Mohan Rao. From population control to reproductive health: Malthusian arithmetic. New Delhi: Sage Publications, 2004. Rs 350, pp 287. ISBN 81-7829-409-5

Ask a group of medical students to name the country’s biggest public health problem and all of them will mention the ‘population explosion’.

That’s what the author of this book says and indeed health professionals have cited the National Family Planning Programme as justification for research on potentially dangerous drugs, or for persuading women to use controversial contraceptives. Many women approaching the public sector for abortions report being forced to undergo sterilisation as well. It seems as if the Indian medical profession’s paternalism is most evident when dealing with the poor and their decisions on child-bearing. One of the greatest challenges is to convince doctors that the problems in poor people’s lives do not get solved by tubectomies – which, incidentally, account for almost 75 % of all contraceptive use in India, and which leaves one in four with long-term complications.

Medical students learn to diagnose a medical problem and perform technical procedures to it. They are not taught to make the link between ill-health and its social, economic and environmental causes. As Rao points out, “…my training as a doctor did not teach me to understand a problem historically.” (p. 13)

From population control… analyses the Indian family planning programme and its ideological roots and the larger social, political and historical context.

1 provides a short history of the world’s first national family planning programme. Various strategies were launched enthusiastically – condoms, IUCDs, sterilisation – but much of the drop in fertility is attributable to other causes. Family planning budgets grew even as overall health budgets shrunk. By 2002, the government had given up most pretenses of providing free health care as a right, to concentrate on family planning. Coercion became an intrinsic part of the programme, as state laws were enacted offering incentives and disincentives to enforce the two-child norm. The groundwork had been laid for unethical research including the blatantly illegal promotion of quinacrine for ‘chemical sterilisation’ using a network of unregistered medical practitioners. In other words, anything goes when it comes to contraception.

‘Red herrings: Malthusianism and neo-Malthusianism’, sketches the ideological foundations of the Indian programme. Thomas Malthus argued that uncontrolled population growth would create a crisis in resource availability. Essentially, Malthus and his successors justified the status quo distribution of resources in society, and called for population control to safeguard this distribution pattern. This view drives the international population control establishment with its Indian variations, supported by national governments and funding agencies.

‘Beyond Malthusian arithmetic’ describes the way in which studies in family planning in India have supported this population control programme. The author argues that these studies do not recognise the complex influences on decision-making on family size.

‘Reifying reproduction’, looks at the ‘paradigm shift’ from ‘population control’ to ‘reproductive rights’ at the 1994 International Conference on Population and Development in Cairo. Reproductive rights seem to be an acknowledgement of women’s concerns. However, the author suggests that this shift should be seen in the context of the structural adjustment programmes of the 1990s, and governments’ abandonment of their commitment to health for all through primary health care as promised in the 1978 Alma Ata Declaration. Reproductive health and rights refer to programmes targeted at women as potential child-bearers. Further, the overall goal remained the same — of reducing fertility, rather than providing health care. The concept of reproductive rights co-opted the language of feminist health activists for population control.

‘Into the 1990s: old wine in new bottles?’ is an analysis of the government’s Reproductive and Child Health programme launched after the Cairo Conference. ‘Conclusion: the many avatars of Malthus’ asks why people are drawn to this ideology in its new forms today. Why do people continue to believe that our problems are due to population? The author suggests that this ideology allows us not to question the inequities responsible for ill-health.

The author’s arguments are supported by extensive documentation from studies, government documents and other literature. The book is an invaluable resource for health professionals, policy makers, journalists and others interested in understanding the background to our obsession with population.