Medical tourism, commercial surrogacy and women in India Output or exploitation?
Ásdís Lýðsdóttir
Lokaverkefni til MA–gráðu í Þróunarfræðum
Félagsvísindasvið
Medical tourism, commercial surrogacy and women in India Opportunity or exploitation?
Ásdís Lýðsdóttir
Lokaverkefni til MA–gráðu í Þróunarfræðum Leiðbeinandi: Jónína Einarsdóttir
Félags- og mannvísindadeild Félagsvísindasvið Háskóla Íslands október 2015
Ritgerð þessi er lokaverkefni til MA–gráðu í Þróunarfræðumog er óheimilt að afrita ritgerðina á nokkurn hátt nema með leyfi rétthafa.
© Ásdís Lýðsdóttir, 2015
Reykjavík, Ísland 2015
Foreword.
This thesis marks the completion of my MA programme in Development Studies at the
University of Iceland. Four months of field research in India contributed to the thesis, which has a value of 60 ECTS units. I would like to dedicate this thesis to my loving parents,
Guðbjörg Eiríksdóttir and Lýður Hallbertson, for supporting me and encouraging me in everything that I have taken on in my life. I know my world travels have often caused them grief and worries but they supported me throughout it all.
I want to express my sincere gratitude to my research supervisor Jónína Einarsdóttir,
Professor of Anthropology at the Faculty of Social and Human Science at the University of
Iceland, for her guidance and encouragement.
I give special thanks to all my friends and family for their help, consideration, motivation and support throughout this study. You know who you are.
3 Abstract
Globalisation has made health care a global industry through a phenomenon called medical tourism. Surrogacy is a part of medical tourism and involves a woman carrying a child for a couple or individual for altruistic or commercial reasons. With increasing infertility in the world more couples/individuals have started looking towards “developing countries” in order to hire surrogate mothers to carry their biological child at cost saving prices. India has in recent decades become a leading force in medical tourism and commercial surrogacy.
Commercial surrogacy in India has been criticised for the lack of empirical data on the surrogate mothers’ wellbeing.
The aim of this research is to shed light on the awareness of the general public in India about medical tourism, with a particular focus on knowledge and ideas regarding commercial surrogacy. It is also important to understand the status of women in India since they are the means of production in surrogacy. This research was conducted in the Indian cities of Jaipur and Udaipur, between March and August 2012. The 47 participants were obtained by snowball sampling and the data collected using Interviews and questionnaires.
The results of this study indicate that surrogate motherhood as a profession was seen as taboo within Indian society, but that participants found it to be acceptable for the “poor”, “needy” and “uneducated” women for whom few options existed to earn enough to change their living standards. However, surrogacy is generally considered socially inappropriate for educated women with financial means to “choose” a better profession. Medical tourism was seen as a positive development for India whereas commercial surrogacy was not embraced with the same positivity; interviewees felt more ethically conflicted and found it difficult to pick a side.
Keywords: Commercial surrogacy, medical tourism, India, exploitation, free will, choose, surrogate mother, discrimination, power, knowledge
4 Úrdráttur
Hnattvæðing hefur gert heilbrigðisþjónustu að alþjóðlegu viðskiptarfyrirbæri sem ber nafnið heilsuferðamennska (medical tourism). Staðgöngumæðrun (surrogacy) er hluti af heilsuferðamennsku og felur í sér að kona gengur með barn annarra einstaklinga af velgjörð
(altruistic surrogacy) eða í hagnaðarskyni (commercial surrogacy). Barnalán er ekki sjálfgefið, ófrjósemi hefur áhrif á einstaklinga og pör um allan heim eru í auknu mæli að leita sér að staðgöngumæðrum í þróunarlöndum til þess að ganga með líffræðilega skylt barn
þeirra á lágu verði. Indland hefur á síðustu áratugum orðið leiðandi afl í heilsuferðamennsku og staðgöngu í hagnaðarskyni. Staðgöngumæðrun í hagnarskyni hefur einnig verið gagnrýnd fyrir skort á áþreifanlegum gögnum um velferð staðgöngumæðranna.
Markmið rannsóknarinnar er að varpa ljósi á þekkingu indversks almennings á heilsuferðamennsku og með sérstakan áherslu á þekkingu og hugmyndir um staðgöngumæðrun. Það er einnig mikilvægt að skilja stöðu kvenna á Indlandi þar sem þær sjá um framleiðslun iðnaðarins. Þessi rannsókn var framkvæmd á Indlandi í borgunum Jaipur og
Udaipur milli mars og april 2012. Þátttakendurnir voru 47 og fengust til þátttöku með snjóboltaúrtaki og gagnasöfnum fór fram með viðtölum og spurningarlistum.
Niðurstöður rannsóknarinnar gefa til kynna að staðgöngumæðrun var séð sem forboðin atvinnugrein innan indversks samfélags, en þátttakendur sáu það samt sem viðunnandi valkost fyrir “fátækar”, “þurfandi”, “ómenntaðar” konur sem höfðu ekki marga valkosti til að afla tekna sem myndi hjálpa þeim að breyta lífsafkomu sinni til hins betra. Hins vegar var staðgöngumæðrun séð sem óásættanleg atvinna fyrir menntaða kona sem hefði fjármuni til þess að velja sér betri farveg í lífinu. Heilsuferðamennska var séð sem hafandi jákvæð áhrif á Indland á meðan staðgöngumæðrun var ekki tekið með sama jákvæða viðurhorfinu, og áttu viðmælendur í siðferðilegum vanda með að taka afsöðu til staðgöngum í hagnaðarskyni
Lykilorð: Staðgöngumæðrun í hagnaðarskyni, heilsuferðamennska, Indland, arðrán, frelsi, val, staðgöngumóðir, misrétti, vald, þekking.
5 Table of Contents Foreword...... 3 Abstract ...... 4 Úrdráttur ...... 5 Introduction ...... 10 1 Theoretical framework and the state of the art of surrogacy ...... 13 1.1 Surrogacy: concepts and history ...... 13 1.2 Feminist theories ...... 19 1.2.1 Reproduction as exploitation ...... 20 1.2.2 Polarized camps ...... 21 1.2.3 Exploitation or aid? ...... 24 1.3 Additional theoretical perspectives ...... 25 1.3.1 Foucault - Bio-power ...... 26 1.3.2 Prospect Theory, Conflict Theory and Theory of Exchange ...... 28 1.3.3 David Ricardo - Comparative advantage ...... 29 1.4 Summary ...... 31 2 Fieldwork settings ...... 33 2.1 General Information ...... 33 2.1.1 Diverged and historical ...... 35 2.2 Indian women ...... 36 2.2.1 Violence against women ...... 38 2.3 Health care ...... 42 2.3.1 The state run health care sector ...... 43 2.3.2 Private health care ...... 44 2.3.3 Unequal access to health care ...... 44 2.3.4 Women’s access to health care ...... 45 2.4 Medical tourism in India ...... 48 2.4.1 Medical tourism: Global phenomenon ...... 48 2.4.2 Medical tourism in India ...... 49 2.4.3 Why choose India? ...... 52 2.4.4 Marketing on a global scale ...... 53 2.5 Commercial surrogacy ...... 53 2.5.1 The Indian surrogate mother ...... 55 2.5.2 Ethical issues and commercial surrogacy ...... 57 2.6 Summary ...... 60 3 Methodology ...... 62 3.1 Qualitative research ...... 63 3.2 Data collection ...... 64 3.2.1 Interviews ...... 66 3.2.2 Questionnaire ...... 68 3.3 Data analysis ...... 70 3.3.1 Grounded theory ...... 70 3.3.2 Discourse analysis ...... 72 3.4 Ethical challenges ...... 74 4 Results ...... 77 4.1 Women in Indian society ...... 77
6 4.1.1 Gender equality ...... 78 4.1.2 Is the educated woman independent? ...... 81 4.1.3 Violated, invisible and quiet women ...... 83 4.1.4 Sub-section summary ...... 84 4.2 Medical tourism industry ...... 85 4.2.1 A booming industry ...... 85 4.2.2 Importance of promotion ...... 89 4.2.3 Admired from a distance ...... 91 4.2.4 All that glitters is not gold...... 92 4.2.5 Sub-section summary ...... 94 4.3 Commercial surrogacy ...... 95 4.3.1 Positive approach to a sensitive subject ...... 96 4.3.2 Negative approach to a sensitive subject ...... 99 4.3.3 Exploitation or financial opportunity? ...... 101 4.3.4 Hidden from society ...... 103 4.3.5 Surrogacy in Bollywood ...... 104 4.3.6 Sub-section summary ...... 105 4.4 Summary ...... 106 5 Discussions ...... 109 Conclusion ...... 116 References...... 119 Table of figures: ...... 134 Appendix ...... 135
7
Better than Heaven or Arcadia I love thee, O my India! And thy love I shall give To very brother nation that lives. God made the Earth; Man made confining countries And their fancy-frozen boundaries. But with unfound boundless love I behold the borderland of my India. Expanding into the World. Hail, mother of religions, lotus, scenic beauty, and sages! Thy wide doors are open, Welcoming Gods true sons through all ages. Where Ganges, woods, Himalayan caves, and Men dream God- I am hallowed; my body touched the sod.
-Swami Yogananda Paramhansa
8
Figure 1: India
Source: Map of India, e.d.
9 Introduction
Globalisation has made health care a global industry through a phenomenon referred to as medical tourism. Patients from developed countries are increasingly seeking medical diagnosis and treatment in developing countries to avail the opportunity of exploring exotic locations while receiving world class medical treatment. What patients are looking for is high quality medical care at low cost, with short waiting lists and speedy service (Herrick, 2007;
Upadhyay, 2011). Reproductive tourism is a section within medical tourism where reproductive services, such as commercial surrogacy have been made affordable and accessible. India is a lead runner in medical tourism and Mecca for reproductive technology.
Though the medical tourism industry is generally supported worldwide, commercial surrogacy is an ethically debated issue. Critical voices express that uneducated and disadvantageous “third world” women, with limited financial prospects and powerless in a patriarchal society, might experience economic and family pressures to become surrogate mothers. Supporters of this industry see it as an opportunity for women with limited financial prospects to earn enough money to increase their living standards. In their view it gives surrogate mothers an opportunity to offer their own children and family a better life.
Little is known about the effect of industries such as commercial surrogacy on surrogate mothers and on society as a whole. There is little evidence to suggest that systematic monitoring of the health and psychological condition of the surrogate mother is carried out after delivering the child. This lack of available data on the industry has raised great concerns (Lal, 2008; Qadeer, 2009). In this MA thesis I aimed to explore surrogacy in
India from the point of view of common citizens of India.
I arrived in India for the first time in March 2005 as a volunteer; I taught English to young children in a day-care centre in the small town of Palampur, which is located in North
India. I stayed in this beautiful mountain town for two months and enjoyed breathing the fresh
10 Himalayan air. After my stay in Palampur I spent two months in the desert climate of Jaipur,
Rajasthan, where I made many close friends. During the four months that I lived in India I fell in love with its beautiful nature, colours, culture and people. I went to India again in 2007 to visit friends who I had kept in close contact with, and this period helped me to enhance my experience and understanding of Indian society and cultural values. Many years later I was browsing through an Icelandic newspaper and came across the story of Jóel, a little boy that an Indian surrogate mother had given birth to. At the time I had completed a year in
Development Studies at the University of Iceland and was searching for a research topic that I was passionate about to undertake for my master’s degree. After reading Jóel´s story I was fascinated and, after careful consideration, decided that this should be my research topic. I was surprised that in a country where I had been told on numerous occasions that it was considered unthinkable, if not impossible, for children to be born out of wedlock, a reproductive industry such as commercial surrogacy could start to flourish. I wanted to investigate the general knowledge of surrogacy among the Indian public to find out the extent of knowledge of this industry such an industry and how much it is accepted within Indian society. Commercial surrogacy is linked with the heated discussions on women's rights over their own bodies. It begs the question to what extent commercial surrogacy aids or exploits
Indian women? I knew that I was longing to go back to my beloved India, so there was no doubt in my mind where I wanted to conduct field research.
The aim of this research is to shed light on the awareness of the general public about medical tourism, with a particular focus on knowledge and ideas regarding commercial surrogacy. India is an optimal fieldwork setting, however it is important to point out that the country is geographically large, and as the second largest population in the world it offers a great variety of ethnicities, religions, languages and cultures. It is also important to understand the status of women in India since they are the means of production in surrogacy. These
11 important factors combined with deep-rooted class division make it difficult, if not impossible, to generalise anything about Indian society. Thus, I have chosen Rajasthan as my setting for fieldwork, more precisely Jaipur and Udaipur.
In chapter one, the thesis begins with the state of the art of the surrogacy industry and of crucial concepts related to surrogacy and theoretical frameworks of relevance to surrogacy research. The history of surrogacy is traced and crucial concepts such as “free will” and
“choice” discussed. The theoretical framework of medical tourism and commercial surrogacy as pure business are also discussed. In chapter two I present the fieldwork setting for the research. In this chapter I will discuss the surroundings that shape the field, India is introduced, as well as its health care system and the status of its women. In chapter three I discuss the methodology of this research. I will discuss which research methods suited my research and which tools I used to analyse the data collected. In chapter four I present my results in three sub-chapters, each dedicated to different aspects important to this discussion: the status of women in India, medical tourism, and commercial surrogacy. In chapter five I discuss my findings and present my conclusions.
12 1 Theoretical framework and the state of the art of surrogacy
In this section I present crucial concepts and the theoretical framework. In the first sub- chapter I will discuss the state of current knowledge on the field. In the second sub-chapter I discuss feminist approaches to surrogacy and women’s right to choose what happens to their bodies. Within feminist groups there is a great deal of controversy regarding surrogacy and the concepts of “free will” and “choice” in that regard. Radical feminists saw early on the dangers of “reproductive brothels” and “breeders” developing through an industry like surrogacy. In the third sub-chapter I discuss additional theoretical perspectives in relation to surrogacy. Firstly, I present the concept of “bio-power”, a concept coined by the French postmodernist and philosopher Michel Foucault, which addresses the notion of power and is relevant for considering forms of power over the body. The concept of choice will be discussed using Prospect Theory, Conflict Theory and Theory of Exchange. When facing two difficult choices, how does one make the right decision? Finally I present David Ricardo’s theory of “comparative advantage”. Does India have a comparative advantage over other nations when it comes to its medical knowledge and access to surrogate mothers?
1.1 Surrogacy: concepts and history
The word surrogate has Latin origins and refers to a person who is appointed to act in the place of another. Oxford Dictionaries (e.d.-d-e) define surrogacy as “[t]he process of giving birth as a surrogate mother or of arranging such a birth” and they define surrogate mothers as
“[a] woman who bears a child on behalf of another woman, either from her own egg fertilised by other woman’s partner, or from the implantation in her womb of a fertilised egg from the other woman”. The inability of Lack of ability for couples to conceive has grown with increasing infertility rates in the world. The World Health Organization (WHO) defines
13 infertility as the inability to become pregnant, maintain a pregnancy or carry a pregnancy to a live birth (WHO, e.d.). In 2010 it was estimated that 40.2 – 120.6 million women between the ages 20 and 44 were unable to get pregnant after 12 months of unprotected sex, and almost 50 million couples were unable to have children after five years of trying to conceive. One in eight couples had trouble getting pregnant or sustaining a pregnancy, almost half (44 percent) of women with infertility problems have sought medical assistance and 65 percent of those successfully gave birth (Encyclopedia Britannica, e.d.-b; Palattiyil et.al. 2010; Resolve, 2014;
ScienceDaily, 2012).
Surrogacy is divided into two categories; gestational surrogacy and traditional surrogacy. Gestational surrogacy, also referred to as full surrogacy implies that the surrogate mother is not genetically related to the child. The gametes are provided by the couple or by sperm-egg banks, the egg is then fertilised by In Vitro Fertilization (IVF) and the fertilised embryo is implanted into the surrogate mother's uterus. The surrogate mother carries the fetus/child in her womb until giving it to the couple at birth. The first gestational surrogacy occurred in 1985. Traditional surrogacy, also named partial surrogacy, occurs when the surrogate mother is genetically related to the child. The surrogate mother’s eggs are fertilised by artificial insemination with the sperm of the male individual seeking the arrangement (or donor sperms), she carries the fetus/child in her womb and gives the child to the couple/individual at birth.
There are two different types of surrogate arrangements; altruistic surrogacy and commercial surrogacy. Within altruistic surrogacy the surrogate mother does not receive any financial reward for offering her womb. The surrogate mother enters into the contract because of kindness and/or compassion, not because she is encouraged by financial incentives.
Commercial Surrogacy is a form of surrogacy where the surrogate mother receives financial incentives for carrying a child for others (Brandel, 1995; Delhi IVF, e.d.; Encyclopedia
14 Britannica, e.d.-b; Government of India, 2009; Grynberg, et. al.: 2011; Karandikar et. al.,
2014; Palattiyil, et. al., 2010; Rotabi and Bromfield, 2012). Countries that legally allow both types of surrogate arrangements (altruistic and commercial) are the Russian Federation, India,
Ukraine, Belarus, Georgia, Armenia, Cyprus, South Africa and some states in the United
States. Countries where all forms of surrogacy are banned by law are China, Japan, Iceland,
Germany, France, Italy, Spain, Switzerland, Austria, Norway, Sweden, Estonia, Moldova,
Turkey, Saudi Arabia, Pakistan, Canada (Quebec), and some states of United States. Reasons for countries prohibiting surrogacy can be cultural, ethical or religious; it could also be that the country does not consider the procedure sufficiently safe. In some countries altruistic surrogacy is considered to be a legal procedure while commercial surrogacy is banned by law
(Blyth and Farrand, 2005; Surrogate baby, 2012; Teman, 2006).
One of the reasons why surrogacy is sought by heterosexual couples is that they have experienced a repeatedly failed IVF or miscarriage. The women might have an infected, absent or physiologically incapable uterus, making it impossible for her to carry a child for a full term. Reasons also include an excessive medical risk associated with the pregnancy, or from failed attempts at conception with standard treatment options. Commercial surrogacy has also become an attractive option for homosexual couples or single individuals that want to become parents (Jadva, et. al.: 2003).
Commercial surrogacy is ethically debated, and it is considered to be immoral by its critics and a possible gateway to exploitation. Nonetheless, surrogacy is not a new phenomenon. Throughout history infertile couples have sought different means to fulfil their desiresfor parenthood. Surrogacy, in the form of traditional surrogacy, can be traced back to biblical times when the biological father inseminated the surrogate mother through sexual intercourse. Surrogacy today occurs in a lab, often with little physical contact between the surrogate mother and the expected parent/parents. In the biblical stories strong power relations
15 are very visible. The surrogate mothers were often employees of the household and had very little say in their fate. An example of one such biblical story can be found in Genesis chapter
16, where Abeam’s wife Sarai was unable to conceive. To satisfy their desire to become parents Abeam impregnated a handmaid, an Egyptian girl named Hagar. The handmaid carried the child in her womb until she gave birth to it, the child was then raised by Sarai and
Abram as their own (Palattiyil, et. al.: 2010; Stephenson, 2009). Insemination by a donor does not necessary have to involve health care professionals, since it can be performed with simple tools such as a turkey neck. Such procedures can be traced back to the 19th century, and are even believed to have been practised long before that.
In her book The Mother Machine: Reproductive Technologies from Artificial
Insemination to Artificial Wombs, published in 1985, the feminist Gena Corea traces the history of surrogacy. During slavery, children of black women were “legally” sold without their consent; the children were seen as the property of the slave owner. The mothers did not have any legal claims to the children because they were sold on as a product. Corea refers to these women as ʻbreedersʼ, not mothers, since their body was sold for reproductive purposes.
During World War II, the Nazis had plans to attempt to purify the German race by using reproductive prostitutes. Female children showing desirable physical features (blond, blue eyes etc.) were kidnapped and raised to be breeders. After they had given birth to several children the girls would be killed, because they had served their purpose, and the children adopted by “pure” German families (Corea, 1985).
A new pathway for surrogacy opened in the 1970s with new scientific developments in techniques for human embryology, and a reduction in the number of children available for adoption. IVF made its debut with the birth of the first “test-tube baby”, Louise Joy Brown, on 25th July 1978. With IVF the technology was there to offer egg and embryo donation and intracytoplasmic sperm injection (ICSI), which is very important for surrogacy (Blyth and
16 Farrand, 2005; Rosenberg, e.d.). The first recognized surrogate contract in USA was drafted in 1976 by a Michigan lawyer named Noel Keane, founder of surrogacy-for-hire, between
William Stern and surrogate mother Mary Beth Whitehead. In 1985 Mary Beth gave birth to
Melissa Stern (often referred to as the Baby M case), the first child born in the USA with gestational surrogacy. The surrogate contract did not run smoothly and the surrogate mother wanted custody over the girl after giving birth. This custody battle became a media circus and ended with the biological parents, Mr. William Stern and Elizabeth Stern, being granted custody over the baby girl by the court (Corea, 1985; Rothman, 1989). The first commercial surrogacy baby born in the United Kingdom was on the 4th January in 1985. A surrogate mother, Mrs Kim Cotton, gave birth to “Baby cotton” (a name given by the media) to an
American couple and was paid £6.500 at the time for her services (Brahams, 1987).
