In the Sheikhpura area of Patna, past rows of slatted stalls where rickshaw-wallahs fill their rickshaws with heaps of cauliflowers and brinjals bound for stands around the city, is a complex of government buildings. I arrived there on a Wednesday morning at the same time a rowdy group of broom-wielding protestors were storming the State Institute of Health and Family Welfare, demanding retroviral medicines for people with HIV.

A pack of a half-dozen male photojournalists scrambled around the building in an effort to get a good angle, but they lost interest once the shouting crowd crammed itself into a narrow hallway. A security guard watched listlessly until three police officers arrived, one with a rifle slung over his shoulder. I headed over to the adjacent State Health Society building, past a rusting hulk of a bus and a chai stand. I was late.

I was meeting Sanjay Kumar, the executive director of the State Health Society in Bihar, the state’s arm of the NRHM. Deferential subordinates slinked in and out of his door until I was led into his palatial office. I was offered a chair in front of his voluminous desk, a dozen chairs set up behind me, as though a classroom of students had just filed out. A tropical fish swam in circles in an aquamarine tank and a Buddha’s head stood perched on a stand. A large flat-screen television was playing the news channel Times Now, broadcasting live President Barack Obama’s acceptance speech just hours after he had secured office for a second term.

Kumar sat relaxed in his chair, glasses off, behind his citadel of a desk. We figured out that, while I was in high school in New Jersey, he had been studying at Stonybrook University in nearby New York. But he was a Patna boy, born and bred. And like the others I interviewed, he was full of statistics.

“Our TFR’ – total fertility rate – ‘is not one of the highest in India, it is the highest, at 3.7,” he began.

“The good thing is it was stuck at 3.9, and at least we were able to get a .2 TFR reduction, which we hope to do again each year,” he said optimistically. But the government faced multiple challenges in helping its citizens control their reproductive lives. He told me that the nearly 40 per cent of couples who want to use birth control can’t access it. “The government can’t keep up with the need, and our primary health care centres are not properly stocked.”

Patna girls, he explained, were getting married at a very early age. Nearly half were already married by the time they turned sixteen. A few years later, most became mothers. “The single determinant that is affecting the fertility behaviour of women,” he said, “is education.”

Even with the high fertility rate in Bihar, women with ten years of education gave birth to only two children on average, he said. Those with twelve years of education, both in Bihar and across India, brought the average down further still. Multiple studies have shown that the single most influencing determinant for the number of children a woman will have in her lifetime—superseding race, religion, nationality and class— is her education level.

Education as birth control. Education is birth control.

Kumar had aspirations for Bihar. NRHM was working on opening high schools closer to villages, so that girls wouldn’t drop out because of travel hindrances. In 2006, the Bihar government gave bicycles to girls to help them get to secondary schools, and attendance increased 30 per cent. NRHM was also bringing family counsellors into birthing centres to encourage women who’d just had a child to consider long-term forms of birth control like IUDs that would help them delay their next. Getting women to use reproductive services before they’d had three or four children was the only way the TFR would decrease, he said.

We spoke of Pathfinder’s PRACHAR programme, which seemed to be highly effective but was ending. PRACHAR had been a three-phase, ten-year project co-funded by the David and Lucille Packard Foundation, the UNFPA, the Government of Bihar and local non-profit partners. By the time Pathfinder was showing me around, the ten-year period was over and funds were drying up. What would happen to the decade of accumulated data, the networks of youth that had been established, all those educational posters?

Kumar didn’t dismiss Pathfinder’s work, but he stressed its limitations. “Their programme is only five blocks in the Gaya district. There are 533 blocks in Bihar. If you’re going to do a programme in five blocks for ten years, and have no scope for scaling up, it’s not going to have the desired effect.”

“Is it the non-profit’s job to scale up or the government’s?” I asked him. Pathfinder, with a lot of foreign money, had done a great job determining what were the most effective forms of education. When would the government play its part?

“I’ve told them, you’ve done this training for so many years, make a template, make a standard operating principle for how this is to be done,” he told me. “If they’ve made such a thing, I’m not aware of it.”

Binod Singh had told me that Pathfinder was trying, unsuccessfully it seemed, to get the state to step up. He said Pathfinder had passed along all its teaching materials, yet neither Sanjay Kumar nor others in his department seemed to know anything about this.

For all his resignation about programmes like PRACHAR, Kumar did seem to genuinely care about women’s equality.

“RCH” – reproductive and child health – “is nothing but gender equality,” he said. “You may put in the best services, but if the gender balance or imbalance remains as it is, perhaps it won’t be of much use to women. Women must come out and access these services, and that is going to come only when the gender balance is restored in this society by way of more education, by way of more economic empowerment. And also, I would say, political empowerment. Our problems,” he acknowledged, “are very acute.”

He recognised the impact of the growing population, the bodies and lives created out of the ether, hungry and dependent on what their parents, their country, earth and water could give them to survive.

Kumar had seen a big change in Bihar since the political shift in 2006, but he wished, he said, that he’d seen it a long while back. He laughed and shrugged. The television showed President Obama reaching the end of his address. We’re not as cynical as the pundits believe, he said in his distinct cadence. We are greater than the sum of our individual ambitions...

“There are advantages of beginning late. You can learn from the best examples everywhere. But there are also disadvantages of beginning late. In spite of all the changes taking place, our baseline still remains low.” Change for the girls of Bihar was heading in the right direction, he believed, but it was not going fast enough.

“Time is the only thing,” he said, “that is not on our side.”

Excerpted with permission from Elemental India: The Natural World at a Time of Crisis and Opportunity, Meera Subramanian, HarperCollins India.