Day 3: Dharavi

It’s taken me awhile to put my experience in Dharavi into words. I’m still having issues sorting through what we saw and the immense socioeconomical implications… so bear with me. After visiting the E. Andheri slums, I was expecting something much different in Dharavi. The first day, in E. Andheri, we were coming in with a medical van and witnessing the immense health and living disparities the residents faced on a daily basis. I felt thrown into the experience with complete sensory overload. In Dharavi, I gained a greater perspective of how the community of 1.5 million plays a role in the larger Indian economy, as well as the impossible obstacles faced by residents of Dharavi to change their socioeconomic status – thus, making the plight of social entrepreneurship even more difficult.

First, we stopped by the ACORN India Foundation offices that sit on the outside border of the slum -- right next to freshly demolished block of land (a scare tactic from the Indian government to show control over the slum). Mr. Vinod Shetty introduced us to the educational programs set in place by ACORN as well as the waste management system implemented throughout Dharavi. Mumbai’s waste was already finding its way to Dharavi, but ACORN was able to systematically legitimize the recycling efforts of Dharavi workers into profitable jobs. It was interesting to hear how ACORN was also working to make the lives of those living in Dharavi more fulfilling through music and sports. Two young boys put on a drum concert with empty barrels to showcase their musical talents developed through the ACORN Foundation.

After learning about ACORN and receiving a brief explanation of the political history surrounding Dharavi, we set out through the industrial side of the slums. It was truly a hidden city within the walls. Small shops lined the mud paths and were filled with workers meticulously sorting shoes, sewing jeans or repairing cardboard. Mr. Shetty emphasized the legitimacy of their work and the importance it plays in the larger economy. The waste from the city was being reused as well as providing the workers a way of life. While these workers have no control over their living conditions, they provide so many material goods to the larger economy – to the point where a majority of the larger industries in India could not survive without them. I couldn’t help but think of the American stereotype of the poor being lazy when I walked through Dharavi… and how untrue that is in this case. The government has excluded these people from society and provided no assistance that they’ve been forced to fend for themselves and have created an entire economy within their community… an economy in which India relies on very heavily.

With each visit throughout our trip, different aspects of social entrepreneurship arise and exemplify the complexity of the field and work involved. It is impossible for immediate change in Dharavi. ACORN and Mr. Shetty (the self-proclaimed bleeding heart) are doing great work enhancing the lives of those within Dharavi but the opportunity to actually change their greater social situation is still lacking. A point that is reiterated throughout this trip is that change takes a significant amount of time in the social sector. That being said, it is important to acknowledge the smaller scale of what ACORN is doing within the community to provide workers with a sense of livelihood and children the chance to take pride in something they enjoy doing – whether it be playing drums or futbol.

Dharavi

Today we visited Dharavi, one of the largest slums in India with a population of over one million people. We met with Vinod Shetty from the Acorn India Foundation to learn about waste management in Dharavi. We all had the chance to learn about Dharavi from the National Geographic film, “The Real Slumdogs,” we watched in class. It was an incredible opportunity to meet with Mr. Shetty and talk to him about his experiences with the Acorn Foundation after having watched the film. Mr. Shetty is a human rights lawyer and has taken an active role in social movements for over 25 years. Only 8% of the workforce is involved in trade unions, and Mr. Shetty is very involved with them. He believes that his organization could bring attention to the workforce in India, which is very important to the survival of the Indian economy. Mr. Shetty mainly utilizes his family and friends as volunteers and to fundraise for the organization. Funds are used to run the community center, pay the salary of one staff member, and the rest is used for basic organizational costs distributed to the various social projects within the Dharavi project. Like most people in this line of work, Mr. Shetty told the group that his motivation for working on the project is because he wants to change the world for the people living in his own city. For him, the only way of living is to be involved in social movements working with people in poverty.

The Dharavi project trains rag pickers in proper methods of waste handling, segregation, and recycling. They use social-impact programs in an effort to change the living conditions of the more than 100,000 rag pickers that segregate waste in and around landfills in Mumbai for a living. There are a lot of negative connotations surrounding slum dwellers as perceived in the movie Slumdog Millionaire. The people living in the slums are there because they don’t have any other choice and the struggle for survival forces them to fend for themselves. Even though they are shunned by much of society, they are fighting for their right to live with dignity. Thousands of tons of waste are processed by rag pickers each day, making this work force essential to the daily operations of society.

Several programs and workshops conducted by the Dharavi project are used to educate and engage young children in music and other arts. When we first got to Dharavi, we visited the Acorn Foundation’s main hub, where two little boys greeted us with friendly smiles. They played their drums and sang for us, and truly sounded amazing. We were all very moved by the performance, and I think that was the moment everything from the last few days really hit me. Watching them perform in all of their innocence made me realize how much potential so many of them have. It is rather unsettling knowing my life is vastly different from theirs, and that all of their potential may go unnoticed or underutilized if social enterprises, like Acorn, fail to succeed in instituting change.

We had the opportunity to walk through the more industrial area of Dharavi. The organization of each industry was not at all what I expected. Even though everything is incredibly dirty and the quality of living is unlike anything we are used to, I was surprised to see how organized each mini industry was, and how efficient their operations were. From an occupational health perspective, I immediately noticed how little to no safety precautions were utilized. Workers do not have gloves, goggles, shoes, or any form of personal protective equipment. The water that runs along the street is stained blue in some areas from dye leaking out from one of the businesses. The noise in some areas was very loud and no workers had any protective ear equipment on. I can only imagine how many occupational injuries take place in Dharavi, and I am sure workplace injuries cause a lot of death and disability.

