The Khanna Study: Population Problems in the Rural Punjab [Reprint 2014 ed.] 9780674594098, 9780674594081

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The Khanna Study

The Khanna Study Population Problems in the Rural Punjab

John B. Wyon and John E. Gordon

Harvard University Press, Cambridge, Massachusetts, 1971

© Copyright 1971 by the President and Fellows of Harvard College All rights reserved Distributed in Great Britain by Oxford University Press, London Library of Congress Catalog Card Number 75-123571 SBN 674-50325-2 Printed in the United States of America

Contents

Figures Tables Preface Acknowledgments Chapter 1 A Field Study of Population Dynamics 2 Study Plan for Field Work 3 The People of the Punjab 4 Field and Analytical Procedures 5 An Intensive Community Program for Contraception 6 The Building of Families and the Birth Rate 7 Deaths and Population Pressure 8 Migrations and the Microcosm 9 Population Control in the Community 10 Broader Implications of the Khanna Findings 11 Khanna, 1960-1969 Appendices: A — Record Forms B — Edge-Mark Method of Data Analysis C — Definition of Contraceptive Practice D — Measurement of Birth Interval Components E — Examples of Demographic Influences on Crude Birth Rates and Population Growth Glossary Khanna Study Papers References Index

vii xiii xvii xxi 1 20 50 104 134 152 171 208 228 257 291 317 361 362 363 366 369 381 385 405

Figures

1. Moghul fortress, Khanna. 2. The Punjab as divided between India and Pakistan, 1947. 3. Valleys of the Indus and Ganges rivers. 4. District Ludhiana within the Punjab State, 1961. 5. Bullocks in winter. 6. District Ludhiana, its three Tehsils and location of study villages. 7. Villages of District Ludhiana and their surrounding agricultural lands. 8. Chakohi and adjacent fields owned by village residents, 1953. 9. Study headquarters, Khanna, 1954. 10. Villages of the Khanna Study. 11. A Persian well. 12. A field worker on her way between villages. 13. Men of Chakohi and staff members. 14. A Punjabi farmer interviewed. 15. Regular monthly interview of a housewife. 16. Wife and daughter-in-law of a substantial farmer. (Photograph by Pierre Streit) 17. Wives accepting contraceptive practice; acceptors aged 15 to 44 years by method chosen, Chakohi, March 1955 and March 1956. 18. Sardar Boorh Singh, patriarch of Chakohi, tells Dr. Gideon the history of the village. 19. Village well. 20. Home sites, shops and schools, Chakohi. 21. Closely packed houses along village lane. 22. Courtyard of study headquarters, Chakohi. 23. Water-proofing a building. 24. Neighbors visit headquarters in Chakohi. 25. Village water carrier. 26. Population growth and decline in India, the Punjab State, and District Ludhiana, 1881 to 1961. 27. Net population change in India, the Punjab State and District Ludhiana, 1871 to 1961. 28. Population of rural District Ludhiana, 1881 to 1961; test villages, 1911 to 1961; net population change,

Page 8 21 21 22 23 24 24 25 27 28 29 32 34 39 39 40

42 51 51 52 53 54 54 55 56 57 58

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29.

30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56.

57. 58.

Figures Page natural increase and net migration in the rural District. 59 Population of urban District Ludhiana; net population change, natural increase and net migration, 1881 to 1961. 60 Residence of farmers and leather workers, Manupur, 1955. 62 Gateway to a Punjab village. 63 Cow dung cakes stored for kitchen fuel. 64 Outdoor kitchen of a village home. (Photograph by Pierre Streit) 64 Rooftops of Chakohi. 65 Leather worker fills sewn-up skins with tanning fluid. 66 Farmers ploughing a field. 67 Population growth and selected agricultural indices, District Ludhiana, 1868 to 1961. 69 Electric power lines erected. 71 High grade Hissar bull. 72 Sinking an irrigation well. 72 Net export or import of food grains by 5-year periods, India and Pakistan combined from 1891 to 1946; thereafter, India alone. 73 An itinerant vegetable peddler. 74 A farmer and his family traveling by bicycle. 74 Brickkiln. 75 Carpenter at work on a plow. 76 Branch irrigation canal. 77 An elder of the Brahmin caste. 78 Goldsmith at work. 79 Leather worker fashioning sandals. 79 Three generations of women of a joint household. 82 Village men and women gather to welcome a bride. 84 Women making unleavened bread. (Photograph by Pierre Streit) 84 Farmer wives take food to their husbands. 85 The Dussehra festival, Khanna. 90 A Sikh resplendent in traditional dress. 92 Populations of the rural Punjab Plains Division 1961; rural District Ludhiana 1961; and of test and control A villages 1959; by sex and age. 95 Populations of test villages; by sex and age, July 1959. 98 Populations of control villages; by sex and by age, July 1959 and December 1959. 99

Figures

59. Males aged 15 to 64 years; study villages, July 1959. 60. Males aged 15 to 64 years; individual study villages by caste, July 1959. 61. Mean annual rates of birth, death, immigration, emigration, and net population growth; test and control A populations, 1957 to 1959. 62. Mean annual rates of birth, death, immigration, emigration, and net population growth; individual villages, 1957 to 1959. 63. Members of the elected council, Chakohi. 64. Sketch map of "B" Street, Manupur. 65. Preparing a village map and household list. 66. Sketch map of field wells, Manki. 67. A trained midwife with her assistant, a patient, and onlookers. 68. Study staff compile a village coded register. 69. Reported birth control practice before the study; husbands of wives aged 15 to 44, by caste, urban experience and by educational attainment, test villages, 1956. 70. Marital age-specific birth rates of women by age; farmer and leather workers, 1956 to 1959; Hutterites of the United States, 1936 to 1940. 71. Wives agreeing to practice contraception, and those reporting actual practice at successive months; percent of all wives aged 15 to 44, in postpartum amenorrhea and menstruating, 1956 to 1959. 72. Reported contraceptive practice, 12 months or more; wives aged 15 to 44 years by caste, age of wife, and education of husband, 1956 to 1959. 73. Wives with accumulated contraceptive practice, 12 months or more; by number of surviving sons and age of wife, 1956 to 1959. 74. Onset of pregnancy by months after first menses following delivery; by wives reporting and not reporting contraception, 1956 to 1959. 75. Wives pregnant and wives menstruating by month of contraceptive program; test and control A villages, 1956 to 1959. 76. A marriage cart. 77. Resumption of menses by month after delivery; percent of wives with child surviving 28 days or more, death

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103 114 119 120 121 122 129

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151 155

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Figures Page

78.

79. 80. 81. 82. 83. 84. 85. 86.

87.

88. 89. 90.

91. 92.

93. 94. 95.

within 28 days of birth, a stillbirth, or an abortion, 1956 to 1959. Conception by month after first postpartum menstruation; percent of wives with child surviving 28 days or more, death within 28 days of birth, a stillbirth, or an abortion, 1956 to 1959. Live births to wives aged 45 years or more, still living with first husband, 1959. Onset of menopause; percent of wives by age, 1956 to 1958. Females never cohabiting; by caste and age, 1959. Females never cohabiting; percent of eight caste groups by age, 1959. Official death register. Shrines of the smallpox goddess and a public water pump. Average annual crude birth and death rates, 5-year intervals, District Ludhiana, 1885 to 1961. Average annual crude death rate and infant mortality rate at 5-year intervals, Punjab State, India, 1901 to 1961. Age-specific death rates of preschool children by years; villages of Khanna Study area, 1957 to 1959; United States, 1951. Mean life expectancy of males by age; villages of the Khanna Study, 1955 to 1959; United States, 1963. A farmer with sickle. Estimated deaths of live-born children per 1000 live births; death rates by sex and by age to 36 months, 1955 to 1959. Estimated survivors until age 24 months per 1000 live births of each sex, 1955 to 1959. Age-specific deaths and death rates, from birth to two years; deaths and causes of death, by feeding regimen; test II and control A villages, except Gowadhi, 1955 to 1960. A child with protein-calorie malnutrition. Death rates by age and by groups of preventable causes, 1957 to 1959. Estimated survivors until age 80 years per 1000 live births, each sex, 1956 to 1959.

157

158 162 163 165 166 173 174 176

179

182 182 185

186 186

188 190 194 195

Figures

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Page 96. Three generations of a family living as one household. (Photograph by Pierre Streit) 97. Migration of males; annual rates, net, into and out of study villages; by caste and by age, 1957 to 1959. 98. Mean annual rates of birth, death, immigration, emigration, and net population growth by caste, 1957 to 1959. 99. Populations of farmers and other high castes; by sex and age, 1959. 100. Populations of leather workers and other low castes; by sex and by age, 1959. 101. Migration of males; net, into and out of study villages by rural or urban origin or destination; by age, 1957 to 1959. 102. Migration of males; net, into and out of study villages by rural or urban origin or destination; by age and by caste, 1957 to 1959. 103. Migration of females for reasons other than marriage; net, into and out of study villages by rural or urban origin or destination, by age, 1957 to 1959. 104. Migration of males, and of females for reasons other than marriage; net, into and out of study villages as members of groups or as individuals, 1957 to 1959. 105. Education, grade 3 or more; by sex, caste and age, 1959. 106. Urban experience prior to 1956; husbands of wives aged 15 to 44 years, by caste, 1959. 107. Elementary school in a study village. (Photograph by Pierre Streit. © Copyright 1960 by The New York Times Company. Reprinted by permission.) 108. Education, grade 3 or more; all castes by sex and age, 1959. 109. A soldier returning home. 110. Village patriarch. (Photograph by Pierre Streit) 111. Leather worker using sewing machine. 112. Punjabi father and son. (Photograph by Pierre Streit) 113. A farmer and his sons prepare the land for irrigation. 114. Occupation of males aged 15 to 64 years; man-months employed, by caste, 1959. 115. Increase in world population, 250 B.C. to A.D. 1960. 116. Demographic gap between birth and death rates, and

205 214

215 216 217

218

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221 222 223

224 224 225 235 236 237 242 250 261

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Figures Page

resulting population growth, Germany and Japan, 1840 to 1960. 117. World population by continents, 1650 to 1960. 118. Annual rates of birth, death, and net population growth, 1957 to 1969. 119. Annual production of food grains and cash crops; value in rupees, District Ludhiana, Punjab, 1960 to 1968.

261 262 300

305

Appendices Figures A-l. A-2. A-3. A-4. A-5. A-6. A-7. A-8. A-9. A-10. A-ll. A-l3.

Family record card. Menstrual and pregnancy record. Male reproductive record. Menstrual index card. Field notebook. Coded register. Pregnancy and birth card. Cohort study card. Record of death. Accident record. Final census. Khanna follow-up census form, page 2; vital events, 1960-1969. A-14. Khanna follow-up family planning practices, 19601969. E - l . Women aged 15 to 44 years and those currently married; by age, test and control A villages of the Khanna Study 1959, Sweden 1960, Ireland 1961. E-2. Marital age-specific birth rates of women aged 15 to 44 years; test and control A villages of the Khanna Study 1959, Sweden 1960, Ireland 1961.

318 321 325 327 329 332 334 338 341 345 348 356 360

366

367

Tables

Page 1. Stages, functions, and field staff of the Khanna Study, 1953 to 1969. 16, 17 2. Pregnancy rates of wives practicing contraception; exploratory and pilot villages, March 1955 to March 1956, and pre-study pregnancy rates. 43 3. Castes in the Khanna Study, by name and usual occupation, 1959. 80, 81 4. Demographic characteristics of test and control A villages, and of rural District Ludhiana, Punjab Plains Division and India, 1951 and 1959. 88 5. Demographic characteristics of the study populations, test and control villages, 1959. 96 6. Staff of the Khanna Study, 1953 to 1960. 107 7. Field staff of the Khanna Study, 1954 to 1960. 108, 109 8. Sample list of households and married couples living in a segment of "B" Street, Manupur, July 1958. 118 9. Contraceptive practice, 580 couples; by method, 1956 to 1959. 124 10. Children born live to women aged 45 years or more; mean survivors and deaths, by caste and education of husband, 1959. 140 11. Wives in postpartum amenorrhea practicing contraception at the twelfth and at the last month of the study program, by month since childbirth; test population, 1956 to 1959. 144 12. Wives practicing contraception, by interval since first menstruation after delivery, 1956 to 1959. 145 13. Wives practicing contraception for at least 12 accumulated months; by urban experience and age of wife, 1956 to 1959. 148 14. Wives practicing contraception; (a) uninterrupted practice including month twelve, and (b) total accumulated months of practice during the study, 1956 to 1959. 149 15. Reported frequency of coitus; 1094 couples by age, 156 1959. 16. Marital status of women by age, 1959. 164 17. First ten causes of death, all ages, January 1957 to December 1959. 175

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Tables Page

18. Death rates of preschool children by age; the Punjab 1896-1900, test and control A villages of the study population 1957-1959, United States 1951. 19. Death rates, first year of life; study population 19571959, United States 1951. 20. Deaths by cause; study villages, 1957-1959. 192, 21. Live-born and surviving children to married women aged 40 to 59 years; by caste, 1959. 22. Completed families of married women aged 40 to 59 years, husband alive until wife aged 45 years; families by child deaths per family, and by caste, 1959. 23. Live births and surviving children of women aged 40 to 59 years, parity 6 or more; mean number and percent of children of parity 7 or more who died, by survivors from the first 6 live births, 1959. 24. Deaths from early-parity births related to subsequent live births, wives aged 40 to 59 years; mean number of total live births and of all survivors, 1959. 25. Survivors of births at early parities and subsequent live births, wives aged 40 to 59; mean total live births and all survivors, 1959. 26. Migration of males and females for marriage and for other reasons; into and out of study villages, and annual net migration rate by age, 1957 to 1959. 27. Sources of livelihood; persons or households by caste, 1959. 28. Migration of males into or out of study villages; migrations per person; in-, out-, and all migrations, 1957 to 1959. 29. Factors influencing population growth in study villages, 1956 to 1960. 231, 30. Factors influencing resources for livelihood of study village members, 1956 to 1960. 31. Means to modify selected determinants of population pressure in study villages. 238, 32. Population characteristics of village and caste groups, District Ludhiana. 33. Demographic characteristics of study populations by caste, 1959. 34. Evaluation of means to relieve population pressure; rank order by caste.

