Rage of the voiceless

It was 3.15 PM. I had lost count of the number of patients I had already seen in my government-run internal medicine clinic, and I was informed that there were at least thirty patients left to be seen. I felt frustrated and burnt out. As I waited for my next patient to walk in, I ran through my mental checklist. There were a billion things to get done. I could only hope to grab a substantial meal somewhere along the way.

I was lost in thought when my next patient entered.

Mrs. Sunita# was a thirty-three-year-old woman with two children. She sat down with an unsure look on her face. She nervously adjusted her sari as she took her seat. I barely glanced at her while I started scribbling her medical details. I asked her the reason for her visit.

Silence.

I asked yet again with barely concealed irritation and informed her that I had more patients to tend to.

She started speaking in rushed sentences.? She couldn’t sleep. She had headaches. Her entire body ached. She couldn’t get up from bed. She had no energy. She couldn’t digest her food. The list of complaints were never-ending. I examined her and there was nothing abnormal. She was a seemingly healthy young woman who was in all sorts of pain. We would probably label it as “psychosomatic” or “medically unexplained physical symptoms”, as did I.

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As a female growing up in a patriarchal Indian society, I was no stranger to similar such stories.

Women who I knew. ?Women whose male relatives ignored their symptoms and pleas for help.

Eventually, they would be escorted to hospitals. I saw male (and many female) physicians mock them. It was assumed that women were being hysterical or attention-seeking. Their male relatives would wholeheartedly agree with this assumption. This was assumed to be the case unless they had an extremely overt medical illness, that could not be ignored. “Non-specific” pain and a psychiatry review were very common methods of dealing with female patients.

I had been a child who heard these anecdotes. I had been a child who was made to believe that women exaggerate.

It was probably these lived experiences that made me abruptly tranquil. Tranquil amid a bustling clinic.?????????????????????????????????????????????????????????????? ??????

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I looked at Sunita again. This time I ‘saw’ her. I saw the lines creasing her forehead and the scanty hair on her scalp. The anxious, sunken eyes buried under swollen eyelids. Her dry skin and unkempt nails. She kept fidgeting with the ends of her sari. She had a disconsolate air surrounding her. She was crouching on her seat as if to minimize the space she took.

I placed down my pen. For the first time during our interaction, I spoke to her. Did she feel sad? Did she feel hopeless? Did she feel like crying for no reason? Was family life, ok? Was her husband good to her?

“Life is tough ma’am. What can one do about it?” ?“I don’t care about myself anymore. ?I just want the best for my daughters” she said

We continued to speak for the next twenty minutes. She revealed to me that she was her husband’s second wife. He was an alcoholic who hit her almost every day. As she gained confidence, she revealed that he would rape her quite regularly.

She broke down repeatedly as we tried to explore her options.

Could she leave with her daughters to her maternal home? No, her family expected her to accept the abuse and stay with her husband. They could not afford the financial burden of Sunita and her children

Could she report her husband to the police? No, the police would ask them to sort out domestic disputes at home. She would be accused of provoking her husband. Her husband would abuse her even more to punish her insolence.

Could she work to save some money for herself and her daughters? No, her family hadn’t educated her, since she was a girl. In addition, her husband suspected her of infidelity if she stepped out of home. That would lead to more severe beatings and rape.

We were dealing with a young woman, of poor socioeconomic standing, without any education, enduring unspeakable abuse regularly. She was continuing to do so because she had no support system and she needed to safeguard her daughters.

She came to me with “non-specific” pain.

What could I do for her? My heart ached at the thought of her ongoing agony. I couldn’t offer her a home or refuge. I did the next best thing I could think of. I gave her the number of a collective that worked with abused women. I also gave her my number.

She walked out of my clinic with a prescription for her physical symptoms. The disease, however, remained untouched.

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Recently an analysis was performed of 20 years of domestic violence data (in India) from the National Crime Records Bureau (NCRB). This showed a 53% increase in cases filed under ‘cruelty by husband or his relatives’. 1 According to the 2019–21 Indian National Family Health Survey (NFHS-5), ?29% of women who had ever been married reported physical or sexual intimate partner violence (IPV).2

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In India, government hospitals are crushed under the expectations of an ever-burgeoning population.