After having walked through the slums in E. Andheri and now Dharavi, we have witnessed poverty that many endure every day. With so many people living in such a small area, it seems overwhelming that any one non-profit organization or social enterprise could even begin to know where to start and actually make a difference. Especially after the class discussion we had this evening, I am not feeling too optimistic about my ability to design any business model that could actual institute social change and be sustainable for years to come. I know there isn’t much literature available on how to successfully be a social entrepreneur available to teach students, but maybe it is that uncertainty that drew so many of us to take this class. I still feel like I have a lot of unanswered questions and unexplainable emotions, but we are only 3 days in, and each day we learn a little more.

The Women of Aastha Parivaar, and The Women of GW

The past 48 hours in India have exposed me to more diversity than I I have seen in my 28 years on this Earth. The people, the culture, the hardship, the hope, the dignity, the fatigue and optimism we have been seen has undoubtedly been experienced different by each of us on this journey. It is clear that our time here has exposed us to many individuals who are struggling. Whether they struggle with health, violence, cleanliness, harassment, stigma or poverty – they all share a common thread.
Yesterday, we split into two groups and held sessions with Aastha Parivaar. My particular group has the distinct pleasure of meeting with a group of 15 or so commercial sex workers who also had become part of the community based organization (CBO) that educates and supports sex workers throughout Mumbai. Going into our session, I will admit that I was nervous and apprehensive; however, once we arrived it was clear that the women were open-minded, compassionate, positive and genuinely interested and excited to learn from us and to teach us what they know.
Our session was spectacular and was a great success. While we waited for the bus we had the opportunity to sit with three of the sex workers and I used this time to really ask some of the tougher questions that were on my mind, but seemed inappropriate to ask in a larger group. Issues such as violence, the opinions of the husbands of sex workers regarding their profession, family life, career opportunities and harassment were touched upon and it was an incredibly special and moving experience. Of all the questions we asked of them, what the women wanted to know most about us during that small group chat was why we weren’t married with babies yet!
We have had two wonderful yoga sessions since arriving in India and two key takeaways, for me, have been to respect one another and to have an open mind to all different experiences. The women of Aastha Parivaar truly embody these concepts and we could all stand to learn from them. Every day they face hardship, discrimination, harassment and a profession that is challenging in a way we can never truly understand. Each day I am in India, I have tried to remain present so that I can act as a sponge to all of the different interactions we are having and the lessons to be learned from them.
Traveling in a group of almost 20 women, from all different backgrounds and perspectives, can be a challenge. I doubt that anyone on this journey will disagree! The inherent diversity of each individual is what makes for a rich learning environment and I am learning everyday not only from the “India experience” but also from each person I am experiencing India with. What I may see as optimistic and hopeful, a friend may see as depressing – this simply provides a wonderful opportunity for conversation and social learning.
Each day I have been impressed, and sometimes overwhelmed, with this trip as a whole. In our on the ground orientation, Dr. Vyas addressed how each individual here would experience India in their own way. Some may be extremely extroverted about it and want to share every detail and some may be more timid, wishing to process internally and keep their individual feeling to themselves. Both are ok and I certainly find myself wavering somewhere in between.
India is unpredictable, and that is part of the charm. The one thing that I can predict is as we continue on this incredible trip we will be able to learn not only from the meetings and projects that are part of our curriculum, but also from each other.

Day 2: The Empowered Women of Aastha Parivaar

As you’ve heard from the other bloggers, we visited Aastha Parivaar yesterday and gave a presentation on reproductive health to a group of Indian sex workers. It was an incredible opportunity to practice our real-world health promotion and education skills with an extremely at-risk population eager to learn. In most public health interventions or health education programs within the US, cultural differences often create a barrier to effectively communicate with different groups of people. That wasn’t the case at Aastha Parivaar. We were welcomed with smiles and there was an immediate sense of mutual respect.

Our presentation didn’t go quite as planned as we worked through the language barriers and gauged their expectations for our session. It showed how important it is to be flexible and really read your audience in order to get your message across. I’m not going to lie… I was a little nervous going in to the session. Not because I didn’t think our presentation was thoroughly researched or anything along those lines. It was more based on the fact that I’ve never given a reproductive or women’s health presentation before, and given our audience, I just didn’t know how it was going to go. Everyone did a fabulous job presenting the material in a positive, uplifting manner and really engaged the group…. even with the impromptu female condom demonstration. I was very surprised at how many educated questions we received from the women. It was clear that the work Aastha Parivaar has done thus far to educate and empower these women has been extremely effective.

During the introductions for the session, we learned that a lot of women in the group were peer educators and working on different health education topics themselves. When we completed our portion of the presentation, they showed us the different activities they use to inform other sex workers of the risk to their trade. It was clear that the main tenet to their health education is HIV prevention. They demonstrated how HIV can spread through a network of people as well as promoted getting tested for HIV.

As we waited for the bus we were able to sit down with a few women and ask more personal questions about working in the sex trade. It was extremely interesting to find out that these women are the bread winners in their families and therefore find supportive husbands waiting for them at home after they make the 20 kilometer trek into work 7 days a week. They prefer to keep their children unaware of the work they do so they don’t fall into the same circumstances. We asked why not look for some other form of income but unfortunately these women are discriminated against because of what they do. They also wouldn’t be generating the income they do now working anywhere else. Although they feel trapped within their trade, the group we spoke with was empowered through the education they receive from Aastha Parivaar and able maintain control of their bodies even within such a dehumanizing industry. I couldn’t help but leave with a sense of pride for our team of health educators. We're not only learning about Indian culture through experience but also how to work effectively as a team.

