case study g

Swasthya: The Politics of Women’s Health in Rural South India

Page 1 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

The Practice of International Health: A Case- Based Orientation Daniel Perlman and Ananya Roy

Print publication date: 2009 Print ISBN-13: 9780195310276 Published to Oxford Scholarship Online: September 2009 DOI: 10.1093/acprof:oso/9780195310276.001.0001

Swasthya: The Politics of Women’s Health in Rural South India Suneeta Krishnan

DOI:10.1093/acprof:oso/9780195310276.003.07

Abstract and Keywords This chapter looks at experiences providing health care to rural women in India. It shares thoughts about the quality of health care offered to women. The chapter also describes the establishment of the Well Woman Clinics, aimed at providing empathic reproductive health care, including information, counseling, and clinical services to women. Community health workers (CHWs) were trained to take a comprehensive, broadly defined health history and provide pre- examination counseling to help women assess what kind of clinical consultation they required and become acquainted with routine examinations.

Keywords:   health services, reproductive health care, women's health, rural health, public health practice, health workers

In August 1997, three American students, including two of Indian origin, met at a newly opened cyber café in Bangalore city, India, to plan a women’s health program in Vijaygiri,i a rural community 350 kilometers away. Rajiv, whose brainchild the program was and who had raised funds for it, did not turn up for the meeting. The others decided to go ahead with their trip to Vijaygiri anyway. So, at the height of the monsoon season, the trio traveled to Vijaygiri to conduct a needs assessment for the program. I heard of their plans through a friend. In search of inspiration for my dissertation research, I decided to tag along. My father had passed away recently, and the sudden loss had left me drifting. I needed to find an anchor, a focus.

Swasthya: The Politics of Women’s Health in Rural South India

Page 2 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

At around 9 P.M., we boarded a “luxury” government bus that turned out to be anything but luxurious. Last-minute booking meant that we had the last row. After a few hours on a relatively straight highway, we started to climb up through the mountains. In the last row, even the most minor pothole tossed us high off our seats. And the rain! The rain came pouring down the whole night, leaking through the cracks around the edges of the windows. The next morning I stepped off the bus at the Vijaygiri bus stand damp and aching.

The bus stand was a patch of ground big enough to accommodate two buses and a few auto rickshaws. Coconut, arecanut, and other trees bordered the stand and houses crowded in on the sides. It was about 5 o’clock in the morning. Faint strains of the traditional Sanskrit morning chants played on a radio. A few auto drivers were standing around, yawning and stretching. Now that the rain had ended, the air was crisp, cold, and damp. Leaves on the trees were fresh with dew and (p.129) rain. Ah, how peaceful, how idyllic were those first few moments in Vijaygiri after the hustle and bustle of Bangalore. “Perhaps here I will find a dissertation topic and peace after the turmoil of my father’s death,” I thought.

No one was there to meet us, so we approached an auto rickshaw driver and asked to be taken to the hospital. We drove through what looked like the main road of the town, up a hill and around a corner. There at the top of the hill was a sprawling pink building. To the left, by the side of the parking area, was a badminton court. People slowly moved about with toothburshes, towels, and flasks. No one seemed to notice us. We wandered in through the main entrance and reached an inner courtyard with hallways going left and right and stairs going down. Just as I began to feel a bit frustrated, we saw a tall man, maybe in his fifties, walking toward us from the corridor on the left. He carried himself with an air of authority, but at the same time his smile was open, welcoming. He reminded me a bit of my grandfather. It was Dr. Vasan, the chief medical officer of the hospital.

Rajiv and the students I was with had worked out the broad goals of the project with Dr. Vasan. The idea was to extend the mobile clinics that the hospital was conducting to make outreach more regular and to recruit a group of local women to engage in health education. The initial mission was to “empower women with information and other tools to make and act upon health care decisions.” I was wary of the fact that the project did not have an explicit ideological or theoretical orientation. Further, there had been no discussion about roles and responsibilities—of the student group, the hospital, or the health workers we would recruit. I was apprehensive that the undertaking might turn out to be a haphazard student project rather than a formal program and about being saddled with responsibilities that I had not had time to fully comprehend. I was already a year into my “all but dissertation” status in the doctoral program in epidemiology at the University of California, Berkeley, and was conscious of

Swasthya: The Politics of Women’s Health in Rural South India

Page 3 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

the need to stay focused on completing the dissertation. I was also committed to a project that would keep me linked to my childhood roots in India—a desire that had shaped the focus of my undergraduate and graduate studies in the United States. Thus, quite quickly, I became the group’s point person.

Later that first morning, after we had showered and dressed, we met Dr. Vasan at the canteen, a low-roofed annex to the main hospital building. As we devoured the iddlis (steamed rice cakes), chutney, and sweet hot coffee served in 2-inch- high steel cups, a doctor who looked to be in his early thirties greeted Dr. Vasan with respect and then turned to us with an excited smile.

“So these are the Americans.”

“This is Jagan,” introduced Dr. Vasan. “He has been running the hospitals’s nursing program and the community outreach.”

Dr. Jagan seemed excited and enthusiastic about meeting people interested in his line of work. We began to discuss what our role at the hospital would be, and once our conversation was under way, Dr. Vasan excused himself to begin morning rounds and left us to our discussions with Jagan.

(p.130) A few days later, in an airy, spacious office of the hospital, I met with Dr. Jagan and the honorary secretary of the hospital, an elderly, sprightly man who had retired from the banking sector. Jagan seemed far more relaxed in the presence of the secretary than in that of Dr. Vasan. In fact, he was in his element.

“What we need is mass education,” he announced. “Now is the time to start. I have 20 girls finishing the nursing course this month.” Dr. Jagan had been running a 1-year training program for nursing assistants, who were simply called nurses. If we did not move fast, we would lose the opportunity to recruit a few of the graduates. Most got hired by nursing homes and clinics in the district and neighboring districts. Once they got jobs, it would be difficult to recruit them for our project. And once we hired them, we would need to initiate training as well.

At first I was reluctant to rush to action, hoping instead to take our time in developing a solid plan. However, I caved in.

“We’ll interview the candidates tomorrow,” announced Dr. Jagan.

The secretary seconded the proposal. Dr. Jagan recognized the importance of identifying young women with a commitment to staying back in their home communities, with an interest in working on women’s health. But I learned from him that in order to accomplish our goals, we had to work very strategically

Swasthya: The Politics of Women’s Health in Rural South India

Page 4 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

In her more recent work, Suneeta Krishnan has been operating out of urban clinics in Bangalore, India, interviewing young women about their marriages, economic situation, and sex lives. (Photo: Jason Taylor for Time.)

within the hospital. We had to bring on board the authorities, like the secretary, and the staff, like the head nurse, by trying to work on terms acceptable to them.

On one of my early trips, I drove back to Bangalore with Dr. Vasan and his wife, Dr. Sarojini. Dr. Vasan was in a nostalgic mood and eager to confide. We spoke

(p.131) at length about the hospital during our ride to Bangalore—about the 10 years they had spent struggling to establish the hospital, and about Dr. Jagan. I learned that Jagan was a native of the town, trained in Ayurvedic medicine. “We sent him to get training in anesthesia. The main problem with him is that he doesn’t have confidence. He doesn’t focus,” Dr Vasan said.

“You know, for even a little thing, he will send people for an x-ray, an electrocardiogram,” added Dr. Sarojini.

Dr. Vasan continued in a resigned voice, “I manage with him. His main strength is public relations. He will be good at helping you with the training of these health workers and talking to the panchayat [village council].ii He’s good at handling politics. But I will come to the weekly clinics myself.”

In contrast with what Dr. Vasan had told me, Dr. Jagan seemed very confident. As the project evolved, the student group and the community health workers (CHWs) relied on him to negotiate with the hospital authorities as well as with local village authorities like the panchayats and local landlords. He had the ability to connect with people and to speak in ways that they could identify with. I felt that ultimately it was Dr. Jagan who understood the project—and in many ways it was his project: it emerged as an extension of his nursing training program and his community outreach work. For years, before Dr. Vasan and Dr. Sarojini had joined the hospital, Jagan would hitch rides with taxis and jeeps going out to the villages to offer health care and information. He had a strong commitment to social service, which made him a natural leader for our project.

Our new recruits, the CHWs, participated in a 3-month training program in community health. During this time, Jagan lobbied with wealthy families and local panchayats to donate space for the CHWs’ health centers. In January 1998, we launched health centers in six villages within a 30 kilometer radius of

Swasthya: The Politics of Women’s Health in Rural South India

Page 5 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

Vijaygiri. Jagan and Dr. Vasan planned a grand launch—a large multispecialty camp. Camps are a common strategy used in India to promote health-care access as well as utilization of particular kinds of health services such as sterilization or screening. A number of doctors we met at Vijaygiri and Bangalore who were involved in community health all felt that the most effective ways of establishing oneself in the community was by providing basic medical care through camps and outreach clinics. Dr. Vasan and Jagan too felt that this was crucial.

The day of the launch, Jagan was extremely tense but in charge. He paced up and down, checklist in hand, overseeing the packing of equipment and materials. We left the hospital as a convoy of four vehicles. The hospital van left at around 8:45 A.M. with a team of student nurses, laboratory technicians, and equipment. Jagan followed in his car with the CHWs, his wife Ila, his daughter Ashwini, and Ashwini’s puppy Amitabh, named after a famous Bollywood actor. I followed in a jeep with Dr. Vasan and a few other doctors.

The first center, located in hilly estate country, was being launched at the village farthest away from the hospital. It consisted of two rooms within the village government office at the foot of a hill. Areca nut trees dripping with black pepper (p.132) vines and sweet-smelling coffee bushes in bloom grew on the slopes. Closer to the summit were the neatly cropped tea plantations.

By the time we reached the site at about 10 A.M., at least 50 people had gathered. The majority were women, some with children. The panchayat officials, registers and pens in hand, seemed extremely organized, as did several community volunteers. There must have been a team of about 20 organizers and a total of about 8 clinical specialists at the camp. It was 10:15, and a festive atmosphere prevailed. Hindi pop music blared on the speakers. The panchayat officials decided it was time to begin.

The next thing I knew, the owner of a local tea estate who was sponsoring the day’s program was announcing my name, and I was led to the stage by one of the camp volunteers.

With a dry mouth and a racing heart I walked to the microphone. Over 100 people had gathered by then. Dr. Jagan introduced me: “Now, Mrs. Suneeta Krishnan will say a few words about Swasthya. She is one of the dedicated students who has come all the way from America to work with us.”

