policing, bad security arrangements, slow-moving judicial system, and, ultimately, the callousness of the society.

Legal Reform and Social Change

One of the salutary effects of the public agitation about women’s insecurity and the inadequacy of the law and policing was the appointment—within a week of the December 16 incident—of a Committee on Amendments to Criminal Law, chaired by a former chief justice of the Supreme Court of India, J.S. Verma, with two other leading jurists, Leila Seth and Gopal Subramanium, as members. Their report, which was thoroughly researched yet delivered in less than a month, led to a new law, enacted in Parliament by the end of March, aimed at providing more adequate, and quicker, legal remedy to violated or threatened women.
Some of the proposals of the Verma Committee were diluted in Parliament, and many human rights activists have plausibly criticized this weakening, including the continued failure to include among sexual offenses what is sometimes called “marital rape”—forced sexual activity with an unwilling partner. There are other gaps too in the parliamentary act; but taking everything into account, the new act is a substantial, though partial, step forward in dealing with gender injustice in India.
Four new provisions are important. First, the act has a broader and more inclusive definition of the crime of “sexual assault”: it includes, but goes beyond, what counts technically as rape. Second, there is a prima facie presumption of nonconsensual sex when the affected woman affirms (even if unilaterally) that there was no consent. Third, “sexual harassment”—common on the streets of some cities in India—is included among the list of criminal acts. Finally, there is a new emphasis on the criminality of the sexual trafficking of young women, mainly for the purpose of forced prostitution.
Such trafficking—sometimes even of very young girls—remains disturbingly common in India, although few serious statistics have been collected about it. There is, however, considerable evidence that the sex trade is indeed big business in India. And yet the newspapers are still shockingly negligent in their failure to investigate this area of darkness (unlike what has happened in the case of rape). Most cases of sexual trafficking involve young women from very poor families, and here the difficulty in getting authorities and journalists, among others, to cross class barriers in their care and concern—a distressingly general phenomenon in India—affects the zeal with which information is sought. There is a clear need for the new activism of newspapers to go well beyond the reporting and discussion of only rapes.
To some extent, the class barrier preventing information from being collected is a problem even in dealing with rapes, not just sex trafficking. Even though Jyoti came from a family of modest means (her father is a baggage loader at the airport), her family was upwardly mobile. It was easier for the Indian middle classes, including the educated middle classes, to take an immediate interest in the predicament of a young medical student than it would have been in the case of a rape of a poor and socially distant Dalit woman. There is a broad and urgent need to supplement the new provisions of the recently enacted law with ways to obtain and disseminate information about the treatment of women from the poorer classes.
There is also a regional dimension to the problem of women’s insecurity in India. It is clear that Delhi, where Jyoti’s rape occurred, has a very special problem that may not apply, in quite that form, to the other megacities in India. The rate of recorded rape per 100,000 people was 2.8 for Delhi in 2011, compared with 1.2 in Mumbai, 1.1 in Bangalore, 0.9 in Chennai, and 0.3 in Calcutta. Since there is nothing to indicate that keeping track of rape is much more efficient in Delhi than in the other cities, it is indeed remarkable that Delhi has a record that is more than nine times worse than Calcutta’s. No matter how unfriendly to women Indian society may be, huge differences exist between different regions of India, which apply to other kinds of gender inequality as well. In many ways India can be seen as a collection of distinct countries with diverse records, experiences, and problems.