“Creating wealth out of nothing”

Today we had the pleasure of meeting with Mr. Vinod Shetty of ACORN India who showed us around Dharavi, the slum made famous by Slumdog Millionaire. Unlike its portrayal in the movie, Dharavi is comprised of millions (1.5 to be exact) of industrious and creative people and hundreds of thriving enterprises that are truly “creating wealth out of nothing,” as Mr. Shetty said.

Our walk through Dharavi was a mind-blowing, humbling, thought-provoking, sensory overload. I found myself fascinated by the distinct industries and processes represented in each “hut” we passed. We spent much of our time in the recycling district. There is really no formal recycling industry in Mumbai because, as Mr. Shetty said, the economics just don’t work. So “rag-pickers” around the city bring garbage to Dharavi’s recycling centers, which have grown up over decades. Individual enterprises throughout the district handle various types of materials and parts of the recycling process. For example, in one multi-level building men disassembled cardboard boxes, fixed them with staples, and reassembled them for sale to small businesses. In another, women and men sat crossed legged in front of multi-colored bins, sorting small pieces of plastic to be grinded down to powder. The sorters could determine the chemical makeup of the plastic just based on the weight and feel.

But recycling isn’t the only industry in Dharavi. We also saw dye shops where people were making fabrics, welding shops making metal products, and people hand weaving brooms. And there were services to meet the workers’ needs – everything from convenience stores and restaurants to barber shops.

While the people of Dharavi have, over the last 75 to 100 years, created this huge economic engine, it is of course not without problems. Looking at it with a health lenses, we could not help but notice the occupational hazards everywhere. Men were welding and grinding metal without eye protection, gloves, or earplugs. People, including children, were touching dirty, potentially contaminated recycling materials without gloves. And workers were crouched in one spot, working with little light, for long periods of time. Beyond occupational hazards, there was abundant pollution, fruit covered in bugs being sold on the streets, and children running around barefoot. The government had recently demolished a large section of the slum that ran overtop a water pipeline, supposedly in an effort to avoid water contamination. However, they had left the oil and chemicals and garbage strewn on top of the pipes and it had a putrid smell coming up from it, so it did not seem safe at all. We smoke with Laxmi, one of the women features in The Real Slumdogs, National Geographic documentary we watched in class, and she explained how she had suffered from asthma right after the demolition.

ACORN India is doing great work to correct some of the problems in Dharavi. It works to educate workers about safety precautions they should take to avoid injury and chemical poisoning. It also provides children of Dharavi – many of whom must work to help feed their families – with educational opportunities including English classes, computer training, and even music lessons. Two boys from the ACORN program played drums for us, using recycled goods including plastic tubs as instruments. Perhaps most importantly, ACORN advocates for Dhavari citizens to protect them from injustice and abuse from the government and corporations. While as we discussed in a class meeting later, ACORN is not a true social enterprise, it is delivering valuable services that will hopefully help the next generation of Dharavi by educating children. I was truly humbled in meeting Mr. Shetty and hearing about the tremendous effort he and his small team of volunteers are making in Dharavi. Our glimpse into the real Dharavi is an experience I will never forget.

Here are some photos I took today.

The water pipeline and potential contaminants:

A recycling shop, that's a stack of old car bumpers:

The plastic sorters:

The ACORN boys playing drums and singing:

Dharavi: An Urban Slum & Solid Waste Recycling

It’s Day Four in India, the monsoon weather continues, leaving the roads alternately wet and dry. The sun has rarely been out from behind the clouds. This morning dawned cloudy but not rainy. Today we visited, Dharavi, once considered Asia’s largest slum. Started over 75 years ago by impoverished migrants who migrated from the economically depressed rural areas to the city of Mumbai in search of work and money. The majority of these migrants and residents of Dharavi are men, far away from their families who are left behind in the villages, but there are some women and children as well. The men send money back home periodically and some return to the villages for the harvest season or for family occasions. Our host in Dharavi was ACORN India and Vinod Shetty, Esq., who leads The Dharavi Project. This group is geared towards providing education and resources to the children of Dharavi and helping the residents mobilize to improve their communal conditions.

One of the main industries in Dharavi is the solid waste management and recycling industry. Just about every kind of solid waste from plastics, paper, and glass to white goods, wood, auto parts and sheet metal in every shape and form are recycled by ragpickers or other recyclers and either re-constituted in situ or collated for transport to other processing plants in the city. Residents earn money through the sales of these recyclable materials. For instance a cardboard recycler (of which there are about a 50-75 in a 100 meter stretch of road) receives brown cardboard boxes from all parts of the city, breaks them down by removing staples, and collates them into batches which are then sold to a pulp and paper mill on the outskirts of the city to be converted to papier mache and then re-constituted back into boxes. One of the small businesses we stopped by reported receiving 2000Kg/day of cardboard which it can then sell to the paper mill for Rs.7/Kg for approximately Rs. 14,000/day. Plastic can be sold for Rs. 25-30/Kg. Each day, 10,000 tons of solid waste trash arrives in Dharavi to be processed and without the vital intermediate recycling services provided by the small businesses of the slum factories, the solid waste would be sent to a landfill.