I reminded myself that I was the “laudable American” and could do no wrong. Braced by this thought, I launched into my speech, in English: “Today’s program is a true representation of what Swasthya is trying to accomplish: local communities, the hospital, and the Swasthya team working together to promote health. We hope this partnership will be a long and successful one.”

Swasthya: The Politics of Women’s Health in Rural South India

Page 6 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

Dr. Jagan stepped up to translate and then launched into a few of his own remarks: “Our goal is to provide not merely treatment but also health education. Illness prevention is the goal.” Throughout the life of the project, he would repeatedly emphasize this goal.

Finally, after what seemed to be an eternity, the speeches came to a close. The panchayat president (head of the village government) kicked off the camp by requesting all those who wanted a health checkup to register. In minutes, a long queue of men, women, and children formed at the registration desk in front of the panchayat office. Three young men, panchayat volunteers, sat at the registration desk and asked each individual to identify which specialists he or she wanted to consult. I watched the proceedings for a few minutes. There were many women in line—dressed in their holiday finest, with flowers in their hair and colorful glass bangles on their arms. Some had babies on their hips. A few were chatting and joking; others looked tense.

“Do you live here—in this village? It looks like the entire village is here!” I asked a group of women in broken Kannada, the local language, peppered with Tamil and Malayalam, the two languages that I spoke growing up in Kerala, another South Indian state.

“No, we are from the tea estates up over the hill behind you. We had to walk nearly 8 kilometers to get here,” they replied. Behind me was a steep hill, crowded with tall, lanky silver oak trees whose leaves glistened like silver in the sun. The district had many large estates tucked away at the tops of remote hills. Some provided (p.133) basic primary health care, but in general accessing care was a considerable challenge, given the terrain and the distances involved.

I was with another Indian-American student, Preeti, who was taking about 6 months off before starting medical school in the United States. For us, this first camp was an opportunity to begin understanding the range of health problems that women had, how they talked about them, what they did, and how local clinicians responded. We decided to split up, observe, and take notes.

I continued to stand by the registration desk to observe the requests being made. Once the women realized that I could speak a little Kannada, they started to talk.

“My two children and I walked 10 kilometers across the paddy fields over there,” a woman told me, pointing to the valley down below the panchayat office. Green fields beginning to turn a golden brown, approaching the winter harvest, extended for several kilometers ahead. Near the horizon I could make out a settlement. At the camp, we learned how important the local terrain was in shaping women’s access to care. This region is heavily forested and mountainous. Many villages are tucked into the hillsides and surrounded by dense vegetation. Because of heavy rainfall, there is extensive paddy cultivation

Swasthya: The Politics of Women’s Health in Rural South India

Page 7 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

in the valleys where “villages,” consisting often of just a handful of homes, are separated by kilometers of fields. Distance and lack of transportation were therefore important barriers to health-care access.

“We even missed a day’s pay to come to the camp! Management is like that— they won’t even give us a day off if we are sick,” said one young woman.

“Sixty kilos we pluck. Is it any wonder that we have back pain and white discharge?!” questioned another.

Many of the large estates are mandated by law to provide basic amenities such as health care and primary education. However, most of these clinics are run by male doctors. Doctors and women are uncomfortable with physical exams; therefore, if a woman does seek care for a gynecological problem (which she may not), treatment is usually based only on reported symptoms. Without the estate doctor’s permission, women would incur leave without pay if they needed a day off to seek gynecological care from a woman doctor, who might be anywhere from 10 to 30 kilometers away.

One woman explained, “When we to go to the town to see a lady doctor, we have to spend so much—5 rupees bus charge and another 50 rupees to the doctor. And then the medicines.”

Even when health care was accessible, as in the case of our camp, the culture of silence around women’s gynecological health was so pervasive that women would not reveal their problems. The fact that we were requiring everyone to publicly state which specialist they wanted to see was clearly not conducive to making women comfortable about indicating gynecological concerns. Further, we had young men sitting at the registration desk noting down this information. This did not strike me immediately. But as I stood there for 5, 10, 15 minutes and found that so (p.134) few of the women were stating gynecological problems and seeking consultations with the gynecologist, I began to become suspicious.

My uneasiness was confirmed when I struck up a conversation with a tall, thin woman who looked to be in her thirties. She seemed tense and apprehensive, wringing the edge of her sari, scanning the crowd. I approached her with a smile and welcomed her to the inauguration of our new health center.

Bharati was her name. I described Swasthya’s services and focus on women and I asked her what concerns brought her to the camp.

“Headaches,” she said.

“Have you been having any other problems?” I asked as we waited for her turn to register.

Swasthya: The Politics of Women’s Health in Rural South India

Page 8 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

“No,” she said uncertainly. Given her hesitation, I engaged her in some lighter conversation. “So, how many children do you have?”

“Three—two girls and a boy.”

“Have you brought them also for a checkup, or did you come on your own?”

“I came on my own.”

“So tell me, how is your health? What kinds of problems do you have?”

She moved closer to me, and while keeping her eyes downcast, confided, “I have been bleeding a lot, more than what is my usual, and throughout the month.”

I asked how long it had been happening.

“It’s been more than half a year now. But the estate doctor said not to worry, he didn’t even need to look at me. He said that it happens to women at my time of life and that it would stop soon. I am waiting, and yet I feel so weak. Every day is more difficult.”

At 35, Bharati seemed young for menopause. I felt that her symptoms merited an examination, if not some extended treatment, and I was angry the estate doctor had not even examined her. I was sure she would benefit from an exam from the female gynecologist at our camp.

“Oh, there is really no need,” she said, “I am sure I will be feeling better soon.”

We had been speaking with a friendly rapport, but I reverted to playing the health professional role, and after a few more words of encouragement, Bharati nervously agreed to an exam. I completed her registration and then accompanied her to the line in front of the gynecologist’s room. I returned to the main registration queue to continue talking to others.

I saw Jagan nearby: “You have to tell the men at the registration desk to ask all the women if they want to see a ‘lady’ doctor,” I said anxiously. “The women are too shy to ask and they’re going to miss out on an opportunity to see the gynecologist!”

I watched understanding flash across Jagan’s face. Immediately, he headed to the registration desk to make our request. This approach worked much better. The doctors’ consultations went on all day.

A typical exam took place like this: The doctor is sitting behind a wooden desk. The nurse is standing, attentive, by her elbow. The patient enters and stands, (p.135) waiting to be acknowledged. She moves to sit on a stool by the side of the desk when the doctor motions her to do so. “So what is the problem?” the doctor asks, without lifting her eyes from the case sheet on the desk. The patient

Swasthya: The Politics of Women’s Health in Rural South India

Page 9 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

describes her symptoms and the doctor orders her to the examination table, chiding her if she does not cooperate by getting into the lithotomy position to facilitate a pelvic exam. Occasionally, if the patient resists out of fear, her legs are pried apart.

Later, we noticed the marked difference when doctors treated women whom they perceived to be their social “equals,” that is women of an upper caste. Upper-caste women were welcomed into the consultation room with a smile. Eye contact would be made and explanations given. The women would be put at ease before the examinations began.

The most common problems that women at the camp reported were white discharge, excessive bleeding during menstruation, and missed periods. The doctors examined the women who complained of white discharge (some with a speculum and some without), but most of the time they could not find anything wrong and would either prescribe ayurvedic medications or order a blood test. The doctors did not offer much advice to the patients. Mostly, they simply prescribed medications.

The experience of Lakshmi, a thin, diminutive 28-year-old woman who worked on the tea estate, was illustrative of the lack of dialogue during medical consultations. She came to the gynecologist because she had still not started menstruating. Dr. Sarojini took her into an inner room for an examination. Shortly after, she returned to tell us that Lakshmi had poorly developed female sexual organs (immature breasts and poorly developed genitals), probably due to reduced production of female hormones. Dr. Sarojini told us that this problem should have been addressed when Lakshmi was much younger and that it was probably too late to do anything about it. While she explained all this to us in English, Lakshmi was standing patiently next to the desk, waiting for something to be conveyed to her in Kannada.

Dr. Sarojini asked her to come to the hospital at Vijaygiri on a day that doctors from the nearby teaching hospital visited for special consultations. Not surprising but telling was the fact that during the discussion with Lakshmi, Dr. Sarojini provided no information about her health problem or prospects for treatment.

About an hour later, I saw Bharati standing in a corner of the compound. The kohl she was wearing around her eyes was smudged down her cheeks. She was distraught and could barely speak.

“The doctor just said that I had to come to the hospital this week to have my uterus removed!”

“But didn’t she tell you why?” I asked.

Swasthya: The Politics of Women’s Health in Rural South India

Page 10 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

“No, she examined me and just said to come to the hospital to get my uterus removed.” Fresh tears poured forth. “It’s going to cost so much money. And I’m sure the doctor won’t give me leave!”

I was confused. I had thought that Bharati was upset about having to undergo a surgery. “What do you mean—the doctor won’t give you leave?”

(p.136) Bharati explained that she needed to get a referral for the surgery from the estate doctor, otherwise she would not get sick leave or reimbursement for her expenses. I told her that I would go with her to talk to the estate doctor, who was also at the camp, and convince him to give her a referral to the hospital.

The doctor, a short, bespectacled man, was not someone I would see as an intimidating person. However, he clearly wielded great power over Bharati; she was even quieter in front of him, almost fearful. Later, while recounting the incident to Jagan, he explained that the estate doctors are quite powerful but also find themselves in the crossfire between estate workers and the management. Estate management wants the doctors to cut down costs and limit referrals and expensive procedures, but workers look to the doctors to help keep them in good health. The success of his job depends on his ability to establish good rapport with the workers and their families so that they follow his advice. This estate doctor seemed open to listening, and after I explained the situation to him, he agreed to give Bharati the referral letter she needed in order to get the estate’s health insurance coverage for her surgery.

Bharati thanked me profusely for talking to the estate doctor and started to cry. I went to ask the gynecologist what was wrong with Bharati. She only had a moment between other examinations to inform me that Bharati had uterine fibroids and that a hysterectomy had therefore been recommended.

I returned to where Bharati was waiting and explained what a fibroid is and how it could be treated. Bharati told me that she had been experiencing bleeding for quite some time but had not been told by any of the doctors she had consulted why it was happening. The estate doctor, who had not examined her, had just given her some tablets for stomach pain and said that the problem would go away.

While I was describing fibroids to Bharati, a number of other women, also tea estate workers, gathered around us. One of them said that she was really very happy that we had come to her village: “We have no one to talk to about our health problems.”

Yet another woman emphatically added, “It’s very important for us to know more about diseases. Doctors never give any explanations.” This lack of engagement

Swasthya: The Politics of Women’s Health in Rural South India

Page 11 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

on the part of doctors was brought up by several women, all of whom seemed eager for more information on health and illness.

