Day 3 – The other side of the tracks

With Vinod Shetty from ACORN India as our guide, we made our way through the industrial side of Dharavi, one of the largest slums in Mumbai, made famous by the film, Slumdog Millionaire. A large part of the Dharavi community's livelihood is what is called ragpicking, or scouring the piles of trash dumped near by for recyclables which can be cleaned, sorted and resold to companies seeking cheap materials. There is no real sense of occupational health awareness, never mind regulation – most workers were barefoot, and not one worker was wearing gloves or eye protection, even when operating the heavy machinery used to chop cardboard or plastics into tiny pieces. It was very muddy; we had to hop between stray bricks sticking out of the mud to traverse the paths between the buildings, some of which were 4 stories tall, many comprised of metal siding.

When I initially heard about Dharavi, after seeing Slumdog Millionaire and a documentary in class about Shetty and ACORN India's work in Dharavi, which focuses on providing educational opportunities for the children of Dharavi, I learned that this community is largely comprised of migrant workers or others forced out of their communities for one reason or other. I was appalled to learn, not only about the water supply and sanitation issues, but that many do not even hold citizenship, do not have access to basic health services or educational opportunities for their children. “Where is the government?,” I demanded to know. It reminded me of pre- into industrial New York and Boston, and made me think of my own family, immigrants looking for work and opportunities. They would have been on the streets or forced to create makeshift shelters too, had it not been for the government housing projects to which they had been assigned. I was sympathetic, and am still – but its not so simple in Dharavi.

There is currently a ton of contention between the people of Dharavi and the government: the government sees this group and their community as a burden and an eyesore on prime real estate – sandwiched between two major sets of train tracks, in the middle of the city. Redevelopment projects have been suggested time and time again (Dharavi has been around for the better part of the last 70 years; its not a new phenomenon), but for one reason or other, just have not panned out. This is not just because the government or NGOs are not trying hard enough, but many in Dharavi simply don't see a need for change. They are largely self-sustaining – Dharavi is responsible for almost the entire recycling industry for the city, and business, so I have been told, is pretty good.

While speaking to the owner/manager (it was not clear, but he was definitely in charge) of a cardboard recycling operation I was informed that the operation makes about $10,000 a month – yeah, US dollars. Though many workers in this operations, and many like it, live in their workspace, they earn up to $400 a month – that's pretty good, considering there are people in this county living on less than $1 a day. Like all businesses in Dharavi, the whole operation runs under the table, is not registered by the government and thus, does not pay taxes. If the people of Dharavi were to agree to a redevelopment initiative, they would have to give up their work spaces, pay for a living space, and most likely have to legitimize (i.e. pay taxes on) their businesses. From that perspective, I can see why they prefer to keep the status quo.

Dharavi is not clean, healthy, or anywhere that people would prefer to spend their lives or raise a family, but to certain extent, I get it. I can understand why, in a community of people brought together by the commonality of the need to survive, they're doing a pretty good job at just that.

A little perspective with my tea

08.03.11

Wednesday was incredible and really eye-opening. All preconceptions and assumptions destroyed.

Also I should point out that this post will be a little bit more graphic than others, given the reality of the amazing people we interviewed and my area of interest.

The organization met with on Wednesday was Aastha Panivar, a collaborative community organization that focuses on health education and respect for sex workers (prostitutes) in Mumbai. Yes, I was going to meet with actual Indian sex workers. The idea was that our group of 20 students would divide into 2 groups and meet with two separate groups of sex workers. We were asked by the organization to prepare health education materials on menstruation and hygiene, menopause, and breast cancer. These were topics that one of the organization’s directors had told Dr. Vyas that the sex workers wanted to learn about and have more information on.