Despite playing such an integral role in the economy and the waste management sector, these small businesses are considered to be part of the informal work sector and lack essential occupational health and safety practices. The workers wear minimal clothing due to the heat exposing limbs, fingers, feet to unguarded machinery blades, welders working with sheet metal from cars use sunglasses in place of welding goggles, and none of the workers use hearing protection despite the near deafening noise.

Hence occupational health and safety represents a possible area of intervention either by ACORN India and The Dharavi Project or an alterate organization interested in amerliorating the health and safety conditions of this key workforce.

Sponge

Ok, I think everyone in my inner circle of friends knows this about me, but I’m all about women empowerment and respect, and after yesterday’s site visit to the Women’s Welfare Society in South Mumbai, I really need to touch on the topic of menstruation in India. I’ll be honest, I wrestled around about writing on the topic, but I believe there is an importance to the issue.

I just want to forewarn the men that read this blog, if you are not comfortable reading about menstruation and the societal gender bias in relations to development of women’s issues, I advise you to stop reading at this point.

To start, my mother raised me on the belief to never allow my gender be my Achilles’ heel. Growing up with four brothers, I wasn’t raised like all typical girls. I still wore my pigtails and pretty pink dresses, but my mom raised me to be tough just like the boys. So when little Jenn transformed and entered to adulthood Jenn (this is as subtle as I can go), my mother taught me to embrace my femininity and the wonderful responsibilities of womanhood that include the cramps, the bloating, the headaches, and the crazy cravings that occur on the first and second day. When a woman gets her period 12 times a year (less, if on birth control), she becomes a pro. Unfortunately, women outside our western culture are not so lucky and privilege when our Aunt Flow comes to visit once a month.

Yesterday, I was very lucky and privileged to visit the Women’s Welfare Society in the south part of Mumbai. The Women’s Welfare Society is a community-based organization supported by the Social Activities Integration (SAI) that works with sex workers. Our group was very privilege to provide site training on the topics of menstruation, menopause, and breast cancer to community outreach workers who go out on the field every day and work in helping sex workers in providing HIV/AIDS health services, vocational training, prevention/rehabilitation for substance abuse, and other array of programs including the sale of their own products for income generation, which is a core aspect of social entrepreneurship and self-organization sustainability.

The reason why I am blogging about menstruation is because it became a hot topic. In India, women sex workers who cannot afford the use of maxi pads or tampons, use sponges. We are still unsure, but we suspect that kitchen sponges are used. For the women in my group, including myself, we were shocked. What we take advantage in our western, American culture is out of reach for many poor women in India that cannot afford these resources. As public health practitioners in-training, we asked questions and wanted answers. The use of the kitchen sponge as a method to collect menstruation flow is a health hazard that includes the growth of bacteria and an array of other infections, especially if the sponge is not wash and dried in a proper matter.

Overall, the point that I want to make and I have seen this in other cultures where women issues are also a grave concern is that a girl that is about to enter womanhood should not face the obstacles in not being able to afford proper sanitary products in every race and economic stature level.

After yesterday’s site visit, my brain started to run a thousand miles per hour and I started to think on how I can use social entrepreneurship and the topic of providing proper sanitary products for poor women around the world. A light bulb turned on, and I started to think how cool would it be to donate the Diva cup (a silicone cup that collects menstruation flow) or reusable cloth maxi pad from the manufacturers to the community-based organizations and the community-based organizations can sell them at discount price or even provide them free as a form of self-sustainability.

As a woman, I find it as a gift that I get my period once a months and the beauty that I can reproduce life. Education is vital for change. The idea just because a girl or woman cannot afford sanitary products when she has her period and cannot to go to school or left with the last resort to use a kitchen sponge is backward for a country that is able to provide top IT technology around the world.

"That's just India"...?

The last three days have been somewhat of a crash-course in India. The first night were stuck in 2+ hours of traffic on our way to dinner. I mentioned to Dr. Vyas that I thought it was interesting that, from our hotel room windows, 6 stories up, there is not a single building at tall anywhere nearby. Rather, scattered below are rows upon rows of cinder block and brick structures with metal siding for roofs, covered in tarps weighed down by bricks. I assume to prevent the roof from leaking during Monsoon season. I was informed that this was “just India” – movie stars in million dollar hotels live right next to others who sleep on the sidewalk under a tarp. Interesting concept; “just India”...

This phrase came up again on day 2, which started with a meeting with AmeriCares India, an NGO focusing on providing basic medical care and emergency preparedness training. The India branch operates in conjunction with 57 other local affiliates as well as sites across the country and serves almost 100 people per day, per site. The branch with which we met has made a commitment to visit each of their service sites once every 15 days. We were told we would be shadowing and assisting the medical team with patient intake and organization.

We joined AmeriCares in the slums of East Anheri, not far from where we are staying. Apparently this area is one of the largest slums in the city, even larger now than Dharavi, where Slumdog Millionaire was filmed, which we will visit on Thursday. We stopped first on a main thoroughfare and followed one of the AmeriCares outreach workers, an undergrad student at Johns Hopkins, but a Mumbai native, a lap around one square block, just to observe. This may seem surprising- it was to me – he informed us that most people in India, regardless of socioeconomic standing, have cell phones. He said that people may not have running water, but they go out of their way to have TV and order pizzas when they want to. “That's just India,” he said as we walked through the alleyways, hearing cricket matches and other programs blasting through various windows.