180 181 193 197

198

199

200

201

210 212

213 232 233 239 249 251 252

Tables

xv Page

35. Occupations of males aged 15 to 64 years; man-months by caste, 1959. 36. World population growth by geographic regions, 1940 to 1970. 37. Menstruating married women aged 15 to 44 years practicing contraception, 1957, 1959, and 1969. 38. Age of women at consummation of marriage, 1956 to 1969. 39. Proportion of the study population less than age 10 years; males per 1000 females aged less than 10 years, and all ages, 1959 and 1969. 40. Birth, death, net emigration and population growth rates by caste, 1957 to 1968. 41. Children dying within 2 years of birth, by caste and sex, 1956 to 1967. 42. Populations, test and control villages; by caste and by years, 1957 to 1969.

253 260 297 298

299 301 302 303

Appendix Table

D-l. Life-table of postpartum amenorrhea following birth of children surviving one month or more.

364

Preface

This book describes an eight-year prospective field study of population dynamics in rural India, and gives selected findings from a follow-up investigation 10 years later. It discusses ideas behind study design, some notions and points of view of the Punjab villagers among whom the work was done, and concepts developed from findings of this and other field studies. Plans for the study began soon after the Second World War in response to a realization that rapid population growth was becoming a world health hazard. The study itself came from a preceding experience in preventive medicine and public health, primarily epidemiologic, studying disease behavior as it affects populations. Designed by members of the Harvard School of Public Health, field work lasted from 1953 to 1960, in collaboration with the Governments of India and the Punjab State and with support from the Christian Medical College at Ludhiana. The title of the book, The Khanna Study, comes from the name of the market town where field headquarters were established. A scientifically controlled test of a contraceptive program as a means to lessen birth rates provided a frame for field work based on observing whole populations. At the same time, the study was concerned with persons as individuals and with the formal and informal structure of social units. A deliberate hardship was accepted in the decision to measure results in terms of altered birth rates. Numbers and constitution of a population due to deaths had detailed attention, migrations less. These objectives meant setting up procedures for accurate, repeated surveys of the population and a record of vital events as they happened. The aim was to trace the relation between changes in the size of a population, and in its environment, as they affect community health and social wellbeing. Techniques were directed toward a clearer understanding of influences acting on numbers of births, deaths, and migrations. The chosen approach gave informative and satisfying results, yet by no means is it offered as a single substitute for other kinds of demographic, social, and epidemiologic study, nor for clinical and biological investigation of particular features. The Khanna Study has three distinctive contributions. Few other investigations have attempted to document demographic variations of a defined population in such detail over a prolonged period. The field trial of a contraceptive program in a poorly educated, rural population of an underdeveloped country was at that

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Preface

time unique. The program's limited success in lower birth rates was investigated thoroughly during and after the study, to give significant implications for future population studies. The collateral studies of factors influencing population dynamics yielded important data and concepts applicable to local and national birth control programs. A precise and adequate field methodology had to be developed. Some procedures and analyses were derived from conventional methods, but all had to be fitted to epidemiologic effort in an unfamiliar field. In interpreting the findings and ideas presented here, the reader must, of necessity, bear in mind two cultural biases — his own and those of the persons responsible for the study. Design, analysis, and interpretation of findings were by Westerners. Their scientific training and experience in clinical medicine and public health and their cultural and religious heritage inevitably influenced what they saw and heard in a Hindu-dominated society, and a local culture chiefly Sikh. Their colleagues were Punjabi, mostly Sikhs and Hindus. Despite this advantage, the authors claim no unusual freedom from their own cultural prejudices as they sought to record objectively facts, opinions, and ideas. As field work progressed, the staff came to think increasingly in terms of the pressures of a population on available resources, and of what the villagers were doing to deal with difficulties arising from their growing numbers. Population pressure is a worldwide malady affecting most social units. The handful of Punjab villages in this study is no more than a molecule within the larger mass; yet the authors believe it is in the context of small social units that families mainly make the decisions determining migrations and births. To an extent, these decisions influence numbers of deaths and the production of resources. The results are reflected in the broader regional and national population problems. The concept of population pressure obviously is open to subjective interpretation. No observer can claim a perfect insight into the feelings of others, particularly in a society initially unfamiliar. Nevertheless, this study ventures an objective evaluation of how the local people were responding to population pressure. Westerners have strong feelings about the value of persons and of human life not necessarily shared by Punjabi villagers. Some readers may feel that the pressures arising from growing numbers of people were self-evident. The villagers did not always hold that view. The first four chapters describe the origins of the study and the field methods used. Chapter 3 presents primarily the personal impressions of the field staff as they first encountered a Punjab vil-

Preface

xix

lage society. Subsequently collected information on the history, social organization, and political development of the Punjab enlarges the account. Chapters 5 through 8 report results of the program for contraception and detailed findings on births, deaths, and migrations in 11 Punjab villages during four years. Chapters 9 and 10 summarize and interpret the results; first as they apply to the Khanna region, and then generally. The final chapter presents findings from a follow-up study in 1969. Summaries at the end of each chapter carry the main thread of the book. Cross-references in the text are by chapter, section, and subsection. Figures and tables of the appendices are distinguished by a prefix (A, B, etc.). The glossary defines Indian, technical, and unusual terms, and indicates pronunciation of Indian words and proper names. Some of the material has appeared in technical and scientific journals of India, the United States, Great Britain, and Latin America. Much is new, particularly an integrated interpretation of the main body of results. We trust the book will serve persons with a wide range of interests touching on modern population problems: social and economic planners, administrators, demographers, sociologists, epidemiologists; and particularly public health workers concerned with family planning, the physiology of reproduction, and illnesses and deaths during the first years of life.

Acknowledgments

To the many persons and institutions who contributed time, effort, advice and encouragement, and administrative and financial support to this seventeen-year project, we extend our warmest thanks. This has been a collaborative study spanning wide differences in places, in cultures, and in technical skills. Without forbearance and a willingness to go the second mile on the part of many people, some named and many not, this study would never have reached its conclusion. As the idea for the study took shape, two key persons encouraged and supported the originator of the plan, Dr. John Gordon. They were Dr. James Bryant Conant, President of Harvard University, and the late Brig. Gen. James Stephens Simmons, Dean of the Harvard University School of Public Health from 1946 to 1956. Professor John Cray ton Snyder, dean since 1956, gave solid support to the study during the years of field work, analysis and report of findings. The Ministries of Health of the Government of India and of the Punjab State provided crucial support during work in the field, particularly in the early days when ideas for the study were developing. The Hon. Rajkumari Amrit Kaur, the Hon. D. P. Karmarkar, Lt. Col. C. K. Lakshmanan, Sri Lala Jagat Narain, Dr. H. B. N. Swift, and other officials were graciously helpful. The Indian Advisory Committee strengthened the field study by continuing advice, a diverse experience, and a variety of skills. The Director of the Christian Medical College at Ludhiana City, Dr. Eileen Snow, and the members of her faculty gave academic backing and encouragement. Numerous residents of the town of Khanna participated unofficially in the study through valuable friendship and continued aid in the everyday affairs that made the project function. The staff found continuous kindness and warmth in the study villages from the panchayats and village members, particularly those of Chakohi, who introduced the staff to life in a Punjab village. The advice of Sri Pritham Das of Manupur and Sardar Lai Singh of Rajewal was singularly wise. No words can do justice to the labors of the field staff, all of them Punjabi. They did the hard work, with skill, imagination, devotion, and a wonderful sense of humor. Men, women, and children stuck to their jobs despite heat and cold, dust, mud, flies and mosquitoes. That they enjoyed it may be true, but that many others

xxii

Acknowledgments

would have done all they did is doubtful, as the account of the field work well reflects. Particular appreciation goes to Dr. Helen Gideon and Dr. Sohan Singh, the assistant field directors, and to Miss Balwant Kaur, public health nurse in charge of field activities. Data processing and analysis of findings were carried out in the United States after field work ended in early 1960. Professors Jane Worcester, Ansley Coale, and Ronald Freedman gave valuable advice. Dr. Robert G. Potter, Jr. took major responsibility for several sections of the analyses. Pravin Visaria, Nadipuram Parthasarathy, Stephen Finner, David Hodgson, Paul Kay, Arthur LeGasse, Margaret Parker, and Dan Siegel contributed in various ways to analysis and interpretation of data. Mary New brought to the study her experience in managing data processing and in training technicians. Tillyruth Teixeira and some fifteen others gave technical assistance. Text illustrations are by June Armstrong with guidance in graphics from William Brown. Joan Reid, assisted by Ruth Goulet, had primary responsibility in preparing the manuscript for publication. Maria Caliandro organized and edited the final draft, leaving Carol Pollard to mediate in detail between authors and publishers. For five years and more, the Harvard University Press had been consistently patient and helpful. The authors have consulted numerous friends and colleagues in India and the United States, asking that they identify errors of fact or interpretation. The errors that remain are our own. The directors of the study are indebted to various sources for financial support. Harvard University underwrote the project throughout. The first donor wishes to remain anonymous. The Rockefeller Foundation of New York undertook major financial responsibility for the field work, with supporting grants from the Government of India and the Indian Council of Medical Research. Analysis and report of findings were aided by two grants from the Population Council of America, by funds from the United States Public Health Service (Grant No. RG-5254), and by the National Institutes of Health (Grants No. GM 10760-01 and ROI HD 03460-OIAI EDC PR, and General Research Grant No. 1 SO l-FR-05466, Division of Research Facilities and Resources). Support of professional staff came from a United States Public Health Service traineeship, the Higgins Fund of Harvard University, the National Science Foundation (Grant G-22677), and the Ford Foundation. British Drug Houses, the Fomos Company of New York, and the Ortho Company of New York provided contraceptive supplies. Mrs. Elizabeth Wyon was a friend of the field staff, a field

Acknowledgments

xxiii

worker in study villages, chief interpreter of field records during data processing in Boston, a statistical assistant, and last but not least, a friendly critic. John B. Wyon and John E. Gordon

The Khanna Study

1.

A Field Study of Population Dynamics

Soon after the Second World War demographers pointed out that the human population was growing ever more rapidly. To some individuals the appeal was immediate. A number of economists, sociologists, physicians, and public health workers responded, notably in India and Japan, where the need for action was urgent. Some expressed their concern through the United Nations (U.N. 1953), showing that expanding numbers of people were canceling out strong efforts to raise existing low standards of health and well-being in many less developed countries. Ten years passed, however, before the general public of most countries appreciated the warning. Although the gathering world understanding of the difficulties inherent in population growth is impressive, opinion is still divided about the seriousness of the problem and what should be done to remedy it. About 1949 the Department of Epidemiology at the Harvard University School of Public Health became aware that sharp rises in population were affecting their plans for control of various community diseases. Anticipated improvements in public health expectedly would result in fewer deaths and thereby accelerate population growth by widening the gap between birth and death rates. These circumstances prompted a closer investigation of the influences determining current population trends. Physicians and public health workers had additional justification for concern. To an appreciable extent their activities were responsible for the growing numbers of people. Death rates in some countries had been reduced by half, while birth rates remained little affected. The health professions thus were under obligation to seek a solution for the problem they had to some extent created. The persons at the School of Public Health primarily concerned were John E. Gordon and Theodore H. Ingalls. Both had had a long and varied experience in community control of disease and injury. Carl E. Taylor joined them a year after their first discussions. Taylor had been born and raised in India, had practiced medicine there, and was to return to head a new department of Preventive Medicine at the Christian Medical College in Ludhiana, the Punjab. To a man with Taylor's background, population increase was a pressing reality, beyond academic niceties of thought or theory. All three men agreed that their specific obligations would be met best through a field study by a staff living and working with

2

The Khanna Study

the people of a selected area, testing theories of causation of population increase, seeking a means to curb an expanding population growth. In essence this was an epidemiologic approach, using the tools of the discipline they knew best. Dr. Clarence J. Gamble of the Harvard Medical School contributed information from many years' study of human reproductive processes and methods for conception control. Not only did he impart his specialized knowledge but he contributed a warm enthusiasm, in welcome contrast to the opinion of some other colleagues who denied that physicians and public health workers had any obligation in birth control — their business was the prevention and cure of disease. During a trip to India in 1951 with other interests, Dr. Gordon found opportunity to discuss a possible field study with officials of the Ministry of Health of the Indian Government at New Delhi. India was already much concerned, and welcomed the suggestion of a common effort. The administration of the Christian Medical College at Ludhiana offered sympathetic cooperation. In Calcutta Gordon met John B. Wyon, a medical missionary experienced in health problems of rural people and a former colleague of Taylor. He was ready to commit himself to the project and to the necessary year of postgraduate study in epidemiology and public health. He had two valuable qualifications, a knowledge of the Hindi language and a familiarity with customs and practices in India, a probable site for the study. Back in Boston, Dean Simmons of the School of Public Health and the administration of Harvard University gave Gordon the backing he needed as he sought financial support. An anonymous donor provided a fellowship for Wyon, funds for Gordon to make another visit to India, and means to support the first months of field work. The Rockefeller Foundation of New York was willing to consider funding the first two years of the field study, and the projected seven years if the initial results so warranted. Subsequently the Foundation made two important grants to Harvard University, one in 1953 and another in 1956. By 1953 the decision had been made that a study was feasible and had promise of a practical result. Gordon was to be director of the investigations, Taylor assistant director, and Wyon field director. A plan of action had been outlined. The next step was to develop theoretical concepts into a standard operating procedure and to choose a study site. After visits to six likely countries in the Far East to acquire familiarity with population problems in a variety of Asian settings,

Field Study of Population Dynamics

3

India was chosen. It had been strongly considered from the beginning. Population growth was rapid, extensive, and of a nature common to many other parts of the world. The Indian Government and the Christian Medical College at Ludhiana had made warm offers of cooperation. Furthermore, not only had the study directors worked and lived in developing areas for long periods, acquiring full appreciation of the differences between life in an industrialized society and that of a traditional agricultural economy, but also two of them had a solid background of experience in India. In the spring of 1953 Gordon spent a month in India to become familiar with places and populations likely to provide a favorable site for the investigation. A valuable part of this experience was a week of camping with Carl Taylor, their tent pitched against the wall of a Punjab village. Days spent in the fields and evenings around a campfire gave the beginnings of an understanding of these village people, their thoughts and ambitions. A friendship began with the sturdy Punjabis that continues to this day. Work with these people was assuredly possible; it promised to be productive. At a subsequent meeting, officials of the Indian Ministry of Health agreed that the rural Punjab was suited to the proposed study. 1.1

Motivations to Undertake the Study

Several incentives impelled the undertaking of this study. Gordon had started his career as a microbiologist and physician. He had devoted long years to the control of communicable diseases and to the behavior of these illnesses as they affected whole populations. Epidemiology in 1949 was commonly restricted to communicable diseases: how a population and its total environment acted and reacted to determine the course of an infectious process. With others, Gordon had pioneered in applying epidemiologic principles to the understanding of a variety of chronic diseases of noncommunicable origin, to traumatic injuries, and to mental disorders, as they affect populations of people (Gordon 1953). From appreciation that physiological as well as pathological processes could be explored to advantage by these methods, there evolved an epidemiology of health as well as disease (Gordon 1953). Because of this experience, Gordon was convinced that epidemiologic methods and procedures could be as usefully employed in defining the social and biological factors determining births and migrations as in analysis of the causes of disease and deaths. Taylor and Wyon had begun their careers in time to see the remarkable im-

4

The Khanna Study

pact on disease incidence and death rates of antibiotics, synthetic insecticides, and other modern methods of disease control. The community approach to health and disease appealed to them; its value had been proved many times. All three investigators were deeply concerned lest the successes of medicine and public health permit more people to survive, only to suffer privation rather than enjoy a healthy and rewarding life. They had learned to look upon epidemiology as medical ecology and to realize that population growth was determined fundamentally by the interplay between a human population and its environment (Gordon 1966). With no reservation they recognized that the consequences of rapid population growth extend beyond health considerations to a variety of man's activities, sufficient to impinge on his general well-being; that population dynamics had political, sociological, economic, and a number of other significant implications. Their main concern was with the community health aspect. This is not to imply that health considerations can be evaluated independently of other factors, nor is there a suggestion that the solution of population difficulties will come from a health approach alone. The physician has no single responsibility for an eventual answer; he does have a part in an effort which demands the full resources of society.