Outsourcing has reached the womb in the form of reproductive tourism, which is a part of the growing industry of medical tourism and globalisation. Reproductive tourism offers assisted reproductive technologies such as (IVF) and surrogate parenthood to international travellers (Whittaker, 2009). Couples and individuals who seek reproductive assistance for their fertility problems outside their home countries, share similar reasons for doing so with those who choose medical tourism for other medical issues. Reasons might be that individuals or couples are excluded from reproductive assistance in their home country because of age, marital status or sexual orientation. Cultural and religious imperatives in some countries may also result in particular difficulties in obtaining donor gametes and embryos.
Couples and individuals might be experiencing long waiting times in their home countries. It might also be because the host country is offering more professional staff and better technological resources, cost and efficiency than their home country has to offer, as well as offering an appealing mix of holiday and treatments. It might also just be that those people want to protect their personal life from the public eye and seeking reproductive assistance in
17 another country would offer such anonymity. There are 75 health clinics and a number of doctors around India that assist in international surrogacy; many are located in India’s larger cities like New Delhi, Mumbai and Bangalore. Examples of successful fertility clinics offering surrogacy services are Akanksa Infertility and IVF Hospital in Anand1, Corion
Fertility Clinic in Mumbai2, Delhi IVF Fertility Research Center in New Delhi3 and Kiran
Infertility Centre (Sai Kiran Hospital) in Hyderbad4 (Blyth and Farrand, 2005;
Globaldoctoroptions, e.d.; Palattiyil et. al.: 2010; Sengupta, 2011; Stephenson, 2009).
Commercial surrogacy is a debated field and one would think that there would be a considerable amount of empirical data on the underlying effects of such an experience on surrogate mothers. The truth is that there is very limited data available. While a new study, A
Comparative study on the regime of surrogacy in EU member states, calls for more studies in all countries where surrogacy is legal, unfortunately there remains little or no data regarding the experience and wellbeing of surrogate mothers (Brunet, et. al., 2013). The findings of
Janice C. Ciccarelli and Linda J. Beckman (2005) also support that conclusion. In their study they focused on the social and psychological aspects which surround the whole process, and found that further empirical research was needed on all phases of the surrogacy process. Very little empirical evidence exists about the decision-making process of Indian women to become surrogate mothers (Karandikar, et. al.: 2014).
1http://ivf-surrogate.com/ 2http://www.corionfertilityclinic.com/ 3http://www.delhi-ivf.com/ 4http://kiranivfgenetic.com/
18 1.2 Feminist theories
Feminist theories have dealt with surrogacy from the very beginning. There is no single feminist theory, rather a wide range of perspectives that have been in tension with one another. In essence, feminist theories seek to explore cultural understandings of what it means to be a woman as well as analyse the conditions that shape women’s lives. These theories promote equality between men and women not just in social spheres but also in economic and political matters (Caragillis, e.d.; Foss, 1982; Jackson and Jones, 1998; Osmond and Thorne,
1993).
Feminist theories are deeply concerned with the concept of motherhood. For instance,
Barbara Katz Rothman (1989) believes that there are three deeply rooted political ideologies which can explain what shapes motherhood. First is the ideology of patriarchy, in which women and children are identified and valued in regard to what they signify to men. The second is the ideology of capitalism, according to which goods are produced for profit; most societies believe that individuals should not be bought or sold as commodities. The third is the ideology of technology, which encourages us to see individuals and people as mechanical parts of a larger machine. Rothman argues that surrogacy changes the relationship of motherhood and fatherhood. The relationship between the mother and a child she carries in her womb becomes irrelevant, as does the father’s relationship with the birthmother. The birthmother is no longer a person that has a personal meaning or connection, instead she is considered as a commodity to carry a product, which also makes the child a commodity that can be bought and sold. According to Rothman (1989: 232), “[s]he is encouraged to think of the baby as no more hers than a factory worker thinks of the car he works on as his”
19 1.2.1 Reproduction as exploitation
According to Corea (1985), the American radical feminist5 Andrea Dworkin expressed her concern regarding a new industry, commercial surrogacy, which was on the rise. She believed that in the future reproductive brothels would start to appear and she linked women selling their reproductive capacities (their wombs, ovaries and eggs) to the act of prostitutes selling their bodies in the form of sexual acts. Corea (1985:276) argued: “with improvements in technology, a brothel employing much more sophisticated assembly-line techniques and providing greater control over women becomes possible”. Corea (1985: 215) also claimed that once the technology to transfer embryos between bodies was developed the surrogate industry would look for “breeders” in developing countries. Women in those countries would be a feasible option as breeders because they are financially deprived and commercial surrogacy might be seen as an option to give their own children a better life. In 1989, Barbara Katz
Rothman (1989: 237) writes in her book, Recreating Motherhood: Ideology and Technology in a Patriarchal Society, that:
Poor, uneducated third world women and women of colour from the United
States and elsewhere, with fewer economic alternatives, can be hired more
cheaply. They can also be controlled more tightly with a legally supported
surrogate motherhood contract, and with the new technology, the marketing
possibilities are enormous – and terrifying.
When commenting on commercial surrogacy she also expressed that “I used to envision such
´baby farms´ located in third world countries, supplying babies to American purchasers”
5Radical feminism believes that the core of society needs to change for equality to occur. Acts of legistions cannot dissolve patriarchy society that is the root of the problem (Caragillis, e.d.).
20 (1989:237). She believed that surrogacy is not just a product of technology, rather that brokers make surrogacy a business transaction and that the rise in surrogacy could be explained by changes in social surroundings. Women faced with unwanted pregnancies had more options to choose from, resulting in a drop in children available for adoption. It also became more socially acceptable to raise a child without a husband and choose to abort unwanted pregnancies (Kesslar, 2009; Rothman, 1989).
1.2.2 Polarized camps
Feminist points of view on commercial surrogacy are widely divided and can be categorised into two polarised camps. Feminists that support surrogacy look at the practice as an additional choice that technology has created, an economic transaction, and as such any attempt made by the state to deny the right of surrogacy would be to limit the women’s right to choose. Surrogacy is seen simply as one more battle in the long war to increase women’s personal freedom of control over their own bodies and reproduction (Brandel, 1995; Kesslar,
2009).
Feminists who criticise surrogacy believe that surrogacy should be illegal because it is a form of exploitation and may lead to slavery or prostitution. Many critics of gestational surrogacy call this process “renting” or “outsourcing” of a womb and equate it with the sale and commodification of children, which in their opinion “demeans us all as a society”
(Brandel, 1995: 494). They recognise the symbolic harm surrogacy can have on society, as well as the potential harm to surrogate mothers. Lori B. Andrews (1988) believes that surrogacy is built upon a symbolic argument and derogatory language within policy debates and the media. According to Andrews (1988:170), surrogacy motherhood is
not only as the buying and selling of children but as reproductive prostitution, reproductive slavery, the renting of a womb, incubatory servitude, factory method of childbearing, and cutting up women into
21 genitalia. The women who are surrogates are labelled paid breeders, biological entrepreneurs, breeder women and prostitutes. Their husbands are seen, alternately as pimps. The children conceived pursuant to a surrogacy agreement have been called chattel or merchandise to be expected in perfect condition.
The Feminist International Network of Resistance to Reproductive and Genetic Engineering and their advocates criticise the development and use of reproductive technologies on several counts, but the central focus of their critique is that these technologies embody and institutionalise the patriarchal domination of women and scientifically managed reproduction, a fight between female autonomy and paternalism (Kesslar, 2009; Brandel, 1995).
Dworking challenged women’s right of “free choice” and she did not agree with her coeval feminists that a woman had the “right” or “free will” to do whatever she wants with her body. She believed that it was grotesque to believe that freedom was recognised as a woman having the right to sell her body as a commodity (Corea: 1985).
Dworking (Corea, 1985: 234) argued:
The bitter fact that the only time that equality is considered a value in this society is in a situation like this where some extremely degrading transaction is being rationalised. And the only time that freedom is considered important to women as such is when we´re taking about the freedom to prostitute oneself in one way or another.
According to Dworking, women’s socioeconomic perspective was the problem when looking at women’s free will to “choose” to become a surrogate mother, as surrogate motherhood was the same exploitation of the women’s body as prostitution, selling access to one’s womb and ovaries did not differ from selling access to the vagina, rectum or mouth (Corea, 1985: 228).
Dworking (Corea, 1985: 228) also claimed that it was a grim reality when women believed that it was their “will” to sell access to their body; she argued:
22 the state has constructed the social, economic and political situation in
which the sale of some sexual or reproductive capacity is necessary to the
survival of the woman. It fixes her social place so that her sex and her
reproductive capacity are commodities.
According to Abby Brandel (1995), many feminists share Dworking's position. They see women’s economic condition as a factor that perpetuates the exploitation of the female body.
Poor women have few financial opportunities, a factor that contributes to their lack of choice in becoming breeders. A poor economic situation pushes women to become surrogate mother, not desire. Feminists also believe that a woman can never give full informed consent to become a surrogate mother because it is impossible for a woman to fully understand the psychological implications mental complication that such an act can have for her. Brandel
(1995:498) argues that “surrogacy fosters a societal perception of women as ´breeders´ and suggests that evolution of an entire class of ´breeder women´”. Some feminists believe that risk of commercial exploitation can be kept to a minimum if only altruistic surrogacy were legal, reducing the numbers of surrogate mothers.
Women’s emotional constitution structure is seen as a factor by many feminists in perpetuating exploitation. Corea (1985) argues that it has been engrained in women’s brains that one of the most important roles they play is tending to others, fostering their growth and happiness. It is engraved into women that the needs and difficulties of others are above their own. Janice G. Raymond (1993: 68) said that women are penalised for pregnancy; “Equality in law is false” according to her, because only women can become pregnant and can be discriminated against on those grounds. Women becoming surrogate mothers in gestational surrogacy, where the child that she carries in her womb is not genetically related to her, are more likely to be seen in a negative light and they are assumed to suffer social abuse because of it.
23 1.2.3 Exploitation or aid?
There is no agreement among feminists about how to understand surrogacy. There are feminists who find themselves uncertain when it comes to their opinion about surrogate motherhood. Rothman identifies herself as belonging to the “liberal”6 wing of feminists and she identifies both negative and positive aspects of the practice. She argues that the state should support surrogate contracts if the surrogate mother enters into the contract under her own free will and maintains autonomy over her body during the pregnancy. Rothman’s (1989:
242) opinions are based on the value system that she places on all pregnancies, an emphasis upon the mother’s personal relationships and experiences during pregnancy. As a feminist she also suggests that an “understanding of surrogacy contracts is the value of women’s bodily autonomy, our control over our own bodies”. She (1989: 243) argues: “Women never bear anybody else’s baby: not their husbands, not the states and not the purchasers in a surrogacy contract. Every woman bears her own baby”. Rothman rejects the traditional patriarchal value that the foetus is a part of the father’s body because he planted his seed in the uterus of the woman. She sees it as a matter of concern that the birthmother is being looked upon as a
“rented womb” while the women that owned the fertilised egg, or contracted the surrogate mother, is declared the real mother. She (1989: 244) believes that it compromises autonomy over a woman’s body because she has given contracted it away by entering into a surrogate contract:
6 Liberal feminists believe that oppression exists in society because of how men and women are socialised, women are seen to be equal to men at any level and we were created as such. Liberal feminists support acts of legislation to remove barriers of inequality (Caragillis, e.d.).
24 I feel that kind of ´compromise´ does a profound disservice to women. I cannot ever believe that a woman is pregnant with someone else’s baby. The idea is repugnant – it reduces the woman to a container. The ´preciousness´ of the very wanted, very expensive baby will far outweigh the value given to the ´cheap labour´ of the surrogate.
Brandel (1995: 489) also sees surrogacy as having the potential both to liberate women as well as exploit them. She takes feminist critics as valid and a cause for concern, however she maintains that a “carefully drafted legislation can minimise the potentially exploitative aspects of surrogacy and protect the individuals who choose it as a reproductive option”. Likewise,
Andrews (1988: 168) argues “the very existence of surrogacy is a predictable outgrowth of the feminist movement”, and that feminist policy arguments have given women the opportunity to enter professions such as surrogacy. Over two decades, feminists have fought for changes in the ideology of reproduction and family matters, women’s right to control their own bodies and be able to choose to use contraception, get an abortion or raise a child out of wedlock. That fight opened up a door in education and employment formerly reserved for men, and as a consequence more women started to delay having children, often to the extent that they needed medical assistance to conceive, with many having to look towards other options. According to Andrews, the environment that feminism created made it comfortable for women to seek assistance from surrogate mothers, and for women to become surrogate mothers. The core of feminist theory is women’s right of choice, to choose to become pregnant, to choose to abort when facing an unwanted pregnancy, to choose what happens to one’s body. This has given women the freedom to choose to become surrogate mothers.
1.3 Additional theoretical perspectives
When researching an industry such as commercial surrogacy, there are many different theoretical perspectives that you can explore as a researcher. Feminist theories focus on concepts of choice, free will and autonomy over one’s body, but other theoretical frameworks
25 reflect on the same concept from a different perspective. Autonomy over one’s own body has been thoroughly debated; do we have control over our own bodies or is it just an illusion? If commercial surrogacy is an industry, and as such surrogate mothers are contracted workers, what is the economic perspective of the industry?
1.3.1 Foucault - Bio-power
Power relations are very important when looking at a field such as commercial surrogacy, and it is equally important to understand the political technologies of life that discipline the body.
Ginsburg and Rapp (1995:5) encourage us to “focus on ´nexes´ of power shaping reproduction and not simply on the technologies themselves”, since the working practices concerning reproduction are contested in everyday society. The French postmodernist and philosopher Michel Foucault believed that power and truth are entirely separate concepts. He also believed that power demands dominance so the two (power and dominance) would be difficult to distinguish between. Foucault (Dreyfus and Rabinow, 1982: 130) argued that: “All
[power] it can do is forbid, and all it can command is obedience. Power, ultimately, is repression; ultimately, is the imposition of the law; the law, ultimately, demands submission”.
Foucault (1978: 86) also argued that: “Power is tolerable only on condition that it masks a substantial part of itself”.
Power relations are used to achieve goals intentionally and non-subjectively. The authorities implement disciplinary mechanisms to mould certain behaviours that are “socially acceptable” publicly as well as privately. According to Foucault (1978: 143) “one would have to speak of bio-power to designate what brought life and its mechanisms into the realm of explicit calculations and made knowledge-power an agent of transformation of human life”.
Bio-power is “the power to ´make´ live and ´let´ die” argued Foucault (1976: 241); that the government would decide what would be a socially acceptable behaviour in society, and then
26 mould the public’s behaviour and thoughts without them having anything to say about it. In fact, individuals were unaware that they are being moulded; a well disciplined society is easier for the government to control and fewer problems exist. Discipline is linked to the production of useful and docile individuals “with the production of controlled and efficient population” (Foucault, 1978: 193).
In the 20th century modern society started to emerge with new political and structural characteristics in the form of state. According to Foucault, society is about a modern state and power. New political thoughts started to emerge while dominance and exploitation became the main aim of the government via the construction of new laws. Previously, the power of the government revolved around the human as an individual who had rights and needed to be protected. New political thought started to revolve around how individuals behave in society.
Micro power mechanism, such as surveillance, gave the government power to watch individuals in their everyday activities. While in the past an individual’s needs and welfare were considered important by the government, such ideas were pushed aside with new political thoughts and focus placed on welfare in the form of reproduction and diseases. The goal of the government was to have control over everybody by having power over individuals’ bodies and behaviour (Dreyfus and Rabinow, 1982; Foucault, 1978; Hindess,
1996; Kesslar, 2009).
According to Molly R. Sir (2015), assisted reproductive technology (ART) functions as bio-power when analysing surrogacy. Surrogacy allows the genetic line of white wealthy individuals to live on by producing genetically related offspring. She argues (2015: 2): “While giving life to those who can afford to use ARTs, our society ´lets´ the gestational surrogate
´die´ by not viewing the role as valuable or fitting into normative notions of family” (2015:
2). In her research she focused on how “commercial gestational surrogacy upholds white
27 supremacist hetero-patriarchy through its perpetuation of nuclear family structure” (Sir,
2015:1).
1.3.2 Prospect Theory, Conflict Theory and Theory of Exchange
Prospect theory was developed by Daniel Kahneman and Amos Tversky and it regards how people manage risk and uncertainty, how people choose the lesser of two evils by evaluating losses and gains when provided with two equal choices (Investopedia, e.d.-b, Watkins, e.d.).
When looking at commercial surrogacy in India cost-benefit analysis to determine the lesser evil is very relevant. N. Jani's (2010) analysis used prospect theory to explain how commercial surrogate mothers in developing countries make a “choice” to participate in global commercial surrogacy. Commercial surrogacy in developing countries involves nine months under constant medical monitoring in a restrictive environment. Jani theorised that for a woman in a developing country, becoming a surrogate mother was a superior option than working in factories or on the roads, where wages were poor and working conditions often terrible. Surrogate motherhood is also preferable to being forced into prostitution or being human trafficked, or other violent acts that poor woman in developing countries might face
(Jani, 2010; Rotabi and Bromfield, 2012).
Karen Smith Rotabi and Nicole F. Bromfield argue that surrogacy recruitment procedures were unlikely to follow the highest ethical standards, making it difficult to prevent the exploitation of surrogate mothers. They argue (2012: 136):
In a hopeful prospect, some surrogates will choose to participate in global
surrogacy. Then, there may be those who do not have an active choice
because the ´prospecting´ is being carried out by husbands, fathers, brothers,
or other family or community members (including recruiters) who may
entice and/or coerce the women to engage in surrogacy activity
28 They emphasise that the surrogate industry as a business resembles an assembly-line and that the procedure could be likened to baby farming. They (2012: 137) also lay emphasis on the notion that “[s]elf-determination of marginalised women requires critical thought and action”.
Karl Marx’s Conflict Theory claims that “society is in a state of perpetual conflict due to competition for limited resources” (Investopedia, e.d. - a). According to theory those with wealth and power attempt to hold on to it by maintaining social order through suppression of the poor that are powerless by domination. Jani (2010) was analysing the dynamics of human trafficking and applied conflict theory when researching the concepts of free will and self- determination of women in India. She explained that to avoid exploitation such as human trafficking, Indian women would choose to participate in sex work or surrogacy. Due to the social structure of impoverished nations with limited economic options, women feel suppressed and may decide to become surrogate mothers (Investopedia, e.d.-a; Jani, 2010;
Rotabi and Bromfield, 2012).
George Casper Homans, the father of behavioural sociology, introduced exchange theory, which revolves around social interaction and relationships. Exchange theory has two approaches: the first approach focuses on how individuals try to acquire what they desire
(want and need) by exchanging valuable resources with others; the second approach focuses on the exchange between groups and social systems (Crossman, e.d.). By applying Exchange
Theory, Jani explained that being trapped in debt-burdens would force many women to consent to work in undesirable industries such as the sex industry or commercial surrogacy
(Jani, 2010; Rotabi and Bromfield, 2012).
1.3.3 David Ricardo - Comparative advantage
In the 18th century, David Ricardo, a British political economist put forward a theory of economical rule, which he called comparative advantage. The core of the theory was a
29 country’s ability to produce a particular good or service at a lower marginal cost in comparison to other countries. Businesses are profitable if both parties (countries) have different relative efficiencies, e.g. a country that can produce a product efficiently over another country has superiority over the product. According to Ricardo, if the country has superiority in producing two products, it should choose the product it can more efficiently produce over the other. For instance, if a poor country can produce a sack of coffee with five hours of labour, and a sack of tea in ten hours, a rich country that is more productive can, by comparison, produce a sack of coffee in three hours and a sack of tea in one hour. If the cost for the poor country to produce coffee is lower than to produce tea even though it has higher labour costs than the rich country, for every sack of coffee it gives up half a sack of tea. The rich country on the other hand gives up three sacks of coffee to make a sack of tea. In this example the poor country has a comparative advantage over the rich country in producing coffee; the rich country has a comparative advantage in producing tea (Library Economics
Liberty, e.d.; Kurz, 2010; Peet and Hartwick, 2009; Stephenson, 2009).
An Indian surrogacy lawyer Amit Karkhanis (Carney, 2010: e.d.) expresses in the journal Mother Jones that “surrogacy is a type of employment, plain and simple; Foreigners are not coming here for their love of India. They are coming here to save money”. What kind of business can international commercial surrogacy be classified as? International commercial surrogacy does not fit under any definition for service or product provided by the World
Trade Organization (WTO)7, indeed commercial surrogacy blurs the line between the two.
