The Government of India and its thoughtful citizens have been aware of the problems posed by the rapid growth of India's population during the past decade and a half; but the adverse economic circumstances of the last two or three years brought home to them, as nothing had done in the past, the disturbing nature of India's population explosion. The psychological climate necessary for the serious implementation of the family-planning program had arrived.
The dimensions and magnitude of India's population problem may be briefly recalled. India's total population passed the 520 million mark in mid-1968. That is, one out of every seven persons in the world is a citizen of India. With only 2.4 percent of the world's total land area, India has to support 14 percent of the world's total population. To this population a baby is born every second and a half, 21 million births a year, a birth rate of 41 per thousand per year. Some 8 million persons die every year-a high death rate of 16 per thousand per year. Thus the nation adds 13 million people- Australia's present population-to the existing population every year. The population is growing at the rate of slightly over 2.5 percent per year. And at the current rate of increase it may double itself in the next 28 years, reaching the incredible figure of one billion before the end of this century.
The major cause of this high rate of growth is not so much the high birth rate as the increasing success, in terms of Asian standards, with which India's health and medical services have been implemented in the last three five-year plans. Major communicable diseases like cholera, malaria and smallpox have been nearly brought under control and measures to eradicate them are now being put into effect. And, in response to these relatively improved health conditions, life expectancy has risen from 32 years in 1950 to 51 years in 1968.
But India has also registered remarkable progress in both the agricultural and industrial sectors during the last 20 years of her political freedom. This progress, far exceeding anything registered during any comparable earlier period, is all the more significant considering the heavy odds and unprecedented problems that the new Government of India had to face, ranging all the way from the forced Hindu migration from Pakistan into India, which involved the settlement and rehabilitation of millions of refugees, to the brief but costly border wars with Communist China and Pakistan. In addition, the food problem has been a cause of considerable anxiety, especially over the past few years.
Although the availability of goods and services has increased threefold over the last decade, their per capita consumption has not increased at all. While this year a partial breakthrough in agricultural production has been achieved, resulting in bumper crops of nearly 100 million tons, compared to about 65 million tons a year in the past few years, the per capita consumption of foodgrains has not markedly increased. As for educational facilities, the number of universities has increased from 16 in 1947 to 67 in 1968, and the liberal arts colleges affiliated to these universities have increased proportionately-an impressive achievement. But thousands of students with the requisite academic credentials continue to find it difficult to secure admission to these colleges. The increased facilities simply do not keep pace with the needs of the growing population. This is true of almost every aspect of life in India.
All this is reflected in the national income figures. India's total national income increased from Rs. 86 billion in 1948-49 to Rs. 149 billion in 1966-67, or an increase of 73.25 percent over a period of nearly two decades. But the per capita income increased during the same period from Rs. 248 to Rs. 297, a meagre 19.76 percent. Not only is India's per capita income today among the lowest in the world, but the rate of increase over two decades of overall national development is remarkably insignificant.
The main reason why the Indian economy continues to be an economy of shortages is the country's excessive population growth. Between mid-1947 when India gained her political freedom and mid-1968 she has added 182.7 million to her total population. Like other underdeveloped countries, India bears witness to the fact that the technology of health and hygiene can be more rapidly transmitted than the technology of production and economic growth. This means that the population increases rapidly as a result of death control, but the increase in the production of food and other necessities does not keep pace.1
Hence the declared objective of the Government of India to reduce the birth rate from the present 41 per thousand to 25-if not 20-per thousand as expeditiously as possible. Although a policy of population control has been in force for the last few years, it was only after the formation of the new cabinet early in 1967 that a vigorous, new anti-natalist policy was formulated and an all-out campaign begun to halve the nation's birth rate by 1975-76 if possible.
This population policy has to be made effective within the framework of an open society with centuries-old customs and traditions. India today is the largest democracy in the world, but an overwhelming majority of the people are illiterate (more than 70 percent), are small-scale farmers (about 80 percent), and live in some 564,000 far-flung villages; some 14 major languages and more than 200 dialects are in use. The cultural levels of the population vary all the way from a Nobel-prize winner to a pre-literate peasant. What is more, according to the Constitution, health and family planning are responsibilities of the States. Since the efficiency of the administrative machinery of the various State governments is not uniform, there are considerable differences in the achievement of family-planning targets.