1.2

Epidemiology and the Population Problem

In the search for means to prevent and cure physical and mental illness, medicine and public health take three broad approaches. Each has its particular worth. The first is at the level of molecules, cells, and tissues, exploring the processes of microscopic pathology in the laboratory. Numerous scientific disciplines are involved — histology, physiology, microbiology, biochemistry, and biophysics — along with multiple subdivisions of increasing complexity. The second general approach centers on the individual, the whole person, and employs the methods of the practicing physician. The objective is to define clinical pathology, to investigate those morbid disturbances arising through inherent defects in body or mind or acquired through action of the external environment. Epidemiologic analysis comes into play as the third general method. The unit of observation in this instance is an aggregate of people viewed as a society that functions as a whole, in contrast to clinical study which sums the findings from observation of individuals. A population and its environment interact and constitute an ecological unit or ecosystem. Epidemiology studies pop-

Field Study of Population Dynamics

5

ulation pathology (Gordon 1955), and the physiological functioning evidenced by groups of people. The principle is the same in all three approaches. Methods vary, but a central theme dominates: the search for reasons why a biological process comes into being and why it behaves as it does. The distinctive difference between an epidemiological approach and the other two lies in the unit of observation: in laboratory investigation, the elementary divisions of the human body; in clinical study, the whole human being; and in epidemiologic analysis, a population of people. An epidemiologist sets out first to identify the nature and extent of a community health problem. He searches for its immediate and remote causes — causes which invariably are multiple and diverse — some arising from the characteristics and behavior of the affected population, others from one or more features of the environment. The next objective is to judge the likely course of the trouble and its probable outcome, to determine prognosis as in the practice of medicine where individuals are the units observed. There follows in order an endeavor to design and test methods for control, and eventually to evaluate the end result of administrative and professional procedures used to manage the situation. Basically, then, the procedure in epidemiology is to study the disease or health problems of a population, a group of people viewed as a unit and observed under natural conditions. This involves field investigation of people in their homes, in relation to their environmental surroundings, and with regard to their cultural and biological characteristics. Two simple precepts are standard in epidemiologic procedure. One is to study events according to their distributions in time, by place, and by kinds of persons, in search of fractions of a population differing in respect to some selected characteristic — variously, numbers of children, a specific disease, or a behavioral factor. The second is to relate such events qualitatively and quantitatively to characteristics of the environment, again in search of attributes conceivably related to cause and extent of the process under study. Environment is broadly conceived: first, the obvious physical surroundings; then the biological environment which includes all living things, plant or animal other than man, as they affect human health or welfare; and last, and perhaps most important, the influences arising from the association of man with his fellow man, the social environment. Cultural and economic features have prime significance in this social environment. In field studies directed toward a broadly prevailing situation

6

The Khanna Study

such as population growth, an epidemiologist looks for a population fulfilling several conditions. Desirably, it is representative of larger populations to which he may extend his findings; it needs to be an aggregate of human beings normally interacting with one another; and, last, the population must be of a size sufficient to permit sound conclusions, yet not so large that collection of accurate information is prohibitively difficult. Three fundamental events govern changes in population numbers: births, deaths, and migrations. They act in concert. The concepts of time, place, and person and the physical, biological, and social aspects of environment together provide a framework for identifying the characteristics of each and the manner in which they interact to give population growth or recession. In recent years field epidemiology has enlarged its methods and techniques. Laboratory procedures are now as much a part of field study as they are in clinical investigation. Clinical examination has always been a feature of epidemiologic inquiry; its field practice now incorporates even the more intricate procedures of formal clinic and hospital. All three methods, in their totality a medical approach, contribute directly to the technical evaluation of population growth. Laboratory research is concerned with the fundamental physiology of reproduction. Clinical investigation assesses the efficacy of contraceptive methods, their limitations, and their side effects. Epidemiologic analysis measures acceptance by a society of procedures which promote or limit births and determine numbers of deaths. It expresses the results in terms of mathematically defined birth and death rates. The epidemiologic method has direct application if only because population dynamics is a phenomenon of aggregates of people. 1.3

Study Design

1.3.1

The Conceptual Idea: Population

Pressure

Rapid population growth and its attendant problems provoked the idea of a field study. The established principles so long the pattern of biologic research guided its design. Throughout the investigation a formative influence was the concept of population pressure; namely that through undue increase in numbers, man's requirements come to exceed his material and other resources with a resultant cost to health and well-being. The population of any area has a beginning, a life span ordinarily many generations long, and as so often has occurred, an

Field Study of Population Dynamics

7

eventual end. Men select a settlement site to obtain material or spiritual rewards or to escape disturbances and danger. As long as advantages outweigh disadvantages, the population tends to grow. Economic and sentimental investments accumulate. If for any reason population growth is excessive or the environment becomes less able to provide support, the people experience conflict between the size of their needs and the amount of resources available. For centuries, north Indian villages have existed as distinct and more or less independent population units. They have shown a remarkable ability to survive for long periods. Some villages have been abandoned in the course of time and elsewhere new ones have come into being. An end result is that the number of villages in this area has increased only slightly in the last 100 years. Each rural north Indian resident and almost every Indian city dweller has a recognized native village. Compared to other geographic population units, the Indian village is a permanent and enduring institution. The central administrative and political divisions of the country as a whole, including many villages, a few towns, and some cities, have had a more precarious existence. Political power has passed from Hindu dynasties to Muslim, back to Hindu or Sikh rulers, then to Britain, and now to a democratic parliamentary government with district, state, and federal jurisdictions. The village populations of north India are far more than aggregates of people brought together by chance. Village after village repeats a common social and economic organization, based on the requirement that each community have men with the variety of skills necessary to support the agricultural way of living. Every caste and subcaste in a village has certain hereditarily assigned tasks which no other group performs. A man belonging to the farmer caste does not make his tools, weave his cloth, or perform important ceremonies. On the other hand, a weaver does not farm. The sometimes extreme division of labor creates a network of interdependencies among groups of highly skilled specialists with generations of training. Family and religious traditions compel each man in the village to follow his caste occupation; its uniqueness provides him with a reason for existence and a place in the social and economic hierarchy. Over the centuries many external forces have exerted pressure on the village populations of the Punjab. Until the end of the AngloSikh wars in mid-nineteenth century, invaders and marauders were

8

The Khanna Study

so much a part of life that villages were built more or less as fortresses, each with its walls and defensive gates (Fig. 1). Droughts, floods, swarms of locusts, and other disasters came at irregular intervals, with good years in between when fertile soil produced food to spare, and even enough to satisfy the rapacious tax-gatherers of the locally dominant ruler. Epidemic disease, sometimes with an accompanying famine, has been a frequent visitor, occasionally decimating populations and even wiping out whole groups of villages. The present way of life in the rural Punjab is thus the product of centuries of exposure to widely varying conditions. When times were bad, populations decreased. Early marriage and numerous pregnancies, however, produced the sons to support the extended family and other kinship groups, to defend their villages, and to till the land. When times were good and the numbers of people increased, villages found themselves hemmed in by their neighbors. If civil authority was weak, individual villages or groups of villages fought one another to acquire more land. To avoid such local wars, two courses were open: either to send the excess people elsewhere to seek a livelihood, or to find some other way to restrict population growth. With expected irregular fluctuations, growth of these small com-

Fig. 1 Moghul fortress walls and entrance gate, Khanna.

Field Study of Population Dynamics

9

munities has exceeded attrition; reproduction and immigration have more than neutralized deaths and emigration. Northern Indians have, furthermore, a long history of generating or borrowing fresh ideas. Their willingness to adopt new technical methods has aided their survival. A continuing but irregular trend toward fewer deaths has increased the rate of population rise not only in the Punjab but in the rest of India as well. Rising numbers of a predominantly agricultural people who depend on fixed amounts of land creates a condition called "population pressure." The term was used by Malthus, writing between 1798 and 1834, to support his theory that populations tend to fluctuate around an average number (Malthus 1872). He postulated generally that all populations tend to increase to the limit of their means of subsistence and that unless two preventive checks are applied, human population size is controlled by the positive checks of famine, pestilence, and war. He favored delayed marriage and abstinence from coitus before and during marriage as methods of population control. He did not approve of contraception and induced abortion, and surgical sterilization did not exist in his day. Malthus advanced the idea that, figuratively, populations press upon their means of subsistence. He failed to foresee the technological advances which now support many more people within a given area than was possible during his era. Obviously the number of people in a population can exceed actual procurement of the means for subsistence only for a short time. Persistent shortages result in excessive numbers of deaths; they drive some people to leave their homes, to restrict births, or to plunder their neighbors. Malthus reasoned that a population approaching the limits of its subsistence exerts increasing pressure on its sources of sustenance, its surroundings, and itself. However, the Malthusian idea of a population pressing on its environment is but one aspect of a mutual interaction. A population approaching the limits of its capacity for self-maintenance is in danger of social disintegration; the ecological pressures on its structure are nearing a critical point. Although continuously present, these pressures may not become apparent until population size draws near the limit of environmental capacity. No precise definition of population pressure exists, nor was infection satisfactorily defined during the many years that concept was used before Pasteur discovered bacteria and other infectious agents. Fever, swelling, rash, or cough nevertheless distinguished some individual infectious diseases from others and, within limits,

10

The Khanna Study

measured the intensity of the process. A definition of population pressure is not in Webster or in the United Nations Demographic Dictionary. We propose the following: manifest population pressure is the condition within a group or community of people whose numbers are increasing more rapidly than the means for their support, with consequent danger to the lives of the more vulnerable members; or, again, the predicament of a community whose means for support declines to dangerously low levels through repeated crop failure, breakdown in transport, or other disasters having long-term consequences. With population pressure manifest, men and women become distraught and even reduced to despair by the difficulties involved in providing their dependents with a reasonable livelihood. Thus householders and community leaders are compelled to take agricultural, fiscal, or moral risks in an attempt to provide for too many people from too limited resources. An increase in numbers of people in an Indian village or any other population unit, in the absence of a commensurate rise in household income, is interpreted as manifest population pressure, and if present to an acute degree, as "over-population." Evidence that the inhabitants of a given area are making efforts to restrain population growth, to increase production of goods, and to find sources of livelihood outside the area indicates that the people are experiencing population pressure sufficiently severe to evoke a response. Manifest population pressure is the particular malady of society with which this study is concerned. The birth control program, its central activity, was not directed toward reducing birth rates as an end in itself, but rather as a means to lessen population pressure. The basic objectives were to mobilize evidence bearing on the development and present status of population pressure in the study area, and to discover effective ways to modify it. More specifically, we tested the ability of a contraceptive program, using then existing methods, to decrease prevailing birth rates in a representative population of a developing region. Test of this hypothesis was combined with a series of detailed analytical studies on rates of birth, death, and migration. Of special interest were factors influencing these determinants of population change, including social structure, cultural patterns, and sources of livelihood. Conclusions hopefully would extend to larger jurisdictions of which the study area was a part.