Even as Bharati’s health concerns had been dismissed by the doctor on the estate, her fears and anxieties and her right to information had been dismissed within the auspices of our own well-intentioned program. Clearly, there was more to offering health care to women than providing them with access to doctors.

Irked by these experiences at the camp, we began to conduct monthly outreach visits to one of the largest tea estates in the area. We also made several overnight trips during which the estate management would host us at their guest house—a cottage nestled in the center of the estate, surrounded by rolling hills of verdant tea plants. On our first trip, we walked down to the “lines” with Geeta, an estate worker whose husband was the president of the local panchayat. The lines typically consist of two long single-story buildings side by side. Each houses between 5 and (p.137) 10 families. We went from door to door inviting women to join us outside for a discussion on health. Once we had invited all the women, we arranged ourselves in a circle on grass mats that the women had spread out on the ground in front of their homes and talked late into the night. Based on that night’s discussion, we decided to conduct two more evening programs—one on hygiene and the other on body aches and pains. We divided the presentation by kinds of pain and explained each one and its remedy: stomach pain, back pain, shoulder and neck pain, chest pain, headache, and tired eyes. The premise of our work was that women could take charge of their lives, take their health into their own hands.

One evening, our Jeep did not turn up to take us to the lines. We walked along the winding, tarred road through the estate for several kilometers. The sun was setting and the silver oaks gently swayed in the breeze. Neither the estate nurse or the doctor attended and everyone seemed relaxed. Nearly 40 people—men, women, and children—had gathered and there was a festive atmosphere. We set up our battery-powered lamp (as there were no street lights) and our poster board. When it came time to demonstrate the exercises for relieving back pain (a common problem, particularly among women who plucked tea leaves), we asked the men to leave. We wanted the women to feel comfortable practicing the exercises we demonstrated. The men left reluctantly and then the party began. Amid fits of giggling and laughter, Saraswasthy, one of the CHWs, demonstrated the exercises. First, the younger women stepped forward to try them out. Then one by one the others joined in. Several different demonstration circles formed and half an hour later, women were dragging their friends to the circle and teaching them the exercises themselves!

Swasthya: The Politics of Women’s Health in Rural South India

Page 12 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

There were these special moments when I would have a visceral understanding of the feminist texts that I read as an undergraduate at Barnard College. I drew inspiration from efforts like Our Bodies, Ourselves and an Indian equivalent called Na shariram nadi (My body is mine). During the CHW training, I drew extensively from these texts and from the literature on the women’s health movement in the United States.

The CHWs were at first shy and merely giggled through these sessions. As, time went on, they not only became comfortable with the process but began to talk about how exciting it was to actually understand their bodies. This was the experience that we wanted to extend to other women in the community.

A combination of factors usually helped me establish an easy rapport with women—the fact that I had come all the way from America to work on women’s health in Vijaygiri, that I could speak Kannada (within 4 to 6 months I was reasonably fluent), and that I was married and wore the local signs of marriage —a mangalsutra (a thread worn around the neck) and toe rings. One of the most inspiring aspects of the work that we did in Vijaygiri were these exchanges with women, when women opened up to us and shared their stories.

The Swasthya mission grew out of these encounters—we recognized that mere provision of medical consultations, the presence of health-care infrastructure in (p.138) terms of a health center, a physician, a nurse, and medicines were insufficient and irrelevant if the quality of care was poor. An important aspect of quality of care is the nature of the interactions between health-care providers and individuals: to what extent are individuals’ concerns and problems elicited? To what extent are the health-care providers’ diagnoses actually communicated? How are they communicated? Do sensitivity and empathy imbue the interaction?

We began by setting up a network of women’s health centers with a strong linkage to a referral hospital. With Dr. Vasan and Jagan at the hospital, we had assumed that care would be both appropriate and empathic. Dr. Vasan expected his junior colleagues to ask questions, observe, and follow by example. However, not all the junior doctors were sufficiently motivated and sensitive the way Jagan was. We, the volunteers and the CHWs, did not feel comfortable discussing these challenges with Dr. Vasan. Rather, we debriefed with Jagan about the insensitive and even discriminatory attitudes held by some of the junior doctors. But unfortunately, because Jagan had a degree in Ayurvedic medicine, few of the interns and junior resident doctors (practicing biomedicine) respected Jagan’s style of health care provision and his openly expressed insistence on treating all people equally.

We tried to tackle this issue of empathy and sensitivity during our team’s interpersonal interactions in a number of ways. In our training sessions with CHWs, we not only emphasized the importance of sharing information on health

Swasthya: The Politics of Women’s Health in Rural South India

Page 13 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

and disease but also worked on the more subtle aspects of the ways in which we shared information and the importance of recognizing and understanding the emotional and social dimensions of the interaction. Pay attention to the emotional state of the person who has sought your advice or care. Acknowledge and facilitate discussion about their emotional state. These were some of the guidelines we discussed in our training and that we tried to put into practice.

Such encounters led us to initiate the Well Woman Clinics. The main goal of these clinics was to provide empathic reproductive health care, including information, counseling, and clinical services to women. The CHWs were trained to take a comprehensive, broadly defined health history and provide pre- examination counseling to help women assess what kind of clinical consultation they required and become acquainted with routine examinations. Typically, the CHWs would offer to do a speculum examination (with visual inspection of the cervix to identify cervical abnormalities), a pelvic exam, and a breast exam. Then they would conduct a postexamination counseling session in which health promotion information and any other concerns (including the need to visit the hospital or our outreach clinic for further care from a physician) were addressed. The CHWs did not prescribe antibiotics. So, if such an examination indicated that a woman might have a reproductive tract infection, she would be referred to our outreach clinic or the hospital for further treatment. We also encouraged patients to help themselves by doing breast examinations and exercises.

Interpersonal dynamics in the health care setting were to a great extent shaped by caste and class. I was conscious of the existence of caste inequalities, perhaps in (p.139) part because I had grown up privileged. My grandfather, whom everyone in our family referred to as Anna, had rejected caste and religious divides at a time when Kerala’s rigid caste system was being challenged by lower caste–led social movements. To demonstrate his rejection, he dropped his caste surname, an act of defiance that few upper-caste Brahmins committed. Anna instilled in my father not only a nationalist spirit but a commitment to work against caste divides. My father often recalled how he would bring home a diverse group of friends, belonging to various religions and castes, and the ease with which my grandmother would feed them in her kitchen —a practice normally taboo in any caste-observant Brahmin home. Thus equality and respect were key values that imbued my formative years—a sense that all people are not only equal but have the right to be treated equally. However, the fact that my grandfather and father relinquished their caste name did not mean that we did not continue to benefit from our caste heritage. Neither I nor the other students, a few of whom had no awareness of their caste backgrounds, had expected to find that caste still remained central, particularly in rural communities like Vijaygiri.

Swasthya: The Politics of Women’s Health in Rural South India

Page 14 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

Shantha belonged to the scheduled caste (also known as Dalits)—historically the most disadvantaged group within the Indian caste system, the majority of whom owned no land and were relegated to the role of menial laborers. She had finished 12 years of education at an English medium school, which is very unusual for any woman in Vijaygiri. The medium of instruction in most schools in the region is Kannada; it is only a very few who have the chance to study in schools where English is the medium of instruction. Although her parents were poor and had several children, they valued education and decided to send their youngest daughter to a “convent school.” Shantha studied hard and did well. Moreover, she was acutely aware of the privilege she had enjoyed and was very interested in doing community health work.

The honorary secretary of the hospital, a devout Brahmin, recognized the importance of having a multicaste team. Further, Shantha was clearly very bright and ambitious, having earned scholarships all the way through her schooling. I was excited to find a Dalit woman with the qualifications to work for Swasthya, and I enthusiastically presented the idea to the other CHWs. Their response—total silence and, when repeatedly goaded, muted acceptance— surprised me. Although they did not openly refuse to accept Shantha as a colleague, there was marked hesitation and implicit resistance among them. Although the CHWs were all of the middle and upper castes, I did not expect a negative response from them, as they had been serving scheduled-caste clients up to this point without issue. Because of their excellent work, I assumed that they shared the Swasthya vision of equality.

For a week, there was a great deal of tension between me and the CHWs. We had the custom of beginning every meeting with a “check in,” a 30-second sharing of our frame of mind, and ending with a “check out,” another 30 second sharing about how we felt the meeting went. That week after I had communicated our interest in hiring Shanta, I felt that the check ins and check outs were strained, as though the women had something on their minds but could not say it. The situation (p.140) finally became so intolerable that I decided to take the CHWs for a one-day retreat to discuss the issue away from the day-to-day stress and rush of the hospital. We traveled outside the village to a lovely and tranquil bird sanctuary in the forest. Despite the serene beauty of the place, the tension between us remained thick. I was disappointed in their response to Shantha, and they felt defensive.

“I have no personal objections to this woman,” said one of the health workers, who seemed unable to finish her thought.

“She is obviously well educated and willing to work hard,” said another, filling in for the first, “but the truth is, if she comes into the field with us, she will not be permitted to enter the homes of higher-caste people. We will be scolded for bringing a scheduled-caste woman into their houses.” She pointed out that this

Swasthya: The Politics of Women’s Health in Rural South India

Page 15 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

would especially be a problem amongst the Brahmins and Gowdas, the two main upper castes in Vijaygiri. The other CHWs murmured their agreement.

“I am afraid that upper-caste community members will complain to my parents,” said another. There were more nods of assent. “My parents don’t want me to be known as one who challenges the caste system,” she continued, “In fact, I’m not even sure if they would appreciate my bringing Shantha to our own home.” I could understand her concern, as she and three out of the four other health workers were unmarried at the time, and thus answerable to their parents.

“Swasthya is meant to meet the needs of the most disadvantaged individuals and families in Vijaygiri, and Shantha belongs to the scheduled castes, the most disadvantaged of all.” I implored, “If we can’t accept one of “them” as a colleague, then how can we possibly help them overcome the obstacles they face?” Yet even in that lovely, isolated place, away from the eyes of the village, we could not find a resolution.

Up to this point, I viewed my role as project director primarily as facilitator and coordinator. I would bring together resources that local women did not have access to, help to define the problems that we would address, and identify ways in which we could address them. From my perspective, the project fundamentally belonged to the CHWs and the other Vijaygiri women, not to me. However, the CHWs’ resistance to taking Shantha on as a colleague challenged me: should I redefine my role and the nature of “ownership” over the project? My choice was to either accept their decision, going against my own convictions about the importance of hiring Shantha in furthering the fundamental sociopolitical commitment of the project, or to assert authority and set aside the participatory principles that I hoped would underlie the organizational structure.