The major problem before the Government is to reach the country's married couples and convince them of the need for small families. During the last 20 years we have conducted some 30 surveys of attitudes of parents among rural and urban populations, comprising various caste, religious, cultural and income groups. A summary of these random samplings shows that about 70 percent of wives and about 66 percent of husbands among couples with at least three children are in favor of family planning for economic and health reasons. It may be assumed, then, that a majority of Indian couples is in favor, at least in principle, of family planning. Of the 105 million married couples in the country today, living together and leading a normal conjugal life, 90 million couples are in the reproductive age group; and these are our target couples who must be brought to accept the small-family norm. They are distributed over 17 States, 11 Union Territories (comparable to the District of Columbia), 326 administrative districts, some 2,690 towns and cities and 564,258 villages. In each of India's 17 States (except four Hindi-speaking States) a different language is spoken and each can be considered a country in itself. Indeed, if the State of Uttar Pradesh were to join the United Nations, its population of a little over 80 million would make it the seventh largest member.
India's towns and cities are well knit and it is not difficult to reach their inhabitants. They have government hospitals and clinics, schools and colleges; they are served by railroads and many are connected by airways. Literacy rates are high, newspapers and periodicals are read avidly, and people listen to All-India Radio. But our communications program nevertheless has to take into account wide differences in culture, religion, custom and tradition. To carry it through we have set up a media section in the Health and Family Planning Ministry. The basic approach is to present only a few simple messages, in a few words, repeated in the same form in all possible media. An example of this approach is the use of the happy faces of the "family of four" with the slogan "Two or three children- enough" and the Red Triangle to identify the program and the location of family-planning facilities. This simple message is being propagated through motion pictures, on the radio, through a family-planning song, in the press, on billboards, posters, cinema slides and on the sides of buses.
But the villages pose a problem; and it is the 60 million farm couples, illiterate and poor, who need family planning most. Talks, group discussions and Bhajans (religious musical discourses) on family planning have been promoted; and peripatetic clinics have been organized in rural areas. But although radio should be the most effective instrument of our propaganda, the community radio sets presented to a fourth of the village Panchayats are frequently out of order.
Though India is the second largest film-producing country in the world, commercial films deal primarily with mythologies and religious subjects and very few are devoted to family planning. The Government of India has produced movies that deal with the subject in most of the regional languages, but all movies reach only about 20 percent of the total population. As for television, only one experimental station in New Delhi with a 30-mile radius is functioning now. Fortunately, the Prime Minister is in favor of developing TV stations all over the country, for the educational value of TV for an illiterate country like India cannot be overemphasized; but our financial resources are limited and some consider TV a luxury for a poor country like ours. In view of these difficulties, audiovisual methods are found most rewarding.
Perhaps the most difficult problem before us is the choice of a contraceptive that is acceptable under Indian conditions, particularly in the depressed rural areas where privacy, running water, electricity, any knowledge of reproductive physiology and, most important, motivation, are more or less absent. Besides, among such diverse groups no single method, however good, can be suitable to all. Hence, we have adopted what we call the cafeteria approach: theoretically all the scientifically approved contraceptives are available to the people in the Government Family Planning clinics, but for mass consumption only four methods are now advocated and made available.
The first of these is sterilization-vasectomy for fathers or tubectomy for mothers. Vasectomy, the simple operation on the male, which I popularized in Madras State fifteen years ago, has now caught on and is becoming popular. Generally Indian couples marry early and have three or four children; they then want a simple and permanent method of conception control. Sometimes, when the husband is unwilling, the wife may undergo tubectomy, which is a relatively major operation needing at least a week's hospitalization. All services are free-the surgeon's fee, the hospital and drugs, and in addition a few rupees are given to the patient to offset the loss of wages and incidental expenses. These few rupees-about five dollars- have assumed the nature of an incentive. In fact, in large industrial establishments like the Tatas and others, workers who are willing to undergo vasectomy after the third child are offered an incentive of Rs. 250/-and a few days' leave with pay. Up to mid-June 1968, 4.2 million persons had been sterilized. Ninety percent of these sterilizations are vasectomies and the rest are tubectomies.