Field Study of Population Dynamics 1.3.2

11

Reconnaisance

The experimental design came from library study, from conferences with demographers, and from observations of clinical and field conditions in the Punjab and elsewhere. Factors presumably influencing population growth were documented; birth and death rates were reviewed, and the methods of birth control then available were evaluated (Gordon, Wyon, and Ingalls 1954). All principal contraceptive methods available in 1953 were considered for use in the study program. A limiting factor was that few physicians and fewer nurses practice in rural areas of developing countries. At that time vaginal diaphragms and cervical caps used with a contraceptive paste or jelly were considered the most effective methods of contraception for women; and condoms for men. However, the methods for women required medical aid for initial fitting and to assure subsequent proper use. A decade or more would pass before the first rural health centers brought much of any scientific medical practice to rural sectors of the proposed study area. At that time and for practical reasons, reliance was on simpler methods of contraception usable without direct medical supervision. Evidence from Europe and North America indicated that birth rates had declined by half within the preceding century, mainly as a result of methods not requiring attention from a physician or nurse: delayed marriage of women, withdrawal, vaginal douching, and the condom (Lewis-Faning 1949; Kiser and Whelpton 1958). 1.3.3

The Study Design in Principle

The experimental design of the Khanna Study was modeled on community field trials of a vaccine or drug, the objective of which is to determine changes in numbers of deaths or cases of a disease attributable to a newly introduced procedure. The key feature is the concomitant observation of two similar populations: a test population supplied with the material, and a second population left as a control, either untreated or administered a placebo. In the present case the immediate objective was to measure a change in birth rates. It was of course appreciated that any change in deaths or migrations would also affect population growth. 1.3.4

Selection of

Populations

Once India had been agreed upon as the study area, there followed the selection of the particular population to be studied and

12

The Khanna Study

the precise place. The choice of District Ludhiana as the general site for field operations was influenced largely by the opportunity to work in cooperation with the Christian Medical College in Ludhiana City and its Preventive Medicine Department. The first demand was to decide between an urban and a rural area. It was possible that urban populations would respond to a program for birth control more readily than rural people. City dwellers are popularly assumed to be more knowledgeable than village people. They have greater familiarity with the aims and methods of modern medicine. By contrast, country folk are judged to be less sophisticated. In India they certainly have had less contact with the thought and practices of modern medicine. However, a rural population was the eventual choice, mainly because 82 percent of India's population is rural. Villages are the typical expression of the Indian way of life and, with few exceptions, they represent aggregates of people long associated. Experience in epidemiologic field work had taught that causal relationships in the mass phenomena of disease often were more easily perceived and defined in a rural than in an urban situation. The ecosystem is simpler, with a more direct connection between the people and their production of food and other necessities of life; and at the same time the complicating factors are fewer. Field explorations and study of existing data had shown rural populations in the Punjab to have characteristics similar to those of other rural Indian populations. The people were shrewd, frank, straightforward, and seemed likely to cooperate in long-term field study that involved a test of birth control. Since the study was concerned with population dynamics, it was almost obligatory to deal with whole populations, in units of entire villages, and with sufficient numbers of people to meet statistical requirements for significance. Villages selected for study were to be unaffected, as far as possible, by the contemporary influx of refugees from Pakistan. Partition of the Punjab in 1947 had disturbed the solidarity of many communities, especially cities. The possibility of studying a random sample of households representative of the Punjab State, or one of its administrative districts, was considered and rejected. The primary concern was to be with communities, not individual families. Furthermore, repeated visits to a random sample of households within an appreciable area would be costly and require excessive travel. During June and July of 1953 the strands of a study plan which

Field Study of Population Dynamics

13

had been developing over several years were pulled together and fitted to the particular Indian rural area where the study was to be done. The plan was laid out in detail, filling four typescript binders, for it was to guide field operations during the next several years. A general description of the problem came first, then an appraisal of birth control methods, a statement of proposed objectives, and lastly a description of places of operation, field methods, timetable, and budget. The study design took full account of the chief features of India's rural population, namely, that most people depended on agriculture for a livelihood, that they were densely settled, and that only 30 percent of the Indian medical profession practiced among the 82 percent of the population living in rural areas. The population of India was then growing by an estimated 1.3 percent each year. By 1961, annual growth reached 2.2 percent. The study plan called for a resident staff, supervised by physicians, to visit every home once a month or oftener as circumstances demanded. The purpose was to acquaint each family in the test population with the advantages of family planning, to enlist participation in the contraceptive program, and to supply the necessary advice and materials for satisfactory practice. These visits would give monthly information on which couples practiced contraception and which did not. Births, deaths, and migrations were to be recorded for all families of the village. An annual census would provide the denominator for demographic rates. Without doubt, persons belonging to the Punjab could best do this work, and suitably qualified people were found available. Two control populations were needed because of the necessarily intensive field methods employed in the test population. The frequent presence of physicians in a village, the continuing activities of the resident staff, and a concentration on health matters unusual in village life could affect birth and death rates, aside from any direct influence of contraceptive method. The first control (control A) was designed to measure the influence of the data collection and intervention techniques. Field methods duplicated all procedures followed in the test population, except for the birth control program. The same kinds of information were collected on menstruation, births, and deaths, on living conditions, population structure, and cultural patterns. A central health theme — the prevention of accidental traumatic injury — corresponded to the contraceptive program and was chosen because of no possible relation to birth control. Observations in the second control population (control B) were

14

The Khanna Study

limited to numbers of births and deaths. The purpose was to determine rates of natural increase in comparable villages under normal, undisturbed conditions, unaffected by known investigative activities, the presence of a resident staff, and frequent visits by physicians. Such activities, in the absence of any direct measure under test, have been demonstrated elsewhere to have a nonspecific effect (Landsberger 1958). A public health nurse visited the area once a month, had no contact with the general population, and obtained her information from the official registrar of the village, the headman, and the practicing midwives. At the end of the study a census supplied the denominator for rates. 1.3.5

Field Investigation

Field work was planned within five blocks of time. An initial four to five months established an operating base and assembled a staff. The next stage was an exploratory study of nine months, followed by a year-long pilot study. The fourth block of time, from 1956 to 1960, comprised the definitive investigation. A follow-up, cross-sectional, prevalence study in evaluation of the long-term effect of the program was scheduled for five years later. Table 1 summarizes the planned and actual dates of the five stages of the study, their functions, and the staff employed. A pilot study is a usual technical feature of long-term prospective field studies. In this case the extra step of an exploratory study was added because there was so much to learn about specific methods, population response to discussions of sex, and the introduction of contraceptive procedures. A principal gain from the pilot study was the demonstrated need for deeper study of illnesses and deaths. Many children died soon after birth; in the subsequent two years of life, deaths from diarrheal and other infectious diseases were strikingly frequent. Five corollary studies were developed, materially extending the original plan. Annual cohorts of newborn infants were followed in succeeding years to determine the cumulative effect of repeated illnesses, especially acute diarrheal disease. Causes of death in a general population and medical care of illnesses ending fatally were determined. A series of studies was initiated on obstetrical practice and traumatic accidental injuries. At the same time, the biological and social influences acting on contraceptive practice, pregnancy wastage, and birth intervals were intensively investigated. Observations in the village originally serving for the exploratory study were extended over the next four years. Staff operations had

Field Study of Population Dynamics

15

ceased. No further effort was made to promote birth control. What was done was to continue collection of information on births, deaths, and use of contraceptives with the purpose of determining the continuing influence exerted by an original brief but intensive effort in the promotion of birth control, what people would do on their own after an initial stimulus. Such information was not to be had from the definitive study. The follow-up study was far in the future, and existing circumstances supported a suspicion that it might be even further delayed. The small numbers from a single village would lack statistical reliability but the results could be indicative. 1.4

Analysis of Results and Interpretation of Findings

Provision for concurrent analysis of data was a strong feature of the study design. Monthly reports summarized significant findings. Annual reports brought together accumulated evidence, noted evolving concepts, and recorded changes in emphasis. The study plan provided for publication of results in professional journals as a particular line of investigation was completed. Thirty-six published titles, listed in a bibliography appended to this volume, resulted from the study itself or were generalizations applicable to other places and conditions. A preliminary report of general results, six months after field activities ended, confirmed impressions that the people of the study area were using emigration as a major remedy for population pressure (Wyon and Gordon 1962). A further conclusion was that they practiced appreciably more birth control than originally supposed. The basic concepts endured: to study people, their circumstances, and their way of life in order to achieve a clearer understanding of the causes and consequences of rapid population growth. The ultimate practical objective remains unfulfilled — the demonstration of effective ways to modify and prevent the stresses arising from excessive numbers of people in association with limited resources. 1.5

Summary

Staff members of the Harvard School of Public Health were prompted to search for answers to disturbing questions about the rapidly growing populations in so many parts of the world. They were impressed by the extent to which medical and public health

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110

The Khanna Study

and control A (Fig. 10). The division known as test I consisted of three villages, of 1100 to 1500 population; test II division had one village of 1600 persons, two of about 1000, and one of less than 500 persons. Control A included a village of about 2000 persons, one of nearly 1500, and two small villages. The number of people in each group by village is shown in Figs. 61 and 62. Two resident field workers, a man and a woman, were assigned to each of six working units in the definitive test population (Table 7 ) . They were responsible for home visits in a general population of about 1500 persons, or 200 households. A man and a woman physician oversaw the work in each of the two test divisions. A physician took the lead during the initial phases of the study and, accompanied by the resident field worker, made the first offer of contraception to a family. Thereafter the local workers made monthly visits at a time and place convenient to a wife or husband. One day each week a physician consulted with the resident workers, answered medical questions of the people, and gave needed help in illness. The three health visitors were assigned to control A villages and were supervised by a woman physician who made weekly visits. A male physician also visited each week to keep in touch with the village leaders, to review illnesses of preschool children, to investigate deaths in the study area, and to conduct personally the specific medical investigation which provided the counterpart of the contraceptive study in the test population. Initially the subject was eye diseases (Taylor, Gulati, and Harinarain 1958) and during the definitive study, traumatic accidental injuries (Gordon, Gulati and Wyon 1962a/1962b). The aims were to match the medical implications inherent in the contraceptive program of the test areas and to enlist initial interest in home interviews through a subject with which the people were reasonably informed and which had no possible relation to birth control. Factors other than population size strongly came into play in determining the work load of a field worker. One worker could manage two small villages, but not three. Never was it satisfactory for two persons to share the work in the same village. In the test area most pairs of workers were married couples; activities in control A required only women field workers. In two small test villages one or both field workers were physicians, an arrangement favoring close contact with the special field studies for which they had direct responsibility (Sec. 4.12). Regular working hours for resident village workers were impossible. People had to be found before they could be interviewed;

Field and Analytical Procedures

111

repeated visits often were necessary because of absence. Supervising physicians from Khanna headquarters frequently stayed overnight in the villages, working on study records until a late hour with the local field representative. The rigorous conditions of service were compensated by modifications of the working week. Village staff ordinarily began work on Monday evenings, leaving Khanna by jeep at 5 P.M. for their village homes. They returned to headquarters on Saturday evenings. One weekend a month they had three days off, with a break of a single day the following week. Six times a year the long weekend was combined with a public holiday to permit a longer leave. This arrangement provided a five-day working week, and time to attend to personal business and for relaxation in Khanna or elsewhere. Ordinarily the staff spent their weekends at Khanna in accommodations provided for that purpose. Annual vacations of one month were so arranged as to assure continued coverage of monthly visits and weekly recording of vital events. One statistician was able to handle the work of assembling and tabulating data during the pilot study; as the definitive study developed, two others and eventually two clerks were fully occupied. 4.4

Field Methods

4.4.1

Principles

Field procedures were designed to give maximum information on contemporary events, within established standards of quality. Before field work began, all items were defined and incorporated in a working manual, some on appropriate forms, others by description. Good working relations with the village populations were emphasized as essential to reliable information. A syllabus prescribing procedures to be used and the precise information to be collected was a feature of every printed or multigraphed form. The syllabus spelled out in detail how to ask questions in order to give respondents the best chance to express themselves freely and to arrive at accurate, clear, unambiguous answers. Whenever possible, cross-checks were built into the interviews. This does not imply that methods were fixed and final. Field procedures were reviewed frequently during the early months and periodically thereafter. Desirable refinements and necessary additions were incorporated. The essential consideration was that, at a given time, the exact meaning of each recorded item was known, along with information on how the data were obtained.

112

The Khanna Study

4.4.2

Development

of Field

Procedures

This account of field methods is restricted to fundamental procedures. Details of field record forms and of a hand technique for data processing are in Appendices A and B. Field collection of data involved many everyday considerations. Travel by jeep on the unimproved dirt roads was practical everywhere in dry weather. During seasonal rains a knowledge of alternate routes through sandy soil was profitable; the mud on roads running through common loam could be highly discouraging. Setting up housekeeping in a Punjab village required a special effort. The usual items of field equipment so commonly taken for granted often were lacking, and the field staff had to improvise or import. A water pump and other improvements, such as a kitchen chimney and a bored-hole latrine, were installed in houses occupied by the field staff. These improvements remained the property of the owner. Staff lived in typical village houses, had the same water, food, and facilities as the local people, and adjusted to their style of life as much as possible. In time the field workers were considered part of the communities. Their close familiarity with village life was useful for deciding what hours of the day and what kind of working week provided the best opportunities for interviews. 4.4.3

Prospective

Data

Although a national census had been taken in India every ten years since 1871, records of migrations and censuses of individual villages had insufficient detail for study purposes. Officially reported births and deaths were too incomplete and unreliable to serve as determinants of population change. Information on past births and deaths, obtained through personal interview of heads of families, had a certain value but had serious limitations as well. Recall was subject to error, especially in regard to dates. More reliable information was required. The alternative was to have the resident staff, in continued close contact with the people, make monthly home visits to all families in the village and record events as they happened. They would describe the use of birth control as stated by couples, the course of pregnancies and the result in terms of fetal loss or full-term birth, and population depletion by death or emigration. Such prospective information, observed and recorded as it occurs, has a level of accuracy beyond that derived from recall of past events and far more than that obtained from the demonstrably faulty village

Field and Analytical Procedures

113

records of births and deaths (Gordon, Singh, and Wyon 1961a). The procedure had special importance in this instance since the contraceptive effect of the program was to be judged not by the number of families who accepted contraceptive advice or said they would practice contraception but by numbers of pregnancies and births in families reporting use of birth control measures, compared to those who did not. 4.5

Required Information

The fundamentals of successful field operation are precise recognition of what data are required, a willing cooperation on the part of those who are asked to give information, and the integrity of the persons collecting it. The technical demographic requirements of the study were (1) an unambiguous definition of a resident in the study area; (2) the best possible estimate of the person's age; and (3) accurate identification of each resident, birth, death, and migration. Every month the staff recorded the methods of contraception each couple of the test population used, their statement of contraceptive practice since the last visit, and the extent of use as judged by supplies furnished. Although not central to the study, the collection of pertinent data on the causes of disease and injury, causes of death, and on medical care, contributed to interpretation of the findings; it was possible because of medical supervision of village field workers. A rough measure of the economic status of households was devised in 1959 by Dr. Gertrude Woodruff, a staff anthropologist. She pointed out that the floor area of houses could be measured by counting the rectangular roof sections formed by the beams and walls. Roofs in the study villages were constructed of units known as khans, usually 12 feet by 4 feet. Further observations were of the quality of the walls, whether of brick dried in the sun, burnt and sun-dried brick, or wholly burnt brick. These measurements served in assessing the size and quality of the housing. On the assumption that wealthier households have larger and better housing than the poor, a crude but practical economic ranking of households was possible. The distribution of households by floor area of houses varied between castes, as would be expected (Table 33, App. A . l l ) . Questions about income were avoided for several reasons. Estimating true income would have been formidable in this society where money is little used and most people live directly off the produce of their land and by exchange of goods in kind. The

114

The Khanna Study

villagers also feared lest such information find its way to the tax collectors. Finally, measuring economic status was no more than a peripheral interest of the study, not worth endangering the rapport with the villagers that direct questioning would have meant. 4.6

Study Plan of a Village Investigation

The field director and his senior male assistant sought out initially the sirpanch, the head of the village panchayat (Fig. 63), or governing council, and arranged with him for a subsequent conference with the whole council. Wyon and Sohan Singh explained the connection with the Christian Medical College at Ludhiana and with Harvard University in the United States, their association with the Ministries of Health of India and the Punjab, and their aim of better information on the health problems of rural people. They outlined the plan of living and working in villages and made clear their obligation to report all findings to the Government for use in designing better health services for rural people. They stressed as particular interests the health of mothers and children, the diseases most commonly responsible for deaths, the care provided at births, and the numbers of people taking up residence in the village or leaving it. The proposed scheduling and nature of home visits was clearly delineated, particularly that men would visit men and women workers the women. In villages where contraceptive measures were to be introduced, the subject of birth control was straightforwardly included among important concerns

Fig. 63. The sirpanch or chairman (left), and three members of the panchayat, or elected village council (left center), Chakohi, and the village watchman (right) prepare to go to Khanna on official business. The panchayathas the power to grant or refuse permission for research in their village.

