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. 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.

Inspired by Sex Workers

Day 2: Yoga, Sex Workers, and Indian Celebrations…

“Because of my work, my daughter is getting her Bcomm and my other daughter now works at the bank” – Sex Worker

“Because of the work I do, I was able to provide a computer for my children so they can learn” – Sex Worker

“I hope in my next life, I am as educated as you” - Sex worker

Today, we began our day with an hour of Ashtanga Yoga, or eight-fold path. We then enjoyed a nice mix of Indian and Continental breakfast at the hotel.

Our assignment for today was to prepare a training protocol on reproductive health for commercial sex workers who also work with community based organizations (CBOs) empowering sex workers to better understand their bodies and use protection. Our group of 20 was divided into two groups so we could train two CBO sites. Our group went to the Kranti Mahila Sanstha (KMS) community based organization. We met with approximately a dozen sex workers who were excited to learn from us. We focused mainly on the menstrual cycle, hygiene, menopause, and breast cancer.

I was in awe of how much they understood what we taught them. At the same time, they were eager to listen so they could be assured that what we were teaching them is what they also knew. They needed the assurance. They mimicked our demonstration so they could then later teach their peers.

What I was most amazed by was their curiosity in wanting to know if there were other sex workers in Washington, DC and if these sex workers were also illiterate as them. They wanted to feel that they weren’t alone.

Once the group left – we had to wait for our bus for approximately 20 minutes. During this time we met with three sex workers that were also waiting for a ride. We used this opportunity to learn more from them – how their families felt; how their husbands felt; How much money they make; and if they want to leave the business.

The women shared with us that they met their husbands as clients first. They do have children but have put their children in boarding schools, as they do not want their children to know or understand their line of work. The women want to leave this work for many reasons – violence, drunk men, harassment; however, they receive approximately Rs 15,000 a month which allows them to provide for their families. The conversation was so humble and frank. They were proud of the fact they were able to do so much for their families. Though they wanted to live this line of work, they have learned a lot about society, themselves, and used the opportunity to empower other sex workers to be safe. It was inspiring to watch these women take advantage of an opportunity that many do not. The quotes I mentioned above, are exact quotations from the women we met today. They taught me that no matter the situation, I too should be better about taking the best opportunity I can.

After spending a few hours with them, we went to dinner to have a traditional thali meal. The women in our group loved it. One of the women had turned 21 so we celebrated with a cake (which was actually good) and the Indian version of Happy Birthday. It was the perfect way to end such a fascinating day.

So factual Information about Sex workers:

• The Largest Red Light Districts in India are in Mumbai and Kolkota
• There are many organizations in India that promote sex sexual practices and educate them on HIV and other STI preventions but very limited NGOs that actually help sex workers leave this line of work
• 50% of Sex workers have HIV.
  

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.