There it is again! I don't know what to make of that statement on his part, or that line of thinking on the part of those about whom he was speaking. I have not been here long enough to and do not know enough about the culture to say one way or another. Even if I had been here for longer, India is full so many different people, cultures, and lifestyles that to make a sweeping statement like that (not that he knew it would be talked about in my blog) is simply unfair and hopefully untrue. I'm beginning to think that, along with observing example of social entrepreneurship, that's part of what I'm here to find out.

As we drove to where the medical team would set up, we couldn't help but notice the huge hill that rose above the street, taller than most of the buildings. That is when we were told that this community lived, essentially, on top of one of the largest garbage dumps in the city. Our bus was preceded and followed by garbage trucks coming in and out of the dump. Tall gates surrounded the compound, but only in the very front, and from the bus we could seen people roaming through the piles of trash. Across the street, where the community's buildings actually began, conditions were not much better. Small children roamed barefoot, a few of them carrying their younger siblings, among smaller piles of trash and potholes full of standing water from which stray dogs, cows and goats ate and drank. We passed a couple of fruit stands, the produce covered in flies. This community has little to no running water; I noticed a few large blue barrels set out to collect rain water which, as we were told eventually, people used for washing. Someone muttered under their breath that it was a public health nightmare. Far be it from me to pass judgments, but yeah, I can see what they mean.

The medical team set up shop in a mostly-empty storage compartment an quickly got to work. They were equipped with one computer, one blood pressure cuff and a camera, to do patient intake. They were totally not prepared to put all of us to work, so most of us spent our time talking with the people and smiling at the children. We were followed down the street by a small hoard of children which grew into a mass of members of the community, who all wanted to shake our hands and speak to us in the few English words they knew - “Hello”, “Good day”, etc. The few people in the community who did speak English served as translators for the others. One of whom was a young girl, probably in her late teens, who came to the medical van with her mother and cousins. I found out that many members of the community were Muslim and she, along with her cousins went to the Muslim school. The girls asked me everything from whether I was married to whether I was wearing colored contact lenses to change my eye color. Many others took pictures of our group on their cell phones.

The experience of visiting this community was very complicated for me. How do you stand there and tell someone, who you know has next to nothing, that you can't come to their house when they have invited you for tea? What do you say to the little girls who ask when you are coming back to visit again? How do you explain to someone trying to tell you about their pain and other medical ailments that you are not a doctor? You smile, you thank them, you apologize, or at least that's what I did. Because I was grateful for their hospitality, and regretted that I couldn't do more in that moment. I suppose “that's India” for me today, but who knows what tomorrow will bring.

A lesson in flexibility

Yesterday our training session with Aastha Parivaar was a lesson in flexibility. We arrived at the drop-in center to find a small meeting room with several women already gathering around the table. We found out quickly that we did not have a translator per se but that two of the program staff understand English enough to translate, but Pavitra and Rashi jumped right in and ended up doing most of the translating.

Next, our well thought out plans of having all of the participants sit intermixed with us in the circle were quickly changed when we realized we did not have enough chairs and the staff continually urged us to sit while others stood. Then, in the biggest change to our plans we discovered that the group was not in fact sex workers but community outreach volunteers and staff who work with sex workers. There were even several men in the group, which we thought would reduce the women’s openness to discuss sensitive topics, but they assured us it was fine. This was an ironic realization, that we – a bunch of Americans – were actually being too concerned about cultural sensitivities!

But at last we began our introductions, which lead into incredibly insightful introductions from all of the participants and staff about their organizations and what they do. We had board members and representatives from several organizations affiliated with Aastha Parivaar including Social Activities Integration (SAI) and Women Welfare Society. We learned that Aastha Parivaar means a sympathetic family, which is not only a beautiful phrase but actually what the organization becomes for the sex workers, or Didis, who in some cases might be ostracized from their own families. In addition to outreach with sex workers, the organizations present also provide community-based and mobile healthcare, HIV awareness through street plays, education for children of sex workers, prevention efforts with men who have sex with men and transgendered communities, and prevention of mother to child transmission of HIV, among other efforts. And they have a social enterprise side, which includes selling makeup, incense, and perfume to support the social programs. It was heartwarming to see how the women were so eager and proud to show us their products.

When we started the training session we quickly realized that the women already knew all about menstruation and menopause – two of the topics the program staff had requested we cover. So, with Dr. Parrish’s suggestion, we flipped the session around to ask them to review our training materials and give us suggestions on how they might be more culturally relevant. Having just finished a course in global health communication and done some background reading in preparation for this session about participatory resource creation, I was pleased to get the opportunity to conduct this kind of a session. Despite a few stops and starts as we adjusted to the new format, the women who were so warm and open, and I just felt honored to spend time with them.

When it came time for Jenn and I to talk about breast cancer, we found that the women were not as informed, so we were able to educate them a bit about the importance of self breast exams and when and how they should do them. Although two women shared stories of family members and friends who had suffered from breast cancer and one woman had herself recently found a lump, the women as a whole did not feel the topic was terribly important, compared to the more widespread and immediate threat of HIV among sex workers. However, by the end of the session we were able to help them see the growing risk for breast cancer and the importance of being familiar with their breasts in order to proactively manage their health. Dr. Parrish made the very good point that breast self exams are an empowering activity because, unlike most health activities that require a third-party such as a doctor or a nurse, women can do these themselves. It is also a good way to teach women to be proactive about their health in general. In the end, the women agreed that they would find training materials on breast cancer useful.

I am excited to work with the group and Dr. Parrish to create these materials and then get feedback from Aastha Parivaar about their effectiveness. And, I know that throughout my career I will look back at this experience as a perfect example of how no matter how much preparation you do, or how many stakeholders you speak with to try to understand their expectations, you might have to completely switch on the spot. You just have to pause, readjust your thinking, keep on smiling, and see the value in the unplanned.