Field and Analytical Procedures

115

of the study. The topic was carefully avoided in control villages. Other less formal meetings with the village council, often including other leading men of the village, were held at intervals of several days. The negotiations were deliberately prolonged to allow full discussion in the village, so that questions and difficulties could be settled. There was a frank attempt to avoid a quick or forced decision. As acquaintances grew, the need was explained for mapping village houses, for a census, and for a record of births, deaths and migrations. Field workers emphasized that the study would not provide a permanent medical service, that it would likely last about four years, and that the purpose was planning for such services. The staff asked for village cooperation through provision of a house for field workers to live in and to use as a working headquarters. In return the staff undertook to provide on request simple medical care for members of the village, to prescribe for more serious illnesses, and even to arrange for hospital care when necessary. Early in these visits a point was made of visiting local practitioners of indigenous medicine to assure them that physicians on the study staff had no intent to compete with them but would indeed refer patients for continued care. There were no physicians resident in the villages. The study staff toured the village lanes meeting shopkeepers, the school master and others, to introduce themselves and to answer questions about who they were and what they were doing. When the time neared for a decision on acceptance of the study, the senior woman physician and the chief health visitor called on a number of the women, particularly the wives and families of influential men. Agreement by the village leaders was far from automatic. In the early days of one exploration a group of men not on the village council called on Dr. Gideon and demanded to see a letter from the District Commissioner giving permission for the study. Various rumors had circulated that the real reasons for the study were variously for levying more taxes, for missionary work, or for foreign intervention. The letter was produced and the rumors subsided. The Minister of Health for the Punjab later visited the village, explained to authorities and to the people the interest of the Government in the study, and confirmed what we had firmly emphasized: that while they were under no compulsion to take part in the study, it was hoped they would. The foundation of the working arrangement between villagers and study staff was that of host and guests. At the outset, and

116

The Khanna Study

thereafter if any question arose, the staff insisted that field work should take place only at the pleasure of the officials and people of the village, that they were free at any time to ask the staff to leave, and that the staff would do so without demur. Local factions or parties existed in all study villages. From first contact of the staff with a village and throughout the stay, particular care was taken to consult all influential persons before starting a new phase of the study. In the one village where the proposed study was not accepted, the difficulty hinged on the inability of rival factions to agree on which house the staff would use as the base of operations. The five villages of control area B were handled differently. The experimental design required that only simple contact be made with a few officials, avoiding general familiarity with the people themselves, and yet when the time came at the end of the study for the required census, map making, and listing of households, the residents of all five villages took part personally and actively in the operation. New staff members were advised that all sorts of people were likely to ask them who they were and the nature of their job. Anyone who asked was to be given clear and unambiguous answers. The supervisor's first job with a recruit was to ensure that he understood the purposes, methods, affiliations, and likely duration of the study and was able to explain that to people of the village who might ask. Another quality expected of field workers was an ability to listen and to learn, for unexpected wisdom often was to be had even from the usual illiterate person, although it might arrive indirectly. The truth was frequently wrapped in story or myth. The listening required patience and sometimes a canny ability to recognize useful facts when they appeared. At other times information came most directly: for example, the statement that breast-feeding prevents babies. 4.7

Village History and Age of Residents

In the rural Punjab most persons have only a general idea of their age, and yet accuracy in that information is important for virtually all population measurements. Two aids to accurate estimates are a calendar of local events and the pregnancy histories of women. The calendar of local events was an important by-product of the history of a village, the usual first field operation. The older

Field and Analytical Procedures

117

men were delighted to share their unique knowledge of past events. Sitting in homes, shops, or under a tree, the staff cross-checked the events noted by different informants. Eventually in most villages it was possible to build a calendar of well-known local happenings, going back as far as the famous plague epidemic of 1889. These events served to check stated dates of births, marriages, and deaths. Both men and women recalled their age at marriage more accurately than most other events. In the families of bride and groom the actual and relative ages of the couple were regularly topics of interest. The date of marriage could be fixed within a year or two by reference to the event-calendar. Most women had reasonably clear memory of the time elapsed between the marriage ceremony and when they went to live with their husbands; from then until the birth of their first child; and the intervals between births of their children. Ages of younger children ordinarily can be estimated with reasonable accuracy. The ages of older children were checked against the event-calendar to determine date of birth. Ages of children were useful in further cross-checking the years of birth and marriage of their parents. 4.8

Field Identification of Individual Persons

The lack of any system of street names and house numbers raised the question of how to identify households and individuals. The solution was to map each village, identifying streets by letters of the alphabet and numbering the houses. The map ordinarily required the work of two men during two weeks (using a board, prismatic compass, and protractor, Figs. 64 and 65), with a further week to list houses and households (Table 8) with the help of the village watchman. Headquarters staff then made copies of maps and household lists for use in field operations. During home visits the local village worker completed the roster of persons within each household. These family record lists were not only a means to identify individuals by place of residence, but also collectively constituted the village census. A household frequently included several nuclear families, for example, Household B05 in Table 8. Occasionally, a house served more than a single household, and infrequently one household lived in more than one house, for example, B07.

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Families and the Birth Rate

157

six months. The median delay for the group who did go away was 18 months (Potter et al. 1965a). No women had systematic antenatal care (Gordon, Gideon, and Wyon 1965c), and few were delivered in hospitals. Wives customarily returned to the home of their parents for the first, second, and even later children. During the study, 80 percent of first live births took place outside the husband's family home, 36 percent of second deliveries, 24 percent of third, and 15 percent of fourth. Thereafter the proportion was less than 5 percent. Not only did fewer wives return to their native village, but when they did they stayed for shorter periods. That the visits delayed subsequent conception is evident, in that 766 wives 30 to 44 years old in 1959 had an average interval between first and second births of 33.1 months; the interval between the second and third child was 31.3 months — small differences yet with some contraceptive effect. Thereafter birth intervals were about 31 months, increasing after age 30 years to 35 months (Potter et al. 1965c). These observations on patterns of coital frequency and of temporary separations of husband and wife partially explain the age-specific birth rates shown in Fig. 70. 6.2.5

Postpartum

Amenorrhea

Menstruation returned promptly after delivery of a child who died soon after birth or was stillborn; half of the women menstruated within six weeks, and more than 80 percent within six months (Fig. 77). All who had had an abortion menstruated

INITIAL CASES

CHILD SURVIVED 28 DAYS OR MORE CHILD DIED W I T H I N 28 DAYS OF BIRTH STILLBIRTH

1390 102 54

ABORTION

Fig. 77. Wives who resumed menses (terminating postpartum amenorrhea) by month after delivery; percent of wives aged 15 to 44 years with child surviving 28 days or more, death within 28 days of birth, a stillbirth or an abortion; test and control A villages, 1956 to 1959. Lifetable method of analysis (App. C.l).

MONTHS

AFTER

DELIVERY

158

The Khanna Study

within three months. Amenorrhea was much longer when the child survived and breast-feeding continued: by 11 months after delivery only 50 percent of mothers whose child survived had resumed menstruation. Almost all had menstruated at least once by the time the child was 30 months old. Breast-feeding of the newborn in the Khanna area was virtually universal. Three fourths of mothers still breast-fed their children 20 months after delivery, half at 26 months, and one quarter at 33 months after delivery. Breast-feeding evidently suppressed menstruation for a median of ten months past the time otherwise expected. The strong association between postpartum amenorrhea and inhibited ovulation is evident in that only seven percent of conceptions observed prospectively took place before the start of menses. Lactation with accompanying menstruation had much less influence on conception. Figure 78 presents the same four groups of wives as Fig. 77. Differences are small. Women whose live-born child died within the neonatal period conceived more promptly than any other group, although the small number of neonatal deaths — 92 during the study — precludes statistical significance. Age of Mother. Experience establishes that older women conceive less frequently than younger. Associations between maternal age, length of postpartum amenorrhea, and menstruating intervals explain this in part. Wives whose child survived at least one month were considered according to age, above and below 30 years. A year after delivery, 8 percent of the older group and 13 percent of the younger were pregnant and soon stopped lactation. Also,

Fig. 78. Wives conceiving, by month after first postpartum menstruation; percent of wives aged 15 to 44 years with child surviving 28 days or more, death within 28 days of birth, a stillbirth or an abortion, test and control A villages, 1956 to 1959. Life-table method of analysis (App. D . l ) .

> 2

CHILD

SURVIVED

C H I L D DIED

AFTER

WITHIN

28 D A Y S O F BIRTH

INITIAL CASES 966 92

STILLBIRTH

49

ABORTION

183

10

MONTHS

2 8 D A Y S O R MORE

20

FIRST

POSTPARTUM

30

MENSTRUATION

Families and the Birth Rate

159

by a year after delivery, 47 percent of women over age 30 and 62 percent of the younger wives had started menstruating. More detailed analyses indicated that postpartum amenorrhea of Khanna Study women was about one month longer with each added four years of age (Potter et al. 1965c). Once menstruation resumed, women of both groups conceived at about the same rate for the next six months; thereafter the older group lagged. Within 18 months, nearly three fourths of the younger women had conceived, as had a little more than a half of the older group (Potter et al. 1965b). The mean menstruating interval for wives under 30 years was 10 months and for those more than 30 years, 13 months (Potter et al. 1965c). Possible explanation of the longer menstruating intervals of older women could be a reduced capacity to conceive, or that most women past age 30 had one surviving son; many had two or more, and decided they wanted no more children. While use of birth control, including infrequent coitus or unreported induced abortion, could explain the longer menstruating intervals, it would have little effect on length of postpartum amenorrhea. Contraceptive practice was in fact associated with longer menstruating intervals, especially among wives over 30. Postpartum Abstinence. Particularly in African societies (Lorimer 1954), women avoid sexual intercourse during the two or three years they breast-feed children. In rural Mysore, India, 80 percent of a sample of 135 wives reported abstinence from coitus for six months or more after childbirth. A similar study of 142 wives in urban Delhi rarely recorded abstinence of more than three months (Chandrasekeran 1952). The average for 172 women in one village of the Khanna Study was between three and four months, with no essential differences according to parity or caste. The 183 wives of another study village gave average abstinence from coitus after childbirth as five months. A collection of 31 wives who said they abstained until they menstruated, waited for an average of seven months. Another 29 wives whose pregnancy was terminated by abortion, stillbirth, or a child who died neonatally, reported resumption of coitus after two months. A four-month postpartum abstinence from coitus would be expected to have little effect on birth intervals in a society where postpartum amenorrhea averages 11 months; before the first postpartum menstruation the chance of conceiving is low. The evidence in Fig. 78 indicates that menstruating intervals were much the same for women whose infant died soon after birth and those with a child who survived and suckled.

160

The Khanna Study

6.2.6

Pregnancy Wastage

Pregnancies that end in abortion or stillbirth have an evident relation to intervals between live births and consequently to numbers of live-born children and to birth rates. In the Khanna Study region stillbirths were followed by a period of postpartum amenorrhea and then a mean of 11 menstruating months (Potter et al. 1965c) before another conception. Women less than 30 years old lost 11 percent of their children before or during birth, while women over 30 lost 16 percent. This alone would result in older women having longer intervals between live births than younger women. However, older women had longer intervals between conceptions after any delivery — abortion, stillbirth, or live birth. The average addition to intervals between live births attributable to pregnancy loss is estimated in this experience at 1.7 months per birth interval for women under 30 years and 3.1 months for women over that age (Potter et al. 1965c). Reports of early pregnancy loss are so unreliable that rates of spontaneous abortion for a general population are no more than crude approximations. Failure to menstruate within a few days of the expected time is no proof that conception has occurred; conversely, some women bleed after conception in a manner indistinguishable from normal menstruation. Although some women of the Khanna area induced an abortion, the practice was not approved by the community. Numerous women hesitated to report the early spontaneous end of a pregnancy, fearing that they might be thought to have induced it. Almost all abortions they did report were designated as spontaneous. The program of home visits offset some of the difficulties in detecting pregnancy and its loss. To the extent that the reporting was accurate, it permitted precise records of delayed menstruation in a general population and so, presumably, favored early and accurate detection of pregnancy. Information was gathered on 1765 pregnancies; 56 ended in stillbirths and 184 in abortions, giving a stillbirth ratio of 31 per 1000 pregnancies and an abortion ratio of 105 (Potter et al. 1965d). The stillbirth ratio clearly exceeds the 10 to 20 per 1000 pregnancies characteristic of Western countries. By contrast, the spontaneous abortion rate is less than the estimates of 200 and higher advanced by Shapiro, Jones, and Densen (1962), Tietze and Martin (1957), Erhardt (1963), and French and Bierman (1962). The inverse results increase the