Discussing childbirths and surrogacy as an industry may seem vulgar for some but from an
7WTO definition of international service: https://www.wto.org/english/tratop_e/serv_e/cbt_course_e/c1s3p1_e.htm And product: https://www.wto.org/english/tratop_e/dispu_e/repertory_e/d1_e.htm
30 economic point of view Indian surrogate mothers and fertility clinics have comparative advantage over western countries (Stephenson, 2009). According to Christina Stephenson
(2009), surrogate mothers provide a service and consequently the child would be classified as a product if we look at WTO, GATT General Agreement on Tariffs and Trade, and definitions of international business. However, surrogacy has limited value as a service since the potential parents will not have consumed the service fully until they have been presented with the “product”. Service cannot be stored however the birth of the child violates the definition of surrogacy as service. There has to be a user-producer interaction in the provision of service; those who do not need biological proximity to the service provider and those who do.
However, surrogacy does not fully fall under the definition of user-producer communication.
If we look at international commercial surrogacy, in a way it needs a user-producer interaction. Stephenson argues that a surrogate contract can be processed through an intermediary or a broker without the surrogate mother or the potential parents ever meeting, but adds that is “obvious that some communication needs to occur of any conceivable version of surrogate contract” (2009: 196).
1.4 Summary
The concept of “free will” and “choice” has been highly debated within the academic world since groundbreaking discoveries in the 1970s within reproductive technology. As early as the
1980s, feminists started to predict that the newly developed reproductive industry would exploit the poor and financially needy women of developing countries. The industry would be in a need of feasible “breeders”, women that would be easily exploitable because of their economic desperations. Feminists saw “reproductive brothels” starting to develop in the third world. Feminists are in polarised camps when it comes to their stand towards commercial surrogacy, with “choice” and “free will” being central to the debate. Advocates of commercial surrogacy argue that women should have the right to choose what happens to
31 their bodies that their autonomy should be respected, and this is yet another phenomenon where women’s rights are being questioned. Critics of commercial surrogacy question if women in financial despair “choosing” to become surrogate mothers can really be defined as having a “choice”. Surrogacy is seen as exploitation and an extension of patriarchal domination. Foucault’s bio-power questions the idea of power, if we really have power over our own bodies or if it is just an illusion. Molly R Sir applied commercial surrogacy as a function of bio-power and likened it with sexism, racism and capitalism. Prospect theory, conflict theory and theory of exchange question the concept of “choice” when it comes to surrogacy, suggesting that Indian surrogate women choose to be a surrogate mother because it is the lesser of two evils. The other option might be a far worse one, and their “choice” is based on those parameters. If we look at economic theories, India has a comparative advantage in the world of surrogacy: they have the ability to produce more babies in a much more cost effective way than other countries due to their untapped resources of potential surrogate mothers. What kind of business transaction commercial surrogacy should be classified as was also discussed.
32 2 Fieldwork settings
2.1 General Information
India is, the cradle of the human race, the birthplace of human speech, the mother of history, the grandmother of legend, and the great grandmother of tradition. Our most valuable and most instructive materials in the history of man are treasured up in India only. -Mark Twain
The Republic of India is the second most populated country in the world after China, with a population of approximately 1.252 billion, and the seventh largest country with an area of
3.287.590 km². India is located in Asia and shares borders with Pakistan to the northeast,
Nepal to the north and Bangladesh to the northwest. There are 29 states in India with New
Delhi being the capital of the country, and other popular cosmopolitan cities being Mumbai,
Kolkata and Chennai. India is a land of striking contrasts. The entire north part of the country is bounded by the highest mountains in the world in the Himalayan range, in the west of the country the Thar desert stretches over most of the state of Rajasthan and in the south are beaches and rainforests. The vast Gangetic plains and numerous rivers are also breath-taking and tickle the imagination of the rest of the country. The climate varies depending on the time of year and location; it ranges from tropical in the south to temperate and alpine in the
Himalayas. India has three seasons – summer, monsoon and winter (Allchin, 2015; CIA,
2014; International Monetary Fund, 2014; Kundu, 2012; Manas, e.d.; Singh and Kumar,
2015; The Times of India, 2014; The World Bank, e.d.-a; Trading Economics, e.d.).
33 Figure 2: The land of striking contrasts: Munnar (top left), Palampur (top right),
Jaisalmer (below left), Alleppy (below right)
Source: Personal collection
India is considered to be one the most ethnically diverse country in the world; it is the home of the world’s largest population of tribal people who constitute 8.6 percent of India’s total population (104.28 million individuals). Today there are over 780 different languages spoken in India from several language families and 86 scripts are used. The estimated age structure in
India (2014) suggests that 28.5 percent of individuals are under 14 years of age8, 58.7 percent
8Male 31,660 and 30,720 women (CIA, 2014)
34 between the ages of 15-549 and 12.810 percent are 55 years old and above. The religion with the most followers in India is Hinduism (78.35 percent) followed by Islam (14.88 percent).Other minority religions are Christianity, Sikhs, Buddhists and Jains (Allchin, 2015;
EcoIndia, e.d.; Ians, 2013; Tribes India, e.d.). India’s gross domestic product (GDP) is $2.04 trillion (estimated 2014) which is $1,625 per capital and with growth of 7.4 percent. The service sector alone attributes 64.8 percent of India's GDP.
Unemployment in India is a serious issue, with unemployment rates in the year 2013 at 4.9 percent. Though that seems reasonable, unfortunately the number does not show an accurate picture of the employment situation in India. Self-employed individuals account for
60 percent of India’s employed population, 30 percent are casual workers that work irregularly and only 10 percent of the Indian population are regular workers. Today, with
India experiencing economic slowdown, unemployment is on the rise (Allchin, 2015; CIA,
2014; International Monetary Fund, 2014; Kundu, 2012; Singh and Kumar, 2015; The Times of India, 2014; The World Bank, e.d.-a; Trading Economics, e.d.).
2.1.1 Diverged and historical
The history of India can be traced back 75,000 years to the first evidence of anatomically modern humans (e. Homo Sapiens). Archaeological evidence shows Indus Valley civilisation flourishing, which was a highly sophisticated and urbanised culture, about 2600 B.C. to 1700
B.C. That civilisation gave birth to the world’s first urban sanitation system as well as the first well-planned streets and the most sophisticated water supply and drainage systems.
Throughout the centuries India had continued to develop a rich intellectual life in various
9Male 376,899,075 and 348,635,907 women (CIA, 2014) 10Male 77,758,843 and 80,985,710 women (CIA, 2014)
35 fields such as mathematics, astronomy and architecture. India was ruled by Muslims from the
12th to the 16th century and then by the British Empire from 1858 until they gained independence in 1947 (Allchin, 2015; EcoIndia, e.d.; The British Museum, e.d.; Tribes India, e.d.)
Figure 3: Colourful India
Source: Personal collection
2.2 Indian women
It has been stated that economic growth and development can increase by empowering women. It has also been stated that intra-household allocation and poverty reduction can be expected with improvements in the education system. According to this idea, an educated working woman should be able to exercise higher bargaining power within the household, which opens up more opportunities for women outside marriage. Yoo-Mi Chin (2012) questions that better social or economic status of Indian women will necessarily translate into higher bargaining power. In India women live in a patriarchal culture where divorce is not an
36 option for many, and where a better economic status might challenge the socially prescribed dominance of men and trigger what Yoo-Mi Chin calls “male backlash”. If we look at the pattern of spousal violence in India it suggests that women who participate in the labour market are more likely to be subjected to physical violence than non-working women. It is important to take into account that poor women work more than rich women but at the same time they are subject to more violence. Thus poverty is an important factor when looking at the effect of female employment on domestic violence towards women (Chin, 2012).
Figure 4: Rural woman in Jaisalmer Rajasthan
Source: Personal collection
37 2.2.1 Violence against women
Violence against women is a well recognised human rights violation worldwide and an important risk factor on women’s mental and physical health. The subordinate status of women in many societies, where men are assumed to be superior to women, is party the reason why gender violence is considered normal and even enjoys social approval (Burnette and Hosni, 1993; Saravanan, 2000). Violence against women can manifest itself as
(Saravanan, 2000: e.d.):
violence include physical aggression, such as blows of varying intensity, burns, attempted hanging, sexual abuse and rape, psychological violence through insults, humiliation, coercion, blackmail, economic or emotional threats, and control over speech and action.
Sheela Saravanan (2000) argues that in countries like India female children are raised to identify themselves as weak and because of that they are in constant need of protection. Girls grow up feeling helpless and without control over their own life, leading them to be exploited at every stage of their lives. According to the National Crime Records Bureau, there were
2.325.575 cases involving violence against women reported in India in 2011 which is an increase from 1.989.673 in 2007 (National Crime Records Bureau, 2011 and 2013). This increase is of great concern and it is estimated that the growth rate will increase. In India, every three minutes a crime is recorded against women, every six minutes two women are raped and every six hours a woman is found beaten or burned to death. R. Kalaiyarasi (2015:
52) argues in her article, Violence against women in India that women have worked hard to prove themselves in every field but still:
38 behind closed doors of homes all across our [India] country, people are
being tortured, beaten and killed. It is happening in rural areas, towns, cities
and in metropolitans as well. It is crossing all social classes, genders, racial
lines and age groups. It is becoming a legacy being passed on from one
generation to another.
Women in India experience many forms of violence throughout their lifespan, starting in the womb. Technologies such as ultrasound and amniocentesis are used in most parts of the world to detect foetal abnormalities. In India it has been misused to determine the sex of the foetus; if a female child is detected it is aborted, a process called sex selection abortion (also known as Female Foeticide) (Patel, 1996). Sex selection abortion is illegal in India but still it is widely practiced. Female Infanticide is the practice of killing unwanted girl children soon after birth (Oxford Dictionaries, e.d.-c). Female infants experience higher mortality rates in all major states in India and this has lead to a skewed child sex ratio. It is difficult to estimate how many female infants are killed but if data from the Central Statistic Office (2012) in
India from the year 2011 is compared to data from 2001, around three million girls are
“missing” from the statistics. According to Kalaiyarsi (2015), hospitals are a major source to speculate about female infanticide. Hospitals all around India have experience of new born female children and their mothers vanishing from the hospital after the sex is determined. In
Usilampatti government hospital 570 female infants vanished from the hospital out of 600 born and it is estimated that 80 percent of them were victims of infanticide. The Majority of female infanticides occur within the first seven days of their lives (Saravanan, 2000). It is important to mention that the majority of births do not occur in hospitals, so it is very difficult to accurately estimate the rate of female infanticide in India.
Eve-Teasing is a systematic way to make women feel week, afraid and inferior to men. It could be an unwanted sexual remark and/or advances (Kalaiyarasi, 2015; Oxford
39 Dictionaries, e.d.-b). In India 8,570 cases of Eve-Teasing were reported in 2011 which is a decrease from 10,950 cases reported in 2007 (National Crime Records Bureau, 2011 and
2013).
Dowry death, often referred to as bride-burning, is violence towards a married woman caused by a dispute over her dowry or prompted by a dispute over the inadequacy of the dowry payment by the in-laws after marriage (Oxford Dictionaries, e.d.-a). In 2011 8,618 cases of dowry death were reported in 2011, which is an increase from 8,093 cases in 2007
(National Crime Records Bureau, 2011 and 2012). Around 90 percent of weddings in India are arranged by parents and family members and a dowry amount is negotiated between the two emerging families before the marriage takes place. The dowry is paid by the bride’s family to the new in-laws and never falls under the control of the bride. After the wedding the bride moves from her parents’ house into her in-laws’ house, where she will start her new life.
Dowry payments cause distress to parents, often leading them to resort to infanticide and other forms of abuse against women. After marriage women are often harassed by their in- laws because of an inadequate dowry, resulting in dowry deaths or even bride-burning. Dowry practices became illegal in 1961 but due to lack of enforcement it is still practiced by the majority of Indians (Burnette and Hosni, 1993; Kalaiyarasi, 2015; National Crime Records
Bureau, 2011 and 2013).
Sati, or widow burning, is a practice that was prohibited in 1829 but is still practiced.
When a husband died it was considered to be the duty of a virtuous wife to purposely throw herself on her husband’s funeral pyre so that both of them could enjoy “heavenly pleasures”
(Mani, 1998: 1; Oxford Dictionaries, e.d.-f). According to the National Crime Records Bureau
1 case was reported in 2011 (National Crime Records Bureau, 2011).
An acid attack is the deliberate use of acid, such as sulphuric acid, to disfigure or kill another human being. Acid attacks are in the majority of cases used towards women and girls
40 that have rejected a marriage proposal, are unable to meet dowry demands, or because of family feuds. It was not until 2013 that acid attacks started to be recorded as a separate criminal offence and because of that there are no reliable statistics on the practice. The Indian government has estimated that it could range from 100 to 500 attacks annually,whilethe
Indian Journal of Plastic Surgery conclude that it might in fact be closer to 700 – 800 attacks annually (Acid Survivors Foundation India, 2013; Kalaiyarasi, 2015).
Domestic violence cases have dramatically increased in India from 75,950 cases reported in 2007 to 99,135 cases in 2011 (National Crime Records Bureau, 2011 and 2013).
In India there is a wide societal tolerance for violence against the wife. Abuse is considered justified in circumstances such as dowry disputes, if the wife neglects household duties, when infidelities occur or if a wife is disobedient towards her husband. Women do not often report domestic violence unless it becomes unbearable or an attempt has been made on their lives
(Saravanan, 2000).
Reported rapes cases have increased in India from 20,737 cases reported in 2007 to
24,206 cases in 2011 (National Crime Records Bureau, 2011 and 2013).The vast majority of rapes are never reported due to the stigma and trauma associated with them. It is estimated that one-quarter of the reported rapes involve girls under the age of 16. Studies carried out by an NGO named Samvads in Bangalore in 1994, concluded that 83 percent of 348 girls in the study had experienced sexual abuse and 85 percent of rapes involved a relative. Media has reported stories such as the rape of a three year old girl by her father because his wife refused to have sex with him when he desired it (Human Rights Watch, 2013; Kalaiyarasi, 2015;
Saravanan, 2010; The Times of India, 2013). Recently a documentary named India’s
Daughter was made by the British film maker Leslee Udwin which shed light upon the gang rape of a 23 year old medical student. She was brutally tortured and sexually assaulted in a bus before she was left on the side of the road to die. That attack sparked an outrage in India
41 and people started to walk on the streets demanding a change in society, a change in culture and protection for women (Bloom, 2015).
2.3 Health care
A wise man should consider that health is the greatest of human blessings, and learn how by his own thought to derive benefit from his illnesses -Hippocrates, Regimen in Health
India’s total health expenditure as a percentage of GDP was four percent in the year 2012, with 33.1 percent allocated to the state run health sector, 76 percent allocated to the private health sector and expenditure per capita of $61 (World Bank, e.d.-a, -c, -d, -e; World Health
Rankings, e.d.). Life expectancy in India is 65.5 years11. India has over 1,400,000 physicians and nurses, with over 30,000 graduating every year from Indian medical schools, working in over 15,000 hospitals, with 870,000 hospital beds. India is tapping into its human resources from its enormous population. Indian health care is divided into three sectors: the state run health sector, the private health sector and the households utilising the service that the health sector provides. Only 10 percent of doctors work for the Indian state-run health care sector in
India. Overall 75 percent of all human resources and 68 percent of all hospitals are in the private sector (Kumar, 2009; Ministry of Health and Family Welfare, 2005, 2007; Nandraj,
1997; Upadhyay, 2011; Vijaya, 2010).
11 63.8 years of male and 67.3 years for women (World Health Rankings, e.d.)
42 2.3.1 The state run health care sector
The state run health care sector consists of the central government that contributes to health through grants and centrally sponsored programs. Many departments of the government and ministries have their own health service providing for their employees, which is also a part of the state run health sector.
The sector is divided into primary, secondary and tertiary health care:
• Primary Care: encompasses most of the outpatients and involves prevention of
illnesses as a well as every day care like maternal and child health, basic laboratory
services, family planning and health education and referrals. Medical care in the rural
area (difficult terrains, deserts, Hill and “backward” areas) is on primary level (Bagchi,
2008; Palva, 2008)
• Secondary Care: encompasses patients that require expert doctors or surgeons to be
treated, and in many cases hospitalisation is involved. Secondary health care occurs at
district hospitals and communality health centres (Bagchi, 2008; Palvia, 2008)
• Tertiary Care: Procedures that require higher and more specialised services like organ
transplants and cancer treatments. Tertiary medical care occurs in specialised hospitals,
medical college hospitals, regional institutes etc. Usually the patient is referred from
primary and secondary medical care to specialised tertiary health care (Bagchi, 2008;
Kareem, e.d.; Palvia, 2008)
More than half of public health sector funding is allocated to The Family Planning and
Welfare Program resulting in negation of other health programs. The Indian government puts great emphasis on population control programs that The Family Planning and Welfare
Program enforces using the entire local infrastructure and human resources of the rural areas
(Nandraj, 1997)
43 2.3.2 Private health care
Private health is highly supported by the Indian government, both directly and indirectly.
India ranks among the top twenty countries in the world in terms of private expenditure on health as a percentage of GDP. A minority of the Indian population, ten percent made up ofthe Indian elite, have financial access to private health care in India. Over 86 percent of the private health care sector is paid for in the form of out of pocket expenses12, or those expenses that are not covered by any health insurance plan. It is interesting to note that only one percent of the Indian population is covered by health insurance (Bagchi, 2008: Kumar, 2009; Nandraj,
1997; Sengupta, 2011; Upadhyay, 2011; Vijaya, 2010; World Bank, e.d.-j).
2.3.3 Unequal access to health care
Figure 5: Waiting area at Motihari District Government Hospital in East Champaran,
Bikhar vs. waiting area at the private hospital of Max Healthcare in Delhi.
Source: Flatow, e.d; Velasquez, 2014.
12Out of pocket expenditure is a part of private health care expenditures. It might be explained as any direct expenditure by households to any good or services provided by the private health care sector to improve individual or groups health (World Bank, e.d.-j)
44 There is huge inequality in health care in India; it is home to one-fourth of the world’s poor, with around 21.9 percent of the population below the poverty line. The poor have limited access to food, clean water, shelter and sanitation, yet at the same time the poorest spend the most in health care in terms of their proportion to consumption expenditure and income
(Aragwal, 2015; Kumar, 2009; Ministry of Health and Family Welfare, 2005, 2007; Nandraj,
1997; Upadhyay, 2011; Vijaya, 2010). In rural areas the medical service is very poor and there is a great need for trained health workers; for example, in rural areas there are less than four doctors for every 10,000 inhabitants. Rural medical service also lacks finances and on top of that it is highly corrupted. Medical facilities are often far apart and millions walk many miles to see a physician regarding their health problems or end up seeking medical assistance from unskilled individuals. Because of this many simply do not seek essential health service
(Chinai and Goswami, 2007; Kumar, 2009; Palattiyil, et.al., 2010; Sen, 2011;).
The discussion about the right to health care in India is very delicate and sensitive. It was not until the draft of the National Health Bill was published in the year 2009 that equal access to essential health care was addressed. For the first time the poor individuals of the
Indian population, the vulnerable and marginalised ones, were considered to have the right to essential drugs, health facilities and services as well as essentials like food, housing, sanitation and clean water. Unfortunately, though the draft addressed important long overdue issues, it did not give clear guidelines about how the solution should be financed (Nandraj,
1997; Sen, 2011).
2.3.4 Women’s access to health care
India is a country with deep-rooted gender inequality. According to the 2005-2006 National
Family Health Survey (NFHS-3), only 27.1 percent of women in India make decisions about their health care, while 62.2 percent jointly take decisions with their husbands and 30.1
45 percent have nothing to say about their access to health care. Under half of rural Indian women (41.5 percent) are allowed to visit a health facility alone compared to 60.3 percent of their urban sisters (Ministry of Health and Family Welfare Government in India, 2007;
Sengupta & Jena, 2009). There is a big gap between men and women regarding socioeconomic achievements. Indian women have constrained access to resources such as land, water, health, education and capital (Sengupta and Jena, 2009). India is the home of one- third of all illiterate women in the world. If we look at India’s literacy rate and categorise it by gender we can see that 74 percent of Indian men have at least a basic level of literacy compared to 51 percent of women. Women's work participation was only 29 percent in 2009-
2010 but dropped down to 27 percent in 2013, compared to 80 percent for males. The reason for this gap might be because of occupational segregation. Indian women do not have equal access to the same sectors as their male counterparts; they tend to be grouped in certain industries and occupations that are not seeing employment growth (International Labour
Organization, 2013; Sengupta and Jena, 2009; World Bank, e.d.-f; World Bank, e.d.-g).
Health is an area of special concern when it comes to gender inequality, but it also depends on factors such as location, employment, education or income. Infant mortality and malnutrition is high in India. The birth rate in India is 19.89 births/1000 individual13 and the infant mortality rate is 43.19 deaths/100014 live births; 44.63 females compared to 44.9 males.