I decided to override the CHWs’ resistance and hired Shantha. Further, I threatened to fire anyone who was not willing to work with her.

Back at the hospital the following Monday, I described my discussions with the CHWs at the bird sanctuary to Jagan. He was not only disappointed but incensed.

“No longer do we have untouchability in India!” he exclaimed. He marched over to our meeting room and launched into a tirade: “As long as you are in your (p. 141) uniforms, you are nurses—not individuals belonging to this or that caste. Caste should not enter into your professional activities.”

I do not think this lecture changed the CHWs’ attitudes. However, I realized how important it was that we critically examined the issue of caste and caste identity within our group. If it was this difficult for an educated Dalit woman to gain

Swasthya: The Politics of Women’s Health in Rural South India

Page 16 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

acceptance in a setting such as ours, I could hardly imagine the treatment she would get elsewhere.

In January 1999, Shantha enrolled in Jagan’s nursing program to prepare for her work with Swasthya. In addition, we thought that Shantha could shadow the other CHWs while they engaged in community outreach. Thus, she would have the opportunity to learn by observing, and we would also be able to gauge community reactions to her. In the meantime, we had also initiated plans to set up a counseling service in the hospital, and since Shantha was being trained there, we decided that she would spend the majority of her hours outside of class working in the hospital as a counselor. So the issue of caste was sidestepped to some extent. On the infrequent occasions when Shantha did go into the community with her colleagues, they avoided the upper-caste neighborhoods. I still wonder whether or not this was the ideal situation.

A couple of months after Shantha began working with us, we conducted a door- to-door reproductive health survey in Vijaygiri. Initially, we were apprehensive about what would happen when Shantha attempted to recruit individuals for the survey, which did entail going into homes to conduct interviews. Yet we faced no problems. She was never once challenged and never saw any kind of negative reaction. In fact, community members respected her in her role as a Swasthya Community Health Worker, seeing her as a health worker rather than a scheduled-caste woman. Jagan’s statement that caste was irrelevant once one donned the nurse’s uniform seemed to finally have been established.

A number of months later, I saw Shantha at the hospital and we had the opportunity to talk about her experience thus far. “How did it go for you in the beginning?” I asked. Shantha did not answer my question. Instead, she told me, as she had many times before, how pleased and honored she was to have the job.

“Please, Shantha, it’s important for me to know about your experiences, especially in the initial days.”

Although reluctant to voice displeasure or discontent to me, she finally revealed the pain that she had experienced. “I was hurt,” she said, “particularly by Anita.” Anita is an upper-caste CHW with whom Shantha spent time in the field, and I had thought Anita would be a help to her. Shantha had been of the same mind.

“I thought Anita would be my greatest source of support, but she turned away from me, as did the others. Usually she would turn away when another was there; if one of the other CHWs was also present during outreach, the two of them would talk and walk together, leaving me out. At our weekly meeting days at the hospital, everyone would sit together and eat and talk, but no one would talk to me. I know they did not want me here.”

Swasthya: The Politics of Women’s Health in Rural South India

Page 17 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

(p.142) Shantha had been hurt and sad but unable to talk to her parents. “I haven’t talked to anyone about this until today. You know that my parents are old and my sister is always worried about me. I wanted them to think that I was happy here. And I am. I am so happy to have this job,” Shantha said in her quiet, composed way. She was new to the hospital environment and did not have any friends or support in the hospital itself. I was the boss, and so she did not feel comfortable coming to me because she did not want to me to think that she was complaining. She had suffered silently, thankful for the position and determined to make the most of it.

“Things are getting better now,” she said, “I am glad the survey went so well; I can feel that the others are beginning to trust me.” But what struck me was the fact that I had not stopped to think of what the ordeal must have been like for her. Of course she knew that her caste status was an issue with the other CHWs, and they had made it clear to her, perhaps fueled by resentment at my insistence that they accept her.

At this point, we, the group of international students, decided to consciously confront caste inequality and build alliances with groups that were trying to promote the interest of the lower castes. Jagan, too, felt passionate about this need. His sensitivity and political commitments sometimes surprised the student group and always elicited respect from them. Jagan was born and brought up in Vijaygiri, steeped in the cultural milieu, yet he seemed acutely aware and unaccepting of these entrenched inequities. Jagan pursued connections with a Dalit group and a tribal development group. The tribal development group invited us to give a presentation at one of their festivals and printed pamphlets that had our names on them as among the invitees. Someone at the hospital saw the pamphlet and got very upset because the tribal group was engaged in political work. Hospital staff for the most part believed that their work was apolitical. Although a number of hospital staff engaged in politics in their personal time, their job was to provide health care to all, and therefore they felt that they should not take a political stand.

The hospital was set up by an ashram originally founded by Shankracharya, a Sanskrit scholar who lived in the eleventh century. He was responsible for the revival of Brahmanical Hinduism in South India at a time when Buddhism and Jainism were gaining popularity. Brahmanical Hinduism is a more conservative form of Hinduism in which Brahmins dominated. The ashram is a very old, powerful Brahmin institution. It runs a Sanskrit school for Brahmin boys and trains them to be priests. About 20 years ago, the leader of the ashram, the Swamiji, who was committed to serving the local community, founded this hospital. The hospital administration was willing to accept our work to promote women’s health and even, to a certain extent, our efforts to promote women’s leadership. But they were unwilling to accept a collaboration with a group that was explicitly political. This posed another dilemma, whether to distance

Swasthya: The Politics of Women’s Health in Rural South India

Page 18 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

ourselves from the political struggle for tribal and scheduled-caste equality or to jeopardize the partnership with the hospital on (p.143) which our program was founded. We decided that our partnership with the hospital was so crucial to the functioning of our program that we would have to accept the attendant constraints. Thus ended our links to the tribal development group.

One morning, we traveled to a Dalit colony to visit Lalitha, a woman who was in need of our help. The colony was deserted because everyone was out working in the fields, but Lalitha was at home; she was lying on a straw mat in the corner of her one-room mud house. She had been unwell. Three years prior to our meeting she had started having health problems and had to stop working. She had two sons, who were 15 and 12 years old at the time. Both had been good students, but she had to take them out of school to work, to compensate for her lost wages.

Before her illness, Lalitha would go to the fields at about 6:30 in the morning and return home around 4 in the afternoon. Some of the landlords who are more generous give the workers some buttermilk and rice at lunchtime, but there are many that give absolutely no food at all. Therefore, many workers might eat something in the morning and then not eat again until 4 or 5 in the afternoon. The going wage in this area is 25 rupees a day (about 50 cents). The basic diet is rice and a watery curry with cucumbers, which has very little nutritional value. Lentils, which are part of the staple diet of the upper castes, are unaffordable for people like Lalitha. They cost about 15 to 20 rupees a kilo. The work was constant, and Lalitha and her husband were in the field every day, vowing to work so that their sons could finish school.

When her health problems led to economic hardship, Lalitha’s relationship with her husband began to deteriorate. She had been experiencing burning, pain, and anger during sex. “I started to feel really tired. In the evenings he drinks. Then he calls me to sleep with him, and we fight because I do not want to…. My husband took me to see a doctor who gave me some tablets, saying that once my head was fixed, all my diseases would disappear.”

It was difficult for me, as a nonphysician, to really make sense of Lalitha’s symptoms. Much has been written in India about women’s experience of fatigue, locally known as susthu. When we were presenting exercises to women in Vijaygiri, we would ask them—in groups and individually—to list the major health problems that women in their area experienced, and susthu was always mentioned. Susthu might be a result of anemia and the hard physical labor that most women engaged in, and may have been compounded by the other more psychosocial stresses (arising from poverty, marital discord, trouble with neighbors/landlords/bosses, raising children) that women, particularly poor, lower-caste women, coped with day in and day out.

Swasthya: The Politics of Women’s Health in Rural South India

Page 19 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

The pills that Lalitha had been given were tranquilizers, meant to sedate rather than cure her. After several years of taking such drugs, trying to figure out what was wrong with her body, and receiving no answers, Lalitha was feeling weak and disinterested in life.

Although Lalitha and her husband spent whatever little money they had in visits to private physicians, the doctors could not diagnose her properly. They had (p. 144) gone to the full range of health-care providers: village healer, a man who used herbal remedies to treat illnesses, the local ayurvedic doctor, the registered medical practitioner, and allopathic/biomedical practitioners. They branded her neurotic, a “basket case” for whom little could be done. They did not see that when she left their office, she would return to the stresses of her everyday life— poverty, marital discord, and the burdens of raising two sons. These were invisible to the doctors. Caste segregation is so complete that the physicians could not know these things and so could not know of the despair that Lalitha felt about her life; in other words, they could never truly address her problems.

The Swasthya research teams found that Lalitha’s case is not unique. Her story mirrors that of many women in Vijaygiri, who have no choice but to go to physicians with physical manifestations of problems related to stress and social and economic hardship. Although these women are in need of social and psychological support, physicians rarely recognized this.

I had accompanied our young physician interns on a weekly visit to one of our Swasthya health centers. We went in the Swasthya jeep, with the men—the two interns and the driver—in front and a Swasthya CHW, two nursing assistants from the hospital, and me (all women) in the back. The interns, young men in their early twenties studying at a nearby private medical school, were discussing the “regulars” they were expecting to find at the center.

“I hope that lady is not there,” said one.

“Which one?” I asked from the back. I always tried to listen in on these conversations to get a sense of what was happening at the centers.

“You know, that crazy one. She comes every week, complaining of one thing or the other—headaches, stomachaches, exhaustion. There’s nothing wrong with her. She looks totally healthy,” was the reply.

Sure enough, when we reached the center, there she was.

These women, like Lalitha, typically walk away with a questionable set of tablets —vitamins and tranquilizers, for example. They walk away believing that these medicines will suffice to solve their problems. The fact that many of these problems arise from a combination of socioeconomic, cultural, and physical

Swasthya: The Politics of Women’s Health in Rural South India

Page 20 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

circumstances and call for more holistic interventions escaped both the physicians and the women themselves.

A Swasthya CHW visits Lalitha often, providing her with emotional support and encouraging her to participate in programs at the health center. The CHW also provides counseling to Lalitha’s husband, attempting to make him more sensitive to the pressures Lalitha feels and to confront the violence in their relationship. The success of the CHW’s efforts to support Lalitha is limited, however, by the sociopolitical and economic differences between them. The CHW is from an upper caste and is educated. Thus Lalitha and her husband, regardless of whether or not they wish to have her there, are obliged to allow the CHW in their home and to listen to her. They see her leave the colony every evening to return to her home in the more privileged section of the village. Although she is trained to be more sensitive (p.145) than the physicians Lalitha has seen, she is also unable to truly understand what it is like to live as a Dalit in a colony. No matter how long she works there, the CHW will always be an outsider.

