The stories of Shida and Zainab
Shida was a Kammi woman (see below for an explanation of the caste system) who had received no antenatal care and planned on delivering at home. When she went into labour, the baby was in a transverse lie. After two days of labor under attendance of two traditional birth attendants, Shida was taken to a private hospital in a small town a 45-minute drive away. A C-section was performed, but the baby died. On day 41 postpartum, Shida complained of pain in her legs and her health deteriorated rapidly. The doctors of a small nearby hospital referred her to a major teaching hospital, but the family decided they could no longer afford her care and let Shida die. Shida, along with her husband, mother-in-law (also her father’s sister) and parents worked and lived at a bhatta, which is a brick making kiln. Bhatta workers are best described as bonded labor. A family enters this arrangement when the family head is forced to take a loan for whatever reason, which must then be repaid with interest. Workers are paid Rs 300 (US$2.50) per 1000 bricks; a family of four adults can make about 2000 bricks per day, earning the equivalent of US$5.00. In order to keep up with debt payments, men, women, old men and even children as young ten years of age need to work under horrendous conditions from sunrise to sunset (4 am to 7 pm), with only a break for lunch.
When Shida required medical care during childbirth and later, her family had no financial or social resources. The medical and funeral expenses for Shida and her baby were borrowed from the bhatta owner, adding to the family’s never-ending debt.
Zainab, aged 20, also belonged to the Kammi caste, although she was married into a very poor Mianne caste, which is just slightly above the Kammis in status. She lived in an extended marital family outside of her own biradari that included her husband Salim, his mother, his brother, and his sister Ayesha. Approximately six months into the pregnancy, Ayesha kicked Zainab in the abdomen and threw her out of the house. A few hours later, Zainab delivered twin girls who died soon afterwards. Zainab died the next morning, eight hours after the delivery. According to Salim’s mother, Zainab was pale, sweating and limp, and she “just slipped away.” Although the marital family denied there had been any vaginal bleeding, the neighbors said the bed was soaked with blood when Zainab’s body was taken away.
At no stage was Zainab taken to a health facility; no healthcare provider other than a minimally--trained village-based lady health worker was consulted for childbirth, and no one was called between the delivery and Zainab’s death. The family never directly said that they did not seek medical care; we had to probe carefully to confirm that no one was consulted, as the family members were very reticent about discussing these choices. Their narratives were primarily centered on questioning why Zainab died when there was ‘nothing wrong with her’. They were also reluctant to discuss Ayesha’s violence and the role it played in the deaths of Zainab and her babies. Their narratives were devoid of any self-questioning, although the reticence about discussing key events suggests they were aware of it. The neighbors were more forthcoming about injustices meted out to Zainab, primarily in the context of sasural-bahu (marital family-daughter-in-law) relations but even they did not make the links between the beating and subsequent death. A maternal death inquiry too did not identify the prior violence.
Clearly, seeking medical care for Zainab would have incurred financial costs that were not considered justified for a number of reasons. Her husband does not work and never provided for Zainab. Her natal family was also very poor. Since this was an exogamous marriage, her natal family could not advocate on her behalf. All these factors located Zainab in a very weak position structurally and therefore extremely vulnerable to harassment by her marital family.
The social order of the village
Our research revealed the existence of a hierarchal caste system that underpinned chronic poverty and provided some insight into the underlying social and economic dynamics that prevented Shida and Zainab from accessing care that was otherwise physically available. The pivotal social institution of our field site is a kin-group called a biradari. Consisting of a group of households linked by blood, it also constitutes a social, economic and political unit of the village. Members of a biradari adhere quite closely to the basic rules set forth by the rules governing the kinship group. Nonetheless, the biradaris are not necessarily harmonious structures; loyalties, solidarity, and animosity can all exist within the same biradari at different times. The close relationships provide the basis for mutual support and cousins are natural allies against any external threat, but in the absence of that, rivalry over the common grandfather’s land provides the basis for bitter, sometimes violent, conflict.
The second level of the social order is the zaat or caste system. Similar to the Indian caste system, the zaat system is hierarchal, with some blurring at the borders. There are five main zaats in the village with the Chaudhrys (also called Warsis because they are the inheritors of wealth) and Rajas at the top, followed by the Mirzas, the Miannie and finally the Kammis. Pakistan is a context where landownership equates to economic security, power and prestige. Not only do the higher caste Chaudhrys and Rajas own large tracts of land with associated power, they are understood to be ‘khandaani’, a term connoting high moral standards, that their word means something; they never beg.
At the bottom of the zaat hierarchy are the Kammis. Our preliminary data suggests members of the Kammi zaat are socially constructed as inferior. The term Kammi is used to describe this zaat because they are, according to the higher caste, ‘kaam karne wale’ (those who work). A more nuanced analysis, however, suggests it is the root of the term ‘kam’ that is the real descriptor of the social construction of this zaat. The word ‘kam’ translates into ‘less’ and refers to the widely held belief that this caste has a lower level of ‘zameer’ (conscience, virtue or moral character) than people of high castes. The higher castes believe that Kammis, as a group, cannot be relied upon; their word means nothing, they are cowards, they beg. They are quick to point out that they do not consider the Kammis to lack morals because they are the workers, but that the trait of good character is just inherently absent. One insightful informant suggested that the Kammis’ lower zameer has deliberately been cultivated by breaking down these people’s sense of self in order to enslave them economically. They are made to sit on the floor, while the higher castes sit on beds; they are not paid for the work they perform, but are forced to ask for what is their due, and then they are accused of being lowly beggars.
The caste system determines the kind of work a person does and the opportunities available and from there economic security and social power. In the economic structure of the village, Kammi families traditionally provide socially ascribed low status tasks such as construction (mistri), shoemakers (mochi) butchers (kasai) barbers (nai). They do their assigned duties all year round and are paid in-kind, usually wheat. This system, known as the ‘seph’ is inherently abusive as the amount of wheat given varies according to the whims of the higher caste landowners (payment all year long is usually a measure of grain at harvest time, but may be clothing or other items). They are invariably landless and are ‘given’ a small piece of land that they will never own to build a home. This leaves them vulnerable as they can be evicted according to the whims of the landlord. Despite the rigidity of the system, some Kammi families have tried to break away from this sephi system and work for cash, usually as day labourers doing manual work. There is one Kammi family (out of about 20) that has acquired an education and one member works as a medical technician. Nonetheless, chronic, intergenerational poverty is a defining element of this zaat.
Our research also generated a detailed understanding of the gender order of this society. Gender roles are sharply demarcated: men are socially constructed as providers of both economic resources and social identity, while women are their dependants. Marriages are usually endogamous, arranged within the biradari. Although brides move to live with their marital families, a woman’s mother, aunts and others can exert protective authority within the biradari’s structured relationships to ensure her health needs are met. Marrying outside of one’s biradari can leave a woman potentially vulnerable to abuse by unrelated in-laws, and without social support or advocates if she needs help, particularly if the natal family is also poor.