Interview

'Sexual abuse is a social and health issue as well'

Anita Raj has a lot on her professional plate. A developmental psychologist and global public health researcher, she is the founding director of the Center on Gender Equity and Health at the University of California, San Diego (UC San Diego), and a professor in the institution's departments of medicine and education studies. Dr Raj is also a 'Tata Chancellor Professor of Society and Health'.

The quantity of Dr Raj's responsibilities, while vast, is of less import than the quality of the research she has been involved with over the course of a strikingly brilliant academic career. UC San Diego has been both safe harbour and anchor for Dr Raj, who was born and lived in Mississippi, USA, before moving to Georgia to pursue her education, inclusive of a master's and a doctorate.

Dr Raj, who has been an advisor to UNICEF and the World Health Organisation and has addressed the United Nations General Assembly on child marriage, speaks here to Christabelle Noronha about her work and her research. Excerpts from the interview:

Anita Raj

It takes a thick paragraph to include all the work you are involved with, your research and your responsibilities. What's the intersection?

If you want it in one sentence, I'm a professor whose research and academic courses focus on applying advanced social science and data science methodologies to understanding and eliminating gender inequities in global health and development. This work is not limited to the greater vulnerability of women and girls in the face of sexual violence and the ongoing 'son preference' in India. It also takes in the heightened exposure of men and boys in relation to issues such as occupational risk and alcohol use.

One of the best parts of my job is that my research is linked to my educational responsibilities at UC San Diego. I teach graduate courses on behavioural theory and its application to public health education models and to survey development. These are things we do on the ground in our field research as well.

"... 'son preference' is seen in India in quite unique ways, and tackling the problem requires cultural and contextual considerations.”

How is developmental psychology responding to the complexities of the modern world? How has it changed down the years?

Developmental psychology, historically, emphasised individual cognitions and behaviours across the lifespan. Our approach now brings a more social and intersectional lens to this work, considering the role of social groups and social systems as well as the intersecting social inequities that unfold in the context of caste, income and, of course, gender.

For instance, 'son preference' is seen in India in quite unique ways, and tackling the problem requires cultural and contextual considerations. Similarly, female genital mutilation, a traditional practice that compromises the mental and physical health of girls, is seen in specific cultural contexts. You cannot rely on a cookie-cutter approach to deal with these concerns. Rather, you need cultural humility and participatory engagement, allowing affected communities to be the guide in the search for practical and policy solutions.

When it comes to gender equity and health, how do the prisms through which we view the subject change from country to country, culture to culture? What stays the same everywhere?

Across societies, we see similarities in values and beliefs with respect to what men can do relative to women and, correspondingly, gender differences in opportunities and resources offered. Women, for example, are less likely than men to be employed, obtain equal pay for equal work, or move about freely in public spaces without being sexually harassed. In contrast, men are more likely than women to be employed in high-risk occupations and to have social or time restrictions placed on engagement with their children.

There are differences, nonetheless. India contends with son preference in ways and at levels seen in few other places in the world. Deep-seated cultural beliefs and restrictive gender norms ensure that this concern persists. We are finding in our research a shocking lack of change in excess female infant mortality.

India has had a plethora of government health interventions for socially vulnerable sections of its populace. To what extent has the purpose of these interventions been served? How can we, in your view, do better?

The structured and committed public health efforts in India can serve as a model to the world. The shifts we have seen in infant and child vaccinations and the reduction in social inequities, including gender inequities, is laudable. However, more clinical commitment from health systems and better value and support of community outreach efforts could strengthen this work.

There is much research documenting the value of ASHAs [accredited social health activists] in improving maternal and child health outcomes, but these are incentivised rather than salaried positions, undermining their value in clinical care and for the community. Additionally, while health systems have worked to improve outreach to our most socially vulnerable families, this has not included families in which son preference may compromise the survival of girl infants.

How critical is the mother-and-child equation in public health and the delivery of it? What's holding India back here?

Improvements in institutional delivery, antenatal care, childhood vaccinations, etc. are well documented and this demonstrates the strength and capacity of the Indian health system. Concerns include ensuring a strong and valued workforce and, in particular, our largely female frontline providers, among them nurses and ASHAs. Devaluation, mistreatment and overburdening of these cadres of providers compromise quality of care in delivery and also result in high turnover and vacancies in these positions, affecting access to care.

How do we get more committed doctors and other medical staff, professionals who can fulfil their responsibilities?

I think the key is to provide stable salaries and a supportive work environment. In that sense, I do not think this is an obstacle just in India. We have many countries with high rates of unemployment and, simultaneously, a nursing shortage. India has a highly qualified physician workforce, but the number of these physicians, especially female physicians, in rural areas is low. Again, this is not unique to India.