Families and the Birth Rate

161

probability that the true rate of spontaneous abortion in the Khanna villages was considerably more than 105 per 1000 pregnancies. Pregnancies sometimes were not reported until two or even three months after conception. A sample of 226 pregnancies ending in a stillbirth or a live birth was examined for date of last menstrual period by subtracting 280 days from the known delivery date. In roughly one fifth of the cases, menses were recorded more than 56 days after the estimated onset of last menstruation. In some instances this can be explained by vaginal bleeding after conception, and in some by a genuinely short gestation, but in many instances the woman probably just postponed admitting pregnancy. Pregnancy wastage, including stillbirths, varied with age of the mother. Women under 20 and over 35 years had particularly high ratios (Potter et al. 1965d), a finding consistent with observations in Hawaii and New York City (Yerushalmy et al. 1956; Shapiro, Jones, and Densen 1962). As age increased, pregnancy wastage among women of the farmer caste progressively exceeded that of leather worker wives, mainly because of more abortions (Potter et al. 1965d). Both groups of women led vigorous outdoor lives, but the farmer group appeared better fed and healthier. On these grounds an expected difference would be in the direction of a lesser frequency among wives of the farmer caste, not a greater one. Their higher abortion rates may therefore reflect a greater number of induced abortions. 6.2.7

Completed Family

The best information on family size within a population comes from women who have finished childbearing, for practical purposes those over 45 years of age. Errors incident to interrupted or incomplete marriages were avoided by considering the group of 459 women past age 45, married only once, and whose husbands were still living. The sum of age-specific fertility rates of a group of married women provides a reasonable projection of the number of live-born children the women will bear. The wives over 45 years of age in 1959 had given birth to a mean of 7.5 live-born children and had lost 34 to 44 percent of them (Table 10). Frequency of births declined fairly symmetrically either side of eight, the modal number (Fig. 79). The small group of wives whose husbands had completed three or more grades of schooling had fewer live-born children than did others but ended with close to the average num-

162

The Khanna Study

ber of surviving children and surviving sons because of fewer deaths. Even this group had lost 32 percent of live-born children. In every group more than 50 percent of surviving children were boys. The caste with the highest average number of live births per woman exceeded the group with the lowest by 15 percent; the difference in numbers of surviving children, however, was only 10 percent. Deaths evidently tended to level out disparities in numbers of live-born children between caste groups. Age of Mother at Last Birth. Farmer caste women over age 45 averaged 36.3 years when they had their last live birth; wives of leather workers were 38.2 years. These ages are sufficiently young to suspect that some women, and particularly some farmer wives, had practiced birth control toward the end of their fertile period. 6.2.8

Age at

Menopause

When women cease to menstruate at 40 to 50 years of age they also regularly cease to reproduce, although in rare instances women have conceived years after apparent menopause. Most information on age at menopause is retrospective, derived from women no longer menstruating. Within the Khanna Study populations 1083 women were of ages 30 to 54 years in December 1959. They usually were visited every month during the study period, in no instance with a lapse of more than three months. Last menstruation was determined for 132. Menopause was recognized when a woman more than 30 years old had not menstruated for 12 months, had not become pregnant during that time, and had no obvious medical reason for amenor-

Fig. 79. Live births to wives aged 45 years or more, still living with first husband; percent of 459 wives, test and control A villages, 1959.

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Families and the Birth Rate

163

rhea, or when a woman more than 40 years old had not resumed menstruation within 25 months after delivery. This latter end point came from the finding that 95 percent of women of childbearing age menstruate within two years after childbirth (Fig. 7 7 ) . The first group included 122 women and the second group 10. Women widowed or separated from their husbands were excluded. The results were interpreted on a life-table basis to minimize bias of the few wives who had experienced menopause past age 45. The findings are plotted in Fig. 80. Fifty percent of the wives reached menopause at 44.0 years. Of 235 women aged 30 to 55 years who reached menopause by 1956 and reported age at last menstruation, the average estimated retrospectively was 42.6 years (Wyon et al. 1966b). Recent results from retrospective studies on Western women suggest about 48 years as an average at menopause (MacMahon and Worcester 1966). 6.3

Primary and Secondary Sterility

A married couple not achieving a pregnancy within seven years was considered primarily sterile. A couple with one or two pregnancies but none thereafter was considered secondarily sterile. Of 459 wives more than 45 years old, whose first husband was alive until they reached that age, only six had never had a child. Four of 250 wives aged 35 to 39 years and 12 of 334 wives aged 30 to 34 years were childless. The numbers are remarkably small, respectively 1, 2, and 4 percent of married women.

Fig. 80. Age of wives at menopause; percent by age, test and control A villages, 1956 to 1958. Lifetable method of analysis (App. D . l ) , based on approximately 140 woman-years of prospective observation by single years, ages 30 to 44; and 18 womanyears by single years, ages 45 to 54.

1 > K

AGE

(MONTHS)

Deaths and Population Pressure

187

2.8 from typhoid, and 2.1 from tuberculosis (Gordon, Singh, and Wyon 1965). Through the second year of life diarrheal disease maintained its lead with an age-specific death rate of 2150 deaths per 100,000 children per year, again a third of all deaths, while measles, tuberculosis, typhoid fever, whooping cough, and pneumonia had individual age-specific death rates of 430 to 770 per 100,000 children per year, together accounting for just over a third of all deaths. During the third year of life diarrhea and pneumonia took most lives, but age-specific rates for the two causes were each less than 300 deaths per 100,000 persons; taken together both causes accounted for only just over a quarter of all deaths during the third year; causes of the remaining deaths were varied, and some unknown. In the study populations virtually all infants died who did not receive breast milk in the first months of life (Fig. 92). Mothers breast-fed their children for an average (median) duration of 26 months. They started to wean the child some months after birth by giving diluted cow, buffalo, or goat milk. At two months after birth, 25 percent of mothers had started to give their children milk of animal origin as a supplement, 50 percent by six months and 75 percent by ten months. The death rate increased sharply at age six months. By that age few children had received any solid food. At 11 months only 53 percent of the children were receiving solid food, and 10 percent of them did not have any solid food until 17 months or more. Delay in starting solid food was associated with a greatly increased risk of death. The data in Fig. 92 present death rates of the first two years of life by three-month intervals up to 18 months of age, and then for the next six months. These data, taken together with the data in Fig. 90, indicate that the increased death rate after age six months was predominantly among children not receiving solid food. Not one child died among the 147 observed to be receiving solid food and breast milk during their third trimester (ages six to nine months), but 24 of the 531 children of the same age not receiving solid food died, a rate of 185 deaths per 1000 person-years lived. In the fourth and fifth trimesters of life the death rate was three times greater among those children not receiving solid food than among those who did have it. In the sixth trimester the ratio was five times and from 18 to 23 months of age, ten times. The differences are statistically significant. Mothers who added solid food to a diet of breast milk evidently

188

The Khanna Study

saved the lives of many of their children, yet progressive addition to the children's diet of milk from domestic animals and of solid food was also associated with increasing numbers of cases of diarrhea, now known as weanling diarrhea (Gordon, Chitkara, and Wyon 1963). The two observations are not necessarily contradictory. Intake of unfamiliar and probably contaminated food may cause diarrhea, but the ingestion of an improved diet ameliorates the child's nutritional status and presumably his resistance to infection. During the early months of life those children who survived the birth process were progressively faced with infections, and if not reasonably well fed, they suffered the direct and indirect effects of malnutrition (Fig. 93). At each of the critical threemonth periods between 6 and 18 months, close to 40 percent of deaths of children on all four feeding regimens were among those children with symptoms of diarrhea. This observation suggests

F i g . 92. Age-specific death rates by trimesters of life f r o m birth to t w o years, deaths and causes of death, by feeding regimen; test I I and control A villages except Gowhadi, 1955 to 1960. NOTE: Death rates: deaths per 1000 person-years at each trimester of life; feeding regimens: combinations of breast milk and solid food, or no food; causes of death: diarrhea and other causes; these children were observed by the cohort method (App. 8 ) ; starting with 779 live births each trimester of life children were assigned to that category of feeding regimen applying when the trimester ended, or just before the child died or migrated.

FEEDING BREAST MILK GIVEN 0 AGE

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Deaths and Population Pressure

189

that no special infection attacked the children taking one or another feeding regimen. Although they all had essentially the same infections, the more children were deprived of adequate food the more frequently they died. A further observation concerns the quality of the protein consumed by young children. Between the ages of 12 and 18 months the few children taking solid food but no longer receiving breast milk had a higher death rate than children receiving breast milk and food. This suggests the importance of high quality protein as part of the diet at these ages. After 18 months of age few children receiving solid food died whether or not they were still breast-fed. Diarrhea of young children has long been a major cause of death. In 1901 infants in London died from diarrheal disease at an annual rate of 3682 per 100,000, and children aged 1 to 4 years at 150 per 100,000 (Registrar General 1901; Census of England and Wales 1901). In 1900 in New York City, deaths from

REGIMEN NO BREAST MILK G I V E N 0 SOLID

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DIARRHEA OTHER

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190

The Khanna Study

diarrhea and enteritis in the first year of life were at the rate of 5603 per 100,000 infants, and 399 per 100,000 children aged one to four years, 80 percent of those deaths occurring in the second year (Emerson and Hughes 1941). In 1961 corresponding rates for New York City were 45.0 for infants under one year, and 2.4 for children aged one to four years (Erhardt 1962). Death rates from enteritis and diarrhea in New York City among children in the first year of life declined over the years from 1891 along with fewer other infections. Between 1906 and 1911, however, the rate for diarrhea deaths turned sharply down while deaths from other infectious diseases continued at the established rate of decline. One outstanding change occurring at that time was the application to infant feeding of new knowledge on how much and what kinds of foods infants require. During the year 1900, both in London and New York City, the death rates from diarrhea for the first year of life are higher than the rate of 2780 deaths per 100,000 infants observed in the study population. The apparent lifesaving effect of even small supplements of solid food is evident (Fig. 92). Deaths from 5 to 14, and 15 to 44 Years. A few children of school age died, mainly from tuberculosis, typhoid fever, and accidents. Between the ages of 15 and 44 years tuberculosis was the chief cause of death, at the rate of 90 per 100,000 persons per year. This was nearly double the death rate from childbirth and the sequelae of abortions. The death rate of just over 100 per 100,000 per year of females aged 15 to 44 years was not great despite deficiencies in obstetric care (Gordon, Singh, and Wyon 1965). Nevertheless, the 30 maternal deaths per 10,000 deliveries

Fig. 93. A child with protein-calorie malnutrition, held by its grandmother, is fed from a brass feeding cup with a spout while receiving medical attention.

Deaths and Population Pressure

191

are six times as frequent as the present rate in countries with a high standard of obstetrical care. Deaths From 45 to 64, and 65 Years or More. During middle age, cancer exceeded tuberculosis and heart disease as a cause of death. After age 65 senility and heart disease headed the list, followed by pneumonia, bronchitis, and cancer; then stroke, tuberculosis and accidents (Gordon, Singh, and Wyon 1965). Deaths at All Ages. Table 17 lists the ten leading causes of death. Acute diarrheal disease is in first place; specific communicable diseases take the next three. The place of accidental deaths may surprise those accustomed to think of motor cars as the main cause of accidents; no accidental deaths from injuries related to motor transport were noted in the study villages (Gordon, Gulati, and Wyon 1962a). Many young children died from accidents, including burns, falls, drowning, and mishaps involving animals (Fig. 94); as malnutrition and infections become better controlled, accidental traumatic injuries expectedly will take their usual place well up in the list of leading causes of death. Preventable Deaths. Age-specific death rates grouped according to available preventive procedures are given in Fig. 94 and Table 20. Outstanding categories include infectious diseases preventable by immunization and infections associated with malnutrition. Almost all deaths in these two categories occurred in the first two years of life. A third notable category grouped deaths of children soon after birth, presumably related to prenatal care and obstetric practices. The heading Infection and Malnutrition (Table 20 and Fig. 94) classes together deaths attributed to nine causes, according to the "B List" of the International Classification of Diseases (WHO 1957a). Three observations support this classification and suggest that a considerable proportion of the deaths are preventable by supplementing breast feeding before children are six months old. These nine conditions were largely responsible for excess deaths among children aged 6 to 23 months (Fig. 92). A field study in Guatemala among children less than five years old related nutritional status and diarrhea. The more severe the malnutrition, the greater the frequency and severity of diarrhea (Gordon and Scrimshaw 1965). A series of careful observations in Guatemala on cases of diarrheal disease resulted in identification of bacterial pathogens in only 36 percent of cases. Shigella, notorious agent of bacillary dysentery, accounted for less than one half of such cases (Gordon, Behar, and Scrimshaw 1964). Deaths attributed to tuberculosis and to fecal-borne infections

192

The Khanna Study

Table 20. Deaths by cause; number of cases in each selected disease category, test and control A villages, 1957 to 1959 Disease categories»

Cause of death

Cases

TUBERCULOSIS

B1 B2

Respiratory system Other forms

33 7 40

FECAL-BORNE DISEASES

B4 B6, 17 B36, 45

Typhoid fever Dysentery and helminths Gastritis and diarrhea in persons over 2 years old

26 10 11 47

PREVENTABLE BY IMMUNIZATION

B8, 9 B13 B17 (061) B14

Diphtheria and whooping cough Smallpox Tetanus Measles

10 1 33 18 62

INFECTION AND MALNUTRITION

0children under 5 years of age) B6, 17, 21 B31, 32 B36 B44, 46, BE48

Dysentery, pyemic infections, steatorrhea Pneumonia and bronchitis, steatorrhea Diarrhea and gastroenteritis Malnutrition and infections

27 67 31 129

BIRTH INJURY AND PREMATURITY

B42 B43 B44 B45

Birth injuries and postnatal asphyxia Infections of the newborn Immaturity and other diseases peculiar to early infancy Convulsions

29 6 33 2 70

ACCIDENTS

B17 B34, 35 B46 BE48, 50

Rabies Acute surgical emergencies Drug addiction Traumatic injuries

2 6 2 23 ~33

NEOPLASM AND SCLEROSIS

B18 B19, 20 B22 B26 B28 B39, 45, 46

Malignant neoplasms Uterine fibromyoma and diabetes mellitus Cerebral hemorrhage, embolus and thrombosis Arteriosclerotic heart disease Hypertensive disease Hyperplasia of prostate, senility and other arteriosclerotic conditions

27 2 8 18

10 14

Deaths and Population Pressure

193

Table 20 (continued) Disease categories»

Cause of death

Cases

OTHER CAUSES

B3, 10, 12, 17 B21 B22, 23 B25, 27 B31, 32 B36, 37 B38 B40 B41 B45 B46 B46

Infections Anemias Lesions of central nervous system Rheumatic and other heart disease Pneumonia and bronchitis in persons over 5 years old Diseases of intestines and liver Nephritis and nephrosis Fatalities associated with pregnancy and childbirth Congenital defects Ill-defined and unknown (pyrexia of unknown origin, 22 cases) Asthma Other diseases

4 8 2 6 35 6 6 7 8 47 10 16 155

a

B numbers refer to "B-List," International (1955 rev.).