Missing Women and Boy Preference

A distressing aspect of gender bias in India that shows little sign of going away is the preference for boys over girls. One of the most pernicious manifestations of this pro-male bias is the relatively higher mortality rates of girls compared with boys, not because girls are killed, but mainly because of the quiet violence of the neglect of their health and illness in comparison with the attention that male children receive. Studies have shown that male priority in care continues for adults as well as children, raising the mortality rates of adult women above those of men.
A distinct bias of “boy preference” can be found in countries extending from North Africa and West Asia to South Asia, including India, and East Asia, including China. That such discrimination has a place in a large part of the modern world is distressing: the number of “missing women” can be quite large. When I wrote on “missing women” in these pages in December 1990,* and also in the British Medical Journal, I based my conclusion on data available up to the 1980s. The missing women could be identified then as the result of the differences in mortality rates between men and women. These in turn reflected discrimination, mainly in health care, against girls and women.
Over the last couple of decades those kinds of discrimination have substantially declined in most of the countries I wrote about. Even though female mortality is still higher than male mortality for children in many Indian states, and the gap is even higher for infants in China, nevertheless in both China and India, and indeed in many of the other countries in the region, women now have a substantially higher life expectancy at birth than men.
However, since the 1980s, the wide use of new techniques such as sonograms for determining the sex of fetuses has led to huge—and growing—numbers of selective abortions of female fetuses, offsetting the gains in declining difference in mortality rates (as I discussed in the British Medical Journal in December 2003). Selective abortion of female fetuses—what can be called “natality discrimination”—is a kind of high-tech manifestation of preference for boys. Because of this counteracting influence, the proportion of missing women in the total population has not declined in many countries, including China and India. Women’s education, which has been a powerful force in reducing mortality discrimination against women and also in achieving other important social objectives such as the reduction of fertility rates, has not been able to eliminate—at least not yet—natality discrimination.
Still, we must not underestimate the effects of women’s education. There is definitive empirical evidence that women’s literacy and schooling cut down child mortality and work against the selective neglect of the health of girls. They are also the strongest influence, among all relevant causal factors, in cutting down fertility rates. The reduction of fertility that has taken place throughout India (and more sharply in Bangladesh) is clearly connected with the expansion of women’s literacy, which empowers women to have a stronger voice in family decisions. The lives that are most battered by excessive bearing and rearing of children are those of young women; any change that increases the force and impact of their voice, such as girls’ education and women’s ability to earn an independent income, has the effect of sharply reducing childbearing.
Bangladesh’s steep fall in total fertility rate from nearly seven children not long ago to 2.2 now (quite close to the replacement rate of 2.1) is strongly connected with the power of women to gain more control of their lives, and both girls’ education and women’s outside employment have done much to yield that result. I should also note here that even China’s shift from high fertility to below-replacement fertility can in many cases be more easily explained by women’s having more say, and more power, in family life—helped by education and greater economic independence—than by the draconian compulsions of its punitive “one-child policy.”
In India too, expansion of women’s schooling has contributed to its significant reduction in fertility rates. While the average of 2.4 children per family for the entire country is still above the replacement level of 2.1, this reflects a big fall from earlier rates, and nine of the twenty largest states of India have fertility rates now that are below the replacement level, which seems to reflect mainly the impact of the increased power of women to influence decisions about bearing children. Women’s education does not seem to be adequately effective in reducing discrimination against giving birth to girls; but it would be a mistake not to appreciate what female education clearly does achieve.
It is important to ask why women’s education and the corresponding enhancement of women’s voice and influence in family decisions have not done much to eliminate selective abortion of female fetuses. Educated mothers seem clearly less inclined to neglect girls compared with boys once they have been born; but they seem almost as keen on having boys rather than girls as uneducated mothers are. Here larger questions of enlightened understanding and scrutiny of traditional values become central and go beyond women’s role and influence in family decisions. There seems to be a lack of adequate awareness of the oddity of seeing girls as inferior to boys, and a lack of knowledge about what happens in other places where such discrimination against girls is not present.
An analogy can be drawn here with Adam Smith’s discussion, in The Theory of Moral Sentiments, of the willing acceptance of the alleged necessity of infanticide by intellectuals in ancient Greece. Smith quoted Plato and Aristotle in defense of infanticide. He thought that the hold of parochial values can be broken primarily by knowledge of what happens elsewhere and how other people think about the same problems. It was with respect to such parochialism that Smith emphasized the importance of considering how a local custom would look to people at “a certain distance from us,” which is a part of his thought experiment of invoking an “impartial spectator.” What is crucial here is not just freedom of action but also freedom of thought and the ability to overcome parochial boundaries of thinking.
In China and South Korea, the standard routes to women’s empowerment, such as female literacy and economic independence, have resulted in major achievements. But with the new techniques of sex determination of fetuses, discrimination through selective abortion of female fetuses became surprisingly common in both countries. This has led to organized public initiatives to make women aware of the value of having daughters and not just sons. Such efforts have had much more success in Korea than in China, where the female–male ratio at birth remains lower even than in India.