East Andheri Slums

Day 2: East Andheri Slums.

Yesterday was eye-opening. We began our day early at 8am ready to climb onto a bus (without A/C) and go towards AmeriCares India, off Linking Road. The AmeriCares India Foundation is a charitable organization that "provides immediate response to emergency medical needs and supports long-term humanitarian assistance programs in India and neighboring countries". AmeriCares India works across numerous states around India. Specifically, in Mumbai, AmeriCare India provides medical commodities, emergency response & disaster preparedness, mobile medical camps and health promotion programs.

Our day yesterday was focused on working with the mobile medical camp in the East Andheri Slums. After receiving a brief yet extremely motivating and inspiring orientation on the mission of AmeriCares by Dr. Purvesh Parikh, VP and Managing Director, we set out with the mobile van to the slums. All while getting lost and spending an hour on a bus without A/C.

We parked a bit outside of the gully's (or alley's) where we stepped out to a petid smell of human and animal waste, and mounds and mounds of trash that comes from all over the city. We walked towards the alley's and watched the mobile clinic make a makeshift camp. The camp was led by two volunteers and one physician. In the actual "camp", the two volunteers were responsible for registering new patients. This involved one volunteer taking height and blood pressure and the other volunteer typing/recording the patient’s record. It was quite interesting to watch, because the new patients were huddled into a line inside the camp and had to share their ailments one at a time. Each patient would record their ailments to the volunteers as the volunteers recorded them. Then a picture was taken of the patient to keep in the records. The patient was then directed to the mobile van, where the physician was waiting for them to give them medicines. For this particular day, only women and children were seen.

In India, there are so many health issues that are stigmatized, so it was interesting to see this process. Every patient expressed similar ailments – pain in body, dizziness, and fever. Due to the crowding environment it was apparent that women were not sharing and discussing how they were actually feeling. We also later found out that today’s camp was only available to women and children so sex workers could also take advantage of the medical care without being singled out. It makes sense then, in these congested camps, they did not discuss their actual complaints.

It was evident after approximately 30-45 minutes of being at the camp site, our team was more of a distraction to the mobile clinic than helpful. Being in a group of 19, these we were a bit overwhelming and caused excitement and anxiety with all those who walked by the camp. Children came running up to us to share what English they new as did some parents. Children sang to us and hugged us and wanted to learn from us. Yet, the purpose of the day was to get adults and children access to care that they did not normally receive.

It is absolutely amazing to have watched AmeriCare India Volunteers in action. Though only 3 individuals go out in their vans, they go out six days a week from about 9am to 3:30pm. They see approximately 100-150 patients a day and reach hundreds of thousands of individuals, that in normal circumstances would be denied or not be able to obtain access to care. To ensure continuity or care, the vans go back to each slum/ward every 15 days. In addition, AmeriCare India has partnered with various pharma companies and consulting firms to help support the work they do. With this support, AmeriCares India Foundation has already delivered more than Rs13 crores worth of free medical assistance in this past year alone.

Nitasha

Yoga, women's health, and an Indian Birthday

We began the day with a yoga session led by our private yoga instructor Ritu Sethi. I’ve never enjoyed yoga because I remember having to go to sessions with my assistant coach after practice when I was in undergrad and it was always painful forcing myself to stretch. At the beginning of class, Ritu taught us about Ashtanga Yoga, otherwise known as “The Eight Fold Path”. This approach to yoga consists of systematic and definite steps towards the realization of the soul’s oneness with spirit. The first step is “Yama” or the ‘don’ts’ that focus on social behavior and how one treats others and the world around them. The second is “Niyama” or the ‘do’s’ which focuses on inner discipline and responsibility, and how we treat ourselves. The remaining steps focus on the practice of yoga until “Samadhi”, or trans-consciousness. Thinking about yoga in this way is a completely new experience for me, and I’m really thankful that we have the opportunity to take this time to reflect in the morning. Each time I took a moment to close my eyes and focus on the here and now I was able to better process the emotion I have been feeling since we arrived. I can’t quite differentiate any of my thoughts right now as we have immersed ourselves in the culture. I am looking forward to the 90 minute session tomorrow and hope that I leave with a clearer head.

After a brief class session with Dr. Parrish and Dr. Vyas around noon, we headed to Girgaon in South Mumbai. It took us over an hour to arrive at our destination, and the city looked completely different from yesterday. The parts of the city we drove through very much resembled big westernized cities we are used to.

The class split into two groups and each went to a different site. We initially thought that we would be educating sex workers, but the group that attended our session ended up being women that work with the community based organization known as the Women Welfare Society (WWS). The WWS is supported by the Social Activities Integration (SAI) and was formed under the Aastha Project. SAI is funded by the Family Planning Association of India, which is funded by Family Health International, who receives their support from the Bill Gates Foundation. SAI works with 350 brothel based sex workers in the Worli district.

We began our session with introductions. First, we went around and introduced ourselves by talking about what we were studying in school and some background on our family. Then, each of the session attendees introduced themselves. In total, 11 women and 7 men attended our session. We crowded around a long table in a room in building that appeared to house several organizations. Among the attendees was the Vice President, secretary, and treasurer of WWS, a peer nurse, a staff nurse, and several other WWS workers.