India also has a dramatic birth sex-ratio difference of 933 females to that of 1000 males according to Census 2011. India is also home to one-third of all malnourished children15 and
13Estimation for 2014 14Estimation for 2014 15Estimation for 2012
46 ranks 65 with a score of 22.9 on the Country Global Hunger Index list16. Women in India are discriminated against from infancy to adulthood, resulting in low overall levels of nutrition.
Undernourishment of women is also the single largest contributor to the high level of
Anaemia among Indian women (Aragwal, 2015; Census, e.d.; Central Intelligence Agency,
2014.-a; International Food Policy Research Institute, 2012; Sen, 2011; Sengupta and Jena,
2009 World Bank, e.d.-a; World Bank, e.d. – h; World Health Rankings, e.d.;i).
The maternal mortality rate in India is 190 per 100,000 live births. Just for comparison, the maternal mortality rate in Iceland is 4 per 100,000 live births (World Bank, e.d.-i)17. The National Sample Survey Organisation's (NSSO) data from 2004 shows that
47.85 percent of women experienced problems of some sort during child birth and 57.6 percent of women received no post natal care of any sort. Only 50.2 percent received antenatal care from a doctor and 22.85 percent received no antenatal care whatsoever. Only
40.85 percent of births happen in a health facility assisted by trained medical staff (Sengupta and Jena, 2009; Sengupta, 2011). If we look at diseases like HIV, in 2013 2.1 million Indians were living with HIV (UNAIDS, 2013) which makes up the third-highest number of people living with HIV in any country of the world. Gender inequality, as well as poverty, is one of the strongest enhancers of risk of exposure to HIV. Factors like violence against women, trafficking and differential power relations between men and women subject women to the risk of HIV/AIDS, a risk amplified by the denial of access to safe sex practices (Kumar, 2009;
Sengupta and Jena, 2009; The Hindu, 2014). Factors such as women being economically poorer than men contribute to Indian women’s constricted access to health care. Health care
16Estimate for 2012 17Estimate for 2013
47 expenses are higher for rural women in comparison with rural men, which impacts upon their ability to get medical treatment in a private hospital.
2.4 Medical tourism in India
The global industry of medical tourism has changed the delivery and consumption of healthcare services (Upadhyay, 2011). The concept of traveling to seek medical care is not a new phenomenon. Archaeological evidence has shown that ancient civilisations travelled to experience the therapeutic effects of mineral thermal springs and baths all the way back to
4000 BC. Medical tourism emerged as an industry after the economic crisis in Asia in 1997.
Before the crisis the wealthy global minority could afford to travel for high-end medical care, however, after 1997 it became possible for the global general public to seek high-end medical care in foreign countries for a fraction of the price that they would have to pay in their home country (Lunt et al, 2011)
2.4.1 Medical tourism: Global phenomenon
Medical tourism is a complex phenomenon. According to Qadeer and Reddy (2013: 20) medical tourism involves “international demand and policy shifts from service to commercialization of health care to trade, gross domestic profit, and foreign exchange”.
According to Lunt et al (2011: 9) the medical tourism industry is “dynamic and volatile”, with many different factors affecting the industry such as “economic climate, domestic policy changes, political instability, travel restrictions, advertising practices, geo-political shifts, and innovative and pioneering forms of treatments”.
Patients Beyond Boarders (2014) estimated that the market size of the global medical tourism industry is around $35.8-55 billion. In contrast, Deloitte management consultancy estimates that the industry is around $60 billion with 60,000-85,000 medical tourists travelling annually (Lunt et al, 2011). It is important to state that there are no
48 dependable data that show the true extent of the medical tourism market. While statistics concerning the scope of the market are imprecise, there is no doubt about its sheer growth
(Lunt et. al., 2011; Patients Beyond Borders, 2014).
The reason why patients choose to use medical facilities and care in foreign countries can differ depending on the medical resources available in their home country. Patients from the USA seek treatment outside their countries mainly because of financial reasons. Patients that are uninsured, or have inadequate coverage, look at medical tourism as a more feasible option for cost saving. Insured patients from the USA are often looking for lower prices for treatments that are not covered by insurance, like weight loss surgery, dental reconstruction, cosmetic surgery, gender reassignment and fertility treatments (commercial surrogacy would qualify as such). Countries like Canada and the United Kingdom that have national health insurance are also seeing a change in their health care environment. Long waiting lists are usually the reason for patients in these countries to offshore medical care, but there are also other reasons. Patients might be denied treatment within national health insurance or else the treatment may not be available within the insurance system. Treatments like cosmetic surgery or surrogacy are not covered by national insurance, and medical tourism can offer better prices. Reasons for choosing medical tourism could also be personal, involve a privacy issue or simply the desire to travel to an exotic location in luxurious surroundings (Duggal and
Nandarag, 1991; Herrick, 2007; Lunt et al, 2011; Puri, Singh and Yashik, 2010; Upadhyay,
2011).
2.4.2 Medical tourism in India
According to the World Health Organization (WHO), Medical tourism is an example of how
India makes profit from globalisation and outsourcing (Stephenson, 200: 190). India has long been a popular tourist destination and is now combining its forces, mesmerising nature and
49 cultural heritage, with its first class trained medical staff, highly technical medical facilities, and good reputation in health care. This creates a diversity that gives it a comparative advantage over many other countries within the field of medical tourism. India’s economic system has grown rapidly since liberalisation in 1990-2000, making the country more competitive in comparison to other developing countries. India’s government started around
2002 to promote medical tourism when the Confederation of Indian Industry (CII)18 conducted research on the medical tourism industry in collaboration with international operations consultant McKinsey and Company, which showed substantive potential in the sector. Today India is a front-runner in medical tourism, making the industry the second largest in the country (ASSOCHAM, 2013; Chinai and Goswami, 2007; Ghose, 2010;
Herrick, 2007; Jose and Sachdeva, 2010; Lee, 2006; Palattiyil, et. al., 2010; Puri, et.al., 2010;
Upadhyay, 2011).
Medical tourism is a major foreign exchange revenue earner for India. The industry does not just benefit the health care sector; it also benefits hotels and other accommodation providers, travel agents and tour operators (Puri, et.al., 2010). When looking at the market size of medical tourism in India The Associated Chamber of Commerce and Industry of India
(ASSOCHAM) estimated that in 2013 the market was around 7,500 crore ($ 12.5 billion) and would reach 9,500 crore ($ 15.9 billion) by the end of 2015 (ASSOCHAM, 2013; Puri, et.al.,
2010). The current flow of international patients is around 25 lakh (2,500,000) patients and is estimated to reach 45 lakh (4.500,000) patients by 2015. By 2017 the medical tourism industry is estimated to reach 25 percent of India’s GDP (ASSOCHAM, 2013; Samal, 2012;
Sundar, 2012).
18The Confederation of Indian Industry (CII) consults and advice the Indian goverment and industries within India, they also help to create and sustain a feasible enviroment for businesses (CII, e.d.)
50 It was a conscious policy decision by the Indian government to transfer its medical care from its service sector into a commodity (Qadeer and Reddy, 2013). By 2003 the Indian state had already started to shift its policy focus in health care towards commercialisation, transforming the medical tourism industry with flows of foreign currency and profit. In the
2003 annual budget speech the Indian Minister of Finance, Jaswant Singh, placed emphasis on India’s potential in the medical tourism Industry as a global health destination (Singh,
2003). In the draft of the Indian National Health Bill, it was very clear that great emphasis had been put on the private health care sector, with medical tourism as the main focus
(Government of India, 2009). The Indian government promotes medical tourism by passing favourable tax laws, allowing 100 percent FDI (Foreign direct investment) under the automatic route and offering export incentives to practicing hospitals. They also offer lower tariffs (5-8 percent) on medical equipment and devices, while life saving medical equipment has an increased rate of depreciation (25-40 percent) and good land is provided at subsidised rates (Gupta, 2008). Furthermore, medical tourism patients would be granted with a so called
M-visa (Medical-visa), for up to one year and extendible by another year. It is worth mentioning that tourist visas are only granted for a maximum of six months. An MX-visa is also granted for individuals that are accommodating the patient (Sengupta, 2011).
The government ensures that the hospitals obtain international standard accreditations like The Joint Commission (JCI)19 and local government The Confederation of Indian
Industry (CII) (Brady, 2007; Ghose, 2010; Jose and Sachdeva, 2010; Puri, et. al., 2010). By achieving accreditation hospitals can guarantee high quality care by continuous improvement,
19The Joint Commission (JCI) is the Internatioal body of the American company The Joint Commission on Accreditation of Healthcare Organization (JCAHO) that is responsible for accrediting the quality of hospitals (Joint Commission International, e.d.).
51 analysis and tracking the quality of all areas of the hospital’s operations. International accreditation needs to be updated every three years. CII accreditation hospitals need to follow a price list, and CII lawyers draw up a contract to ensure that any litigation occurring will be dealt with in Indian courts (Brady, 2007; Ghose, 2010; Jose and Sachdeva, 2010; Puri, et. al.,
2010).
2.4.3 Why choose India?
The medical tourism industry is estimated to have generated employment growth of 2.5 million in 2012 (Sundar, 2012). Every year a vast number of medical health professionals graduate from medical colleges. The national language of India is Hindi and English; being a former British colony India has great language competency in English which is an advantage when it comes to medical tourism. Physicians and all professional medical staff can communicate effectively with their patients in English, preventing misunderstanding and frustration (Gan and Song, 2012; Jose and Sachdeva, 2010). Geographical proximity is also an influential factor, though not the most important when patients are choosing a destination for medical tourism (Lunt et. al., 2011). Indian medical tourism prides itselfon price transparency, low labour costs and fewer factors that delay the process, such as fewer regulations and lower litigation costsin the case of malpractice suits (George and Swamy,
2007; Herrick, 2007). India’s ace card is its cost effectiveness, offering its patients an almost
90 percent saving on the price of similar treatments in their home countries (George and
Swamy, 2007; Herrick, 2007).
The medical tourism industry reimburses India’s economy by increasing the flow of foreign currency into India. The scholars Sen (2011) and Nadraj (1997) expressed that with health care becoming market driven, inequality in access to health care will increase, widening the inequality gap. With increasing investments being made in the private health care sector in India, there will be increasing inequalities in the future.
52 Private health companies that want to buy land from the Indian government can get the price subsidised greatly if they allocate a percentage of their hospital beds for the poor that cannot afford treatment on that scale. In Delhi, the arrangement is that the hospitals will provide free health care to a quarter of inpatients and 40 percent of outpatients. This social responsibility is very important since it reflects the image of India as a global medical tourism destination (Puri, et. al., 2010; Sen, 2011; Shetty, 2010). Unfortunately many private hospitals do not comply with their obligations, so only 15-20 percent of the general Indian population are able to use these top-notch hospital suites (Shetty, 2010).
2.4.4 Marketing on a global scale
The medical tourism industry can only thrive with international promotion of its services; websites, brochures, tradeshows and other international promotion events, to inform and offer potential patients or partner’s treatment options at a competitive price. To attract international patients, developing countries are operating in the medical tourism market. In order to do this they need to combat the perception that the medical service they offer is inferior to health services in the west. Incredible India is a campaign by the Indian government to promote tourism and improve India’s image. International accreditation is sought after, as is the promotion of links between the Indian health care brand and the slogan “safety, trust and excellence” (Brady, 2007; Cook, et. al., 2011; Royal Medical Tours (Mumbai), 2004).
2.5 Commercial surrogacy
A relaxed legal environment, low costs and a well developed healthcare system make India a very favourable investment for international surrogacy. India is looked at as a Mecca of IVF; it has a very high success rate in IVF and untapped resources of women willing to become surrogate mothers. If we combine that with relaxed legislation it becomes commercial surrogacy heaven (Stephenson, 2009; Qadeer, 2010). The world’s second IVF baby,
53 Kanupriya Alias Durga, was born in Kolkata on 3rd October 1978 and since then the field of assisted reproductive technology (ART) has grown rapidly in India. Today India has become the leading force in commercial surrogacy and the reproductive tourism market is flourishing under medical tourism. The field is estimated to generate $445 million a year. The commercial surrogacy market in India is mostly managed through private commercial agencies that screen, match and regulate agreements according to their own criteria and without interference from the government (Panda, 2010). Why choose India as a reproductive assistance destination? India is an attractive option for foreign individuals and couples that are seeking parenthood because of the shorter waiting lists and affordable prices, mixed with relaxed legal status. A commercial surrogacy clinic in the USA will charge between $38,000 and $120,000 for the commercial surrogate package and the lead time is months. Indian clinics charge between $5,000-$35,000 for their services (data differs between sources) and have shorter lead times. Another important factor is that it is legal in India to hire a surrogate mother (Chang, 2009; Palattiyil, et. al., 2010; Surrogacy Laws India, 2015).
The Indian government was been harshly criticised for not offering regulations and a legal framework for the reproductive technology market, and for allowing the fertility clinics to make up their own laws and regulations without interference. Commercial surrogacy was legalised in 2002, but it was not until 2009 when the Ministry of Health and Family Welfare and the Indian Council of Medical Research put forward a draft known as the Assisted
Reproductive Technologies (Regulation) Bill and Rules 2009,to control and watch over the commercial surrogate market (Palattiyil, et. al., 2010; Pande, 2010; Rotabi and Bromfield,
2012). The bill put a much needed legal framework around the industry, and it contains the most permissive surrogate laws in the world, making surrogate agreements between two individuals legal as a business contract. According to the bill, gestational surrogacy is allowed though traditional surrogacy is not, which is to delete any emotional connection between the
54 surrogate mother and the child. The Indian surrogate mother has to be an Indian citizen between the ages of 21-35 and not have had more than five successful living births including her own children. Birth certificates are only issued to biological parents of the child and according to the new health bill all ART banks have to be registered with the Indian government. Also, the bill offers legally enforceable contracts to be agreed between ART banks and surrogate mothers, and between potential parents and surrogate mothers (Palattiyil, et. al., 2010: 692; Pande, 2010; Stephenson, 2009).
2.5.1 The Indian surrogate mother
Not many researchers have focused on Indian surrogate mothers and their welfare, and there is no data available on their physical and biological welfare after giving the child away.
Sharvari Karandikar, Lindsay B. Gezinski, James R. Carter and Marissa Kaloga (2014) conducted in-depth interviews with surrogate mothers in Gujarat, India. Their research found that Indian surrogate mothers’ main motivations for becoming a surrogate mother were financial, with altruistic secondary motivations. The surrogate mothers said that they were willing to risk social stigmata over poverty (Karandikar, et. al., 2014). Women all over India are being lured to become surrogate mothers by finance incentives. Fertility clinics in the main cities pay surrogate mothers between $3,000 - $6,000 which is equal to 15 years salary for many Indians. These financial incentives are very attractive to poor women that do not have many financial opportunities.
In her ethnography, Commercial Surrogacy in India, Manufacturing a Perfect Mother-
Worker, Amrita Pande (2010) studied commercial surrogacy at a small medical facility in the city of Anand in the state of Gujarat. According to her findings, a good Indian surrogate mother was supposed to be a nurturing and unselfish mother who does not arrange the payments for her service herself, yet is expected to be a disciplined contract worker who gives
55 up the child when the contract is over. Pande (2010: 976) argued that “this mother-worker mix is produced through a disciplinary project that deploys power of language along with meticulous power over the body of the surrogate mother”. Surrogate mothers are often recruited from the guilt-ridden poor, rural, and uneducated (Pande, 2009; Pande, 2010). She explains that the surrogate mothers are told that they are not biological connected to the child and at birth it will be taken away and given to the “parents”. Their roles is like a “vessel” and nothing more (Pande, 2010: 976).
According to Pande, during the 9 months of pregnancy the surrogate mothers in Anand would be under constant supervision and under the control of medical staff. Activities such as what food the surrogate mothers consumed and how much they rested was monitored. Their freedom is limited because they are carrying a valuable “product” in their womb. During the pregnancy the fertility clinic offers their surrogate mothers English language courses and computer skills training, making it easier for them to communicate with the foreign couple that hired them, and making the mothers into better workers in the process. The surrogate mothers would have one of two living environments, living in a surrogate hostel or above the medical facility (Pande, 2010; Shetty, 2012). First time surrogate mothers and women in their first trimester would be monitored by nurses, and usually kept in a little room under tight surveillance above the medical facility where no visitors would be allowed. On their second and third trimester the surrogate mothers would live at a surrogate hostel where they would gain more freedom, where visitors were permitted, andwhere they were able to roam around and self monitor their medicine, syringes, food etc. (Pande, 2010).
Pande (2010) discovered while conducting her ethnography that a part of women’s survival mechanism was to personalise the surrogate arrangement. They would talk about the foreigners who hired them like there was a personal connection between them, resisting the commercial and contractual nature of their relationship and denying the underlining economic
56 desperation for their decisions. They would focus more on higher moral motivations that would engender good karma and positive actions (Palattiyil, et. al., 2010; Pande, 2010).
Pande's (2010: 979) conclusion was that “to become a perfect surrogate mother, the surrogate has to be a good mother first and foremost and second a good contract worker.
Figure 6: Commercial Surrogate mothers in India
Source: Burke, J. (2010).
2.5.2 Ethical issues and commercial surrogacy
There are many ethical concerns regarding surrogacy. For example, the surrogate contracts are usually in English and most surrogate mothers cannot read or speak English so the contract is read and translated for them. The contract takes away all their parental rights and they are also agreeing to foetal reduction if carrying more than one foetus at a time. The surrogate mother cannot sign the surrogacy contract without the agreement of her husband.
After giving birth some surrogate mothers experienced postnatal depression and emptiness but there is no postnatal service provided. The Indian Supreme Court has stated that it is very important for the industry to ensure and protect the rights of Indian surrogate mothers and, to be fair; the Assisted Reproductive Technology Bill does make an effort to reduce any danger to the surrogate mothers, though it does not address all the ethical dilemmas. One concern is
57 that surrogate mothers are unequally paid for their service. Women that are light skinned, of high caste, educated, English speaking are higher paid than uneducated, dark skinned low class Indian women (Chang, 2009; Palattiyil, et. al., 2010; Stephenson, 2009).
Key fundamental guidelines were put forward by the International Federation of
Social Workers (IFSW) to protect surrogate mothers and children. Unfortunately these are the only guidelines and many fertility clinics do not follow them. The guidelines do not guarantee that the surrogate mother will be protected from exploitation and coercion. This agreement between the surrogate mothers and ART banks, and between commercial surrogate mothers and potential parents, is very clear about the responsibility of the surrogate mother but not as clear about her rights. Specially, there does not seem to be any provisions for counselling surrogate mothers, though the provision is necessary within the fertility counselling profession (Palattiyil, et. al., 2010). It is also still very unclear what happens if the surrogate mother dies during childbirth; would her family receive any kind of compensation? In 2012
Indian surrogate mother, Premila Vaghela, died from unexplained complications while eight months pregnant with a child for an American couple. The child that she was carrying was unharmed. Permila was a mother of two children and her family did not receive any compensation after her death. What will happen to her children now? (The Times of India,
2012). Potential parents can choose a desirable birthday for their child with caesarean scheduled around it. In one case reported in India a young surrogate mother died after a caesarean. Her husband reported that his wife had been denied adequate postnatal care by the private surrogacy clinic (Carney, 2010; Rotabi and Bromfield, 2012).
Becoming a surrogate mother is not considered a socially acceptable profession in
India. Most surrogate mothers keep their arrangements a secret from their closest family, friends and society, and therefore become very isolated. There is always a risk of being exposed as a surrogate mother. Such a discovery could ostracise her from everybody, as well
58 as having a serious psychological effect on her children, partner and parents, including the surrogate mother herself. There are stories of surrogate mothers that had to relocate after the community they lived in found out about the surrogacy. It is not surprising that Indian society would react in such a manner; a large part of the Indian population is opposed to surrogacy, which is also highly stigmatised because of its link to prostitution (Jadva, et. al., 2003;
Karandikar, et. al., 2014; Palattiyil, et. al., 2010; Pande, 2010).
Due to the stigmata about surrogacy it is difficult to publicly recruit surrogate mothers.
Indian women are usually hired by formal or informal surrogate brokers that are usually former surrogate mothers or midwifes. The recruitment process often involves playing on the concept of being a bad mother, or on a mother’s desperation to be able to provide for her own children. For example, though India is a patriarchal society where the men of the household take the breadwinner’s role, many are unable to marry their daughter off at the appropriate age, and in such cases the mother often becomes ostracised from society. Many Indian women are seen to be exploited by rich westerners, and their financial difficulties make them turn a blind eye towards possible dangers, they are also seen in general to be unaware of their rights
(Jadva, et. al, 2003: 2196; Palattiyil, et. al, 2010; Pande, 2010).
Other concerns regarding commercial surrogacy include the unsure status of surrogate children. What will happen to the child if its genetically related parents die before it is born?