We have some upcoming studies regarding the value of financial compensation, respect and support for nurses and ASHAs, as well as access to female physicians in rural India. I think India is in a unique position to create a model of higher quality care through better treatment of its healthcare workforce, especially its vastly female frontline providers. The evidence is clearly there to show the value of this approach. What's needed is political will.

MeToo provided an avenue for those who had suffered sexual harassment to have their say. How has the movement evolved, globally and in the developing world, since it burst into public consciousness?

One of the most important elements of progress I have seen come out of the MeToo movement and, preceding it, the Nirbhaya case in India is greater recognition that the 'shame' is on the abuser, not the abused. Women sharing their names and experiences, publically and demanding accountability, is a societal shift. My generation of women should thank my daughter's generation for demanding this change in society. More, certainly, can and should be done, but this developing shift against shaming and blaming victims is progressing.

Anita Raj with villagers during a field visit to Rajuri in the Pune district of Maharashtra

An important first step is to recognise that sexual harassment and assault — all forms of violence against women, in fact — are not just criminal justice issues but social and health issues as well. There is not always sufficient evidence or agreement in an incident of violence, but that does not mean the person making the accusation does not feel traumatised.

What perhaps warrants even greater attention is that these abuses are occurring on a daily basis, and with impunity. People are largely in agreement on what constitutes abuse, but they do not feel it is their place to say something when they see or suspect it. I think that is why the 'Bell Bajao campaign' was so influential. Apps from Safetipin for women in India have been used to mark locations and experiences of public sexual harassment. These are wonderful examples of collaborations to affect change. They speak to the value of social change efforts that go beyond criminal justice reforms.

Sexual abuse in India is on a scale that has led to it being considered the most dangerous country in the world for women. How can Indian society rein in the horror?

I think the report of India being the most dangerous country in the world for women is questionable. But our research has found that the reporting of such crimes remains rare, and conviction rates have not improved at all. India and, frankly, all nations and societies have to recognise to a much greater extent that these abuses are unacceptable, whether they occur in marriage and in families or on the street, and that those engaging in them should be held accountable.

You are a 'Tata Chancellor Professor of Society and Health' at UC San Diego. How did this come about and what does it entail?

My chancellor at UC San Diego, Pradeep Khosla, brought Mr Ratan Tata to our campus and I was invited to meet him to share information about my work in India. I am not sure how I got so lucky to have been selected for this opportunity, but I think it may be because I feel a genuine connection and love for India, where I have worked for more than 15 years. Though I was born in the United States, I define myself as Indian. This is my heritage and my country and I'm proud to be Indian.

How did you get interested in public health and why did you decide to make it your chosen field of study and scholarship?

My parents absolutely wanted me to be a physician; it just was not my interest or passion. But they instilled in me a sense of social responsibility and the recognition that good health makes for strong societies. Public health is about ensuring good health and high-quality healthcare for all, and I liked the combination of social contribution and methodologic rigour in research that this field offers. It is also multidisciplinary, so I get to work with physicians, nurses, economists, political scientists, engineers and policy experts. I am constantly learning new things and getting to work on building solutions using multilevel and sustainable approaches.

Of all the themes you have researched or been otherwise involved with, what interests you the most and why?

That is so hard. I love all the things I get to do. That is the best part of my job. I am always learning and we have so much diversity in the subjects that we tackle. I come from a background of sexual and reproductive health and maternal and child health, but we are looking at issues such as climate change and health now. It is amazingly interesting.

It is particularly stimulating that I work more with Indian academic institutions. We have a partnership with the International Institute for Population Sciences [in Mumbai], where we get to have our students and postdoctoral fellows and junior scientists train together. This has been both fun and fulfilling.

UC San Diego appears to have been both lode star and home base for you. What is it about the institution that appeals to you?

UC San Diego is an extremely creative and collaborative environment, with brilliant and really nice professors and students. If you can think it, then you can find the partners to create it with you. At the same time, if someone else thinks it, they bring you in to be a part of creating it. Team science is really fostered, so it is common to see groups comprising physicians, psychologists, engineers, economists, demographers, political scientists, education experts and public health researchers working together to tackle problems.

Given the many 'work' hats you have on, how do you make time for 'life'? What about pursuits outside of work?

My family is central to my life. I am married to an amazing person [Jay Silverman] and he is a professor at UC San Diego who just happens to work in my field and is also a professor with the same institution. We have a daughter in college and a son in high school. We are close to my parents and siblings and their families as well as my husband's parents and siblings and their families. That keeps me grounded.

Given that my husband and friends are part of UC San Diego, a lot of creative work ideas get generated during walks on the beach and dinners out. But it never feels like work; it just feels like fun.