Contrasts Within India

While female education does not serve as a silver bullet to prevent discrimination against girls, other factors make the experience of the different regions within India quite diverse. In fact, there is a sharp regional divide. In the northern and western states, there is clear evidence of extensive use of selective abortion of female fetuses. In the states in the south and east of India, we do not typically find evidence of its widespread use.
Everywhere in the world more boys are born than girls, and the female–male ratio at conception is even more sharply biased in the direction of males (the standard ratio is often taken to be 910 conceptions of female fetuses compared with 1,000 male conceptions). But females do better than males in survival, if they have equal care, which they tend to get in the uterus. By the time births take place, the female–male ratio is around 940 to 950 females per 1,000 males in European countries. Between 2005 and 2010, the average ratio of females to males at birth for Europe as a whole was 943 females per 1,000 males.
There are variations within the European countries that cannot be plausibly attributed to the effects of presumed practices of sex-selective abortion; and so we have to accept a range of values for “normal” sex ratio at birth. Among the larger European countries, the female–male ratio at birth is 941 in Italy, 940 in Spain, 939 in Greece, and 935 in Ireland. If we take the ratio of 935 per 1,000 (the ratio for Ireland) as a standard against which to measure selective abortion of female fetuses, what can be said about the Indian states?
Since birth registration is incomplete in India, the ratios of girls to boys at birth are calculated by first looking at the actual numbers of girls and boys in the age group between zero and six (counted by the census), and then working backward to the female–male birth ratio by adjusting the zero to six figures for differences in mortality rates at specific ages between birth and age six. Using this method with the data provided by the 2011 census, it appears that all the states in the north and west of India, without exception, show absolutely clear evidence that sex-selective abortion is practiced to a much greater degree than is generally the case in the states in the east and south. Though many of the states even in the south and east have had some fall in female–male ratio among children between the censuses of 2001 and 2011, even in 2011 the female–male ratio at birth in the south and east of India remains not only substantially higher than in the north and the west, but also within the European range for such ratios.
Sen-India_Map-101013
Estimated female-male ratio at birth, per 1,000 males
In fact, we can draw a dividing line to cut India into two halves (see the map above), with the states in the west and north (including Maharashtra, Gujarat, Madhya Pradesh, Uttar Pradesh, Rajasthan, Himachal Pradesh, Punjab, Haryana, Uttarkhand, and Jammu and Kashmir) showing clear evidence of widespread sex-selective abortion, with female–male ratios well below the cut-off line of 935 per 1,000 males. In fact, in all western and northern states this ratio actually is even below 920, and in many of these states well below 900.
This contrasts sharply with the figures for states in the east and south—Kerala, Karnataka, Tamil Nadu, Andhra Pradesh, Chhattisgarh, Jharkhand, Bihar, West Bengal, and Assam—all of which have ratios above 935 (with Odisha marginally so). In those states the use of sex-selective abortion, when present, is not on a scale to pull the female–male ratio below the cut-off line based on Irish figures. Incidentally, the data from Bangladesh, where the female–male ratio for the age-group zero to four years is 972, conform strongly to the pattern of eastern India, which it adjoins.
Why is there such a regional difference? I do not know of any convincing clear-cut answer to this question, even though the correspondence of these gender-specific differences with language groups and cultural practices offers fruitful lines of research. Any serious explanation will demand a much fuller understanding of the diversities between India’s different traditional cultures, as well differences in economic, political, and social influences.
While that important research must be done, there are many necessary actions that need not await the results of that research. There is a need for better policing and for greater media attention to neglected issues, including sexual trafficking and marital rape. There is an extremely powerful case for paying much more attention to schooling for girls, for more political and social discussion of the peculiarity—and the moral strangeness and inequity—of “boy preference,” and for more commitment by India’s mainstream political parties to address the issues central to gender inequality. There is a lot to do on the basis of what we do know, even as we remain engaged in finding out more about regional cultures and divergent behavior within India.
  1. *
    See my “ More Than 100 Million Women Are Missing,” The New York Review, December 20, 1990.