Women, children (especially the girl child), individuals belonging to the lower castes (also known as Dalits or untouchables), queer individuals, and other minorities face double or triple layers of intersectional discrimination when it comes to seeking health care.?

Indian healthcare systems are ravaged by a quagmire of patriarchy, caste, nescience, stigma, and poverty. Our healthcare systems have inadequate liaisons with social service networks. We work in isolation and with hardly any foresight.

Our policies have to transcend the barriers indigenous to our country. They have to further be tailored to local requirements and unique local challenges. Our policies need to come from a space where all stakeholders have a voice. Only when we hear these voices will we know the angst that exists. We need to have the patience to untangle each tortuous snag as it manifests. We need to be adamant yet flexible as we envision the change.

India is a signatory to various human rights conventions that put the onus on the government to recognize violence against women as a human rights issue. Despite the legislative and policy mandates that exist, limited technical and financial resources for the health sector inhibit the implementation of programming to reduce intimate partner violence.3

India’s National Health Policy (NHP) recognized violence against women as a healthcare issue only in 2017. The policy mandates that all survivors of violence must receive free services and recommends that gender sensitization training be carried out in all health facilities and that it be included in the medical curriculum (GoI, 2017).3

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?Based on the population of India, the health consequences of spousal violence, are multi-fold and include injury, chronic physical health consequences, and mental illness in the woman and her offspring. ?Unfortunately, there is a standard of social tolerance and even the health systems accept these abuses against women.4,5

In a context of increasing economic insecurity and volatility globally, a context in which marital violence is likely to escalate, we need to prioritize efforts to tackle marital violence.6

We need to recognize, learn, and teach medical professionals about intimate partner violence. There needs to be better networking between the medical and social sectors to ensure that a survivor has a seamless and safe experience.

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Epilogue

In India, the family unit is considered sacrosanct and the husband or other paternal figures are considered to be faultless. My patient would continue to diminish in the cesspool of her home. Her life and her mental health would be deemed less important than the honor of her husband and his family. She would go to many other physicians for her pain and fatigue. She would suffer till she died or was killed. I would go on to see so many similar women whose health, both physical and mental, was sacrificed at the altar of societal hedonism. I gave each patient a number to call for help. Even as I scratched out the digits, I knew, and she knew that no calls would be made.

A couple of days later after I first met Sunita, I received a call from an unknown number. I picked up and a drunk man was yelling at me. I froze. He said that he was Sunita’s husband and warned me to stay away from his wife. My hands were trembling as I hung up.

I never saw Sunita again.

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References

1.???? Dandona, R., Gupta, A., George, S.?et al.?Domestic violence in Indian women: lessons from nearly 20?years of surveillance.?BMC Women's Health?22, 128 (2022). https://doi.org/10.1186/s12905-022-01703-3

2.???? Ministry of Health and Family WelfareGovernment of IndiaInternational Institute for Population Sciences India and ICF–National Family Health Survey (NFHS5), 2019–21. International Institute for Population Sciences,?Mumbai, India 2021

3.???? Padma Bhate-Deosthali, Sangeeta Rege, Poulomi Pal, Subhalakshmi Nandi, Nandita Bhatla and Alpaxee Kashyap .ROLE OF THE HEALTH SECTOR IN ADDRESSING INTIMATE PARTNER VIOLENCE IN INDIA, A SYNTHESIS REPORT. ICRW (International center for research on women)

4.???? Population of India. Projections by Sex and Age Group; Projections Based on the United Nations World Population Prospects 2017. accessed on November 11, 2019 Available from:?https://statisticstimes.com/demographics/population-of-india.php

5.???? International Institute for Population Sciences. National Family Health Survey (NFHS-4), 2015-16. 2018 Mumbai, India IIPS and ICF

6.???? Raj, Anita1,2,.?Public health impact of marital violence against women in India. Indian Journal of Medical Research 150(6):p 525-531, December 2019. | DOI: 10.4103/ijmr.IJMR_1427_19