The women informed us that one of their biggest concerns is PLHIV, or people living with HIV, health services. As soon as a woman becomes HIV+ she is rejected from her family so the WWS provides support to these women. Their intent is to establish a unified front to assist the women in gaining back their respect. SAI provides clothing, nutrition, medicine, and admission fees for children to attend school. In addition, they network with government hospitals, and educate sex workers on where the safest roads are for them to take. To generate revenue, WWS sells Agarbattis (incense sticks), compacts, pancakes, and perfumes among other things, which they showed to us and were eager to sell.

The presentation we prepared for the group consisted of three parts; 1) Menstruation and Hygiene, 2) Menopause, and 3) Breast Cancer. Courtnay and I planned to present part 1. Our session began with a basic diagram of the Female Reproductive System, which I asked the group if they had ever seen the diagram before. All of the women were quick to let us know that they had seen the diagram and they knew what it meant. We immediately realized that the group we were speaking to was quite different than the group we intended our presentation for. We thought we would be presenting to the sex workers themselves like the other group in our class, but instead we were presenting to the women that work on the Aastha project and they are the ones in the community facilitating the educating.

As is the situation in much of international public health, we had to improvise. Because the group immediately seemed disinterested in the diagrams and what we had to say, we knew we had to shift the focus of our discussion. Dr. Parrish suggested that we ask them if we could present our initial training program to them, and propose that they could provide us with criticism and feedback for how to make it better so that ultimately we can provide the women that work for WWS with training materials to then bring back to the sex workers community. They liked the idea very much, and we went on to give our presentation with some adjustments. After going through the menstrual cycle and female anatomy diagram briefly, Courtnay went on to discuss symptoms associated with the menstrual cycle. It was easy to relate to the women because they too could commiserate with feelings of low back pain, cramps, and other symptoms associated with menstruation. It was a great feeling to see Courtnay point to her lower back and another women smile and respond to feeling that same pain associated with her menstrual cycle. As women, we were all one, bonding over the same exact feeling. I don’t know why something so simple brought so much clarity to me, but it made me feel like there were very little differences between all of us sitting around the table.

As far as hygiene and sanitation regarding sanitary napkins, there were fundamental differences between best practices in the US and in India. We learned a lot from the group about how women in India often use sponges, or pads, reusing the sponges from day to day or even saving them for the following month. Female sex workers usually have 3 days off from work when they are on their period because the customers don’t enjoy it. It was difficult trying to communicate with the women how important it is to not reuse the sponge because they seemed to think it was sanitary after rinsing with hot water and/or detergent. In our proposed revised training module, Dr. Parrish suggested that we create a day by day diagram of best practices for women to maintain cleanliness and properly dispose of sanitation products. The group told us that they usual tell women to manage menstrual symptoms with medicine, putting their feet up, massage, or hot water bottles; all very similar remedies to those used in the US. The women also suggested that our training materials include descriptions next to each part of the female reproductive system, and list out the consequences of not taking care of the female body.

Charlotte did a great job speaking to the women about menopause. They didn’t seem to understand menopause as well as menstruation, and were definitely eager to learn from our presentation. A great conversation was had about common symptoms associated with onset, and we talked at great length about how it is very normal for women to undergo the process. The women felt very strongly that menopause is viewed as a natural and normal part of life for women, and didn’t note any stigma associated with onset amongst the population. The women did let us know that they women appreciate some training materials to have on hand at their office so that they can better educate themselves on the process and further distribute the knowledge to the community.

The breast cancer lecture given by Gen and Kelly was also one that the women really enjoyed. Some of the women were willing to share their personal experiences with the disease; one with a sister diagnosed with breast cancer, another gave an account of a women that uses Aastha Parivaar and how they raised funds for her to have treatment. When we asked the women if they knew how to check for breast cancer, none of them knew how. This definitely hit close to home for my fellow classmates and I Conducting a breast self exam seems second nature to most of us. We are taught how to do them and of their importance in basic health classes. Charlotte gave a great demonstration of how to conduct a breast self exam, and we made sure to highlight the importance to the women that not all lumps are cancerous, but if one is found, they should have it checked by a physician. It became very clear to us that this was a topic we needed to provide more information on. While breast cancer is not at the forefront of their areas of special interest, they acknowledged their desire for us to help them learn more about their body so in the future they are equipped with the self-knowledge to protect themselves.

The entire experience of interacting with the women was a lot different than what I expected. They were so attentive, and open to discuss any topic that we brought up. I know they learned a lot from us, but I really think we learned a lot more from them. They dedicate so much of their time to educating a population of women that is often looked down upon by their family and several members of the community, and it was comforting to know that organizations do exist to assist sex workers with the necessary resources to lead an informed and healthy life.

After the educational sessions, we headed out to a shopping area in South Mumbai known as Colaba. I think I was feeling a bit overwhelmed with emotion by the time we got there because I was not in the mood to purchase anything at all. However, I had a great experience wandering around with Courtnay. Someone walked up to us and said “Bollywood?” which has quickly become an inside joke amongst the group. Courtnay and I were talking about how walking around shopping with me the prices seem to be a bit higher, kind of amusing if you think about it.

We had dinner at vegetarian Indian food restaurant that served food in small dishes on a huge circular plate. The food was delicious, and a great end to the day. The group surprised Courtnay with a birthday cake to celebrate her 21^st birthday India style! The restaurant staff were absolutely wonderful, playing a Happy Birthday song over the speakers in the back room.

Heading back through South Mumbai to the hotel, we went over the sealink bridge. It was a beautiful site to see all of Mumbai. The picture painted in my head of India before this trip is starting to look vastly different than the one I see now.