The second widespread method is the IUD (intra-uterine contraceptive device), or the loop, introduced in 1965. So far 24 million loops have been inserted. But the method is not very popular as it has led to excessive bleeding in about 10 percent of the cases, as well as involuntary expulsion in about 6 percent. Research to devise a better loop is under-way. All the needed loops are manufactured in India in a government-owned factory.
The third contraceptive method we are advocating is the condom or sheath. The total requirement is well above 300 million pieces per annum, and so far indigenous production totals only about 30 million. The rest have to be imported, involving foreign exchange. However, in 1968 we have been able to obtain from the United States Government, as a part of its aid to India's Family Planning Program, 200 million sheaths. In addition, we have set up a factory owned by the Government of India-the Hindustan Latex Limited-in Kerala, with technical assistance from Japan and the United States, This concern will go into production in a few months and will produce 145 million pieces a year.
But apart from production there is also a marketing problem. We have to devise a distribution mechanism to reach the people in our far-flung rural communities, where demand has to be created and supplies provided. Of course, all hospitals, clinics and Family Welfare Centers carry all supplies and distribute them free. Another distribution channel is through postmen, school teachers and members of coöperative societies; they receive the condoms free and in turn sell them at a nominal rate of 5 paise (less than a cent) for three pieces, keeping the proceeds as commission. Thus a large number of people who otherwise would not go to the Family Planning Centers are reached.
Very recently a new system of mass distribution was devised, using such commercial houses as Union Carbide India, Western India Match Company, Lipton India, Hindustan Lever, Brooke Bond India, and the Imperial Tobacco Company India. These large companies have an estimated 400,000 sales outlets penetrating into rural markets. Here the condoms are sold at the rate of 15 paise (less than 2 cents) for three pieces, of which 8 paise comes back to the Government and 7 paise goes for the remuneration of the distributor. This is the first time the Government has ever undertaken the distribution in this manner of any commodity, much less a contraceptive.
The latest contraceptive method we are making available is the pill. My predecessor was opposed to including the pill in the official family- planning program, but after discussions with experts in the World Health Organization and the USAID I have approved its use. Since we do not manufacture the pill in India, the import cost in hard currency was a matter of some concern. But during my discussions with President Johnson and USAID officials earlier this year in Washington, generous American dollar aid to our program was forthcoming and has made it possible for us to embark on a pilot project in which about 100,000 highly motivated urban wives are put on the pill under medical supervision. If the pill proves successful, its use may be extended.
Family-planning methods and the necessary supplies and advice are available in 26,202 centers all over the country, made up of 1,815 urban centers, 5,133 main rural centers and 19,254 rural sub-centers. In addition, 1,592 hospitals and urban institutions and 7,401 rural institutions do family- planning work. The Federal Government has taken the necessary steps to provide male and female doctors for these centers. So far, 13,087 doctors have been trained in various family-planning methods to work in the centers and some 120,520 paramedical personnel have been trained to assist the doctors.
But the paucity of doctors, particularly women doctors trained in family planning and willing to work in rural areas, continues to be an acute problem. In fact, we are faced with the perennial problem of finding trained workers at all levels-whether nurses, health educators or health visitors. But by dint of scholarships to medical students who opt to work in family planning and special emoluments for doctors working in rural hardship posts we hope to meet this difficulty.
What factors-political, economic, social and religious-favor our current efforts to reduce India's birth rate? The foremost factor is the Government's awareness that population growth is the nation's number-one problem, ranking with the question of modernizing India's agriculture and food production. Indeed, food production and family planning are simply two sides of the coin of national economic and social development. Awareness of this fact has led to the creation of the largest official family-planning program of its kind in the world. The Prime Minister, Mrs. Indira Gandhi, is a dedicated champion of the cause and is the chairman of the Federal cabinet committee on family planning. The fact that she is a woman and the mother of two sons gives her support special significance in the Indian cultural milieu.
During the First Five-Year Plan (1951-56) a small sum of Rs. 3 million was appropriated for family planning, but the Health Ministry's energies in popularizing the rhythm method were so misspent that only Rs. 1.5 million was actually used over the five years and only 147 family-planning clinics were set up. During the Second Five-Year Plan (1956-61) Rs. 22 million were spent and the number of clinics increased to 4,165. The Third Five-Year Plan (1961-66) witnessed the introduction of all methods of family planning, including the loop, disseminated through the extension education approach. For the Fourth Five-Year Plan begun in 1966 and currently being discussed, a tentative sum of Rs. 2,300 million is proposed. Under today's program, there are one Primary Health Center for 80,000 of rural population and one urban center for 50,000 population.
