Eva Fiks
State Intimacies: Sterilization, Care and Reproductive Chronicity in Rural North India
New York and Oxford: Berghahn Books, 2024. 264 pages. Hardcover, £104.00; ebook, £27.95. ISBN 9781805394648 (hardcover), 9781805394655 (ebook).
In 1952, India became the first country in the world to introduce what are now known as family planning programs. Neo-Malthusian concerns that overpopulation hinders economic development turned reproduction into a battleground in the fight against poverty and justified state interventions into people’s intimacies. In this volume, UK-trained medical anthropologist Eva Fiks argues that these interventions are lasting which is as remarkable as it is alarming. Rural communities have been especially targeted by these family planning policies since the 1970s. In rural areas, mobile outreach units offer reproductive interventions in so-called “camps,” backed by policy programs, state representatives, and community health workers. The increasingly coercive approach toward population containment peaked with enforced vasectomies, following the national Emergency declared by Prime Minister Indira Gandhi in 1975. Up to 11 million forced sterilizations were carried out on mostly oppressed, illiterate, and economically and politically disadvantaged castes of Adivasi and Muslim men. By the 1980s, however, laparoscopic tubal ligation became the most prevalent method of contraception, and family planning for economic prospering shifted to targeting female bodies.
Fiks builds upon South Asian scholarship that discusses sterilizations in relation to female decision making and reproductive freedom, victimhood in India’s gender and familial power relations, and pressing socioeconomic factors. To advance the discussion, Fiks puts sterilization at center stage in her ethnographic study in rural Rajasthan. She draws on eighteen months of fieldwork (mainly in 2012 and 2013) in mixed Adivasi and caste Hindu villages at the rural, geographic, and political margins of the Udaipur district. In this disadvantaged area—characterized by poverty, a low literacy rate, poor health, and poor health care provisions—she encountered an “absolute everydayness of sterilization” (187).
Fiks situates sterilization within the broader and enduring suffering from reproductive burdens and bodily interventions that rural Indian women experience as a form of chronic suffering she identifies as “reproductive chronicity” (13). In this setting, she argues, care can do violence, and violence can be felt as care; hence, sterilization may emerge as a desirable solution. Since many rural women experience sterilization as a form of care, Fiks suggests making use of the ambivalent dimensions of the concept of care to investigate how women engage with this surgical intervention and how sterilization—experiencing, refusing, or desiring it—becomes part of their everyday life. By 2016, thirty-six percent of married Indian women aged 15–49 used tubal ligation as permanent contraception, and half of them underwent sterilization before the age of twenty-six.
One-third of the sterilizations in rural Rajasthan are conducted in camps, temporary services outsourced to an NGO and held in Community Health Centres (CHS) during the dry months between September and April, locally known as the “sterilization season” (38). Fiks’s fieldwork included participant observation in such sterilization camps. Scholars have criticized the quality of care in sterilization camps. At the time of her fieldwork, “43 per cent of rural married women in Rajasthan aged 15–49 used tubal ligation as their method of contraception . . . [and] 363 women died between 2010 and 2013 during or after surgery in sterilization camps” (7). Despite a subsequent Supreme Court verdict to stop procedures, sterilization camps throughout India were only temporarily suspended during the Covid-19 pandemic. Although India’s fertility rate dropped from six births per woman in 1951 to two in 2020, health policies continue to derive from health metrics that interlink declining fertility rates with socioeconomic progress.
State Intimacies: Sterilization, Care and Reproductive Chronicity in Rural North India is organized in six chapters. Chapter 1 opens to the reader the peculiar politico-medical space of the camp where sterilization is negotiated and performed and where the family planning agenda is implemented by doctors, nurses, bureaucrats, and so-called motivators. The form of care offered here “perpetuates structural inequalities based on caste, class, gender and rurality and contributes to deepening chronicities rather than providing relief” (64). Chapter 2 is dedicated to the laparoscope—a reproductive technology that allows for tubal ligation and brings together infrastructure, history, politics, and gender dynamics. Against the sociohistorical background of forceful vasectomies associated with cutting blades during the Emergency, laparoscopic tubectomies as a minimal invasive surgery emerged as an acceptable form of medicalization for rural women associated with choice. Wrapped in a “biomedical discourse of convenience” (82) emphasizing the procedure as safe, quick, painless, and bloodless, laparoscopic sterilization is not considered as a form of violence but rather as a form of care. It legitimizes the shift of contraceptive burden onto women’s bodies. Chapter 3 focuses on the interactions and power relations between the family planning program, community health workers who serve as brokers, and the rural women to be motivated by an incentive of 600 Indian Rupees. Chapter 4, “Jugad,” dives into these informal arrangements and improvisations that characterize public healthcare in the chronically under-resourced margins and allow it somehow to function. In chapter 5, Fiks looks closely at women’s narratives of sterilization as a form of ambivalent care and develops her aforementioned concept of reproductive chronicity. Analyzing the hierarchies in the sterilization camp in the final chapter, the author argues that this medical intervention also reproduces and perpetuates social differences.
Fiks places sterilization in a space between chronicity and care. She carves out relationships between care, chronicity, power, and violence as revealed by the tensions, uncertainties, and contingencies women encounter in their everyday lives through the concept of care. This ambivalent and fragile form of care available to rural communities in postcolonial India, however—per the central argument of State Intimacies—may temporarily provide relief but inevitably deepens reproductive, hierarchical, and other chronicities. This critical, compassionate, and sensitive ethnographic description of women’s reproductive lives in an area shaped by poverty and medico-political intervention is of relevance to medical and political anthropology scholars, as well as for scholars working on gender and reproduction and on South Asia at large. The author has successfully managed to condense data and insights based on her fieldwork from a previous decade into a convincing and relevant volume that also benefits from both hindsight and recent scholarly debates.
Eva-Maria Knoll
Austrian Academy of Sciences