There is a special provision when it comes to foreign and non-resident potential parents. The potential parents have to show that they are able to take the child to their country, they also have to appoint a local guardian in India that is responsible for the child during the pregnancy and who will also be responsible for the child until the potential parents arrive if they are not able to be present at the birth. The local guardian has custody over the child if the parents do not collect the child within 3 months from birth, he/she is then free to raise the child as his/her own or put it up for adoption (Palattiyil, et. al., 2010). Indian surrogate mothers have to go
59 through very thorough medical checkups before becoming a surrogate mother. Both the potential parents and the surrogate mothers are tested for HIVbefore the procedure starts.
What is not clear is what will happen if the surrogate mother contracts HIV during her pregnancy and the child gets infected. Whose responsibility is the child?
If we look at the Manji Yamada case, Manji was a little girl born on the 25th July,
2008, in Anand in Gujarat as a consequence of a surrogate contract that a Japanese couple made with an Indian surrogate mother. Spermfrom the Japanese husband was used to fertilise a donor egg to create an embryo. Before Manji was born the couple got divorced and neither the commissioning mother nor the surrogate mother nor the egg donor wanted the child. The biological father of the child wanted to keep the child, but he was not allowed to adopt because Indian laws did not acknowledge him as the father of the child – as a single man he was banned from adopting a girl. After massive media coverage, Manji was allowed to leave
India with her paternal grandmother (Palattiyil, et. al., 2010; The Times of India, 2009).
2.6 Summary
With top medical staff and facilities as well as a majority of government funding used by the private health care sector, it is undeniable that access to health care is unequal in India. Only 1 percent of the Indian public have health insurance, and many individuals walk for miles to see professional medical staff. Access to health care is also very gender divided. More than a quarter of women in India do not have a say in if or when they can seek medical assistance.
Infant mortality and maternal mortality rates are very high but still only half of women receive antenatal care and less than half receive post natal care. The issue of unequal access to health care was not seriously addressed by the Indian government until the year 2009, when it expressed for the first time that everybody had the right to clean water, food, health care and
60 shelter. However, the bill did not provide any solutions regarding how to implement changes or how to finance them.
Medical tourism is a growing industry and an offspring of globalisation. Medical tourism offers its customers cost effective medical solutions with short waiting lists. India has all the technology and knowledge needed to compete with the top hospitals in the world. In general medical tourism is seen as a positive thing for India; however, ethical issues have been raised. The majority of the Indian population do not have access to general health care and cannot afford private health care, but still they have a high quality medical service on their doorstep. Reproductive tourism is a part of medical tourism, it offers cost effective solutions in the reproductive industry. Commercial surrogacy was legalised in India in 2002, with legal frameworks put in place in 2009. The industry is very controversial in India; poor women of the south are seen to be exploited by rich western individuals because of their financial need. Their psychological wellbeing was questioned in this chapter in coping with giving up the children, as was the surrogate mothers’ “free choice”. What is concerning is that there is very little data regarding what happens to the surrogate mothers after giving birth and when their contract comes to an end.
61 3 Methodology
The goal of the research is to give an insight into public opinion and knowledge on the growing industries of medical tourism and commercial surrogacy in India. I do not aim to generalise for the whole of India, but rather give an insight into how an ethically controversial industry such as commercial surrogacy is portrayed from within Indian culture, and more precisely in Jaipur and Udaipur. I was uncertain where to locate myself in India at first, and where to conduct the research. Should I focus on the metropolitan cities such as Delhi or
Mumbai? After careful consideration I realised that my social network in Jaipur was an asset.
In March 2012, I travelled to the pink city of Jaipur in the state of Rajasthan, where I was based during my stay in India. In the beautiful City of Lakes, Udaipur, I had an opportunity to conduct interviews in rural areas as well. From March to August 2012 I conducted fieldwork in these two locations. Research data was gathered with interviews and questionnaires. I also collected data from the online websites of Indian fertility clinics as well as commercial surrogacy buyers’ homepages. In this chapter I will discuss my research methods and analytical tools. I will end this chapter by discussing ethical and methodological challenges that I faced as a researcher while conducting this investigation.
Figure 7: Pink city of Jaipur
Source: Great Oaktrail, 2014
62 Figure 8 City of Lakes, Udaipur
Source: Puru, 2013.
3.1 Qualitative research
After reaching a conclusion regarding a research topic and choice of setting, the next step in the process was to select a research method that was suited for the aim of the study. I wanted to collect in-depth data, and thus I chose to use qualitative research methods.
The qualitative research approach is an umbrella term that covers a wide range of philosophies and techniques (Hennink, et.al.:, 2011; Neuman, 2006). Glenn A. Bowen (2010:
865) define qualitative research as “the systematic collection, organization, and analysis of largely textual material. Phenomena and events are studied in their natural settings”.
Qualitative research methods help the researcher to discover as much information regarding the individual or phenomena being studied as possible, to identify the participants’ social and/or cultural norms and experiences, and to understand their behaviour and objectives from their perspective. The researcher does so by using an interpretive approach. To be able to gather such detailed narrative descriptions, the group studied needs to be small (Hennink, et. al: 2011; Neuman, 2006; Taylor, 2005; Trumbull, 2005). According to Hennink, Hutter and
63 Bailey, (2011: 8-9) the researcher needs to be “open-minded, curious and empathic, flexible and able to listen to people telling their own story”.
Figure 8: Qualitative research methods
Qualitative
Purpose: The purpose of using a qualitative research method is to get
answers to questions such as why? And how?
Objective: The objective of using qualitative research methods is to
understand the underlying motivations, beliefs and reasons
Data: Data are displayed in the form of textual data
Population studied: Small groups and populations that are not randomly selected
Data collection method: Data collection methodsused are in-depth interviews, focus
group discussions, observation, content analysis, visual
methods, and life histories or biographies
Analysis: Data are analysed by interpretive approach
Outcome: The outcome of using qualitative methods is to develop and
understand the research topic by identifying and explaining
participants’ beliefs, actions and behaviours.
Source: Hennink, et. al.: 2011; Neuman, 2006; Taylor, 2005.
3.2 Data collection
Before my departure from Iceland I had decided to play it by ear, taking advantage of my social network in India to gather data. India has an enormous social class gap and my social
64 network in India was limited to the middle-upper classes. However, I was hopeful to be able to stretch out into other social classes in order to get more diversified responses. I decided to use snowball sampling to approach participants for both interviews and questionnaires.
Snowball sampling can be described as a non-random sampling of participants; one participator suggests another potential participator and from then on the ball starts to roll
(Atkinson and Flint, 2001; Neuman, 2006). This approach is based on its similarity with a snowball; it starts very small and then gets bigger and bigger as it rolls in the snow and more snow starts accumulating on it. The goal of snowball sampling is to use an individual’s social networks to access data. In a way, your participators are recruiters for your research.
Qualitative research methods mostly use snowball sampling with data gathering. Snowball sampling is cost effective, efficient and can deliver elaborate data. According to Shareen
Hertel, Matthew, M. Singer and Donna Lee Van Cott (2009), using snowball sampling in field studies (vis-á-vis the local culture) can work to the advantage of the researcher. The local people might look at you as exciting and interesting. Negative aspects of using snowball sampling are that it is time consuming and it requires a lot of work. Quality of the data collected could be affected because of biased selection of research participants. Participants are not chosen randomly; meaning that the data collected are steered by the first participant because they control whom you have access to. There is also the danger of excluding individuals because as a researcher using snowball sampling you are dependent upon the interviewees that your former participants linked you to. This means that individuals that do not belong to a past participant’s social network are excluded from the data collection
(Atkinson and Flint, 2001; Neuman, 2006).
In total, 47 individuals participated in the research. I had in-depth open interviews with 19 interviewees using a guided-interview approach, whilst 28 people responded to the questionnaire. Females represented the majority of interviewees; with 11 females, against
65 eight males. Data collected in Udaipur was all in the form of in-depth interviews. I brought a form to the interviews with basic information and guidelines regarding what I wanted to ask about, though I tried to keep the conversations flowing during the interview process. It is important to ask the right questions and ask interviewees to give you an example so as to grasp the right interpretation of their answer (Crang and Cook, 2007). Participants in the study had different educational backgrounds (ranging from uneducated to PhD degree), age ranged between 30-95 years of age and all adhered to Hinduism. Seven of the female interviewees were married, one was unmarried and three widowed. Eight of the women had children, one was pregnant and one was without children. Of the male interviewees, six were married with children and two unmarried without children. During 13 of the interviews I recruited assistants to interpret. I did not seek assistance from professional interpreters. Both of my interpreters were kind enough to assist me without taking any payment for their trouble. One was a dear friend of mine, Dr. Rekha Bhatnager, and the other interpreter, Mr. Manish
Sharma, was recruited through a friend network.
3.2.1 Interviews
During BA studies in Anthropology and courses in Development Studies, I conducted some interviews for training purposes, but I had not conducted interviews as a field researcher before. I have to admit that initially I was insecure during my first interviews, very self conscious and afraid of accidentally offending the interviewees. After a few interviews things started to flow better. The entire interview process went really well and there were no major problems with preparation for the interviews or during the interview. My first interview was conducted on the 1st May 2012 and the last was conducted on the 4th August 2012, with interviews lasting between 15 - 70 minutes. I tried to keep the interview time relatively short, with the potential of then revisiting the interview if further data was needed. I conducted 13 interviews in the comfort of my interviewees’ homes and six at their work places. According
66 to Atkinson and Flint (2007), it is very important to develop trust between the researcher and participant by showing that all data will be treated appropriately.
All of the 19 interviewees were informed about the content of my questions beforehand and were reassured that confidence and anonymity would be respected. None of the participants specifically asked to be kept anonymous, but I decided that it was ethically right to conceal their names and consequently I only refer to them here as “interviewees” or
“participants”. All of my interviewees were informed that if they felt uncomfortable answering any question, we would move on to the next question (O´Reilly, 2005). Before each interview I asked for permission to record the interview, which was permitted in all 19 interviews. The data was then transcribed and the records deleted. According to Shareen
Hertel, Matthew, M. Singer and Donna Lee Van Cott (2009: 306), before giving an interview the researcher should always ask the respondent if they feel comfortable having the interview recorded, to respect their decision if not, and “if you have permission to quote from an interview, use your judgement to avoid any possible harm to your informants”. According to
Ortner (2010), when conducting an interview it is important to watch what you say to your interviewees, you have to be careful not to offend anybody or say something silly that could alienate the interviewee from the interview. During the interviews, I did not write any information, I wanted to keep the flow of the conversation going; I just listened to my interviewees with enthusiasm. The environment during the interview was friendly and created a few laughs, and more often than not the conversation kept flowing after the recorder had been turned off.
When deciding on the interview guide, I wanted to follow what Karen O’Reilly (2006) called “free-flowing” interview, or an instructed interview. Going into a free-flowing interview the interviewer has certain questions or a certain topic in mind and the interviewees have the opportunity to reflect on the topic. According to O´Reilly, informal interviews of
67 such sort are more like a conversation than an interview. Unfortunately, that form of interview style did not fit with my subject and field. Structured interviews have fixed questions and are conducted more like a survey than an interview (O´Reilly, 2005). In Semi-structured interviews “researchers and participant(s) set some broad parameters to a discussion” (Crang and Cook, 2007: 60). I was careful not to ask complicated questions that took lengthy deliberation time, preferring to use short questions that could be easily responded to.
Due to the fact that an interpreter was needed for 13 of my interviews, I faced some minor problems. It proved to be difficult to arrange a time that suited everybody’s needs.
According to Shareen Hertel, Matthew, M. Singer and Donna Lee Van Cott (2009), arranging interviews can be frustrating and also time consuming. They suggest that you hire a person to arrange the interview for you. All interviews were arranged by two individuals and I found it proved to be quite time saving.
3.2.2 Questionnaire
As previously mentioned, 47 individuals participated in the research, of which 28 individuals answered a questionnaire20, including 24 females against six males. Participants were approached using snowball sampling and accepted an invitation to participate before the questionnaires were distributed. Questionnaires were used as additional qualitative data and analysed as such, it is important to state that the aim of using questionnaires was not to present statistical data though discussing how many individuals had a particular view or opinion. It is also important to keep in mind that the size of the sample was small, making it difficult to generalise from the data collected from questionnaires. In total, 18 of the females
20Please see Appendix for a transcript of the questionnaire
68 were married with children and six were unmarried and childless. One of my male participants was married with children and two were unmarried and childless. All 18 participants had higher education qualifications, ranged between 25-65 years of age, and all adhered to Hinduism. I distributed questionnaires manually as well as electronically, the response rate was 100 percent and I sent and received questionnaires from April 2012 until
October 2012.
By using a questionnaire I had the opportunity to reach a larger group of participants.
Using questionnaires is less time consuming than conducting and transcribing interviews, but
I was also aware of the downfalls. My decision to write the questionnaires in English excluded all individuals that did not speak or read English; it also excluded all potential participants who were illiterate. My decision to only use questionnaires in English was due to the fact that I do not understand the national language, Hindi, and I would have had to hire a translator to translate all the answers. The fact that the questionnaire was in English might explain why all participants that completed the list had higher education. When using questionnaires you cannot be sure that participants will answer all the questions, and you are unable to observe participants’ facial expressions and body language when answering.
When structuring a questionnaire, the questions can be open-ended or closed. Using open-ended questions allows respondents to provide their own answers, giving them an opportunity to express their own ideas and opinions, while closed questions list answers and respondents select either one or multiple responses (Neuman, 2006; O´Reilly, 2005). For the purposes of this research I structured the questionnaires with open-ended questions. In the beginning of the questionnaire I wrote a short cover letter to introduce myself and the research. I also disclosed to participants that all information given would be treated as confidential. When explaining the research I emphasised that the issue regarded women in
India. The status of women in India is a very heated subject and I wanted my participants to
69 think about their position regarding women and then answer questions regarding commercial surrogacy with that state of mind. I started with background information on the participant, such as gender, age, marital status and education. I began the questionnaire with questions about their opinion regarding women’s rights in India, the difficulties they experience and threats they face. I followed up with questions regarding the status of knowledge about medical tourism and commercial surrogacy.
3.3 Data analysis
Cindy M. Bird (2005: 226) wrote about herself: “As a novice qualitative researcher, the author had little idea of the significant and vital role of transcription in the qualitative research process until she undertook her own transcription”. The same applies to me. After collecting all relevant data as a researcher, the next task is to take on the longwinded endeavour of analysing the data. In this chapter I will discuss the data analysis techniques used. First I will discuss grounded theory, followed by discourse analysis.
3.3.1 Grounded theory
Grounded theory is an inductive methodology used with both quantitative and qualitative research methods. Grounded theory provides researchers with steps and rigorous procedures that they can easily follow to develop theoretical categories. These categories are related to each other as a theoretical explanation for a particular problem, process, action or interaction being researched, and as a potential solution to it. It can be said that the theory is grounded in the data (Bowen, 2010; Charmaz, 2011; Denzin, 2010; Grounded Theory Institute, 2014;
Grounded theory online, 2015). Norman K. Denzin (2010: 296) explains grounded theory in his article Grounded and Indigenous Theories and the Politics of Pragmatism as:
It is all grounded. It is two things at the same time, a verb, a method of
inquiry, and a noun, a product of inquiry. It is intuitive. You let the obdurate
70 empirical world speak to you, you listen, take notes, write memos to
yourself, form writing groups, No hierarchy, the social theorists are not
privileged. In the world of GT anybody can be a theorist.
Grounded theory guides the researcher not only in how to analyse data but also how to collect data. Through the research these two procedures, data collection and data analysis, go back and forth because they inform and shape each other through an emergent iterative process
(Charmaz, 2011).
Coding empirical data, and working with the resultant codes makes grounded theory distinctive from other analytical methods. Through coding, the researcher develops categories that fit the empirical data collected and then builds his theory. Coding helps the researcher to understand what is happening in his data; not just the obvious elements but also what happens behind spoken words (Charmaz, 2011). When referring to coding in grounded theory it is most often linked to three coding methods: Open coding, intermediate coding and advanced coding.
• Open coding (also referred to as initial coding): is the first step of analysing data. The
open coding process occurs simultaneously with data gathering and continues until
core categories and main concerns are identified. By sticking closely to the data,
researchers identify important words or groups of words by reading over the data line
by line thoroughly. It is also said that initial coding fractures the data. These words are
then labelled and categorised. These categories are explained in terms of their
properties and dimensions (Birks and Mills, 2015; Charmaz, 2014; Crang and Cook,
2007; Grounded theory online, 2015).
• Intermediate coding (also called selective coding): is the second state of coding and
builds on the core variable and major dimensions and properties discovered using open
coding. Intermediate coding can be employed in two ways: to develop properties and
71 individual categories by connecting subcategories formed in the first stage of coding,
or to link fully developed categories together. Intermediate coding reconnects fractured
data from the open coding. The most advanced form of intermediated coding is Axial
coding used to see the core themes in the data and the axial that links them together
(Birks and Mills, 2015; Crang and Cook, 2007; Grounded Theory Institute, 2014).
• Advanced coding (Theoretical Coding): is the third and last step of coding. “It
conceptualizes how the substantive codes may relate to each other as hypotheses” and
how it integrates into the theory (Grounded Theory Institute, 2014). This code is
considered to be the most difficult to accomplish well because grounded theory does
not endeavour to find a “one size fits all” answer because grounded theory providesa
comprehensive explanation that includes variation (Birks and Mills, 2015).
Grounded theory organises the data in order to make it easier to interpret. When analysing the data using grounded theory I started by dividing all interviews into three categories: Women,
Medical tourism and Surrogacy. After that I started to work through each interview one category at a time. I started by using open coding. I went through every sentence in each interview and noted down topics discussed. For example, in the medical tourism category I had 18 topics, in the surrogacy category I had 29 topics and in the women’s category I ended with 33 topics. My next step was to write down all my topics and divide them into groups using intermediate coding. I did not want to mix the categories together so I analysed each separately. The point of doing this is to find the red thread that binds everything together; it is also referred to as axial code.
3.3.2 Discourse analysis
According to Rosalind Gill (2000), we use language from our experience to create, maintain and change our social reality. Through language the exotic is made familiar, which is why we
72 are able to research how we are controlled by dominant discourses by systematically reading texts while keeping this process in mind. Discourse is built on words, ideas and rituals that are repeated in dialogue with others, also called discourse theme. Discourse theme forms a pattern that can be described as historical and legitimating principles. Principles are both direct or indirect that inform us what is acceptable to say in a specific setting; if a person wants to be heard they need to follow certain rules. Discourse analysis never focuses on discourse in isolation; it is always in relation with other elements (Fairclough, 2013; Ingólfur Ásgeir
Jóhannesson, 2006). Concepts such as power and silence are very important in discourse analysis because discourse not only focuses on social practices but also the exercise of power, which can be both direct and indirect in discourse (Jäger and Maier, 2009; Ingólfur Ásgeir
Jóhannesson, 2006). Teun A Van Dijk (2001) argues that controlling discourse is power because it controls people’s minds and reproduces hegemony and dominance. Silence in a text is equally important as the text itself in discourse analysis (Jäger and Maier, 2009; Ingólfur
Ásgeir Jóhannesson, 2006).
Critical discourse analysis is one method used to analyse discourse. It primarily focuses on the way “social power abuse, dominance, and inequality are enacted, reproduced, and resisted by text and talk in the social and political context” (Dijk, 2001: 352), how social inequality is expressed, constituted, legitimised, and how to resist it (Dijk, 2001, Ingólfur
Ásgeir Jóhannesson, 2006; Wodak and Maier, 2009). Norman Fairclough (2013) classifies critical discourse analysis into three basic properties: relational, dialectical and transdisciplinary.
• Relational: primary focus on social relations rather than entities or individuals.
• Dialectical: relations between objects which are different from one another but not
what I shall call discrete, not fully separate in the sense that one excludes the other.
73 • Transdisciplinary: dialogue between theories, disciplines and frameworks which take
place while conducting the research and analysing data.
In this thesis I used discourse analysis to look at power relations in interviews and detected discourse theme in the text. I looked at all the data from the 47 individuals that participated in this research and slowly a theme started so show itself. For example, when talking about the status of women in India, the same words and sentences, such as “powerless”, “right to choose”, “slow change”, and “violence” appeared. When discussing surrogacy, “money”,
“business”, “choice”, “poor” and baby” were commonly used words. There were many contradictions in the text, for instance surrogacy was a good profession for the poor, needy women, but taboo and not suitable for other women. It was quite strange that when discussing surrogacy, discourse theme was not emotionally expressed, but came rather from a business orientated point of view.
3.4 Ethical challenges
When conducting research in a “developing” country many challenges arise. Emanuel,
Wendler, Killen and Grady, (2004) put together three main issues that a researcher from the
“developed” world should have in mind when conducting research in the “developing” world.
The first issue is standard of care, the second is the interventions that are useful during the course of research ,trials, and the third concerns the quality of enquiring and receiving informed consent. Caballero (2002) argues that emphasis on individuals rather than the family, tribe, land or even nature may vary. Furthermore, many vulnerable populations are not in a position to refuse participating in research or to exercise their rights to refuse giving informed consent (ESRC Research Ethics Framework, 2004). There have been ethical concerns regarding whether or not the results of research conducted are beneficial to the groups involved. Hertel, Singer and Cott (2009) argue that researchers coming from western
74 countries to conduct research in the developing world often undertake local research without sharing the findings or research data with the people for whom it would be most valuable.