As almost all the world's religions are represented in India's population the religious attitude to family planning is important. Fortunately there is no objection on religious grounds as such to family planning in India today. As was pointed out by Professor Radhakrishnan, distinguished philosopher and India's former President, "The Hindu dharma gives us a program of rules and regulations and permits their constant change. The rules of dharma are the mortal flesh of immortal ideas and so are mutable." Social flexibility has been the essential characteristic of the Hindu code of ethics. Nor do the Muslims and other religious groups oppose the official family-planning program. Even the old opposition from the small Indian Catholic minority is now diminished.
During the last year and a half, international assistance, support and sympathy for our program have increased. Aid, large and small, is coming from the United States ($30 million),2 Sweden ($2.2 million), Japan and Denmark. Several foreign agencies have also helped, the largest aid coming from the Ford Foundation. This foreign assistance covers a wide variety of programs-provision of technical experts, commodities and supplies and training for our personnel both in India and abroad. A random listing includes vehicles, audiovisual equipment, paper, printing and mailing units, films, condoms, oral contraceptives, raw materials, training and research facilities.
However, there are some unfavorable factors with which we have to contend. Perhaps the most distressing of these is the injection of communal and religious bias into the program. While we have made every effort to keep it truly national, above and beyond party and religious politics, certain opposition parties attack us on the ground that its actual implementation is changing the ratio among the existing religious groups. The argument frequently voiced by the Jana Sangh, the right extremist Hindu opposition party, contends that considerably more Hindus than Muslims (in relation to their respective total populations) are being sterilized. And, secondly, since Hindus are bound by the monogamic law while Muslims are permitted to have four wives according to their law, the total population of the Hindus is likely to dwindle while that of the Muslims is likely to increase rapidly. Since in a democracy numbers matter and since many vote on the basis of religious (and caste) loyalties, the present family-planning program might eventually change the entire complexion of the Indian (Hindu) nation. So runs the argument.
Our reply is that Muslims, Christians (both Protestant and Catholic) and other minority religious communities are all coming to the government clinics and that the communal ratio of the Indian population shows no signs of changing. All evidence shows that these Hindu extremist fears are groundless and that educated and motivated husbands and wives resort to family planning while the very poor, the ignorant and the unmotivated do not-among all religious groups.
But there is force in the argument that in a secular democracy the Muslim minority community alone should not be permitted plurality of wives, no matter what the Islamic religion says. When even avowedly Islamic countries like Turkey, the United Arab Republic and Pakistan have given up polygamy, there is no reason why Indian Muslims should not give up their right to more than one wife, particularly when in practice 95 percent of Indian Muslims have only one. But the demand for this belated social reform must come from the Muslims, especially the Muslim women.
Another serious difficulty is the want of an efficient, modernized and national welfare-oriented administrative machinery. The present bureaucracy owes its existence to the British rulers, who were understandably interested in maintaining law and order and collecting revenues.
The late Prime Minister Jawaharlal Nehru said many things about this "creaking," "slow moving," "red-tape-minded" "delaying bureaucracy" with its countless pettifogging rules. Several serious but by-and-large unsuccessful attempts at reform have been made during the last twenty years. Recently the Administrative Reforms Commission has been working on plans to reform the administration but some believe there is no particular reason to expect any radical recommendations or their immediate implementation. I agree with Nehru that the present administrative machinery is manned largely by men who have been trained to be extremely proficient in old and outdated methods, unsuited to the demands of a modern industrializing economy in a changing world. What India needs is a band of dedicated civil servants who are trained to examine issues competently and quickly and take serious and responsible decisions. In our program particularly, a generalist is at a great disadvantage because he is innocent of basic knowledge of such subjects as demography, vital statistics, gynecology and obstetrics. To this difficulty is added a general ignorance of conditions in advanced countries. However, there are a few exceptions and the family-planning program is being implemented to the greatest possible extent.