Classification

of Diseases, vol. I

Source: Ibid. Geneva, World Health Organization, 1957; Khanna Study records.

other than diarrhea presented relatively minor problems. The remaining categories of death gave little promise of successful preventive action feasible on a wide scale. 7.4.4

Sex

In this population, the rates of death from all causes were higher among females than males. As exceptions, newborn males died from tetanus at three times the rate for females (Gordon, Singh, and Wyon 1961b), and between ages one to five months the death rate of males was slightly higher (Fig. 90). The male death rate did not subsequently exceed the female rate until after age 50 years (Fig. 95). Taking the first five years of life as a whole, the death rate of females at 74 per 1000 substantially exceeded the male death rate of 50 deaths per 1000 per year. By five years of age the survivors from 1000 live-born boys far exceeded the survivors from an equal number of girls. Above 25 years, the gap widened (Figs. 91 and 95). Visaria (1963) studied the relation between death rates by sex and the sex ratio of the Indian population. Northwest India has been known for many years to have an excess of males in the population. In 1911

194

The Khanna Study

there were 1225 males for every 1000 females in the Punjab (Census of India 1911). In most other parts of the world females of a general population have lower death rates than males (United Nations 1963a). Visaria examined and then discarded two possible explanations of the low proportion of females in the Punjab. According to one hypothesis, women in the Punjab gave birth to substantially more than the usual 1050 males for every 1000 newborn female children. Underreporting of females to the census provided another possible explanation, but Visaria disproved both. However, by applying the proportions of male and female surFig. 94. Death rates (deaths per 1000 persons per year); by cause of death grouped according to possible preventive techniques, and by age, test and control A villages, 1957 to 1959. Categories of causes of death are explained in Table 20. SOURCES: International Classification of Diseases, Vol. I (1955 Revision). Geneva, World Health Organization, 1957; Khanna Study records.

C A U S E S OF DEATH SELECTED INFECTIONS FECAL BORNE

TUBERCULOSIS

PREVENTABLE BY IMMUNIZATION

AGE 65 YEARS AND OVER o o o

AGE 45-64 YEARS r b


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by caste are shown in Table 40. The leather workers increased twice as fast as the farmers from 1957 to 1959; in the next nine years, growth rates of the two groups drew closer. Starting with a 1957-1959 growth much less than that of the farmers, other castes had joined farmers with a growth rate of 1.3 percent per year by 1966-1968. During the nine years following the end of field work in 1959 the birth rate declined more than expected. The fall in the death rate also exceeded expectations. Consequently, the rate of natural increase remained essentially constant. The surprisingly lower rate of net emigration from the study villages accounted for the increased population growth of the region, a finding perhaps explained by the improved economy. 11.5.5 Village Economy Larger incomes. The staff had last seen a wheat harvest in the Khanna region in 1960. As the 1969 crop stood in the fields and was delivered to the Khanna grain market at the door of our house, the difference from 1960 was startling. Informants in the villages provide details of the altered situation. Reports by the Intensive Agricultural District Program (IADP 1968), amplified information applying to the district as a whole. Between 1960 and 1969 the land area cultivated in the study villages remained virtually constant. Acreage sown to wheat more than doubled, however, and to maize almost as much. The smaller crops of sugar cane and peanuts increased, while cultivation of cotton decreased and that of lentils (gram) virtually disappeared. Fodder crops and fallow land decreased sharply, presumably a consequence of the growing replacement of draft animals by motor tractors, of increased irrigation from tube wells, and the use of chemical fertilizers. Sandy tracts, formerly suited only as grazing land in winter and for peanut cultivation in summer, now produced wheat in addition to peanuts. Thanks to mechanized ploughing, land used for cotton was cleared during September and October in time to sow wheat. The outstanding change was in wheat cultivation. The land area of individual study villages sown to wheat in 1969 varied by locality from 36 to 80 percent. The proportion for the district in 1967-1968 was 40 percent, twice that of 1960-1961. According to crop-cutting studies, the yield of wheat per acre doubled from 1961 to 1968, and informants in the study villages reported the total production in 1969 as approximately four times

Khanna, 1960-1969

305

that of 1960. Crop prices of wheat and sugar cane more than doubled during the nine years. The price of maize, cotton, and peanuts also increased, although in lesser degree. Between 1961 and 1968 the total value of crops in the district rose from 220 million rupees to over 630 million, with half of the increase in the last two years (Fig. 119). By 1969 the price of land had increased four times, from about 1000 rupees per acre in 1960. Top quality land in ideal locations brought 20,000 rupees per acre at the time of the survey. Agricultural prosperity affected the demand for labor, brought higher wages, and altered relations between employer and employee. Life on farms became less leisurely. The new varieties of grain required more irrigation, and fertilizer had to be applied at fairly precise times. Harvest operations were taking a week or two instead of the former six weeks. The lull in cultivation during the hot dry season of May and June had largely disappeared because tractor ploughing and adequate irrigation made possible an intervening crop. The high costs of modern farming, as well as the innate competitiveness of farmers, stimulated production. Farms were small by Western standards, and mechanization was far from complete. The demand for labor had increased, with the result that wages had more than doubled in nine years. Farmers no longer paid daily wages at harvest time. Many times they let the work by contract to individuals who brought their wives and older children to the task, to receive 1/30 to 1/25 of what they reaped. Landowners devoted more time to managerial functions and less to manual labor. Increased mechanization meant fewer draft animals, with resultant high costs for diesel fuel and the now

Fig. 119. Annual production of food grains, cash crops, and value in rupees; District Ludhiana, Punjab, 1960-61 to 1967-68.

1965-66

AGRICULTURAL

66-67

YEARS

67-68

306

The Khanna Study

needed chemical fertilizer. Consequently, share-cropping declined, and laborers were engaged by the day, month, or year. A year's contract in 1969 brought 600 to 1500 rupees, with meals, but no share in the crop. If the share principle held, the worker was required to deduct the cost of fertilizer from his 1/10 to 1 / 1 6 share. The jajmani system was declining, but where it still obtained, payment was in grain. Brahmins and other non-agricultural high castes were turning to shopkeeping or to service employment outside the village. Money-lenders had given up their profession; they could not complete with government schemes for financing agriculture. Despite increased costs of cultivation, estimates indicated that the income of landholders had increased four times between 1960 and 1969. More investment in domestic and agricultural possessions characterized the decade. In 1969, better than 90 percent of farming families had their own domestic water pump and at least one bicycle; laboring households with these advantages reached over 60 percent. The 1960 levels were 50 percent for farmers and 2 0 percent for laborers. Radios, sewing machines, and electric fans had become features of village households in 1969, enjoyed by some 50 percent of high castes, including farmers, and 10 percent of laborers. The former almost silent bicycle ride between villages was in 1969 often enlivened by music or news from the transistor radio of some companion of the road. Bullocks were still important draft animals. Camels were fewer as the persian wheels installed on open irrigation wells gave way increasingly to tube wells. Some 50 percent of farmer households had camels in 1960, and less than 20 percent in 1969. By the mid1960s, possession of pneumatic tired bullock carts, mechanical threshers, and fodder choppers became commonplace. During this same decade the financing of agriculture underwent major changes. Cooperative banks provided fertilizer on short-term credit, and the state-owned Land Mortgage Bank made loans extending over seven to ten years, mostly for purchase of tube wells and tractors, taking title to the land as the pledge. While numbers of loans increased six times, unpaid loans were only three times as frequent. Among study villages, loans repaid equaled or exceeded new loans in only two villages in 1960, but in 1969 five out of seven villages had attained that solvency. The greater capacity to repay loaned capital reflects the increased income of landowners. Trade, apart from agricultural produce, local manufacturing, and income from outside the home village, contributed minimally to the growing village prosperity.

Khanna, 1960-1969

307

Apparent reasons for the improved economy. Farmers in the study region have learned to drill for water. In the old days the word was that they planted their crops and waited for God to send rain; now they irrigate. In 1966 the monsoon was feeble, but much of the crop was watered adequately by simple pumping sets: small diesel engines and boring machines, mainly of local manufacture. The abundant subsoil water was a priceless advantage. Farmer families using canal water for irrigation dropped from 20 percent to 6 percent. Situated near a large canal, with ground water close to the surface, only 20 percent of farmers of control A had invested in tube wells by 1969, but in the test villages 80 percent had made the change. In 10 years tube wells in the 11 study villages had increased from 11 to 500, distributed among 1000 farmer households. A 1969 sample of 20 farmer households with more than 10 acres of land showed 16 to have a tube well; 23 households owning 5 to 10 acres had 14 tube wells; and 7 of the 14 who owned less than 5 acres. Ownership of tractors in the 11 study villages jumped from one in 1960 to 39 in 1969 — more in the test than in control A villages. By 1964 a majority of large landowners used chemical fertilizers. Smaller landowners adopted that practice somewhat later, but by 1969 virtually all had made the change. Introduction of highyielding varieties of wheat was more recent, yet by 1967 half the farmer households were planting the new varieties, and by 1968 almost all. Agricultural progress owed much to better social organization, particularly availability of capital. Since 1962, nine of the 11 study villages had consolidated their landholdings. Road access during wet weather to and from the test I villages was markedly improved by 1969, and paved roads were under construction to villages of test II and control A. Farmers of the region were much involved in the new agricultural technology. They competed avidly for improved seed wheat as it became available. They listened to daily radio talks, took lessons in maintenance of tractors and other farm machinery, and discussed endlessly the quantities and kinds of fertilizer best used, and the intervals between irrigation suited to particular crops. Cultivation of fruit trees was becoming popular. 11.5.6

Rising

Expectations

Interviews on aspirations were limited to a one-in-five stratified sample of 83 men, heads of households from one test and one control A village. The aim was to compare 1969 ideas and atti-

308

The Khanna Study

tudes with those of the earlier study period concerning means of gaining a livelihood; what they set as goals for themselves and their children; their judgment on desirable and practical financial investments, their goals for the foreseeable future, and why they made these choices. Desired number of children, boys and girls, was a special interest. Expenditures 1964 to 1969. Well over half the households of all castes spent major amounts of money on marriages and other social functions. Almost all farmer households invested either in tube wells or in farming machinery, including tractors. Land purchases had concerned 8 of 48 farmer households, 5 of 30 leather workers, and 3 of 35 other castes. Some members of all social groups purchased, constructed, or renovated dwellings; and five leather worker households had installed a domestic water pump. Expected expenditures, 1969 to 1974. The commonest future ambition, especially among leather worker and other low castes, was to improve housing and to spend more money on marriages of children. One third of the farmer households planned to buy farmland, and about one fifth of leather workers hoped to buy land for house construction. A few mentioned education of children, purchase of cattle, repayment of debts, and investment in business. Four fifths of the farmer and leather worker groups had plans for some special investment; both groups devote themselves primarily to agriculture. Roughly one half of the remaining, non-agricultural groups — high and low caste -— reported no aspiration involving a cash investment. Preferred age at marriage. Twenty years was by far the preferred age for marriage of sons, higher castes tending toward later ages and lower castes to younger. Only 8 percent gave as their choice ages less than 16 years, and 15 percent preferred 24 years or more. The most common preference for daughters was 16 years or less, although nearly 45 percent considered 18 to 20 years as optimal, the means varying from 18 years among farmers to 16 years or less among low castes. These stated choices for daughters are strangely at variance with actual practice as determined by survey in 1969. The power of traditional thinking seemingly overshadows perception of reality. For all castes two modal ages were strongly evident, one between 15 and 16 years, and the other between 18 and 20. Expression of the two preferred ages for marrying daughters may be correlated with their level of education, a possibility worth investigating as more data become available. Family size. Roughly 60 percent of household heads considered seven or more children as too many; 20 percent did not want to

Khanna, 1960-1969

309

exceed four. A further 20 percent would not consider eight children as too many. On the other hand, 60 percent thought three children or less as too few. High-caste families considered five children too many, and low-caste families put the number at seven, with statements concerning too few children varying in corresponding fashion from three to four. About one half of all householders admitted the disadvantages of too large families, mainly the expense in providing for so many, the difficulties in proper education, and the likelihood of family quarrels. Few were concerned that they might be unable to arrange for the marriage of many children, although these events were high on the list of recognized major expenses. More than half the householders could see no disadvantage in limiting numbers of children. Most mentioned less expenditure, a better provision for the family, including education for children, or an improved health of the mother as advantages of a small family; but few thought that a small family would materially lessen the number of family quarrels or affect fragmentation of landholdings. Disadvantages of few children were seen in lower family earnings, mostly from fewer hands for work. Three heads of households were concerned that fewer children would lessen the ability of the family to protect itself, while only one household mentioned a concern that children might die. Summary. An improved standard of living, the augmented social status arising from more expensive marriage functions, and comfortable housing stand out as central aspirations. For the most part, between three and four children were considered desirable, and yet many could see no disadvantage from small families. Attitudes toward family size appear to be in transition, lacking a clear focus on how large or small families affect their present and future interests. Remarkably few seemed to be aware of the existing high mortality among young children. 11.6

Comment

11.6.1

Population Adaptation

in the Rural

Punjab

The 1969 follow-up of the Khanna Study had two main purposes: to trace population adaptation to materially enhanced numbers during a decade, and to observe the long-term response to a preceding introduction to community birth control. Yet, to confine attention to the period 1954 to 1969, only 15 years, is to accept a grossly restricted view. The need is to recapture the broader time perspective of populations adapting — and that dates remotely.