Day 3: The Women Around Me...

I remember the first day I walked into Dr. Vyas’s Social Entrepreneurship class, I was nervous and intimidated by the fact that I was entering an unfamiliar field that I knew little about, and for the first time since my freshman year all unfamiliar faces. There I stood an undergraduate student with a class of 15 young women that have their lives together, and are ready to take on the world. Not only are they graduate students of GWU’s School of Public Health and Health Services, but also the experiences they have had, either in past jobs or travels, are remarkable. I stand beside such inspiring women, with stories to share and a passion to change the world around them.

For the past few days we’ve been working together to put on a session for the women of Aastha Parivaar, an “organization of sex workers, for the sex workers and by the sex workers.” Their purpose is to “strengthen the community and provide a common platform to all typologies of sex workers to address their common issues and needs such as health, human rights, crisis intervention, legal literacy, literacy and support to their children for a sustainable impact.” As a group, we put together talking-materials on the topics of breast cancer, the menstrual cycle, hygiene, and menopause. When we got to the site we sat in a room with about 10 other women of the Women Welfare Society (WWS), a community based organization, here in Mumbai, under the umbrella of Aastha Parivaar. These women, some sex-workers, some mothers, some both, are all leaders of their community. They explained to us that they speak with other women in the area about sexual health, HIV, STDs, condom usage, and women concerns. We went there not to lecture at them but to help explain issues that they may know little about, but at the same time we wanted to learn from them about their culture and how they view and handle some of these topics. We sat in a roundtable, comfortably talking about sex and feminine issues. We learned that in India when women have their period they use a sponge in replacement of a pad for 24 hours, therefore putting themselves at risk for some sort of infection. They said the reason being is that such feminine products are too expensive. In the U.S. a woman’s period is that 3-5 days of annoyance, cramps, fatigue and PMS. Here in India it’s that and more. For the sex-workers it can be a week out of work. In regards to menopause, some of the women saw it as the end to their career. I remember when we explained that menopause happens around the age of 51, a woman put her head in her hands and shook her head. But then again maybe a woman in America would do the same thing.

Though you maybe reading this saying to yourself these women are putting themselves at such a high risk for infections and disease, on the other hand they are speaking out to other women trying to solve at least some of the issues in their community and work of choice. They work extensively to “reduce incidents of violence and harassment.” In addition the women of WWS “carry out numerous income generating activities” for example they sell condoms, incense sticks, and perfumes and put together various training sessions. They make positive changes in the lives of other women. I am no feminist but I do believe that there is something to be said about women being there for one another.

Like the women in my class, these women have come together because they want to help others. Just like them we have become a united group, and a support system to one another. We know that each of us may be facing different obstacles or how to deal with the emotions we have had felt along this trip thus far, but at the end of the day we can laugh together and feel comfortable talking and reflecting with one another. What I’m trying to say is that the women that we met are not so different from us. Though we may be living in two totally different countries, we share the bond of being a woman.

Speaking Woman to Woman

“Namastey-namastey.” After beginning the morning with Yoga, we put together final preparations for our service project with Aastha Parivar. I sat on the bus for what I have come to realize will be longer than any estimated guess--Mumbai traffic is unlike any city I’ve yet seen—and wondered what we would be walking into today.

We knew we would be working and sharing with sex workers who were part of a community based organization that teaches safe sexual practices and prevention of HIV. We had also been given some guidance as to the subject matter they desired, but we knew little else.

From the beginning cultural differences were glaring--and our framework, re-worked. Though these women are sex workers, sex is not a topic that is discussed openly. There are even difficulties in translating some sexual terms into Hindi, because these activities are simply not part of the language. After meeting with a representative of Aastha Parivar we decided diagrams of basic female reproductive anatomy, and illustrations of the menstrual cycle would be the best route—speak objectively. We would figure out the rest as we settled in on site.

--I could not have walked away from our time with the women of Aastha Parivar feeling any more honored, humbled, and awakened.

From the moments we entered, 7 public health students and Dr. Vyas, there was nothing but warmth. I sat next to a few of our new friends who instantly grabbed my hand and had me sit so they could share their HIV pamphlets and educations materials. Their smiles and openness were infectious.

As a group we introduced ourselves, then each took a turn teaching about menstruation, feminine hygiene, menopause, and breast cancer. With the help of an Astha Parivar translator, Dr. Vyas, and Natasha, we were able to communicate simple facts and norms surrounding these health topics. Some was lost to translation, and it was somewhat difficult to understand exactly what was being inquired or posed in reaction to our lesson, but the women could not have been more receptive. We were even asked to deliver an impromptu lesson on the female condom (big thank you to Dr. Wood for our class session involving all types of female condoms!!).

The women of Aastha Parivar then showed us how they educate those in their communities about HIV transmission and safe sex practices. Most sex workers will continue soliciting even after contracting the virus. In this trade, it is normal for more money to be offered in exchange for sexual intercourse without protection.

How do you turn this down when you are the sole provider for your family?

How do you turn away when you are trying to provide a better life for your children?

EACH woman we met was married. EACH woman had a least one child. EACH woman traveled 90 minutes, one-way, for work--EACH day.

Exposure to violence and little hope of leaving their trade is their reality, and yet they sat across from us--they sat among us, with nothing but kindness.

I was in awe.

I am grateful for what little we were able to share with these brave women, and thankful for all they taught us. Our friends at Aastha Parivar will often be on my mind.