There is also some cultural resistance to family planning among certain communities, particularly in rural areas. The desire of Hindu parents for sons is well known. A couple with two sons, for instance, is highly motivated in favor of family planning, but a couple with five daughters would like to try again for a son. This desire for sons is in part a religious attitude, but basically it corresponds to an economic need, for with farming completely unmechanized a villager needs sons as workers on his farm. The village couple with two or three children but only one son is often reluctant to practice family planning on the grounds that, given the high rate of child mortality, their son might not survive the critical first five years. This very real problem argues the need for the intensive program now being launched in India to combat malnutrition (the basis of most child mortality) among preschool-age children. In this group malnutrition is a qualitative as well as a quantitative problem and calls for a reduction in nutrient deficiencies through food fortification (wheat, rice and salt), low-cost formulated foods, and large-scale child-feeding programs. A recent study estimates that nearly 70 percent of the childhood malnutrition in India could be eliminated by the limitation of families to three children.
While, as already pointed out, there are no religious objections as such to family planning, there is always the weight of custom and tradition, apathy and inertia. Here again the difficulty appears to be cultural but the roots are also economic. Our dilemma is that whereas fertility control is needed to check the threatened decline in the already low living standards of our people, the successful widespread practice of family planning requires, and to some extent presupposes, a far higher level of living than is the situation in India. Poverty and low income lead to malnutrition and under- nutrition, which in turn lead to apathy and inertia. It is amazing that our rural labor force is able to do as much work as it does in the light of the protein deficiency of their meagre, unbalanced diet. However, both government and an awakened public are constantly endeavoring to bring about change through a multipronged effort to modernize our whole society, an adequate examination of which is not possible here. Despite an apparent resistance to change, the cake of custom is gradually being broken, the weight of caste is slowly lessening and, in the process of engineered social change, obscurantism is on its way out.
Such are the major features of India's current program to cut down its birth rate. Two further proposals which will help reduce the country's total fertility have been before us for some time and will now go before Parliament in the form of bills to raise the age of consent for girls and to liberalize abortion.
It is an established fact that either as a result of being generally more mature, or because of greater opportunities for education and for gainful employment, or a combination of these, girls marrying at a later age favor and adopt family planning more readily. There is a correlation between raising the marriage age of our girls and reducing the nation's birth rate. Marrying at a higher age cuts down the reproductive span. Some recent studies have shown that if the minimum age at marriage for females were fixed at 20 years the reduction in the birth rate in a decade would range from 12 to 30 percent.
The minimum age at marriage for girls, fixed at 14 by the Child Marriage Restraint Act of 1929, was raised to 15 in 1957. We are hoping to raise it to 18 years. Opposition is not lacking, for some critics maintain that this may cause hardship to rural girls who have no educational opportunities and who marry-the only career open to them-as early as they can. But we feel that Parliament will approve the proposed measure in view of the pressing need to reduce the nation's birth rate.
The second proposal before us is to liberalize the existing law on abortion. The provisions regarding abortion in the Indian Penal Code were enacted about a century ago, in keeping with the British Law on the subject. Abortion was made a crime for which the mother as well as the abortionist could be punished in all cases except where it had to be induced in order to save the mother's life. This law has been observed in the breach in a very large number of cases in rural and urban areas all over India. Whatever may be the moral and ethical feelings professed by some sections of society on the question of induced abortion, it is an undeniable fact that large numbers of Indian mothers are prepared to risk their lives in an illegal abortion rather than carry that particular child to term. Furthermore, it is revealed that a great majority of these mothers are married women.
The main argument in India against liberalizing abortion is that the strain on the existing medical services would be too great. But a recent breakthrough in the Soviet Union would soon make this argument out of date. Soviet scientists have prepared an aborting device on the suction principle which is virtually harmless and does not need special surgical supervision. Moreover the entire operation lasts no more than five minutes.
The skeptics-Indian and foreign-who doubted whether an agrarian, underdeveloped, conservative and "religion-ridden" society could become aware of its excessive fertility have been silenced. Despite many difficulties we have been able to create at many levels an intellectual awareness of the threatening nature of our population explosion. It is remarkable that the people's attitudes toward family planning have changed rapidly during the last twenty years, from unhesitating condemnation of a device believed to promote promiscuity and immorality to approval of a welcome innovation promoting women's health and economic prosperity. India is after all a free society and there is more mental freedom in India than in certain advanced countries. The progressive, positive policy of population control initiated by the late Prime Minister Nehru is being continued with even more vigor by the present Prime Minister.