Photo (1) Sex worker community representatives and GW students

Here’s something that I should point out – a few learned lessons: (1) in health education, be prepared for the unexpected and for things to not go according to plan; and (2) always offer utmost respect and openmindedness towards the population you are serving. I have to admit I had some trepidation about meeting the sex workers. I had seen documentaries, movies, read articles, held class discussions regarding sex workers and the business of sex, but had never actual met someone who has that profession. I was unsure what they would be like, how they would look, what they would say. I’m afraid that I struggled at first with understanding their perspective and why these women did what they did – I had initially ASSUMED that these women were born into brothels or sold to brothels though human and sex trafficking, all devastating human rights issues. However, when I actually had the opportunity to meet these women and sit down and discussion life and health issues, we quickly found out that they were a lot like the incredible women I know and were raised by.

In the end, they all were mothers, daughters, grandmothers, sisters, cousins, and neighbors. One woman shared about her two children, one of whom was just about to get married and all the joy she felt. Another woman shared about how she takes care of her mother and children all by herself. And sex working has become the means of employment for these women. No please do NOT misinterpret my text as thinking that I am condoning sex work, am saying that all of these women chose this occupation or are willingly (100%) continuing sex work by their own volition. My intention is to shine light on the reality of these women, what circumstances led them to their occupation, what sort of life they lead, and what challenges they face.

In the end, like I mentioned, these women are all still mothers, daughters, sisters, etc.

We showed up to the NGO’s main building with our lesson plans in hand and a color print of a uterus to provide visuals for explaining menstruation. How quickly all of our detailed, well-planned itinerary was destroyed. Every conversation and topic – every single spoken word – had to go through the scrutiny of Hindi to English and English to Hindi translation. Dear God, this is going to take forever. We made sure we explained to the ladies meeting with us, who characterized themselves as community leaders and teachers for sex workers in their area. The group we met with never explicitly said that they are or were sex workers, but the idea was implied. More than once. However, we maintained a respectful disposition throughout the entire session and actually learned so much!

To start, we told the women (and some men) in the group that we were there to share some health topics that had been mentioned as important topics for this specific community – ones in which the sex worker community in this part of Mumbai had questions about. Well, within 5 minutes of the start of the lecture on menstruation, we learned that nothing was going to go accordingly to plan. First, a few of the community leaders stopped some of my colleagues in the middle of their “this is a uterus” talk and explained they had the whole reproductive system and menstruation actuality down. Apparently they had been told about sexual and reproductive health by nearly every NGO they’ve encountered. They get it. Well damn, there goes part 1 of the lesson plans. Conversation quickly led into hygiene around menstruation and the use of sponges during their week. Sponges. Yes, sponges. It is becoming more uncommon (old school) with the introduction of maxipads but apparently for a long time, sex workers would use sponges to help with menstruation. Kitchen sponges. They’re cheap and reusable – even though we tried to stress they should only be used once and then thrown away. From this conversation erupted an amazingly vast discussion, dialogue between us public health students and these Indian sex worker community representatives. Within 20 minutes, our lesson plans were shot dead but we opened the forum for conversation and a chance for us to learn from them.

The discussion addressed everything for sanitation and hygiene during menstruation to natural remedies for cramps (apparently the sex workers swear by ibprofin) to symptoms of menopause to breast cancer and self-exams. We had prepared materials on all of these subjects, however, instead of it being a teacher-student setting, we were forced to switch modes into women learning/teaching women; a open dialogue to learn. This seems to be something that arises often in public health: deviations from the plan. But Dean Parrish was there to help guide us towards a cooperative of information. I was still able to share my information on menopause, symptoms, and how older women are still feminine and beautiful, even if they can no longer have children. It provided amazing perspective for me, though, given that the sex worker representatives made note that menopause might mean the end of a sex working career since it was seen as more of an end to femininity. Also, the representatives were hell bent on getting numbers out of us – one woman politely demanded an age when menopause occurs. I explained that it varies woman by women, but she needed a number – so I was forced to settle with the average I found online: age 51 years. When I told her this, she seemed to be satisfied and move the conversation onto the next subject.