ESRC Research Ethics Framework (2004) put forward a paper, Discussion Paper 3:
Social science research ethics in developing countries and contexts, which focuses on ethical issues regarding research conducted in the developing world. In this paper, the shortcomings of researchers from the “developed” world are discussed, including their tendency to rely on non-homogeneous distinctions and to underestimate their complexity, for instance: ´develop´ vs. ´developing´, ´East´ vs. ´West´, or ´North´ vs. ´South´. The asymmetrical power imbalance between researchers and participants is also highlighted. The ESRC Research
Ethics Framework emphases that such power imbalances can have an impact on the welfare of participants as well as influencing the reliability of findings. Another concern is wealth disparities; that researchers coming from the wealthier parts of the world have resources to conduct research in disadvantaged countries, whereas researchers coming from poorer countries have fewer resources with which to conduct studies within the wealthier parts of world (ESRC Research Ethics Framework, 2004)
According to the ESRC Research Ethics Framework (2008: 8), when conducting research in a developing country, researchers coming from the wealthy “west” should consider that those being researched need to agree with any ethical decisions made throughout the research process. For a researcher to reach that kind of understanding he might need to adapt to the group under studydiscipline -universal ethics - to the social conditions of the local population.
I was always aware of the power discrepancy between myself, coming from the
“wealthy west”, and my poor underprivileged interviewees. The people that helped me arrange interviews with all social groups are themselves from the upper-middle class, well educated and well off financially, as were my interpreters. It often crossed my mind whether
75 or not my interviewees from the lower end of the social classes agreed to participate because they felt inferior to the person that was asking them, and during the interview if they moulded their answers to be more socially acceptable. Over a quarter of participants, 28 percent, did not speak English or have access to a computer, making the research findings inaccessible to them. Though the research is accessible online, it does not make a difference to those participants. It did make me nervous that the majority of participants would be able to access and read my findings; would they feel that I showed their opinion in a negative light if it did not follow the overall conclusions of the research?
76
4 Results
In this chapter I will present the results for my thesis Medical tourism, commercial surrogacy and women in India: output or exploitation? I present the findings in three sections. In the first section I discuss the status of women in Indian society. By asking questions on this topic,
I gained insights into the female world as felt and understood by my interviewees. As surrogate mothers are means of production, it was very important to gain an insight into the social environment that they live in. In the second sub-chapter I will detail the results regarding the general knowledge of the concept of medical tourism in India. I wanted to gain understanding of the level of knowledge and information regarding medical tourism, since the industry is growing rapidly and bringing excessive levels of foreign currency. It was equally interesting to see whether commercial surrogacy would be identified as a part of medical tourism or not. Would these two be distinguished? In the third sub-chapter, commercial surrogacy will be discussed in light of my participants’ perspective on the overall status of women in India and medical tourism. Information about three key factors of commercial surrogacy was collected: general knowledge, opinion and thoughts on the subject. How did the participants perceive commercial surrogacy? How did surrogacy fit into their culture and their image of Indian woman- and motherhood?
4.1 Women in Indian society
Men must change their mindset towards women. If they are more respectful towards them, things will change at the grassroot level. It will happen slowly, but everyone has to move together. -Madhuri Dixit, Actor
77 4.1.1 Gender equality
In recent years the world's media has been covering heart-breaking news about violence against women in India and the public outcry to change the mindset of the society and to implement harsher penalty laws for abusers. This has raised questions regarding how women are seen and treated in Indian society. The status of women in India is a heated discussion worldwide and an important topic to be discussed in connection with the understanding of the social framework regarding surrogate mothers. All participants in this research eagerly wanted to discuss the subject and share their opinions and experiences. When asked if they felt satisfied with the work that has been done regarding women’s rights, only eight female participants and three male participants expressed that they were satisfied. It was expressed to me that the modern Indian woman is emerging as a confident and independent individual, and some participants went as far as to say that women are considered equal to men in modern
Indian society. They were positive towards the future and believed that women’s voice was finally being heard. A male in his mid-twenties, educated and unmarried, expressed his thoughts as follows:
There has been an increase in the realisation of women as more than mere show pieces but forces to reckon with. The word of the woman is now given more weight than that of man’s, especially in important decision making for it’s seen through careful observation that women speak through careful deliberation while men through emotions and ego and the results speak for themselves.
In contrast, of the total 47 participants, 14 females and 3 male participants were dissatisfied with the work that has been done regarding the rights of women in their country. They did not believe that a positive social reformation had occurred regarding the status of women in India.
Men were seen to be a dominant force, and within the household women’s voices were often unheard or smothered if they tried to voice their opinion. An educated woman in her late
78 thirties argued that women are “not considered equal to men” within Indian society. This opinion was shared by a young educated married woman; she argued that women and men seen as equal in the society is a myth, a fairytale that unfortunately does not play any part in reality. A Professor in her early sixties argued that girls are told that they are equal to their brothers but the reality is that “all parents don’t want a girl child, they want a boy child, ok they have a girl child she is always discriminated, it is always more given to the boy and less to the girl”. In addition, she told me that when a woman is married off to a man, often a complete stranger chosen by her parents, there is no equality; “the husband she has to follow all the time, she does not really have her opinion”. Furthermore, she argued that as a mother a woman had to compromise over and again, women would compromise their entire life, for parents, then husband and their children. The interviewees often shared their own experience and real life stories with me. A woman in her late sixties recalled: “So when I was growing up they [her parents] used to say: when you get marriage don’t come back, come back when you die. You will get out of that house only when you die”. Society wasn’t seen to offer women enough opportunities to become independent, and lack of freedom and autonomy made it difficult for women to find and identify themselves.
Though the majority of the participants in this study expressed their opinion regarding this subject, 19 individuals were uncertain; they acknowledged that positive changes in society regarding women have been made but they were also very much aware of the difficulties that women still face in society. An educated man in his late sixties argued that women could not expect to be given both equal rights and at the same time be respected in society. He implied that as a woman you would have to choose if you want to be respected in society or if you want to be equal to men.
I was interested to see which social group my participants saw as the “weakest” when discussing which social group was in most need of empowerment. Surprisingly the answers
79 differed greatly. The majority (11 participants) felt that the emphasis should be put on the rural women and six individuals felt that the poor and uneducated women located in the urban or rural areas are most vulnerable. Eight participants said that the lower and “backwards” castes21are in most need of empowerment. In contrast, five of the participants focused on the middle class. Many participants told me that most changes have been occurring among rural women; they are now slowly coming up and claiming their place in society. Other participants felt that it was difficult to execute changes in Indian society because of its culture, and that it was especially hard for the middle class. A man in his late thirties, working in the tourist industry, was concerned about the development of middle class women. He argued: “the problem is that still the primitive mentality, the old mentality of big middle class, they are not sure which one they want,” he further said: “They want to stick with tradition but they want to look modern, they stick with the old mentality”. This view became apparent when I discussed this idea with a male member of society who was in his early forties and a father of two sons.
After being asked what kind of daughter in-law he hoped for, he responded that he wanted a daughter in-law that was “mixture of all the traditional and cultural values as well as education and modern thoughts”. He felt she should be well behaved and not shame the family but at the same time “she should also go out, earn money, and learn new things”. That put enormous amount of pressure on the middle class woman to play both roles well, the traditional Indian housewife and the modern working woman. This point of view was shared by an educated woman in her early sixties, who argued:
I personally feel that the Indian woman has this problem that she is standing at a threshold, keen to move out and yet not keen. Keen to adopt certain customs from other societies and yet not keen to give up anything that may
21See Blunt, 1931/2010
80 type cast her and make her one of those so called stereotypes of femininity, ok? The modern Indian women has this problem that she may in her house voice her opinion but when she goes out she will always ask her husband: what am I supposed to say in public?
4.1.2 Is the educated woman independent?
You educate a man you educate an individual, but if you educate a woman you educate a family -Probably a Fanti
Education was seen as the key to equality, independence, and freedom by 29 participants, although all the 47 participants put some importance on education. A woman working in the health profession believed that education would “bring about all the change”. She argued that women were becoming economically independent, “so education and then economic independence are two factors which are bringing about a lot of changes and confidence in woman in India”. Education was frequently linked to freedom and the right to make one’s own choices. Education would bring about financial independence which was considered to be very important for women in India. It was often emphasised that it was not enough to fight for education and rights and then not claim them. Many women from all social classes were aware of their rights, they knew that they were there for their protection but they would not be inclined to use them.
Equal access to education was seen as crucial by both men and women, and many fathers expressed to me how important it was to them to educate their daughters. A man in his early thirties, married and educated, stated that the basic thing he wanted for the women in his society is that they should be aware of the importance of education in their lives. “If a girl is educated she can educate the entire family,” he said. Another educated father, also in his early
81 thirties, told me that in his father’s generation women worked on the fields and education would never have been considered an option for them. He said girls were oppressed but he could see the changes in his society; they were receiving education now and slowly being given a voice. A voice that they could use to ask for the things they want and demand the rights which are already there for them.
The illiteracy rate of Indian women was considered to be a problem, but still participants were positive because literacy numbers are increasing. A woman in her mid- thirties working in the education sector argued that illiteracy was a major problem for women that resulted in “lack of awareness and lack of freedom for themselves to express their thoughts, opinions and expressions”.
I asked the participants, if they could make a wish for Indian women, what would that be? The most common answers were education and financial independence. A professional woman in her late sixties argued that “when a woman brings money in the house the whole thinking of men changes towards her”. Another professional woman in her early sixties indicated that a woman’s respect declined when she was not earning: “She was just in the house, so men started thinking; oh she is nobody”. Earning money for the household was not just seen as important to earn respect, it was considered equally important for women’s security. A professional woman in her early forties put great emphasis on financial independence and explained that even if a woman would want to leave a “bad” marriage, she would not have the financial means to do so. “A lot of Indian women are still very dependent on money, first fathers, then husbands and then sons; they are always dependent on money, not begging but asking for money,” she argued.
82 4.1.3 Violated, invisible and quiet women
Despite participants’ opinions regarding where Indian women stood in society today and how financial independence would help them gain respect within the household, violence against women was seen as a huge problem. Violence such as honour killings, rapes, dowry deaths, acid attacks, sati, gender testing, infanticide, child labour, mental abuse and domestic violence were often mentioned in the interviews as the biggest challenge faced by Indian women and society. An educated man in his mid-twenties argued “Am sorry to say we Indians are hypocrites: on one hand we hail our women as incarnations of Lakshmi the goddess of wealth and prosperity and on the other hand SATI”.
The majority of participants expressed that they see India as a male dominated society and that this is a problem. Women often become invisible in society. A woman in her late fifties, married and educated, told me that still today many husbands do “not allowed [their wives] to speak or participate in discussions” which shows that the women have “no right to speak”. A few participants noted that many Indian women do not believe that they have a choice about how they are treated or how many children they would give birth to. A professional woman in her late thirties expressed to me: “Shouldn’t Women should decide how many children she is going to bear because she is going to bear them not the man, she is going to bear them and then she is going to rear them it should be her choose, it is never the case”. She also told me that many women do not believe that they have the right to decide if and when they have sexual intercourse with their husband, and they do not have the power to refuse him. Women are not very visible in the employment market in India, and I was told that this is not strange since women would need approval from their father or husband if they wanted to work, and sadly often the permission is not granted. They would also have to get the choice of profession approved. The topic was further discussed by a woman in her early thirties and a mother of three; she shared with me that even if she was earning, her husband
83 would dominate both her and her income: “So I have no say in any decisions and if I decide something I have to ask his [husband’s] permission.”
Domestic violence, as expressed to me, was seen as acceptable in Indian society by many interviewees. A professional woman in her late thirties explained to me that “they
[women] think that men everywhere beats wife so it is no big deal”. She further said that many women see it as a way of life and when asked why they would say: “He has a lot of liquor and comes home and beats me, it is a way of life”. She argued that these women do not want to get help because they just simply did not identify it as a problem, which would make it very difficult to fight domestic violence. A married uneducated woman in her early thirties told me that within Indian household women are often tortured by their family, husbands and/or in-laws. Women would suffer in silence since domestic violence was often accepted in society. A woman in her late sixties who worked in the education system told me that the reason why women would tolerate torture from their husbands was because girls in India were taught from an early age to be tolerant and patient. To endure whatever was thrown at them. A female professor told me that it would be in the best interest of the woman to tolerate the violence and torture from the hand of her husband. She expressed to me that Hindus believe in rebirth and for seven lives you would marry the same man. If you would stay in the marriage and endure the violence it would become less severe with each life, if you would leave you would find yourself in the same position in the next life.
4.1.4 Sub-section summary
Participants were generally positive regarding the future of the women of India, though the process is slow. When asked where the focus should lie when it comes to empowering women, the majority of participants looked towards rural women, the uneducated, poor and to women of lower classes. However, the middle class woman was seen to be facing the most
84 difficulties. She is standing at a crossroad, wanting to follow tradition but at the same time wanting to belong to modern society; a dilemma which causes friction. Participants were unanimous that education would bring women financial independence, freedom to choose and tools to be able to express their needs and opinions. In India, the majority of women are dependent on the males in their family to support them from birth to death. First their father, then husband and finally their son.Education would bring about employment prospects and financial independence. Sadly the Indian woman was seen to be oppressed by male dominance in society. The majority of participants expressed that many women in Indian society were subjected to mental and physical abuse and not seen to have the freedom to speak their mind in public or to be able to make decisions about their lives without the approval of their husband. Girls were taught from an early age to be tolerant and patient, not identifying domestic abuse as a problem and accepting it as a reality of life. Violence was often correlated to the poor uneducated woman that “did not know better” because of her lack of awareness.
4.2 Medical tourism industry
A wise man should consider that health is the greatest of human blessings, and learn how by his own thought to derive benefit from his illnesses -Hippocrates, Regimen in Health
4.2.1 A booming industry
The global focus is increasingly turning to the field of medical tourism; with globalisation and tremendous advances in technology, outsourcing of health care is getting more and more common. Information regarding medical tourism can be easily accessed through the internet if
85 one wants to acquire information about the field. Even the local newspapers and magazines have covered stories on medical tourism in India, both in Hindi and in English as well as television shows and various news programs talking about this widely growing industry. 31 out of the 47 individuals participated in my research were educated individuals and responded with some awareness about medical tourism and they knew that it is a growing field in India.
Many of my participants had sufficient knowledge about this industry and others were just aware of the basic idea of the field. India has long been a popular tourist destination with its breathtaking tourist spots such as beautiful mountains, vast deserts, exotic rainforests and long sandy beaches. The participants were aware that the private health care sector and the tourist industry were two different industries which are combining their resources. India has mesmerising nature and cultural heritage, along with its first class trained medical staff, technologically, well advanced medical facilities, and good reputation in health care. “It is like people are now making packets of illnesses” one of my interviewees joked when asked about medical tourism. My participants also informed me that India also offers its traditional medicine system, Ayurvedic medicine treatments, which are the world’s oldest holistic healing treatments, as well as other non-surgical treatments like meditation and yoga which also play a major role in attracting people to India for medical tourism. 16 out of 47 participants have had little or no education and had limited information regarding medical tourism. They had not heard of it being mentioned in media or within their society before the interview.
Overall, the majority of my participants saw medical tourism as a positive thing for
India and Indian society, 29 individuals out of 31 had prior knowledge about the field. 19 of my participants consider medical tourism as a positive development in all aspects that could affect India socially and economically. I was often told that Indian society would benefit from the interaction with the foreign patients; a professional within a tourist industry said that
86 “Medical tourism, even tourism, where there is interaction from one to another place in the world it is always good for society because you learn a lot about new people, new culture, and new places”. It was also emphasised that medical tourism has a boom effect on the Indian economy due to foreign currencies flowing into the country. A married, educated man with close ties to the Indian travel industry could not see anything negative about the industry:
It is positive on Indian economy definitely, because more and more tourists will come to India, they will spend money, they will go for medical treatment, they will spend foreign currency in India and that will result in our currency getting stronger that will result in giving employment to people so I don’t see any negativity, it is all positive.
Four individuals told me that medical tourism would benefit India because it would improve all health care facilities, keep high-tech medical equipment up to date and increase employment. These improvements were seen as helping India to become stronger in the international market when it comes to health care, medical knowledge and the use of technical equipment. A young man in the hotel industry had great faith that medical tourism would also boost international ties, especially with neighbouring countries that seek medical treatment in
India. This could reduce airfare prices to and from India, opening up new opportunities for the
Indian public.
What does a developing country like India have to offer to a technical field like medical tourism? Without asking I was told by 12 of my participants that India offers highly educated and very experienced doctors as well as technologically advanced hospitals which make India a perfect location for an industry like medical tourism. One of my interviewees, an educated man, told me proudly: “Indian medical education even though India is a developing country our medical education system is one of the best in the world so doctors are performing well outside”. Nobody seemed to doubt the efficiency of the Indian doctors or their level of experience and knowledge. A Professor in the medical field argued:
87 I think that Indian doctors are the best doctors. Because the kind of patients that they see, no one else in the world sees. They see thousands of patients in a month so they know exactly what is happening to that person. The diagnosis is correct.
Two other of my interviewees explained how their over-populated nation would serve well in this aspect, since Indian doctors have greater opportunities to perform complicated surgeries and treatments that doctors in western countries do not because the population is comparatively scarce.
All my participants, with or without the knowledge of medical tourism, had great respect and faith in the public and private Indian healthcare sector. Throughout my interviews and personal conversations, I was often told about people’s personal experience with Indian doctors. These experiences were mostly positive and the qualifications and experience of
Indian doctors was appreciated. My interviewees always praised the medical profession in
India to the fullest, regardless of their opinion on medical tourism. Many of my participants without education, who said they did not have any knowledge about the concept or the practice of medical tourism, told me about the kinds of medical facilities the government had offered them. People from villages told me proudly about their access to government medical facilities near their village.
The participants knew that India offers shorter waiting lists for procedures than many countries in the West. A doctor also reflected on the subject, “in many countries are waiting of two months, three months, four months for surrogacy which can be done here quickly and as well as everywhere else”. The cost aspect was another factor that my participants told me would make India a very desirable location for medical tourism. I was told that India offers cost-effective solutions to medical problems that foreign patients might be facing;medical treatments are very expensive in western parts of the world and often inaccessible financially to middle class people. It became clear to me that India, being a developing country, offers
88 cost and time effective solutions to foreign patients. A young professional was very much aware of the cost effectiveness that India offers to foreign patients:
Because India is a developing country it is cheaper so it is easier for a lots of people to come here and get treatment because they can get the treatment 20 times cheaper than they can have back home, that is one thing whatever it is surgery or any type of medical treatment.
Nine of my interviewees felt that state of art technology and good medical facilities was
India’s comparative advantage in medical tourism; it would increase India´s attractiveness on a global scale, making it a front runner in the field of medical tourism.
4.2.2 Importance of promotion
While I was conducting my research I always kept my eyes open for advertisements that involved medical tourism in the Indian media. I was very keen to find out whether my participants felt that promotion advertisement of medical tourism was visible in the Indian media or if they had noticed any advertisements on the global network. I began thinking about how information regarding medical tourism is marketed to the general public. Surprisingly, only six out of 31 participants seemed to have some information about the subject; they had seen advertisements for medical tourism in the Indian media or the global World Wide Web.
Apparently they had seen a few advertisements here and there from time to time, for instance, in a newspaper article, talk show on television, or sometimes an advertisement on the global web. Five of my participants claimed to have had knowledge about medical tourism but they did not answer my questions on the marketing section, and six of them misunderstood the questions and started once again to expound on the definition of medical tourism. A total of
16 of the participants told me that they thought that it was important that medical tourism in
India should be promoted well on the global market because medical tourism in the country is
89 only in its initial stages. Five participants did not answer any of the questions related to marketing of medical tourism and didn’t give their personal opinion about it.
One of my interviewees, who had worked in the tourism industry for a decade, pointed out some obstacles which this industry might face. He told me that the image of India was very important, both for the tourism and medical tourism industry; hence good marketing would be a crucial factor for both of the industries whether working together or separately:
When they think of India they think about a dark country, there are holes on the roads and on the streets and beggars are walking around, there is a dark side but there is also a lot of bright sight also. Unfortunately India is not marketed well and people are afraid or hesitated to come to India so we have to make an image of India as a safe destination, as a clean destination, better infrastructure and marketed well
From the participants’ point of view, the internet was the best way to promote medical tourism in India on a global scale, and it was considered as being very accessible and a great source of information for international patients. For instance, a professor argued that: “all the hospitals have websites. They are advertising; they have all the details that you can look up on the website”. She was, however, concerned about the mixed quality of doctors, and the patients “should be sure enough that yes this hospital is good, this doctor is good. They should make their own survey, or they should not come”.