Gender, caste, class, and nationality create hierarchies of power and knowledge even within our own group. The authorities at our partner hospital and within the community tend to be men of the upper caste/class. The honorary secretary, the chief medical officer, the head of the laboratory, and even Jagan were all Brahmin men. Even among the nursing staff at the hospital, the matron and many nurses were either Brahmins, other upper castes, or Christians. The women who swept the hospital clean were Dalits. The CHWs, although relatively diverse in terms of caste and class, are privileged because of their training and employment. I, the program director, am a citizen of a globally dominant nation; in part, I have that citizenship because of the privileges that my family enjoyed based on our caste status in India. Given my own caste background and the fact that I was highly educated, to the level of a doctorate, gave me considerable voice. I was in a completely different category. And the struggle for me was to use this strategically—to protect and facilitate the interests of those who were not always heard, including the CHWs, within the prevailing power structures.

Community mobilization requires sustained community involvement and action. This was the weakest aspect of the student-driven model that we were pursuing. Given that students are students only for a short time, a model that is student- dependent is extremely difficult to sustain. In fact, it is likely to be unsustainable unless there is a stable core leadership. Our plan was to work with the CHWs until they could plan and carry out programs on their own. They would form the core group, with Jagan in a leadership position.

Over time, we grew concerned that Jagan was constantly torn between the needs and perspectives of the administration and the CHW/student group. We decided that the CHWs themselves should have greater leadership responsibility.

Swasthya: The Politics of Women’s Health in Rural South India

Page 21 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

In reality, we found that 3 years of working with the CHWs was not enough for them to reach this level of autonomy. They had not reached a point where they could continue to innovate and bring to fruition a vision on their own. Our trips to Vijaygiri over the fourth and fifth years revealed that, for the most part, the CHWs were carrying out activities that we had discussed and planned over the course of the first 3 years. Real innovation had not occurred.

According to one member of the student group who conducted an informal evaluation of Swasthya activities,

When asked if they would like more education or would want any changes in the program, most community residents felt it was nice to have the CHWs come to their house and they would listen to whatever they said. However, these types of comments were made in a way suggesting that they did not really use the information—they just listened to it and were happy that someone was doing good work in their community. It did not seem that anyone was greatly dependent on these visits or that they would be greatly missed. However, (p.146) people did express that they had come in for certain tests and checkups to the hospital at Vijaygiri because the CHWs had encouraged them to do so. Most people seemed to feel that it was helping people in the community and good for the village, even if they themselves did not utilize the resources/information.iii

The project finally wound down 5 years after it began. The student group’s involvement had come to a close after the first 3 years, but we continued to raise small amounts of money to keep the project going. However, we began to finish our degrees and move on with our lives. (I was 7 months pregnant with my second child and on the faculty of the University of California, San Francisco, by the time Swasthya closed.) In our occasional communications via e-mail, it became apparent that there was increasing unhappiness with Swasthya’s governance, the lack of recognition and independence the CHWs had, and the evolution (or perhaps I should call it stagnation) of the program. A few members of the initial student group continued to visit Vijaygiri and found that the CHWs were still giving the same presentations, skits, and role plays that we had developed in the early years. The CHWs also voiced concerns during these visits: they wanted more stable employment.

At the end of a series of discussions with the hospital, we realized it was unlikely that we would be able to resolve these concerns to everyone’s satisfaction. Finally in December 2002, we and the hospital decided to end the partnership.

Each of the CHWs has followed a unique trajectory. Each, I feel, has been touched deeply by the project. Swasthya did provide opportunities for self- expression and independent thought and action—opportunities that few young women, particularly those in rural areas, have access to even today. They opened

Swasthya: The Politics of Women’s Health in Rural South India

Page 22 of 22

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 01 March 2022

Access brought to you by:

and operated bank accounts—some with the support of their families and others clandestinely. Nearly all the CHWs continue to work and pursue careers today. Shantha and Anita are roommates and work as nurses in a large clinic run by a friend of Dr. Vasan’s in a nearby district. Several others are in similar employment. One CHW became involved in village politics; another got married and stopped working.

Jagan remains at the hospital, continuing to run the “nurse aid” training program. The hospital has expanded since my time there. They now have a government-accredited undergraduate nursing college that has overshadowed Jagan’s program. The nursing college is staffed by teachers with bachelor’s and advanced degrees in nursing and follows a state-approved curriculum. However, the graduates of Jagan’s program are still in demand; many small nursing homes continue to look for lower-paid nursing staff and do not care whether their employees have a recognized degree or not. Jagan continues to raise funds through local clubs and associations in order to run outreach clinics. In his desire to keep innovating and contributing to local health promotion, he became certified in counseling through a part-time program offered in a nearby city and received a degree in health administration through a distance learning program. He had hoped that this degree would help him move into a hospital management position. However, the power structure within the hospital has been so entrenched that his plans have not materialized. (p.147) Despite the loss in stature of his nursing program, his unrealized dreams of engaging in mass health education and outreach and his failed attempt to take on a greater administrative role at the hospital, Jagan remains cheerfully optimistic. He and his family visited me a few months ago. In response to my barrage of questions about everyone at the hospital and the goings on, he replied, laughing, “Everything is the same!”

ACKNOWLEDGMENTS This chapter builds on a paper coauthored with Rajesh Vedanthan titled “Experiences of the Perils, Pitfalls and Inspirations of Public Health as Social Justice: The Swasthya Community Health Partnership, India.” I am grateful to Raj and my other Swasthya colleagues for the enriching experiences and relationships that continue to inspire me.

Notes:

(i.) Names of places and individuals have been changed.

(ii.) Village government.

(iii.) Tantri, A. Personal communication.

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 1 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

The Practice of International Health: A Case- Based Orientation Daniel Perlman and Ananya Roy

Print publication date: 2009 Print ISBN-13: 9780195310276 Published to Oxford Scholarship Online: September 2009 DOI: 10.1093/acprof:oso/9780195310276.001.0001

Beijing + 5: What Can International Conferences Achieve for Women’s Health? Nuriye Nalan Sahin Hodoglugil

DOI:10.1093/acprof:oso/9780195310276.003.05

Abstract and Keywords This chapter presents some thoughts about the significance of the United Nations Beijing +5 Conference. In 1995, when the Fourth World Conference for Women was held in Beijing, women came from all over the world to discuss pertinent issues such as health, economic and political power, and violence and oppression. The final document produced at this conference was the Platform for Action, which described the overall status of women internationally based on these issues. The Beijing +5 meetings was organized by the UN's Division for the Advancement of Women to assess the current situations of women globally and to make relevant changes to the Platform for Action while also reaffirming commitment to the original document.

Keywords:   conferences, women's rights, women's issues, gender equality

According to the maps, the United Nations headquarters was only a few blocks from my hotel. Still, I set out early that day, and took my time strolling up First Avenue. As I drew closer, I caught sight of the immense skyscraper rising above the sea of other buildings. Although it was late spring and the sun was well above the horizon, the morning air was chilly, and I pulled my jacket close to my body as I walked. My stomach was jumping with nerves; to ignore it, I forced myself to look around at the city. The streets of Manhattan were just waking up along with me. If I were at home, in Ankara, I too would be moving with the throng of people, headed for the School of Public Health, consumed with my agenda for the day ahead. Being here felt very different as I watched men and

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 2 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

women in spotless suits disappear into the tinted doors of office buildings—I had no idea what to expect from the upcoming morning.

I reached the entrance plaza and gardens within minutes. I shielded my eyes with my hand and looked up at the impossible building. It was so big that, up close, I could no longer see it all at once. Around me, tourists were snapping pictures. Moving through the wide glass entrance, I saw more of the same—they swarmed the lobby, and a long line had already gathered behind a small sign reading simply, “Tours.” I drew a breath and squeezed by the line of people. Their guide, I had read, would lead them past the highlights of the building and through the common areas.

My destination was not so public. Following a discreet sign, I turned into a hallway which led me to a lower level of the building. Soon I turned and followed another hallway. I was now a few floors below the ground level. The walls were (p.98) lined with a dark brown wood, and soft, low bulbs were placed every few feet, casting a dull, artificial light. This was in sharp contrast with the large windows and sunshine that had filled the main lobby.

People walking brusquely in both directions passed me by without a glance. They seemed to take no notice of the absence of light. Some were dressed in brightly colored traditional outfits and the rest wore business suits. My own outfit, in comparison, felt neutral and unimportant. I had tried my best to look both serious and professional, donning a black dress and black leather shoes, but despite the confidence I had felt when my mentor at the university, Dr. Meliha, had asked me to attend the meetings in her place, my insides had been a jumble of nerves ever since I had arrived in New York. Even my dress, at that moment, was a cause of anxiety.

As I continued down the hallway, I tried to quell my worries by reminding myself of my qualifications and of my initial excitement at accepting such an opportunity. As a physician and researcher in Turkey, I was certainly prepared to discuss women’s health needs within my country. Having worked in family planning clinics, I had inserted thousands of IUDs and worked with countless married women to address their health needs.

Just then, I saw a small break in the wood paneling on my right. A placard, stationed next to a small gate, read “General Assembly Conference Room.” The closed door was plain and unadorned, and I pushed it open quickly. The room that spread out in front of me made me catch my breath.

The room was split into two levels, the first of which was designed like an amphitheater. A polished stage stood in front, with the seats spreading outward in rows of semicircles, like the layers of a cinnamon roll. Tags for each country marked off sections of seats, moving along the rows in alphabetical order. Each

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 3 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

country’s section was equipped with a microphone and multiple sets of earphones for listening to the simultaneous translations.

I looked to the second level, which was divided from the first by a high wall and could only be accessed by a separate entrance. Later, I would learn that these seats were reserved for spectators, persons from nongovernmental organizations (NGOs) and others, who, since they were not named as official delegates, were forbidden from directly participating in the meetings. I walked slowly to the center of the amphitheater, searching for Turkey’s tag. A few people sat casually in some of the seats, but the vast majority of the room was empty.

In 1995, when the Fourth World Conference for Women was held in Beijing, women came from all over the world to discuss pertinent issues such as health, economic and political power, and violence and oppression. The final document produced at this conference was the Platform for Action, which described the overall status of women internationally based on these issues. In very strong language, it outlined suggestions to improve gender equality. The Beijing + 5 meetings, which would all take place in the huge room where I was standing, had been organized by the UN’s Division for the Advancement of Women to assess the current (p.99) situations of women globally and to make relevant changes to the Platform for Action while also reaffirming commitment to the original document.