After my brief stint in menopause discussion, we entered the very hard topic of breast cancer. Jennifer Mendoza, another GW student, shared her mother’s own battle with breast cancer and how she is going strong because she chose to take care of herself. We asked the representatives if they knew someone who had breast cancer, and most of the women said they did. Some even shared their own personal struggles with finding lumps and getting them tested. They agreed that cancer was bad and you should go see a doctor if you suspect something, however, they did not see it as a health priority. HIV/AIDS, pregnancy, STDs, menstruation – those are the big concerns for these female sex workers, not breast cancer. But that’s where we found purpose and passion – stressing to the women that they should recognize that taking care of yourself is the most important thing you can do for yourself, your family and that by taking control of your health, women can find empowerment over her own life and outcomes. We were trying to stress in our discussion that by these sex workers taking care of their own health, they are helping themselves be independent in the future – their health is in their own hands.

Think about it like this: sex workers do not always have complete control over their lives, their surroundings, their clients, their rights. Some women are born into sex work, some women are sold into sex work, some women are coerced into sex work, and some women chose to do sex work. However, one thing a sex worker could potentially have control over is her health; if she takes every measure she can to take care of herself, to be clean and healthy, use contraceptives whenever possible, to get tested for STDs, visit doctors when possible, AND be aware of her own mental and physical being she can gain some empowerment over her own life and outcomes. We were trying to stress in our discussion that by these sex workers taking care of their own health, they are helping themselves be independent in the future – their health is in their own hands.

In order to makes sure no information was lost in translation, we proceeded to lead a breast cancer self-exam demonstration. Correction: I proceeded to lead a breast cancer self-exam demonstration. Under the instructions and explanations of Mrs. Kelly Healy, I demonstrated how to place pressure on the breast, with your arm lifted, to check for any irregularities each month. The sex worker representatives were fascinated by the idea of checking every month and being aware of their body. We even promised them an illustrated pamphlet on breast cancer self-exams to distribute to the sex workers. I feel like our first year of back-breaking, headache-causing public health graduate school has finally manifested itself into something real! We have the opportunity to prepare materials to be distributed to real people and potentially make a real difference; maybe even save someone’s life. I mean wow. Teaching a woman about self-exams and taking care of her body could literally save her life. Absolutely incredible! I now am starting to see and understand why I am doing what I am doing – helping people help themselves.

Fair to say nothing turned out the way I expected but it was so much greater than I could have imagined. What an amazing experience and what amazing perspective it provided. As a public health professional I need to always be flexible and always enter into a new, unknown population with an open mind. I am not there to judge or assume – I am there to serve and learn. This was a very humbling experience but one much appreciated.

Day 2: Plans are meant to be broken

Whether you get stuck in 2 hours of unforeseen traffic, or the NGO is not prepared to put a group of 20 to work, as we experienced on the first day, or, as I have been experiencing on my own, traveling in a large group is not as easy as I thought it would be, the idea that things never work out the way you plan, in India, or at least within my experience here, this statement has never been more true.

The very last class before we came to India, we were asked to begin brainstorming to prepare an educational program to present when we met with Aastha Parivar, a local NGO which offers services predominantly to commercial sex workers. Aastha Parivar does outreach work including HIV/AIDS prevention and a social entrepreneurial arm which sells make-up, perfume and incense made by the women. We prepared a three-part program to provide the women served by Aastha Parivar with information topics we were told carry certain stigma within their community, as well as within India on the whole, and which are applicable to their lives – menstruation, menopause and breast cancer.
On Wednesday, our whole group was split between two sites affiliated with Aastha Parivar and our half of the group was dropped off at the Women's Welfare Society, a peer education outreach organization. The women with whom we were meeting turned out to be the executive board of the Women's Welfare Society, many of whom may be current or former sex workers, as well as nurses and administrative staff of the organization. Our group was prepared with the diagrams, scripted outline and materials for an interactive activity, and began as planned. The language barrier was eased by two of our group members fluent in Hindi and a staff member of the organization who all three served as translators.