A medical professional I interviewed wanted to see more true experience stories from the individuals that have already received medical treatment in India. Such positive feedback, based on the patients’ experience as a result of successful treatment, may encourage other foreign patients to consider India as a destination for medical tourism. She argued:
I think it needs to be marketed really well because on the internet, people watch it, and then it should be well marketed and there should also be interview of those people that have come here for surgery and gone back very happy.
90 One of my participants, a young man working within the tourism industry, wanted to see medical tourism being marketed heavily in Asia, Africa and the Middle East because he thought that they would be profitable markets for India. Most of my participants did not have any opinion on medical tourism, although they mentioned during conversations how expensive the medical service was in North America, and how the numbers of patients from the Middle East are increasing.
4.2.3 Admired from a distance
Though more than three quarters, or 31 out of 47 individuals that took part in the research, had prior knowledge on the subject of medical tourism, only three had personal experience related to the industry. One had worked in an environment that was closely connected to medical tourism and frequently had interactions with both customers and service providers.
That participant had also formed a friendship with a foreign couple seeking the assistance of an Indian surrogate mother. Another interviewee, an educated female, was introduced to a couple while visiting a friend in North America that had firsthand experience of medical tourism in India. She told me that this American couple had praised medical tourism in India after a successful eye surgery. She explained to me that “they came to India, Delhi, for their eye surgery. They were picked up from the airport, they were put in a hotel and the next day all the investigations were done and the day after the person was operated”. The couple were very happy with the service and also went sightseeing in Delhi, Jaipur and Agra; “after doing all that they had spent, two people were travelling, less money that they would have paid for one surgery”.
Another interviewee had experienced medical tourism as a medical professional who had operated on foreign visitors. She said that these individuals did not arrive specifically in
India to go through surgery at her relative’s private medical practice. They had sought
91 professional advice from her relative while staying in her home town that then progressed onto surgery. She also stressed that those individuals had been very impressed and happy with the medical treatment they received. When the couple was in India they came for check-ups and also to seek his professional opinion before going through medical treatments or surgery in their home country. One of my participants stated that, although he isn’t personally interacting with the medical tourism whirlpool, he frequently comes across people from the
Middle East at Delhi hospitals who are seeking treatment through medical tourism.
4.2.4 All that glitters is not gold
Although I could sense that people in general were very excited, positive and even proud of a growing business like medical tourism in India, ten of my participants, who were in favour of medical tourism in general, could also see its negative impact on Indian society. Seven of my participants stressed that good medical treatment could become too expensive for the general
Indian public. Medical treatment in the private sector would only be accessible for the rich upper class Indians or rich foreigners. The doctors in the private sector would expect to get paid in foreign currency like American dollars or British pounds, not with the Indian rupee. A highly educated lady explained that “the Indian rupee is falling and the Indians’ purchase power is less so for the villages that want to consult x doctor but that x doctor has no time because he is being paid in dollars”. That foreign patient would be able to afford the best medical treatment that India had to offer while the middle class Indians would not, is something to be concerned about as the industry expands. A business man explained to me:
Well I feel it’s bit negative for Indian society. Because good hospitals charge for treatments keeping in mind the foreign nationals which is far costly for Indian middle class. Which means we have world class hospitals on our doorstep, however charges are so high that middle class people cannot afford treatment at a good hospital.
92
My participants were concerned and seemed to think that although this recent increase in flows of foreign currency has boosted the Indian economy, it did not seem to be reaching or benefiting the Indian public healthcare system in a positive manner. Public healthcare, being free, seemed to be on the sideline while the government focused its energy toward the private sector. When discussing the topic I was asked if I had the opportunity to visit the governmental hospitals, and before I gave an answer I was told that the private hospitals were like five star hotels. Very often in my interviews or conversations about the healthcare system in India, private hospitals were compared to five star hotels. Hotels of this scale are unreachable for the Indian general public, and generally associated with the rich upper class
Indians and wealthy foreigners. A young lady working in the education system expressed her concerns to me:
At some extent medical tourism adversely affects availability of medical care of local citizen. Accessibility of health care to citizen is threatened by medical tourism. Revenue does not contribute to public health sector.
One of my interviewees went as far as to say that medical tourism would increase the inflation rate in India even further than it is now; “Indian economy is facing a recession and medical tourism will only help increase in inflation rate”. Another of my participants told me that medical tourism could become a burden on the health care system, that it would overcrowd the Indian health care system, the hospitals and the doctors. One of my interviewees, an educated man, stressed to me that he was concerned about the lack of ethics when money starts rolling in:
When it comes to economy ethics is just thrown out, money great job just throw ethics out. This is not fair. Somebody needs to come and put the foot down and say that this is unethical and this is maybe economically correct
93 but definitely wrong. Everybody is stealing so nobody wants to put the foot down.
Only two individuals took a strong stand against medical tourism. These two young educated females told me that medical tourism would be negative for India from any standpoint, socially or economically. One of these young women felt really strongly about medical tourism, she was very concerned about the effect that it would have on the public healthcare system and that the wellbeing of the Indian pubic would be put aside for profit. She argued:
From my point of view, my thinking is that a medical facility is a human right of every human being. So all countries and people need not combine medical profession with the world tourism, which is an industry and governed by profit. The focus should not be on profit and impact on economy but on to provide the best care and treatment to all.
The other participant also stressed the lack of medical ethics when medical tourism was discussed. She told me that ethics should be given more importance when it came to discussions about medical tourism; she felt it had become lost in all the excitement. She felt that the focus needed to be changed when looking at the healthcare system; “It should be weighted on wellness and need rather than cost efficiency”
4.2.5 Sub-section summary
The majority of participants responded knowledgeably to questions about medical tourism.
The industry was seen to positively boost India’s economy via flows of foreign currency, and it was also seen as a positive influence in keeping high tech medical equipment up to date, improving all health care facilities as well as increasing employment. Participants were proud of the standard of medical care that India has to offer and were aware that the cost in India was only a fraction of what the cost would be in the western world. Participants also felt that
94 the industry needed to be heavily promoted. The majority of participants had not seen advertisements on medical tourism in newspapers or television but felt that the Global World Wide Web would be the best marketing tool to reach the industry’s targeted market group. Three participants had personal experience of medical tourism and only one had positive stories to share. A few of the participants expressed that, though they were proud of India’s success within the industry, there are also negative aspects to it. Due to high costs, good health care service is getting further out of reach for the general
Indian public and if the government focuses its resources on the private sector, the state run sector will surely suffer.
4.3 Commercial surrogacy Surrogate motherhood has been the subject of much philosophical and political dispute over the years -Thomas Frank
Commercial surrogacy is a sensitive subject and ethically controversial in a society like India.
Early on it became clear to me that knowledge about commercial surrogacy was very limited among the Indian population. An educated man told me that “If you ask a woman on the street nine out of ten will not know about it, at least eight, I’m sure”. However, during my work, 27 out of the 47 individuals participating in the research showed some knowledge of commercial surrogacy in India. The level of knowledge varied from basic information about surrogacy as an industry to a few with extensive in-depth knowledge. One third of the interviewees (15 individuals) were unaware of commercial surrogacy in India. These 15 individuals, who came from all levels of society, included seven men and eight women. Most of the male participants from rural areas had no prior knowledge of surrogacy. When conducting interviews in a rural village in Udaipur, the interpreter informed me that there was no concept of surrogacy in the village: “Because here in this tribal belt, even if we talk about it, if we tell them they would
95 consider it a criminal activity, it would be consider as a kind of rape, something that is hideous in society”. Five educated individuals left the surrogate section blank on the questionnaire. Opinions on surrogacy varied among those who had some knowledge about the issue. Nine participants saw commercial surrogacy as a positive development within India, while seven took a stand against commercial surrogacy and saw it as exploitation and damaging for Indian culture and society. The remaining 11 individuals knowledgeable about the industry found themselves conflicted; they could see positive aspects of commercial surrogacy in India, but the negative aspects weighed quite heavy, making it difficult to take a stand. However, all 27 participants with prior knowledge about the industry saw medical tourism and commercial surrogacy as separate fields. Participants that supported medical tourism and proudly told me about the accomplishment India was making within the field, felt equally that commercial surrogacy was a form of exploitation and slavery. They were surprised, and some of them even seem shocked to know that these two fields were interlinked. For instance, after I had informed one of the participants, who were a strong advocate of medical tourism and equally strong adversary against commercial surrogacy, about the link between medical tourism and commercial surrogacy, he said:
I didn’t realise that surrogacy is such a big part of medical tourism but you are right it is. When I look at medical tourism I only look at health facilities. All the surgically facilities that they provide us are so good and cost effective. I never connected the two.
4.3.1 Positive approach to a sensitive subject
Seven participants in my research, five females and two males, fully supported commercial surrogacy in India as an industry. Five of the participants had higher education qualifications and were parents themselves, one had attained an elementary level certificate and one was uneducated. All participants saw commercial surrogacy as a phenomenon that would benefit
96 both parties; it would support the needy surrogate mother financially, while at the same time the couple that hired her would become parents to a child that would be genetically related to them.
A woman in her late sixties, educated in health science, was very informative regarding the whole surrogacy procedure and she shared her thoughts with me. “Because so far people are writing that we are doing a very good job, should we say a charitable job to give baby to the childless and the woman who’s surrogating does well too,” she said. She thanked science and technology for surrogacy and argued it was “a good thing” and that some commercialisation was reasonable, “but it should not come too much”. The majority shared her opinion on moderation, that surrogacy would be a good thing if it was not too commercialised or pushed too hard. A young educated man confirmed: “Hinduism always preaches that all should be done; but in moderation. …I think of it [surrogacy] as harnessing talents”.
The Indian surrogate mother was described as an uneducated poor woman in great need of financial support. When asked if they would see a profession like surrogacy as good or bad for women in India participants responded that “for needy women it is good. … It is a good profession unless it is forced by somebody else”. This new financial resource would give poor uneducated women a new life and an opportunity to provide a better standard of living for her children. The childless couple would get a child that they desired, and it was often implied that it is the right of every couple to become parents; surrogacy would work in favour of both parties so there would be no victims in this transaction.
A middle aged mother informed me that she knew little about surrogacy through the media. She had heard it being discussed on the television and she believed that this would benefit poor women; she knew herself how hard it was to make a living. She believed that the decision to become a surrogate mother should be up to the woman for the “sake of money”
97 and she saw nothing wrong with it. A widow in her late thirties admitted that she was not informed well enough to understand the whole process of surrogacy, but she knew that foreigners were at an advantage given that the surrogate mothers were poor Indian women in need of money. She agreed that if a woman wanted to carry another woman’s child for money then that should be her choice. An educated woman in her late sixties was a very strong advocate for both medical tourism and commercial surrogacy. She saw surrogacy as a positive development in India and a great opportunity for poor women. She argued:
It speaks so high on surrogacy now. They say that you are not only helping yourself you are helping the other person also. They have given the rate also in that, how much there is being charged. So I think surrogacy is a very positive (small silence) thing and those that can afford, because it has become more and more expensive.
The concept of choice often came up in the conversation. During the interview I was frequently told that becoming a surrogate mother was an individual’s choice. It was implied that it would be less socially acceptable for an educated wealthy woman to become a surrogate mother because she has more options in her life to choose from that where “better”.
However, for a poor uneducated woman who is not so fortunate and with limited choices, commercial surrogacy would be a more “understandable” way to earn revenue. It was even expressed to me that commercial surrogacy would empower poor women.
Two of the interviewees saw surrogacy as pure business. One of them argued: “She is given money, it is a commercial work, she is given money and that is it”. He further expressed to me “Somebody can have a child but need the money. I give you the money and you give me the child. Fine we make arrangement, what is wrong with it?“. One educated male in his late fifties saw surrogacy as very positive. He saw commercial surrogacy as an industry and the Indian surrogate mother as a business woman who made a contract with the couple hiring her. This was a business deal like any other and should be treated as such.
98 4.3.2 Negative approach to a sensitive subject
Only seven individuals, all females with a high level of education, took a firm stance against commercial surrogacy in India. “Why would you need to make another person go through pain and suffering because you want a baby? It is most unfair”, one argued. Three of the participants were unmarried and childless, one was married without a child and three were married with children. Five of these participants were advocates for medical tourism but against commercial surrogacy in India. Most of them did not link medical tourism and commercial surrogacy together. Two of my participants were against both medical tourism and commercial surrogacy. Three participants expressed to me that commercial surrogacy would play on the financial need of poor Indian women. A young woman in her early thirties argued:
It is really bad for Indian women because a big parts of Indian women society are facing economic problems so they have to choose this option to fulfil their basic need. Specially poor and illiterate women mean it as the easiest way of earning money.
An educated woman in her late thirties firmly stated to me that she hated commercial surrogacy, saying: “It is like you are renting a womb and paying your price for it but the womb belongs to a person, it is not a mechanical thing that you can rent and the person is just rented it out because she needs the money”. She further argued: “That poor person is doing it just because she is poor and she wants the money. Who would like to do it by choice, nobody would, it is just the needy”. The need for money as a motivator linked commercial surrogacy to prostitution for one of the interviewees. She told me that if commercial surrogacy was allowed then prostitution should also be allowed because in both cases the commodity is a woman’s body. She argued: “The man is paying so what is wrong with prostitution? Similarly what is wrong with surrogacy? It is the same thing; you are using somebody’s body, even though the prostitute is willing. Prostitution is still not acceptable in India”. She went on to
99 explain, “Because again the women might be poor, might just be willing to make money and the men is paying her for it”.
Four of the interviewees linked commercial surrogacy to social taboo, suggesting that it would have a bad effect on Indian society and culture. An educated woman in her early thirties expressed to me: “commercial surrogacy became legal in India in 2002. The Indian surrogate mothers are exploited. It will destroy our cultural heritage”. Another of the interviewees felt that commercial surrogacy would go against Indian values: “It is not good because it is against the values of Indian society”. It was surprising that more participants did not discuss commercial surrogacy from the point of view of having a child out of wedlock, which was expressed to me as unthinkable on numerous occasions. Surrogacy was not only seen as affecting social values in India, it was also seen to undermine the status of women. A young woman expressed to me that she believed a profession like surrogacy would reflect badly on women. She argued:
Surrogacy should not be commercialised. It’s not good for Indian society especially for women society as they are being treated as thing to use. Commercialisation of surrogacy would decrease the present status of women
One of my participants, a married but childless woman, told me about her struggle with fertility issues. In her quest for parenthood she sought assistance from a fertility doctor and it was suggested after numerous failed IVF attempts that she should look into surrogacy.
She said that she had a very strong opinion on commercial surrogacy. “The doctor said that I should go for surrogacy, everyone does it, it is simple I can explain you and it is not expensive, but I said that I would die if I would do surrogacy, I would rather die”.
100 4.3.3 Exploitation or financial opportunity?
When I conducted the interviews, it became quite clear to me that the majority of participants
(11 individuals) who had some prior knowledge about commercial surrogacy, were unsure about their opinions regarding the whole phenomenon. Would the financial rewards received cover the ethical controversy that followed the industry? Nine women seemed to have more difficulty deciding what they thought of commercial surrogacy in India, compared with two male participants; the majority of them were parents themselves (eight) and ten of them had attained higher education. Of note, 10 out of 11 participants informed me that they supported medical tourism but did not feel as comfortable taking a stand with commercial surrogacy.
“It depends on the person involved in surrogacy” or “It is good or bad both” were common answers. The positive aspect of commercial surrogacy for five of the participants was that the couple that desired to have a child would have the opportunity to become parents with the assistance of the surrogate mother. They believe it is a blessing and that the surrogate mother would be a part of that blessing. However, four participants expressed to me that giving up a child would be psychologically difficult for the surrogate mother after giving birth. A mother in her early forties said to me, “Let the girl decide and women also who are ready to give birth to a child and then give it to someone else. I think it is very difficult”. A pregnant woman in her early thirties expressed to me:
She can’t be sure if any women in heart could be ready to do that but she also understand that a couple need a child and this lady is given them that child. It is understandable, they must be missing not having a kid but at the same time, the lady that is carrying that child for somebody else her sentiments must be hurt that is a negative part.
The financial incentive of commercial surrogacy was mentioned by four of the participants in the interviews and it was considered as the main reason for Indian women becoming surrogate mothers. When asked what she thought about commercial surrogacy in India, one interviewee
101 in her late fifties responded: “In a way it is bad if you are using someone’s womb but those that are needy are just doing it for money. Money is the only criteria, money that is coming in”. When we discussed the deeper meaning of money in this context, she responded “It is a partial help for a little time but it won’t last forever. The only thing that you can buy is a small apartment, which is a great help but apartment is also expensive”. She felt uncertain at the same time and after a little pause she said: “Because what a woman undergoes she may feel bad but because of the money it is nice. Because those who do this are poor and it is good for them and they are not harmed”. Being poor and needy is the main motivator and reason why surrogate mothers would feel drawn to this kind of work. An educated unmarried man in his late thirties commented on the subject: “In a country like India I see it more negative because in a country like India, it is a developing country so there is more need and greed into it, need and greed makes it negative“. A woman in her early thirties expressed to me: “Yes they get financial help but by heart it is a wrong thing. The biggest need is finance because they are poor”. She thought that surrogate mothers in India were exploited in some way and said, “she is saying mainly [exploited by] society because society is responsible for weakness of women that she has to do that.” A male in his late forties suggested that there was always the possibility of the surrogate mothers being forced into surrogacy:
I have not made opinion about it but I think positive about it because it is good for the people that can’t have kids and for the surrogate mother. The negative part, I’m not sure I have not read anything about it but my one wild guess that some women are pushed into it for the money, by their families even by their husband’s maybe. They carry someone’s child they can earn a lot of money. It has become a market so it has make women as a walking shop. Three participants did not see commercial surrogacy in a negative light but did see a problem in promoting it as a profession. An interviewee in her late sixties maintained that there was nothing wrong with commercial surrogacy in India but that “surrogacy as a profession should
102 not be promoted– as there are other options – adoption is one of them”. Likewise, an unmarried professional woman in her late twenties shared her opinion with me; “profession like surrogacy is really bad for women of India as helping someone who is in need can work but taking it as a profession for Indian women is totally challenging”. A gentleman in his late forties working in the tourism industry noted: “Profession is a profession when you choose it; it is not profession when you are into it because there is a need that is pushing you into it”.
One of the participants expressed that, though he is not against surrogacy, commercial surrogacy should not become a business and instead only altruistic surrogacy should be allowed.
Although legal since 2002, four participants were unsure if commercial surrogacy was legal in India when the interviews were conducted in 2012. An unmarried women in her late twenties said “Commercial surrogacy is nowadays a growing business in India, it is now becoming legal”. When asked what he thought about surrogacy as a profession, a thirty year old male in the business sector replied: “Good if it’s legalised or else this will give birth too many problems and illegal ways to make easy money”. I also found that some participants misunderstood what surrogacy was. A woman in her early sixties said that inheritance matters need to be sorted out regarding the child and surrogate mother: “Does the surrogate mother, virtually being the mother of that child does she have the right to stay in that house or is it only a finance contract?”
4.3.4 Hidden from society
It was expressed to me that commercial surrogacy would be seen as taboo within Indian conservative society, and therefore only existed in hidden form. In one of my interviews I asked a man who was in his late thirties if Indian society would ever accept surrogacy as a profession, to which he answered:
103 I don’t think that society will accept it easily, there are so many things that society does not accept and this is much more complicated for Indian society to accept. Basically the people that accept it are monitoring need.
Two participants told me that it is considered an equal social taboo for an Indian couple to hire a surrogate mother as it is for a woman to become one herself. One participant told me that she had friends that had gone through the surrogacy procedure and had welcomed a child into the world with the help of a surrogate mother. The whole procedure was a secret and they even moved away for few months to give the illusion that the baby had been given birth to by the wife rather than a surrogate mother.
Another participant told me that Indian couples go to great lengths to conceal their surrogacy arrangements. She said that it is common for couples that are seeking assistance from a surrogate mother to leave their home for a long “visit” or a holiday to conceal the fact that the wife is not physically pregnant herself. She explained: “For 4-5 months the pregnancy is not that visible so after that if you are not showing any signs of being pregnant people will start asking questions”.
Not all participants thought commercial surrogacy and becoming a surrogate mother was taboo. A woman in her sixties working in the medical profession said: “No it was a taboo but now people are changing, they are realising. Still there are people who do it quietly”.
4.3.5 Surrogacy in Bollywood
With Bollywood stars openly discussing their surrogacy arrangements in the media, the procedure was becoming less of a taboo in society, according to two participants. The glamorous Bollywood movie industry was mentioned on numerous occasions when discussing commercial surrogacy. Two of the participants had no knowledge regarding medical tourism; instead, their knowledge on commercial surrogacy came from media coverage on Bollywood stars hiring surrogate mothers. In one of my interviews the interpreter
104 explained to me; “She had heard that couple of celebrities in India have done that and this is how she knew about it”. Opinions regarding Bollywood stars, such as Aamir Khan, openly admitting to having searched for the help of commercial surrogate mothers differed greatly.