310

The Khanna Study

The study population lays claim to a continuous ancestral male line, residing in the same location, often in the same houses, stretching into history well past British occupation of the Punjab in 1854. The older people had often heard their parents and grandparents recount personal experience of intermittent famines, epidemics, and local wars affecting homes and village lands. Looking further back they recognize and honor the historical and mythical past, the days of Alexander the Great and the Aryan invasion of India. Older men of the study villages still recall, in 1969, the plague epidemics of the century's beginning and the early stirring toward political independence of India. Some few had a part in the First World War; many remember vividly the calamity of the influenza epidemic of 1918. They recall in later years the introduction of peanuts and of "American" long-staple cotton as cash crops. The Second World War and the arrival of national independence involved many as mature adults, their memories scarred by the mass migrations and mayhem accompanying partition of the Punjab. With India's independence in 1947, the nation inherited a number of variously effective official and unofficial efforts to improve the lot of the general population. The Punjab and central governments had departments for agriculture, canals, education, health, roads, railways, posts and telegraphs. All India Radio gave the news. The new national government set to work to coordinate these efforts at the local level through a new Department of Community Development, and in individual villages created panchayats to assume limited administrative responsibility. These activities were in progress when the Khanna field study began in 1953. Industry was already well established in Ludhiana City and elsewhere. The power of the voter in local, state, and national elections was a growing reality. Thus the study staff in 1954 moved into an ecosystem with strong and well-defined characteristics. The climate, terrain, and soil favor cultivation of virtually all staple food grains, and cash crops of cotton, sugar, and peanuts. It is highly suited to doubleor even triple-cropping in a single agricultural year. The rural Punjab in 1954 had experienced 30 years of improving health conditions, and a growing economy. Death rates declined; past epidemics of the killing pestilences receded. An unappreciated gross excess of deaths at early ages still persisted. The population had long practiced population control to a

Khanna, 1960-1969

311

limited and partially effective extent. Birth rates, though high in comparison with Western experience, were in fact considerably modified. Extended breast-feeding, abstinence from coitus, induced abortion, and delayed marriage of women were recognized as effective methods of birth control. The population used them to the degree they considered wise, so that fertility was about 40 births per 1000 per year, instead of a readily attainable 55. Excessive deaths at early ages among girls had been a fact of life in the Punjab at least from 1881, as indicated by official censuses. Differences between boys and girls in survival to reproductive ages also contributed to population control; marriageable young women were scarce. Living in tightly packed villages, the dominant peasant farmers were independent in mind and ambitious. The remainder of the rural population for the most part served agriculture in one way or another. Those persons who could not make a satisfactory living in villages sought jobs or land elsewhere, often remitting money home and eventually returning to their native village for retirement years. The rural Punjab had good communications with local and more distant urban centers, and transport was advancing. Industry, with government encouragement, had long sought expansion into the rural market, potentially an impressive commercial opportunity. The same government had encouraged developments to the benefit of the rural population and their agriculture. The Punjab, as one state within the federation of the Republic of India, had a large hinterland of relatively unrestricted trade. Between 1954 and 1959, when the study staff was in daily contact with the 11 villages, the move toward social and economic development was evident. Progression was toward a climax, still undefined in 1969. As far as the test villages were concerned, the study program for birth control represented an early phase in the national family planning program, later to develop intensively in district and state. That activity, however, was merely one of numerous widely publicized innovations competing for attention. Within a few years after field work ended in 1959, all study populations and the rest of the state were involved in the broad governmental family planning program. In 1969, publicity for that program had reached unprecedented heights, using highly varied techniques, creating clinic facilities and multiplying surgical centers for birth control. Existing commercial channels for distribution of soap, tea, and flashlight cells were enlarged to include dispensing of condoms, at 0.15 rupee for three. It provided new methods of

312

The Khanna Study

birth control for old, but offered little else to modify the total circumstance in which the Punjabis considered and decided the merits not only of method, but how much birth control to apply. The decade ending with the wheat crop of 1969 witnessed a transformation of agricultural method and an enlarged gross community product. Those segments of society involved in agriculture had strengthened their position, while tradesmen and others were losing place in the village economy. For farm workers, landowners as well as employed, this was a new way of life, with long hours of work and new skills to learn. Education was recognized as an increasingly valuable asset, for girls as well as for boys. The age of women at marriage advanced well beyond the trend under way in 1959. New investments directed to the land (fertilizer, high-yielding seed, intensified irrigation, and mechanically aided cultivation) were yielding more return. The people were under pressure to produce still more for trade within the larger economy. They consumed more of the local and national industrial product: machinery, transport, chemicals, and fuels for agriculture; domestic consumer goods and equipment; and such luxuries as radios, sewing machines, alcoholic and other beverages, entertainment and travel. Capital and current costs increased along with the improved standard of living. Expense in educating the next generation for their place in society was rising with the rest. Land prices multiplied. Farmers and others of the rural population were compelled to recalculate the ratio of costs against personal benefits from the children they had or contemplated. Reflecting on changing scales of value a village woman remarked sadly, "Neglected today are wells, parents, and cows." The methods of birth control introduced after 1959 account in part for the subsequently experienced decline in birth rates; postponed marriage for more. The real impress was from the improved way of life and a better economy. These same factors apparently influenced the lesser death rates. The long-established excess of female deaths showed no sign of decline. Net emigrations from villages of the Khanna region continued as a dominant but smaller factor in reducing numbers of persons directly or indirectly dependent on the local land for a livelihood. In terms of social organization, rural populations of the Khanna region were becoming categorized into economic groups of landowners, agricultural laborers, and those supplying services useful to agriculture. The ancient system of caste occupations no longer

Khanna, 1960-1969

313

reflected precisely how individuals and families were contributing to the economy. 11.6.2

Response to Population Pressure in 1969

In the Khanna Study area, the rate of agricultural production between 1960 and 1969 increased more than did population growth. Incomes rose. Birth and death rates declined in parallel, leaving an essentially stable rate of natural increase. The proportion of children failing to survive the early years of life was still high enough to cause parents to hesitate before drastically curtailing pregnancies. The availability of more efficient methods of birth control had precipitated no rush to utilize them. In fact, largely because of an induced greater productivity of the land the balance between numbers of people and resources had improved, and with it a diminished sense of population pressure. 11.7

Conclusions

Findings from the follow-up study confirmed, clarified, and broadened concepts and principles derived from the original study. The people of the Khanna region had gained new and valuable experiences. They had acquired a convincing, personal exposure to a higher standard of living. They proved they were able to master new techniques and reorganize their professional, personal, and social lives to good purpose. They were convinced that education pays. Thanks to the Intensive Agricultural District Programme, experimentally introduced in this selected area, they had attained a temporary yet marginal respite from population pressure. They were taking good advantage of a special and temporary set of circumstances, thereby gaining time to assess the values and the personal profit from a more favorable balance between resources and numbers of people. The observed progress toward lower birth and death rates, small as it is and without demonstrable gain in the proportion of couples practicing birth control, conceivably marks operation of much the same social and economic factors by which European peoples, in the course of years, achieved a reasonable population control. The stimulus from the demonstration agricultural program provided by the state, true enough with active local cooperation, is still temporary. It did not originate in thought or effort by the people themselves. A present opportunity does exist to make it definitive.

314

The Khanna Study

As of 1969 popular response to the family planning program was small, but definite. The program was supplying a felt need, with prospects that it likely would grow as more people became conscious of the benefits resting in restriction of family size to numbers they can adequately prepare for a higher standard of living, now within their grasp. The future is problematical. Rising land prices presage land hunger as acute as in the days of subsistence farming. Easily available capital is likely to end. Numbers of people will surely increase in the absence of more enthusiasm for birth control. The need of the moment is to take advantage of the existing situation through more active effort in birth control, resting primarily on their own initiative and motivation. The demonstrated delayed marriage of women, one potential toward slowed population growth, was of that origin. The relatively restricted increment of children from 1959 to 1969 indicates increasing determination to reduce family obligations, and with that a sufficient command of methods to achieve birth control. Fundamentally these village communities must themselves undertake the task of learning the gains to be made through lesser growth in numbers. More specific direction is needed toward practical methods of keeping young children alive and well before parents will be convinced that two to three children adequately ensure another generation. The motivation and strength of purpose to achieve the desired ecologic balance can issue only from its single effective source, the people themselves.

Appendices Glossary References Index

Appendix A

Record Forms

The various record forms used in this study were printed on cards or on pages of field notebooks (Sec. 4.15). Registers were maintained to record births, deaths, migrations, accidents, and to identify the children taking part in the cohort study on mortality and morbidity (App. A.8). All forms and registers are described in this appendix as to purposes, appearance and definitions of items. Record forms were completed in ink. Use of erasable pencil was forbidden. To make a correction the original entry was circled, leaving it legible; the correction was added, initialed, and dated. The forms described here were developed in accordance with the concepts guiding the study (Sec. 1.3.1), and study design (Sees. 1.3.3, 1.3.4 and 1.3.5) within a specific culture (Chap. 3). Field procedures and the staff who developed and used these record forms are described in Chapter 4. Record cards were stored in packs of their own kind, always in order by village and by household number. A.l

Family Record (Fig. A-l)

Purpose To describe: 1) Identification of all households and families. 2) Personal identification — of each person ever a resident of the study population between April 1, 1956 and March 31, 1960, by: village of residence, household, family and individual number; caste; name of head of household, and either the name of his father or of her husband. 3) Relationship to head of household — of all persons ever resident in the study population. 4) Census — for initial and subsequent censuses. 5) Changes in census status — of individuals, families or households, as they occur, by: birth, death or migration; change in marital status; or transfer from or to another household in the same village. The Family Record was used in conjunction with the map of houses (Fig. 64) and the Household List (Table 8), described in Sec. 4.8, Identification of Individuals.

318

Appendix A

Definitions (of details in Fig. A-l) Item: 1. Village

— t h e group of households recognized by government to constitute a village.

2. H. Hold No. (household number)

—letter A, B, C, etc., identifies the street into which the front door of the residence opens (Fig. 64, Table 8). First two digits, identify the household in the street. Third digit, family number.

. ,~B.HM)

FAMILY RECORD village

2.

H . Hold N o .

Record Forms

319

Definitions continued (Fig. A-- 1 ) 3. Head of Household

— the person recognized by household members as their head.

4. s/o, d/o, w/o, wid./o

— son of, daughter of, wife of, widow of . . . The applicable notation is circled.

5. Caste

— the name of the caste of the head of the household as given or confirmed by him.

6. Informant

— name and household number of individual.

7. s/o, d/o, w/o, wid./o

— same as Item 4.

8. Rein, of infnt. to hd. of H. Hold (relation of informant to head of household)

— Example: use "father's brother" not "uncle".

Column Number: 9. Individual Records

— intended as a master list of all records, but never used.

10. Sr. No. (serial number)

— ( = individual number), the number assigned to the individual at the initial census.

11. Household members

— names of individuals.

12. Sex

— M or F (specified).

13. Marital Status

— at the original interview: (specified). U = unmarried, never married. M M + = married and muklawa ceremony performed, cohabiting (Sec. 3.7.3). MM— = married but not yet cohabiting. W = widow. Wid. = widower. Sep. = separated. Div. = divorced.

14. Rein, to head

— wife, D of 1 = daughter of individual with serial number 1 in Col. 10, etc.

15. Age

— stated age at last birthday, estimated with the help of the village calendar (Sec. 4.7).

16. Change in Family Status: Nature

— for record of births, deaths, migrations, with serial number according to the appropriate register of the village (App. A.12).

320

Appendix A

Definitions continued (Fig. A - l ) 17. Date

— d a y , month (spelled, abbreviated if necessary), year.

18. Remarks

— t h e place to record where a person went to, came from and why.

19-22. Census 1957 . . . 1960

— " P " and the date indicate that the person was present at the census check (Sec. 4.9).

Procedure The Family Record of each family within the study was filled out after the start of field work (Sec. 4.6). Changes in the census (or family) status of individuals by birth, death, migration, marriage, or widowhood were noted on the Family Record (Cols. 16, 17) as soon as the events were confirmed (Sec. 4.11). Every year the census was checked, starting with the map of houses, then the household list, and finally the check of each household (Sec. 4.11). Marriage of a male resident of the village created a new family. The staff deleted his name from the Family Record of his parents, and started a new Family Record for him and his family. When a household split or a new household moved into the village, a new household number was added to the Household List with a note to describe the derivation of the new household. Each household and family number was unique; a household and a family number once assigned was never given to any other household. *

A.2

*

*

Menstrual and Pregnancy Record (Fig. A-2)

Purpose To record, from all married women resident (Sec. 4.9) in study villages: 1) Histories of all marriages and pregnancies. 2) Previous attempts to limit births. 3) Selected sociological information. 4) Response to initial offer of contraception: As originally designed, this form included a place for monthly menstrual dates, lactation, conception and deliveries. After a year of field experience this function was transferred to Field Notebooks (App. A.5) and to Coded Registers (App. A.6). The design, as used and illustrated, did not provide a satisfactory method of recording all marriages. No space was provided to record age at marriage, age at cohabitation and year

Record Forms

321

of cohabitation for second and subsequent marriages, nor for a distinction between the pregnancy histories of second and subsequent marriages. Definitions (of details in Fig. A-2) 1.

Identification Items 1 to 7

2. Pregnancy

— a s Family Record (Fig. A - l , Items 1, 2, 3, 4, 5, 8, and Col. 14).

History

Items: 1. Age

— checked with Family Record, Col. 15.

2. Age at menarche

— reported age at first menstruation.

3. Marital status

— checked with Family Record, Col. 13.

MENSTRUAL AND PREGNANCY RECORD

.Uta/f.i.!.

Village. 1.

4.

7.

A î

2.

Age at marriage. . . / J .

...

5.

Age at

MONTHS

5.

Rein, of (3) to head of h. hold

. / A

3.

Marital

6.

77

« J f e f e « * » » )

1*7...

OF Abstinence

During preg.

Post partum

Age at _death 12

A,

tim&SL WtLAS

%

Cas t e . . .

.WAF*. .9?..

Year of c o h a b i t a t i o n . . . . .

4

JÄti

.fi.!A!..

Pregnancy history.

menarche..

Age at cohabitation...

Amenorrhoea

Month & year of

d/o,(S)wid/o...C..^y^

.. 2.

Ago

H . hold N o . .

Identification.

N a m e . . . . . ^ . . ^ Head of h. h o l d . . J ^ - . .

2.

SU F

.¿r

-

^LS

li.

"/'ABustm