I spotted my country’s tag, between the signs for Trinidad and Tobago and Tuvalu. Our seats were empty; I was the first of my delegation to arrive. Instead of going directly to our section, I hovered in the center of the room, my head tilted back as I stared at the top rows of the second level. For a second, I wanted to scream “Can you hear me?” out into the vacant seats. As children, we would do this every time we visited one of the many ancient amphitheaters scattered along the Mediterranean coast. One would yell “Can you hear me?” to which someone else, poised at the top, would respond “Yes! I can hear you ….” The acoustics amazed us: after screaming the first time, we would drop our voices again and again until we were using only whispers, to see what could still be heard. The important thing was the sense that somebody was listening.

I made my way up the steps to await the arrival of my codelegates. After a few minutes, more and more people began filtering into the room, coming through the same unimposing doorway that I had used. I watched them file in, greeting each other, making their way to various sections. I noticed a group of three women making their way up the stairs, walking directly toward where I sat. They reached me quickly and before I could stand up, the leader, a short, heavy, dark- haired woman with large glasses, stepped forward and put out her hand,

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 4 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

Nuriye Nalan Sahin Hodoglugil.

introducing herself as Cemile. She had a strong, clear voice and held herself in an authoritative

(p.100) manner. It was obvious that she knew who I was, probably having been in contact with Dr. Meliha, because without waiting for an introduction, she used the cordial, official “Mrs. Nalan” to address me. I tried to shake her hand firmly but was struck by her impressive voice—she spoke with the formal emphasis of a government official or television newscaster, and her tone was very serious. She turned to the others and began introducing them, continuing to use the same formal voice. Nuran was nearly Cemile’s physical opposite—petite and blonde. She wore a light-colored suit and struck me as having a soothing, motherly attitude. Despite Cemile’s command of the situation, Nuran was actually her supervisor at the General Directorate of Women’s Status and Problems in Turkey. On the other side of Cemile was Sevgi, a woman who gave me a big smile. Although I did not know her, she was a teacher in the department of Gender and Women’s Studies in Ankara. Behind Sevgi stood Aylin, whom Cemile introduced last. She was younger than the others, had dark, flashing eyes, and wore heavy lipstick.

We shook hands and greeted one another warmly. I smoothed my dress with my palms while the others set their bags down and filed past me into the seats of our section. These would be the women I would be working with, day and night, for the next few weeks.

Just then, a loud banging noise filled the room, and the static of a microphone turning on crackled over the speaker system. The five of us turned; on the polished stage at the center of the room stood a tall woman in a crisp gray suit, leaning into the podium and looking out at the rows of chairs expectantly. The banging noise had come from a long wooden gavel she held in one hand. She poised it over the podium and brought it down again, three staccato raps that amplified out over the audience. A hush fell over the room, followed by the sound of shuffling papers and bodies shifting in chairs. I looked out over the sections below us and craned my neck to see the rows behind. Most of the chairs were filled; however, there were some countries, such as Tuvalu, next to us, that had only empty seats. It was not until that evening, back in my hotel room, that I came to realize that this was because these countries were too impoverished to send delegates.

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 5 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

The woman cleared her throat into the microphone. Across the room, delegates lifted earphone sets and adjusted them on their heads. “Welcome,” the woman began, “to the United Nations Beijing +5 Conference….” While I listened to the opening remarks, I scanned the crowd. If I turned to the side, I could see into the higher sections, where the NGO participants sat leaning forward, some with their arms resting on the top of the dividing wall. We all had, I presumed, been given a copy of the draft outcome document, put out by the UN’s Division for the Advancement of Women (DAW). DAW had asked all countries to submit an assessment of the past 5 years, describing their accomplishments, problem areas, and future plans of action for improving women’s rights. These assessments were put together to create the Outcome Document for Beijing +5. This document would be the focal point for the entirety of the conference—after the World Women’s (p.101) Conference in Beijing, 1995, DAW had taken suggestions from every country and added them to the old platform, coming up with a draft that would be debated and reworked throughout this conference, ending 5 years later. The specific changes each country had requested—most often, it had looked to me, to be deletions, additions, or simple rewording of phrases or single sentences—had been added in bold type.

I listened dutifully to the rest of the opening speech. Next to me, Aylin tapped her foot and shifted in her seat. I wondered what my codelegates had thought about the draft outcome document; we had not gotten that far in our chatting. Mentally, I recounted the changes in the draft that had been suggested by Turkey: honor crimes, abortion, etc. Most likely these changes were made directly by Cemile and Nuran’s Office of Women’s Status, which would have received the draft from DAW.

The woman at the podium began explaining the details of how the conference would be run. The draft document would be read aloud to the conference room, and each time a change had been suggested, the moderator would pause and open the floor for debate. The country that had suggested the change would speak first, followed by any other country that had input. If there was disagreement, the debate would continue until a consensus had been reached. To complicate things, DAW had allowed for additional changes to be suggested during the conference proceedings. The deadline for submitting these written changes, she announced loudly, was 2 days away. Oral changes, the woman continued, could be suggested by a country at any point during the conference. It dawned on me then that the number of potential changes that could be made —if each country had even more additions or deletions to the document—was staggering.

After the opening session had concluded, the five of us made our way to the cafeteria. Like the hallways, it was dim and poorly lit. We carried small trays of food and situated ourselves at one of the square tables. Around us, I saw that numerous other delegates, mostly middle-aged women in suits and formal attire,

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 6 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

were doing the same thing. Interspersed were groups of regular UN employees, whom I quickly learned to recognize by the plastic badges hanging around their necks.

Cemile wasted no time. Without touching her sandwich, she moved her tray aside and dug into her briefcase, withdrawing her copy of the outcome document and a legal pad for notes. On one side of me Aylin lit a cigarette, setting the used match in an empty ashtray at the center of the table. I watched as Sevgi followed suit, pulling out a box from her purse and lighting up. She pulled deeply on the filter while she watched Cemile and waited.

Cemile spread the papers out in front of her and looked up. “We need to make a plan as soon as possible, so that we can begin working tonight and tomorrow.” She ran her fingers along the first pages of the draft document, which was divided into 12 subjects: women and poverty, women and violence, women and health, women and the economy, etc. “We should split up the sections based on our specialties, and review them.”

(p.102) Aylin tapped her cigarette on the rim of the ashtray, and spoke up. “I agree.” she said, leaning forward. “We should come up with a list of priorities from each section—those changes that are most important for Turkey to advocate for.”

The smoke from the cigarettes snaked hazily up towards the ceiling. My eyes already felt parched and itchy. Until about a year before, I too, had been a smoker. When I started smoking, it had been a sign of being a liberal woman in Turkey—all of my activist friends were smokers. At the time, it was considered abnormal for women to smoke in public, and my friends and I would intentionally stand on the street and smoke in protest. It was a small form of activism for us. Now, however, I had grown unaccustomed to it, and I blinked as Aylin continued: “We have to act quickly, decide on the changes as soon as possible, in order to give the committee our written suggestions.” At this she stubbed out her cigarette and pulled out her own copy of the platform draft. Cemile frowned.

“Yes,” she said, “but we can submit our changes orally as well, for many of the subjects, during the meetings.” I thought quickly back to the opening speaker’s instructions. It was true, she had specified that new changes could be suggested both orally and in writing.

“If you don’t write your suggestions down formally, they won’t count,” Aylin said, her voice full of authority. “If you want the changes to be taken seriously, you have to write them down. And the deadline being so soon, we should begin tonight.”

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 7 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

Cemile shook her head. “We have to prioritize, Ms. Aylin. If we write something, we will have to argue for it orally during the meetings. There will be many, many arguments going on. Turkey does not need to participate in all of them, particularly the ones that are not pertinent to our country.”

I looked around the table. Nuran was still reading, and Sevgi sat stonefaced. I felt myself torn between the two sides of the argument. Cemile’s stubbornness reminded me of the attitude typical of Turkish officials and of how much of government seems to work: Don’t poke your nose into things too much, go at the pace that is expected. However, we were dealing with a writing culture, and I understood Aylin’s point about being taken seriously.

At Cemile’s words, Aylin sat up straighter in her seat. “Yes, I understand that,” she said, “but we should still try. No one will listen to an oral intervention, and it’s important that we make a strong statement about Turkey’s position on all the issues.”

Cemile nodded curtly at her. “Of course your ideas on all the issues are important, Ms. Aylin. But we cannot focus on too many things at the same time, and we cannot go to extremes either. Turkey should have a lead role in supporting certain issues, such as reproductive rights, and in including the prevention of honor crimes. My General Directorate is also strongly supporting women’s role in politics, and in relation to the economy. But that’s all. For the rest, we can offer support if we like the idea, and withhold support if we don’t. They are not directly related to us and our problems.” She paused. “We should write, of course, but not on all issues. As the head of the delegation, I feel it is more important to focus on two or three issues that are most important to us.”

(p.103) Aylin opened her mouth to respond, but Cemile cut her off. “Ms. Aylin,” she said, “we are losing time. Prepare as many written statements as you want to. Do you have a laptop?”

At this, Aylin looked, for the first time, hesitant. “No,” she responded.

We decided to use the computer laboratory at the UN the following day, after each reading over the outcome document that evening. We quickly reviewed the 12 sections, then gathered our things to leave. As we cleaned the table, I looked at our trays. Most of the food remained untouched.

That night I read over the document again, paying special attention to the sections on women and health and violence against women. The subsections on reproductive health would be especially contentious. Throughout the section where birth control was mentioned, bold type suggested replacing contraception with family planning. The change had been suggested by the Holy See, the delegation from the Vatican.

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 8 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

Working in the field, in Turkey, my colleagues and I often used the two terms interchangeably. However, in the politics of population policy, family planning implies that birth control is only for a married male and female couple—not for adolescents and unmarried women. In Turkey, too, this is a difficult issue. Sex within the institution of marriage is celebrated in Islam, but anything outside of wedlock is considered unacceptable. I am constantly aware of this in my professional life: often, when teaching at the university or working in a clinic, I am approached by young, unmarried women seeking contraceptives or treatment for sexually transmitted diseases. Even within marriage, too many Turkish women do not have the means or resources to control the number of their pregnancies. I thought briefly of my sister’s mother-in-law, who, like many women living in rural and Eastern Turkey, was a good example of this. When I met her she was 75 years old and told me “I was like a man, I did not menstruate for 30 years.” A tiny woman from a small village in the east, she had delivered 10 children, 6 of whom survived. She spent 2 or 3 years breast-feeding each child, only to find that she was pregnant again before even restarting her menstrual cycle.