An educated woman in her late sixties expressed to me that when high profile people in
Bollywood openly commit to using commercial surrogacy, it will reflect positively on the industry in India.
Aamir Khan married Kiran Rao and Kiran Rao had some trouble, so Aamir Khan got the baby boy by surrogacy and he openly said to the press. So these big people, big shoots, Bollywood people, if they are positive it gives a positive back to society. In contrast, two participants thought that Bollywood was showing a lack of ethics when it came to commercial surrogacy. An educated woman in her late thirties angrily stated:
But my friend Mr Aamir Khan, the righteous actor, on the screen he tells people what is right and what is wrong but himself had a surrogacy. He has two grown up child, I think 18 or 16 year old and now he has another wife and he did surrogacy with her right now. About 4 month ago and he didn’t think it was nothing wrong with it; he broadcasted it that this is a surrogate baby and people are totally ok with it, I’m totally not ok with it. A woman in the education sector told me that: “Aamir Khan had a surrogate child recently and it was aired in a very normal way so in my views media is somehow recoiling the issue but people need to know more about it and government need to make strong laws about it”.
4.3.6 Sub-section summary
Commercial surrogacy was fully supported only by few a participants. Commercial surrogacy was seen as a positive thing for the poor, needy and uneducated woman because it helped her raise her living standards. It was also seen as positive because the surrogate mothers were doing a good deed; giving birth to a child for an infertile woman. That act was seen as noble.
105 Two participants saw the commercial surrogacy industry as purely a business deal, within which the surrogate mother was a contract worker, and the baby a product to be treated as such. A few individuals took a strong stand against the industry and they believed that commercial surrogacy was preying on poor needy women; no woman would agree to carry a child for a stranger if she was not in financial need, and as such why would exploitation of the body in surrogacy be any different from exploitation of the body in prostitution. Emotional difficulties stemming from giving the baby away were also argued as another reason against the industry, and it was seen as unethical to let a women go through such pain. Commercial surrogacy was also seen as negatively affecting Indian core values and culture. It was difficult for the majority of participants to comprehend the full extent of the industry and to have a clear opinion about it. It was seen to be positive among some because poor needy women would receive money while simultaneously doing a good deed. The expected parents would receive the child that they desired and had the financial means to pay for the procedure. At the same time the potential for exploitation becomes apparent. It was also evident that there were some uncertainties and misunderstandings regarding the field that led me to question how many participants truly understood what commercial surrogacy is. Commercial surrogacy was seen by a majority as a social taboo involving both the surrogate mother and the couple seeking her assistance. However, with Bollywood stars openly admitting to using the service of surrogate mothers for having children, it is slowly becoming less of a taboo in society.
4.4 Summary
Positive changes have occurred in Indian society, and many participants acknowledged that, those changes have provided women with more opportunities to seek education and employment in various fields which were once ruled by males only. The majority were still disappointed with the work that had been done so far to increase women’s rights and to improve their status in society. Indian society did not recognise women and men as equals,
106 and women were fighting for the independence to be able to gain respect as individuals, and to have their voices heard in a male dominant society. From the time women are born they are unwanted because the parents desired a boy, and when they come of age they are married off to a strange house and told that never to return. Participants expressed to me that Indian women today are in a very difficult position, being expected to hold on to old value systems and behave in a respectable manner, while concomitantly accepting the modern life style of the working woman. This has put women in a very difficult position in trying to tackle two very different platforms. A woman is expected to be educated and financially independent but at the same time she must be happy to be dominated by the men in her life and not expect an equal say in decisions. Illiteracy of women was seen as very problematic. Moreover, the majority of women do not work, do not earn and thus cannot take care of themselves, leading to financial dependency on others. It was suggested that it was common place for women in
India not to identify domestic violence as a problem; women would experience all kinds of violence in India, from mental abuse to physical abuse, and even death. All social groups were considered to be in need of female empowerment expect for the elite society.
The majority of participants were aware of the medical tourism industry. It was discussed with pride and often stated to me that it is in need of being heavily promoted on platforms such as the Global World Web. Many of the participants still recognised the ethical challenges that the industry would bring, such as the increase in unequal access to basic health care. It was seen as ethically wrong that the private health sector was being made into a profit making machine while no funds were being allocated to the state run health sector. It was also expressed to me that the state run medical facility would continue to lose medical resources to the private health sector.
Medical tourism and the reproductive industry were seen as two separate fields operating individually. In general commercial surrogacy was not well known and very few
107 had in-depth knowledge regarding the field. When discussing commercial surrogacy, discourse themes included; ‘the poor’, ‘needy’ and ‘uneducated’, as well as ‘choice’ and
‘money’. A majority of participants in this research expressed to me that commercial surrogacy was positive because it gives the poor, uneducated needy women opportunities to earn money that would otherwise be out of her reach. That money would help raise her living standards and offer her own children a better life. Commercial surrogacy was also seen as a charitable act because the surrogate mother would have the opportunity to help childless couples to become parents. Two participants saw the industry as purely business orientated, and as such felt that it should not be mixed with sentimental factors. It was often expressed that it was the woman’s right to choose what happens to her body, though “choice” itself was also questioned by some participates. Can it be regarded as “choice” when forced by a husband, the family or financial need? The emotional trauma that surrogate mothers may experience after giving up the child they carried in their womb for nine months was surprisingly rarely mentioned. However, a few participants commented that it would be a difficult experience. Some individuals saw surrogacy as negative, undermining Indian social and cultural systems, as well as working against what had already been done to empower women in India. Being a commercial surrogate mother and seeking the assistance of a surrogate mother was seen as very taboo by participants, however, some believed that times were changing and that society was becoming more tolerant.
108 5 Discussions
The aim of this research is to shed light on the awareness of the general public about medical tourism with a particular focus on knowledge and ideas about commercial surrogacy in India.
Women are the means of production in this industry, and phrases such as “exploitation” and
“lack of choice” often correlated with the field. Understanding the environment of women in
India became very important to understand whether surrogate motherhood was an aid to the women of India or just another form of exploitation. My findings show that participants in this research felt that women in India were slowly coming into their own, but that they were still struggling to find their identity, independence and their voice within the household and society. The image that I received from my participants was that women living in a patriarchal conservative society would be dependent on other people throughout their lives, and make compromises in the best interest of others. The golden path to independence was seen to lie in education and financial independence. Surrogate motherhood was seen as taboo within Indian society as a profession, but participants found it to be acceptable for the “poor”, “needy” and
“uneducated” women without many options to earn enough to change their living standards.
However, surrogacy was considered socially inappropriate for educated women with the financial means to “choose” a better profession. Medical tourism was seen as a separate sector to commercial surrogacy, and it was discussed with great pride by the majority of participants.
Medical tourism was seen as a positive development for India, whereas commercial surrogacy was not embraced with the same positivity, with interviewees feeling more ethically conflicted and finding it difficult to pick a side.
Feminist theorists started debating surrogacy from the time that the first IVF child was born. Feminists from the 1980s, such as Rothman (1989), Corea (1985) and Dworking
(Corea, 1985), predicted that the newly developed reproductive industry would search for
“cheaper” reproductive workers in poor countries. Those poor women would be exploited as a
109 sophisticated baby assembly line, whilst their consent could never be fully voluntary because of their economic necessity. I began this research with the presumption that a few participants would comment that wealthy white western people are exploiting the wombs of the poor, dark women of the developing world. To my surprise it was never mentioned, neither in interviews nor in personal conversations. No distinction was made between foreign couples or individuals seeking the surrogacy services of Indians. After conducting an interview with a gentleman in his late thirties who was conflicted on his stand regarding commercial surrogacy, I casually asked him what he felt about foreign individuals having babies via
Indian surrogate mothers. He answered that he did not see any difference between the children being born brown, white or black. The exploitation was the same no matter what currency the surrogate mother was paid in. Interestingly, when discussing medical tourism in my interviews, participants were critical of the fact that foreign individuals received top quality medical care while the majority of the Indian public barely receive basic health services.
Increasingly unequal access to health care was seen to be caused by medical tourism, and in a way also as a form of exploitation that was considered to be a reason behind the ever expanding inequality gap in health care.
Feminist theorists are much divided in their stand toward such an ethically controversial field as commercial surrogacy. The concepts of “choice” and “free will” are heavily debated. I could see that my participants also had very different views towards the industry. Some interviewees shared feminists’ view point that “choice” could never be made by “free will” when faced with economic destitution. I was also very clear after the interviews about the fact that women were considered oppressed by the dominant patriarchy, and that they were raised to put the needs of everyone else above their own, ultimately affecting their
“choice” to become a surrogate mother. One participant could not see any difference between selling access to women’s wombs or women’s vaginas. They thought it was a distinction
110 without a difference, and the same idea is shared by many feminists such as Dworking. Other interviewees felt it was up to the surrogate mother herself to make that decision. They shared feminists’ position that women should have the right to do what they want with their bodies.
Since women had “no control” over their lives my interviewees felt that women had the right to take control over their bodies. A few participants saw that the industry has the potential to empower poor women.
During my stay in India I was told on numerous occasions that having children out of wedlock was considered unthinkable. My relaxed attitude towards it was often laughed at because for many Indians children could not be conceived if the conception did not occur between two married individuals. However, for many, carrying a child in your womb that was not your husband’s for a sum of money was not considered to be contradictive itself. I found it interesting how attitudes changed when financial incentives were added to the equation. It might even be possible to say that surrogacy pregnancies were not considered as normal pregnancies.
Applying George Casper Homans’ exchange theory, poor “needy” women are forced to work in a taboo industry such as surrogacy because of their debt-burdens. In India a lot of violence against women is provoked because of dowry debts, or being unable to marry a daughter off at the right time, which could push the mother into social scrutiny in society.
There are many undesirable situations that mothers can find themselves in because of a lack of financial resources provoked by poverty. Exchanging access to their wombs for financial stability might seem like a “desirable” choice for such women in these circumstances. My findings show that financial independence is the second most important issue for women in
India. Being able to support themselves and their children was so important that many women saw the sacrifice of renting their wombs as wholly justifiable.
111 If we apply prospect theory, involving choosing the lesser of two evils, commercial surrogacy might be seen as the lesser evil. Surrogate mothers get paid between $3000-$6000
(see fieldwork settings). During my interviews I was often informed how much my interviewees earned; money was considered very important and frequently discussed. In one interview I was informed that an uneducated individual working full time as a cleaner or gardener for an institution such as a high school would be paid a monthly salary of around
$110 USD. Furthermore, I was told that it was difficult to access such well paid jobs and that working on the roads or in construction would only pay a fraction of that amount. Research has shown that surrogate mothers would rather risk social stigma than face poverty. From this standpoint it is fair to say that for a woman with limited options, becoming a surrogate mother would be considered a preferable “choice” over other employment opportunities job expectancies. My findings show that though commercial surrogacy was not seen as a good profession and considered taboo in society, it was acceptable for the “poor”, “needy” women because of the money they would earn. For many surrogacy was better than the worst professions such as prostitution; an opinion shared by all the participants.
I think it is very important to look at the status of women in Indian society. Women are almost absent from the employment market, only 30 percent of women are engaged inIndia’s work force, and only half of all Indian women have a basic level of literacy. Women have restricted access to education, health care, land and water. Interviewees explained to me that women would need permission to work, get educated or speak their mind. Autonomy over one’s body was not seen as something that should be taken for granted. Unfortunately many Indian women also experienced high levels of violence throughout their lives, mentally and physically. I have been travelling to India for the last 10 years and I have noticed that change is taking place in Indian society and that women are becoming more prominent. My friendship circle in India is filled with independent strong women, but I know that the
112 majority of Indian women are not those fortunate ones who are able to speak their own mind and make their own decisions. If we apply conflict theory, we could argue that the people with wealth and power are maintaining their dominance over the powerless and poor by suppression. Within oppressive surroundings where Indian women livewith limited resources, becoming a surrogate mother might seem like a way to avoid exploitative industries such as the sex industry.
The surrogate industry was legalised in 2002 but no legal framework put in place until
2009. Medical tourism and commercial surrogacy grew rapidly and generated huge revenue for the Indian government. However, it was not a priority to protect the “workers”, without which the surrogacy industry would not exist. I discussed in fieldwork settings that payment to surrogate mothers depends on their level of education, status and colour. I believe that this is another way to exploit the poor. The womb of an educated, English speaking, light skinned woman is more highly valued than the womb of a poor, uneducated, dark skinned woman that does not speak English. Because of a lack of data and reporting about the industry, I believe that the chance of exploitation is very high. When looking into women’s access to health care, it is ethically controversial that of the surrogate mothers who deliver their own children, only half receive antenatal care, only 40 percent post natal care and even fewer will give birth with the help of trained medical staff. The infant and maternal mortality rate is high in India, but at the same time success rates in the reproductive industry are very high.
India can tap on its enormous resources of qualified doctors and medical staff for medical tourism. They offer technically top-notch medical facilities and English speaking staff. The legal frame work for the reproductive industry is relaxed, giving medical facilities and fertility clinics liberty to make up their own rules. If we apply David Ricardo’s theory of comparative advantage, India has comparative advantage over western countries when it comes to medical service. They have knowledge, equipment and manpower comparable to
113 most western countries. However it is concerning that good medical treatment is becoming out of reach for the majority of the Indian public. In my interview it was stressed to me that medical tourism is making access to health care more unequal for the poor; the more it grows, the wider the gap becomes.
If we apply Foucault’s (1980) bio-power, and ask who controls the surrogate’s body and its functions, I believe that the Indian government promotes the surrogate’s body as a commodity and in a way is exploiting its legislative power by legalising surrogacy so that they can justify the profession. At the same time funding of state health care has to yield for investments in private health care. There is a great controversy in the academic world about who has the “power” over a surrogate’s body. I question myself whether commercial surrogacy was legalised from the perspective that women have autonomy over their body and can freely “choose” to become a surrogate mother, or, aided by poverty and restrictions to resources, legalising commercial surrogacy can open up profitable opportunities.
I have often reflected on my opinion towards the industry of commercial surrogacy, especially when it is thriving in a poor country such as India. Initially, I recognised the benefits of commercial surrogacy, but I have to be honest, the more I read and research on the subject the more I start to view it in a negative light. I graduated with a BA degree in
Anthropology in 2010 and my final thesis was on different aspects of organ donation, with the sale of organs being one of them. India was of particular interest, where sale of organs was only legal from 1986-1994, yet the industry still thrives today illegally. I could see a striking resemblance between the two fields of commercial surrogacy and organ donation. Wealthy individuals travelled to India to buy a kidney or an eye from a living donor, receiving professional care at a first class medical facility and paying only a fraction of what it would cost in the patient’s home country (Fasting, et. al. 1998; Scheper-Hughes, 2000). Lawrence
Cohen, a professor of Anthropology at the University of California, conducted research on
114 kidney donation in the cities of Chennai, Bangalore, Delhi and Mumbai in India. He discovered that there was no empirical data on the effects that organ donation could have on the donor or his family. He was told by doctors in these cities that it was too difficult to locate the organ donors after the procedure, thus it was difficult to collect reliable data. Despite this, newspaper reporters and researchers such as Dr. Cohen had no difficulties locating organ donors, who were then monitored after the procedure in order to produce epidemiological research on the long-term effects that selling an organ had on individuals. Cohen also discovered that the money did not last for the poor organ donors, who a few years later often found themselves drowning in debts and unable to seek medical care if experiencing health issues related to the organ donation or surgery (Cohen, 1999). The resemblance between commercial surrogacy and the organ trade is frightening.
115 Conclusion
The aim of this research was to shed light on the knowledge and opinions concerning the ethically controversial industries of medical tourism and commercial surrogacy in Jaipur and
Udaipur. Data was gathered through 19 in-depth interviews and 28 questionnaires through snowball sampling in Jaipur and Udaipur from March to August 2012. The findings indicate that the general knowledge on surrogacy is limited and commercial surrogacy is in general seen as socially awkward and unacceptable, but justified for poor and “needy” women.
This research focused on medical tourism, commercial surrogacy and status of women in India. Throughout history we have seen women used as breeders; their reproductive organs have been used to satisfy the needs of more powerful individuals since biblical times in the form of slavery. The louder voices of feminists challenge the concepts of choice and free will.
With an increasing infertility rate in the world people are seeking reproductive assistance in developing countries. With new groundbreaking technology in the 1970s for IVF and a decrease in the number of children being put up for adoption, surrogacy has become a viable option for many. Feminists worry that surrogate mothers are exploited and that surrogate mothers from the developing world could be seen as cheap baby machines or a wombs to rent.
Why women “choose” to become surrogate mothers is explained using prospect theory, conflict theory and exchange theory. Surrogate mothers choose the lesser of two evils as suppressed individuals in a patriarchal society, allowing access to their wombs and justifying it as a reasonable exchange for financial independence. Foucault´s bio-power explains how surrogate mothers are suppressed by the Indian government and ART. They have the control over the surrogate body and its function. The Indian government promotes commercial surrogacy and thus allows the body to be sold as a commodity.
In chapter three I discussed general information about India. The status of women in
India is discussed in regard to their access to health care, equality and violence against
116 women. Medical tourism, a booming private medical industry, is also introduced. India is a leading player in the medical tourism industry offering top-notch technology, high quality medical facilities and professional English speaking staff. Reproductive tourism is a part of medial tourism, with India being a lead player in reproductive assistance technology.
Commercial surrogacy became legal in 2002 but lacked a legal framework until 2009, allowing fertility clinics to make their own rules. The industry is growing and attracting individuals from all across the world to seek assisted reproductive technologies in India.
My results show that people's stance towards commercial surrogacy can be divided into three categories. People that feel positive towards commercial surrogacy, people that feel negative towards commercial surrogacy and people that feels uncertain towards the industry.
The majority of participants felt uncertain and could see both positive and negative viewpoints. Individuals that felt positive towards commercial surrogacy saw the industry as an opportunity for the poor and “needy” women with limited financial resources, a way for such women to raise their living standards which would also give them the ability to give their children better opportunities. Also seen as a positive point is the reward of helping reproductively challenged couples to become parents, and the surrogate mother was seen as fortunate for being able to be a part of that. Individuals that felt negative towards the industry saw it as away to exploit poor financially desperate women. The mental stress it would cause the surrogate mother to give up the child was taken into account, as was the fact that if she would never agree to such a profession if not in financial crisis. All groups agreed that it was socially taboo to be a surrogate mother in Indian society as well as seeking reproductive assistance from another person. In general, participants had little knowledge of commercial surrogacy and there were often misunderstandings regarding the subject. The majority of participants were positive towards medical tourism and felt proud about progress in the industry. However, commercial surrogacy was seen as a separate field from medical tourism.
117 Indeed, participants might feel positive towards medical tourism but negative towards commercial surrogacy. The status of women in India was seen to have improved, though participants felt that there is a long way to go.
Further research needs to be conducted regarding commercial surrogacy in India. It is an unsettling feeling that this industry is as unregulated and unmonitored as the organ transplant industry used to be. More research on surrogate mothers’ physical and mental health after the surrogate process is also called for. Today, it seems that women across the world are taking advantage of the flourishing reproductive industry in India, while the majority of Indian women are being denied basic health care and giving birth without the help of medically trained staff.
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134 Appendix
My name is Asdis Lydsdottir. Iˈm a 29 year old women from Iceland currently working on my Masterˈs thesis in Development Studies from the University of Iceland.
First I want to thank you for taking time out of your day to answer my short questionnaire. What you have to say means a lot to me.
These questions mostly revolve around the status of women in modern India and few questions on your take on medical tourism.
If you feel uncomfortable answering any of these questions then feel free to just move on to the next question.
All information given in this questionnaire will be treated as confidential.
If you have any question regarding this questionnaire then you are welcome to contact me through e-mail: [email protected]. If you feel like you want to discuss any topic further then you are welcome to contact me also.
Sincerely
Ásdís Lýðsdóttir
Basic Questions Sex: Age: Marital status: Do you have children: ------Education: ------
What is your profession: ------
135 Status of women in modern Indian society: Would you say that the status of women in Indian society is changing? ------If yes, in your opinion what would these changes be ?(are they positive or negative for women in India?): ------Have you seen changes in your own personal life? ------If so, what would these changes be? ------What would you say about womenˈs right in India today? ------In your good opinion are you satisfied or dissatisfied with the work evolving around womenˈs right in India? ------In your opinion what are the biggest problems women are facing in India today? ------
136 Do you feel that the access to womenˈs right in India differ between various social groups? ------If so, what social group needs the most attention when it comes to womenˈs empowerment? ------If you had the power to change the world, what would you change for Indian women? ------
Questions on medical tourism in India What do you think about medical tourism in India (just say the first thing that comes to your mind)? ------Is medical tourism positive or negative for Indian economy? ------Is medical tourism positive or negative for Indian society? ------
137 Do you have any opinion on the marketing of medical tourism in India on a global market? ------There are a lot of controversies about commercial surrogacy in the world, what do you think about commerical surrogacy in India? ------
Do you think a profession like surrogacy is good/bad for women of India and why? ------
Thank you
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