We got about 5 minutes in, and couldn't help but notice the bored expressions on the women's faces. Finally one spoke up, informing us that they had already had training on menstruation.

Let me just say that this situation has the potential to be a health promotion student's worst nightmare. Although we were attempting to present this vital information in, what we thought would be, a new format for these women, they were adamant – this was old news. We had not had the opportunity to do any kind of needs assessment, and were only afforded a few short conversations with Samhita staff, and had not even met the women to whom we presented until that day. Ok, good. Now what? We didn't really have the time or resources to prepare a Plan B. After a moment of regrouping, it was suggested that we go ahead and present our information as planned, and give the women, based on trainings they have had and information thy disseminate during they peer outreach, an opportunity to share anything we might have left out, or alternative ways to talk about this information in which they feel are more effective withing the community they serve. This turned out to be a fantastic opportunity for an exchange of information and a mutually beneficial learning experience.

Breast cancer is an emerging health issue in India and at first, the women did not seem entirely convinced that they needed to know the information, but as soon as we asked if anyone had a relative or friend diagnosed with cancer, they all saw that it impacts far more people than they realized. One of the women herself had recently had a biopsy taken of a suspicious lump. After those conversations, the women opened up, asked questions and became much more receptive. They were very intrigued by the idea of self examination, and generally about preventive measures. Apparently, even though many were aware of it, there is not much in the way of literature or health education training on breast cancer. From the session, we offered to create some materials for the Women's Welfare Society – either a pamphlet or a training manual – on breast cancer which they can disseminate to their peers. They were very excited about this, and I think we all left on a little lady-power high.

It was amazing to meet these women who are working to make a difference and empowered other women so incredibly marginalized by society. I can only imagine what it must be like for them, whether or not they themselves are sex workers, knowing that the information and opportunities they provide has the potential to save, or at the very least, change the lives of other women. I was so incredibly inspired. I see myself doing very similar outreach work in the future; a plan which, hopefully works out, and can allow me to make a similar impact on others.

My thoughts summed up thus far...

"To love. To be loved. To never forget your own insignificance. To never get use to the unspeakable violence and the vulgar disparity of life around you. To seek joy in the saddest places. To never simplify what is complicated or complicate what is simple. To respect strength, never power. Above all, to watch. To try and understand. To never look away. And never, never, to forget" - Arundhati Roy

Nitasha

Day 2. Aastha Parivaar

What can be more humbling that someone telling you that in their next life they want to be as educated as you? I’m not sure, but I was humbled. We all were.

We all sat down in a big circle with the wonderful women from Aastha Parivaar, an organization that works with the sex worker community in Mumbai, exchanging smiles and excited looks.

Aastha Parivaar provides reproductive health education, HIV/AIDS counseling as well as medical services. Our goal for the day was to lead and facilitate a session on reproductive health, more specifically the menstrual cycle, hygiene, menopause and breast cancer. We had very little time to plan our session and to gather information, but this did not put a dent in our exciting to converse with these women. The group of sex workers we met has formed a community-based organization that teaches other sex workers about safe sex and how to take care of themselves and of each other.

Listening each one of these women, and sitting next to them was a very inspiring experience. Sex work is illegal in India as it is on most countries in the world. Most of the women we met during the training session have been in this profession for over 20 years, putting themselves at risk everyday so they can provide for their families. One of the women told us that she does not know how to write or read, but she has been able to put her kids in school and even provide them with a computer at home to ensure they have better opportunities than she did.

I hope that the very little time we spent with them, and the very little knowledge I was able to share with them helps their mission. Was I touched and inspired? You better think so. I hope they know we learned more from them, than what they did from us.

I hope in my next life I get to be as inspiring and brave as the women we met today.