Abortion would be another important topic for Turkey. It has been legal for Turkish women since 1983 and is generally not considered a highly sensitive topic. It is, however, utilized as a method of contraception in place of birth control itself. I was proud that Turkey had been the country responsible for suggesting an important change on this part of the document. The draft platform read that women should have access to “safe, legal abortions in countries where it is not against the law.” Turkey had suggested the deletion of the phrase “those countries where it is not against the law.” Although my efforts as a reproductive health practitioner in Turkey were focused on contraception, my attitude, and the attitude of every colleague I know in Turkey, is that the matter of abortion is for each woman to decide independently. In fact, most educated professionals within Turkey seem to support this, making it appropriate for Turkey to assume a leadership role in advocating for safe and legal abortions in the international arena, such as the Beijing +5 conference. (p.104) I was surprised when I learned that things are very different in the United States, and abortion practitioners are sometimes murdered by those opposing legal abortions.

I carefully wrote out a persuasive argument to be submitted and also a draft of Turkey’s oral argument for the issue’s debate during the meetings. I tried to ignore the butterflies that flapped around in my gut at the thought of reading these arguments out loud in that gigantic room. Crumpled papers littered the floor of my hotel room. Surely we could drum up support for the recommendation of safe abortion practices even in places where it was still forbidden. As a doctor, I knew that despite a country’s legal restrictions, women would still have abortions, and if there were no access to safe ones, they would resort to methods that often caused serious physical illness and death. I had detailed some of these as examples in my argument for the deletion, and I

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 9 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

fervently hoped that these arguments would bloom to full fruition at the meetings, influencing the other delegates to agree with Turkey.

The last section I reviewed before the meetings began was the section entitled “Violence against Women,” which referred to honor crimes. This change had been suggested by the European Union (EU) delegation, which included Turkey in its regional preparatory meetings because Turkey was a candidate for EU membership. Aylin had attended and had pushed for the EU’s support on including the issue in the platform. The EU had agreed, and in the draft document it had been added in as follows:

Develop, adopt, and fully implement laws and other measures, as appropriate, such as policies and educational programs, to eradicate harmful customary and traditional practices, including female genital mutilation, early and forced marriage, and so-called honor crimes, which are violations of the human rights of women and girls….

Aylin had also taken the important step of making individual connections within the EU, people who would verbally support the inclusion of honor crimes when the issue arose for debate. As I read over this paragraph, I felt unsettled. As the document noted, honor crimes were considered a traditional practice; although I disagreed with it very strongly, I saw it differently than many western theorists seemed to. The western perspective often condemns honor crimes and “other harmful traditional practices” without having an understanding or sense of the tradition involved. I certainly did not approve of honor crimes, but the question for me was more “When does a traditional practice become coercive?” I set the document on my lap and looked out the window, remembering my year of compulsory service after medical school. I went to work in a tiny village and rented a room in an apartment building where there were several other professional women who were also doing their year of service in the same area. One of these women, whose name was Gulsum, had a long-term boyfriend from college with whom she had broken up. They had not seen one another in 3 or 4 years. However, one weekend while I was out of town, he showed up. He professed his love for her and promised marriage. (p.105) She slept with him then, the first time for her. He left, promising to come back, but disappeared. Only later did she find out that he was already married, with a child. Gulsum was devastated. She believed that the situation had been her fault and that she had lost her honor. I don’t think that she will marry for the rest of her life. Furthermore, she can tell no one about her experience. She comes from a traditional family in Eastern Turkey. If she told anyone in her family what had happened, she would put both herself and the man in danger. Depending on the strength of her brother’s reaction, the man could be beaten or killed, and if Gulsum was thought to have consented to the relationship, the same risks applied to her. Certainly, it was important that honor crimes be recognized in the final document, and it seemed that Aylin had done an important service in bolstering support for Turkey’s position. I wondered how the subject would go over during the debates. If honor crimes were to be included, the document would serve as recognition of the problem and as a point of reference for activists to advocate

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 10 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

from. However, I could not help but wonder if the careful wording was unrelated to actually lowering the incidence of honor crimes. After all, the outcome document would not ensure that the governments of participating countries actually did anything about the issues included.

Within a few days, the debates were in full swing. By the middle of that first week, I had learned that the majority of my time as a delegate would be spent watching and waiting. The experience reminded me of the few baseball games I had attended: nothing of interest happened for long stretches of time and then, suddenly, some excitement. But here, instead of a home run, the excitement came in the form of an especially charged topic.

The session on women and the family exemplified this. For hours, most of the suggested changes had been set with no opposition or debate. Over and over again, when the moderator came to a suggested change in the draft, a delegate from the proposing country, or group of countries—as many nations were organized into groups—would stand and offer one or two sentences on why the change should be approved. The moderator would ask for opposing opinions, and receiving none, would declare the change accepted. This monotony suddenly shifted when, in the early afternoon, the moderator came to a paragraph of two sentences suggested for addition by the delegation from the Vatican, or the Holy See. The text read as follows:

Women play a critical role in the family. The family is the basic unit of society and is a strong force for social cohesion and integration and, as such, should be strengthened. The inadequate support to women and insufficient protection and support to their respective families affect society as a whole and undermine efforts to achieve gender equality. In different cultural, political, and social systems the rights, capabilities, and responsibilities of family members must be respected. Women’s social and economic contributions to the welfare of the family and the social obligation of maternity and paternity continue to be inadequately addressed….

(p.106) The Vatican had suggested these two sentences, which clearly took pains to emphasize the primary importance of the family. This was of no surprise to me; all morning the Vatican had proposed small additions that seemed intent on highlighting women’s role within the family structure as much as possible. After the moderator had finished, the lead delegate from the Vatican raised his hand to ask for the floor. He was a handsome, tall man, who wore a business suit, although the delegates on either side of him were dressed in heavy-looking religious robes. The moderator motioned, and said: “Holy See, you have the floor.”

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 11 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

He gazed out at the audience before speaking. “We want to add these two sentences, because we believe that women’s role in the family must be emphasized.”

With that, he leaned back in his chair, away from the microphone. I was getting used to there being no in-depth discussion around a suggested change. Arguments both for and against a change were generally kept to one or two sentences, rather than the detailed orations I had expected. Predictable, I thought. But what happened next surprised me. Across the room, a representative from the EU motioned to speak. She was middle-aged and impeccably dressed. The energy in the room shifted noticeably as attention focused on her, and everyone waited.

“While we agree that women’s role in the family is important, we are not here to introduce new language to the document, which this suggestion would be doing.”

I was learning that this was a standard way of opposing an addition to the document—using the phrase new language—because the UN and DAW had clearly expressed, in premeeting informational materials and in the opening sessions, that we were not here to rewrite the Platform for Action, but to amend it in order to best address all women’s needs. I had already, several times, heard a country use this argument to oppose a suggested change. The Holy See delegate looked neither surprised nor disappointed. After asking for permission to speak by again raising his hand, he responded.

“We insist that women’s role in the family be emphasized. We would like to keep it in the document.”

I looked quickly at the EU representative, but she, too, seemed void of any emotion on the matter, despite the stubbornness of the Vatican’s representative. Without hesitation she leaned forward and spoke again.

“Yes, women do play a critical role in the family, and have for thousands of years, but do we really need to put it in this document?”

Titters of laughter could be heard throughout the room. Above us, in the NGO section, there were a few claps. I wondered why, with all the Holy See’s suggestions on strengthening the wording of the section on family that morning, this was the one that the EU was choosing to oppose.

The man leaned forward again.

“We believe that the family, and women’s role in it, must be emphasized. We all live in families, do we not? Is there an opposition to the role of the family at this conference?”

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 12 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

(p.107) I wondered where this was going. In the front of the room, the moderator, an Indian man from India’s permanent mission to the UN, said nothing but instead seemed to be waiting for a response from the EU.

The woman reached towards her microphone again. “We can accept the addition of these two sentences only if you add ‘various forms of the family exist’ after the phrase ‘In different cultural, political, and social systems.’ We have to respect families in all forms, such as single-parent families or same-sex couples.”

Above me came more claps from the NGOs. I wanted very badly to applaud along with them—the EU had made several suggestions toward recognizing the rights of lesbian women in other sections of the document, and I admired the representative’s decision to use the Vatican’s suggestion in this paragraph as a bargaining spot. I turned towards Cemile at the same time as Aylin, sitting on the other side of her, did.

“We should say something in support, yes?” Aylin asked, leaning forward so that she was sitting on only the edge of her seat.

But Cemile seemed indifferent to the drama that was unfolding in front of us.

“No,” she said, shaking her head slightly. “This doesn’t concern us, Turkey, very much.” Next to her, Nuran nodded her head in agreement.

I could see lines of frustration etched into Aylin’s face, but there was no time for further discussion, because the Holy See delegate was leaning in to speak again. The room was silent as he turned to address the moderator.

“We will accept the addition suggested by the European Union contingent upon the acceptance of our original suggestion.”

The moderator looked toward the section where EU delegates were spread out, but the woman did not motion to speak again. He nodded and made notes on the papers in front of him. Then, in the same steady voice, he began reading the next paragraph….

The debates continued in this manner. They were intensely time-consuming, and one evening, Nuran, who had remained quiet during much of our time together as a group, commented that even DAW had not expected them to progress so slowly. Thus, it was not until a full week of meetings had passed that the section on women and health was finally read. By this time, the meetings were stretching late into the evening hours, and I had witnessed many more stubborn arguments similar to the one between the EU and the Vatican. Some of the most contentious subjects remained unresolved—the moderator, the same man from India, seemed willing to let an argument go back and forth for only so long. A few times, when there seemed to be no resolution in sight, he ended the discussion and left the section to remain in bold brackets on the document,

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 13 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

which meant that it would be revisited later. However, time was running out before the meetings of the UN’s General Assembly, which would be signing and certifying the document. It was therefore in our best interests to have as many changes decided upon as possible, because if they were left in brackets for a last-minute review, it was probable that they would be addressed hastily or possibly even dismissed.

(p.108) Much to my disappointment, this happened very quickly to Turkey’s suggested change on women’s access to safe and legal abortions. As soon as the suggested addition was read by the moderator, many people raised their hands, wanting to offer both support and opposition. The moderator let the arguments go back and forth for a while, but when it became clear that the potential change would not be accepted or denied easily, because neither side was willing to concede, it was left in brackets. While Aylin and I were angry with this conclusion, Cemile, Nuran, and Sevgi were nonplussed. They had expected such a reaction and had known beforehand that the debate would not get very far. Earlier that week, I had spoken with many other women working in health care, and I was very worried that the Vatican’s suggestion to replace the word contraception with family planning would also remain unresolved.

As the section on women and health continued, I grew increasingly nervous at the approach of this topic. Finally the moderator read the paragraph where the Holy See had inserted the suggestion. It was a spot that Turkey had agreed to speak on; my palms were sweating as I listened to the moderator read over the words: “increased knowledge and use of contraceptive methods as well as increased awareness among men of their responsibility in contraceptive methods and their use….”

At the end of the paragraph he looked up.

“The Holy See has recommended deleting the word contraceptive and replacing it throughout with family planning.”

The tall and handsome man from the Vatican held his hand up. He was speaking for the Holy See on all matters. Earlier in the week, over dinner one night, Nuran had informed me that he was a businessman from California who regularly attended UN meetings on behalf of the Vatican.

“We would like to replace contraception with family planning. We believe that family planning more accurately describes the importance of addressing the health needs of families.”

Across the room, a delegate from SLAC, which stood for Some Latin American Countries, a group of nations that were representing themselves collectively at the meetings, stood up.

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 14 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

“We oppose this change,” the delegate, a tall woman with dark, bobbed hair, said in a loud voice. “We do not feel that family planning is either specific or inclusive.”

She sat down in her seat. To my left, not far from Turkey’s section, a woman from Uruguay’s delegation stood.

“We support the change. Family planning will highlight the role of the family in matters of procreation.”

While she was talking, Cemile turned toward me and gave me a little nod, indicating that my turn was next. I looked at Nuran, who sat next to her, and she gave me a warm, encouraging smile. I took a deep breath and raised my hand as soon as the woman from Uruguay finished her sentence. The moderator noticed me and said, “Turkey, you have the floor.” Immediately, I could feel all the eyes in the room boring in on me.

(p.109) “Turkey,” I began, hearing my voice waver, “opposes this change. To use family planning instead of contraception implies that contraceptive methods are only for families, and we wish to include young people and people not in families.”

I sank down gratefully in my seat and unclenched my hands, pleased that I had remembered exactly what I had planned to say. Aylin leaned forward in her seat and gave me a thumbs-up sign. Beyond her, the Holy See delegate was again waving his hand.

“We still want family planning included in this section of the document.” He was displaying the same unrelenting stubbornness as before. I looked down at my hands, they were still shaking. Across the conference room, the woman from the EU raised her hand.

“Inserting family planning instead of contraception is akin to adding new language, and we oppose it.”

The representative from SLAC began to hold up her hand again, but at that moment the moderator banged twice on the podium with his wooden gavel. Oh no, I thought. He was going to put the topic in brackets, just as we had feared. The SLAC representative remained holding her hand in midair but did not speak.

But instead of ending the topic, the moderator looked at the SLAC delegate and asked a question.

“Are you opposed to the words family planning, or are you opposed to the deletion of the word contraception?”

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 15 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

I felt momentarily confused, but the SLAC delegate did not miss a beat in answering him. “We are firmly opposed to the deletion of the word contraception,” she said, loudly and clearly.

The moderator then looked at the section of seats where the Vatican’s delegation sat.

“Can you accept the addition of family planning without the deletion of contraception?” he asked.

Without bothering to raise his hand, the businessman answered “We will accept this.”

The moderator looked out to the rest of the room. “Is there any opposition to this agreement?” he asked, turning his head to address the span of delegates.

I glanced at Cemile, who in turn glanced at Nuran, who shook her head slightly, causing her blond hair to shimmy back and forth. The room was silent and no hands were raised.

“Accepted,” announced the moderator.

As I sat and listened to the next paragraph begin, I felt conflicting emotions on this resolution. On the one hand, contraception would remain in the final document; on the other, the inclusion of family planning still managed to embed the implications I opposed. It was this kind of change that, in retrospect, seemed to weaken the language of the Platform for Action and hence to insist in less certain terms on rights and autonomy for women.

(p.110) I looked across the room and wondered if the SLAC representative felt similarly conflicted. SLAC was, like the delegation representing the EU, one of the few converged groups of countries that were verbally supporting strong language in favor of women’s health rights. Others, such as the G77 group, which included a large number of developing countries and China, were much more focused on issues of economics and finance in the document, and could not agree as a unified group to either support or oppose issues involving women and health. They had remained silent for much of this portion of the debates. In this way, Turkey was lucky—we were not bound to a coalition of countries, and could therefore decide as a small group which individual issues we wanted to speak on.

By the end of the second week, when the conference finally reached the section on women and violence, time was running out. Looking in the bathroom mirror one morning at my hotel, I was not surprised to find heavy bags under my eyes. The DAW had, for the past few days, been holding its meetings for almost 24

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 16 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

hours a day. More and more frequently, if a topic’s change proved to be highly contested, it was put in brackets for the General Assembly to deal with.

The five of us tried to switch off attending the meetings, allowing each one to retreat for a few hours to sleep. We all went, in rotation, for a few hours to our respective hotels; however, it was very difficult for me to consider missing any of the section on women and violence. I very badly wanted to see that honor crimes would be included in the document. The end of the conference was only a day away, and the General Assembly would convene shortly after. Turkey’s official representative in the General Assembly, a man named Mehmet, who was Turkey’s Minister of Health, had already arrived in New York. The section on women and violence seemed to me one final opportunity to include an issue of high significance for Turkish women in the outcome document.

As I looked around the conference room that morning, it seemed that the other delegates were also feeling the fatigue of the relentless meetings. There was little chatter, a notable difference from the conference’s beginning. Also, delegates seemed at all times to be coming and going—taking turns resting, I assumed, as we were doing.

Aylin, Nuran, Cemile, and I were present when the moderator read the paragraph that would potentially include honor crimes. His voice, I noticed, was an octave or so lower than it had been earlier in the week, and it broke as he read over some of the words. I felt a bit of relief at the knowledge that even he, such a high-level professional, used to this process, was feeling the strain.

We all swiveled our heads towards the EU section when he was done. As the same woman raised her hand, I saw that there were significantly less people in the chairs surrounding her. Even as she was speaking, another delegate scooted in front of her to leave.

“We wish to see the inclusion of so-called honor crimes in this section, because they are an important problem for many women, one that must be prevented.”

(p.111) The moderator looked over the conference room, and quickly asked “Are there any countries opposing this suggestion?”

The tone of his voice suggested that it was a mere formality; he did not expect there to be any arguments. I started to let out my breath in relief, but I had reacted too soon.

From the G77 section, a man stood up. I had not seen him speak previously; however, as the meetings progressed, more and more delegates from individual countries were standing up and speaking on specific issues, despite their allegiance to coalitions. All the procedures and guidelines surrounding this seemed to have dissipated.

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 17 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

The man wore a suit and had dark eyes and hair. “He is from somewhere in the Middle East,” I thought. My stomach turned over as he spoke.

“We do not think it is necessary to add in honor crimes,” he said, “because it is too localized and specific a problem. Honor crimes are never a problem in my country.”

I felt my jaw drop as he sat down. Next to me, even Cemile and Nuram wore looks of shock. All of us knew that honor crimes, in fact, most certainly were a problem in his country, as the notion of a woman’s honor is hugely important in many Middle Eastern and Muslim countries, not just in Turkey.

While the four of us quickly stuck our heads together, the EU representative spoke from her seat. “We would like to see it included,” she said, but did not add more. The moderator nodded.

“We will put the issue in brackets and move on,” he said.

Cemile listened to the moderator and then turned to us. She spoke to all of us but was looking at Nuran. “At this point, if we argue, he will see it as a confrontation and most likely will not back down.”

Nuran was nodding her head in agreement. “We should wait and speak with Mehmet and see if he can approach the other Muslim countries for support privately, and then succeed in including it in the General Assembly,” she said.

Aylin sighed. Mehmet was the Turkish diplomat of the Permanent Mission of the Republic of Turkey to the UN, which meant that it was his job to oversee all of the UN conferences and represent Turkey. Although he seemed to be a quite courteous and sensitive man personally, I suspected that the women’s conference was not high on his list of priorities. I surmised that Aylin probably felt as I did, which was that although the desire to stand and argue with the G77 man was very strong, Cemile was probably right. Mehmet had worked with the General Assembly for a very long time, and most likely had personal relationships with the representatives of the other Muslim countries. I knew, too, that the man speaking from G77 could very well be opposing the inclusion just out of perceived Western pressure against traditional practices, because the suggestion was made officially by the EU.

And so it was done. I sat through the rest of that day listening to the hurried decisions on women and violence and thought about our delegation’s successes and failures at the conference. The outcomes were not as black and white as I had (p.112) expected; rather, two of our most important topics, abortion and honor crimes, were being left to the General Assembly to decide.

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 18 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

Later that day, when the meetings had adjourned for a lunch break, our group managed to hold a quick meeting with Mehmet in the hallway. He greeted Cemile and Nuran warmly, obviously familiar with both of them, but frowned as Cemile described what had happened during the honor crimes debate.

“I have been told,” he began in a low voice, “that some of Turkey’s allies in the Middle East are not pleased with our support of issues such as sexual orientation.”

Cemile nodded and seemed unfazed. “Our support, for the most part on these issues, Mr. Mehmet, has been nonverbal.” She paused. “I understand our need to please our allies. And if the issue comes up in any of the remaining debates today, Turkey will not offer an opinion.”

Mehmet nodded, and spoke directly to Cemile. “Good,” he said. “I will see what I can do to speak with the delegate who opposed the inclusion of honor crimes.”

With that, he turned and walked down the hallway, on his way, no doubt, to one of the many meetings he had to attend. The Beijing +5 conference was only one of many of his concerns, therefore it made sense that he was more concerned with maintaining friendly relationships with Turkey’s allies than with holding a brief on any one particular issue.

Mehmet must have been successful in speaking with the other Middle Eastern assembly members, because a few days later, as I was packing my belongings to catch an evening flight back to Ankara, came news that the document would, after all, include honor crimes. I smiled as Cemile, over the hotel phone, filled me in on what had been finalized at the General Assembly meetings. My smile faded, however, as she described what had happened with abortion. Nothing was changed, and the document would continue to read “in countries where it was safe and legal.” The news was similar on a few other key issues which had been put in brackets.

As I set the phone back in its cradle, I thought that the wording on abortion might someday be a good indicator of women’s progress—that things would have drastically changed for the better by the time “in countries where it is safe and legal” could finally be deleted. While I gathered my things, I wondered if such a time would ever really come. During the past few weeks I had felt that the conference was one of the most important things I would ever do, and yet at times I wondered if it mattered at all. I folded my clothing into neat piles and thought of my daughter—would conferences such as Beijing +5 make a significant difference in her life? In what ways would growing up female in Turkey be different for her and her peers than it was for me and mine?

Beijing + 5: What Can International Conferences Achieve for Women’s Health?

Page 19 of 19

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2022. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: University of Colorado at Boulder; date: 02 March 2022

Access brought to you by: