Well. Here I am. Today is my last day in India. I can’t believe how much time has passed and how much has happened in the last year. I can distinctly remember January 9, 2012, the day I found out I’d been selected as a Global Health Fellow and probably one of the happiest days of my life. I’d been so nervous all day I was almost feeling sick, then came back from lunch to the best email news ever and had to let my friend Mike have his favourite “I told you so” moment. I can remember most of April, when people kept asking me, “Are you excited yet?” and my answer was always “…Uh, no. Not really. Not yet.” I don’t think the excitement really ever came; I was so busy trying to cross things off my to-do list and trying desperately not to freak out that I just went into business-mode as the departure date got closer. I can remember how disoriented and isolated I felt initially when I got here, and how every little task became a personal triumph because the challenge was so real (“Successfully negotiated coriander with the wallah! I am a CHAMPION!”). I remember the unbearable heat and sweat at Agra and Jaipur, the beauty, peacefulness, and smell of coconut oil in Kerala, the kitschy beaches and annoying men in Goa, the magical spirituality of Varanasi, and the fly-buzzing reality of the slums of Lucknow. This whole trip has been such an emotional ride, and I think that was the part I was most unprepared for. Five months ago, I was a disaster, wondering what I’d gotten myself into and how I was going to last till October. Three months ago, I was pretty mellow, was settling into my new life and looking forward to the rest of my fellowship. Two weeks ago, I was in near-panic mode and was completely miserable that my fellowship was almost done. I always thought of myself as a pretty even-keeled kinda person, but I’ve felt a lot of waves rocking my proverbial boat here. Now, I’ve accepted the inevitable end and, while I can’t say I’m happy to be leaving, I am looking forward to home, and most of all, my people. Oh, and those pesky pets too.
But first things first: trip report! As I mentioned previously, I went on a field visit last week to Lucknow, in Uttar Pradesh. I visited the CARE office and two projects: Urban Health Initiatives (UHI) and Join My Village (JMV). Both of these projects concern reproductive and maternal health – I asked specifically to see health projects because I needed some fodder for my GHF essay. And also, this is my favourite area of study.
On Wednesday, I woke up very early to catch the first flight to Lucknow. As an aside, the weather here has FINALLY changed for the better, with daily highs in the high 20s. In the morning, it was a little brisk. I wore my fleece. But I noticed in the taxi on the way to the airport that the few people who were up at that ungodly hour were wearing TOQUES. I kid you not. People are in sweaters now. At yoga, they turned off the overhead fans and now I’m sweating like a beast again while other people are putting on socks. Unbelievable. Anyway. Uneventful flight to Lucknow, found my driver, got to the hotel, had a 15min nap when I should have been eating breakfast, then went straight to the local NGO office for UHI. CARE is only one of the partners involved in this project, and we have partnered with SWARG (I don’t remember what that stands for) to implement the project on the ground. This project is for family planning in urban slums. The way it works is SWARG recruits and trains Peer Educators from the slums. They select women who are well-regarded in their communities so that they will be accepted and hopefully the message will have greater success. The PEs start by mapping their geographical areas with the women who are married and of childbearing potential (basically aged 15-49), how many children they have, and what form of contraception they’re using. They meet with the women one-on-one once per month individually to advise them and educate them about their family planning options. They also have meetings with all the women and play competitive games to educate them about birth control methods, like snakes and ladders, mendi competitions where they draw the different forms of birth control on each others’ hands in henna and whoever does the best job gets a prize. Or stick the bindhi on the woman (like pin the tail on the donkey). They try to make it fun and informative and get women more comfortable talking about these things, because there is absolutely no discussion of reproduction or sexuality at any point in their lives. There are a lot of myths, fears, and resistance to the use of family planning, partly due to religion (Muslim, in this area) and partly lack of information and education. Depending on their circumstances, how many kids they have/want, and all the fears and pressures in their lives, they may chose one of none of these options: condoms, OCP, DMP (injection every 3 months), IUD, sterilization, emergency contraceptives, and abortion. And pregnancy. Only 2 men have gone for sterilization, they’re terrified of it. Women are scared of it too, but since they bear the entire risk of pregnancy and childbirth, they tend to go for it more often.
The PEs were really interested in talking about their work – the CARE worker translating for me couldn’t keep up with them! I really loved seeing the PEs take so much pride in their work, they loved showing off “their” women and it looks like they have great relationships with them. We went on a walk around the slum to meet them. The women looked so young to be having this many children. They’re very shy about talking about birth control and would sort of hide behind the door or hide their faces (also, we’re complete strangers asking some pretty personal questions). Some of the women looked very sick, they were up and dressed and talking, but you could just tell by looking that something wasn’t right, like anemia or something chronic like that. Side effects are a big reason for discontinuation of some of these methods, particularly the IUD and DMP. There is no requirement for tracking AEs in India but the project does keep track for their own purposes (yes, I asked specifically about this!). Most women only want 2 kids, the average is 5. The religious leaders are not on board. Once in a while they have one who is more moderate and this goes over really well because the men and women are more inclined to listen to them. I think a lot of religious leaders of all stripes are against contraception, but it’s interesting that people will only listen to them up to a point. Abortions aren’t allowed either, but women will still have them because they’re more desperate at that point and will do anything to not have the child. I also found the spacing of children interesting. Because these women marry and start families so young, and typically do not work outside the home, they actually have more freedom than women back home in terms of spacing out their kids. One woman had a three year old at home and wanted to have the second when he was 5, so she was on a 5-year IUD. At home, I think women try to “batch” their kids more, and our time to have kids is such a narrow window since we spend a lot of our prime fertility years in school and getting set up in careers and such, so our kids tend to be grouped more closely in age. A woman in India (with access to birth control) might only want 3 kids, has one at 18 or so, then has at least another 20-25 years to get around to having the other 2.
I found the idea of the mother-in-law and husband being the decision makers in the family about the wife’s body to be very strange. I knew it happened, but I can’t imagine what it must be like for a woman to have no say in what happens to her body. They do include the MILs in the education and games too, but social issues take so much more than education, I’m finding, especially when status and power is so tenuous in women’s social circles.
The next day, I went to a village just outside Lucknow to see the Join My Village project. This project has several arms, but we were looking at the maternal health part. CARE works through another local NGO who meets with mothers’ groups in villages to talk about what to do for a healthy pregnancy. They also have men’s groups, which talk about supporting maternal health – which is quite a revolutionary idea. The biggest issues are the social issues. The women do everything in the villages, all the housework and cooking and working in the fields, and it takes up all of their time. Everyone else eats first, and if there’s nothing left, the woman just won’t eat. This is a problem for anyone, but particularly pregnant women. They don’t have time to rest, they still have to do all the heavy lifting (water, firewood, kids), and they just can’t afford to take care of their own health. Trying to get the men involved would be helpful, but there are so many social barriers to this. They admit they want to play with their kids and are willing to help out in the house, but the stigma is so great that they can’t be known or seen to be doing this. When the MIL comes to “help” as the due date comes up, any help the men were doing stops because they can’t let their mothers see them doing anything around the house or they will lose face. The MIL doesn’t really help either, because the MIL and DIL relationship is really something else… During the meeting, a young mother with a newborn sat beside me and had her sari up over her head and she wouldn’t make eye contact or say anything. At first I thought it was because of me, but then discovered it was because her MIL was sitting beside her. It becomes almost a form of self-effacement. Like as long as the MIL is present, the DIL doesn’t really exist. The NGO worker obviously isn’t going to “make” anyone remove their head coverings, but she did ask the MIL, “What’s going to happen if she shows her face?” at least to prompt some thinking. It was all women there, and we were discussing proper nutrition and eating enough while pregnant and breastfeeding. So what’s going to happen if a woman shows her face here?
It’s hard for me to understand that sort of disconnect between what people know and what they do. The MIL may attend all the sessions with her DIL and understand and agree with what is being taught, but it doesn’t change her behavior or the behavior she expects from her DIL. Surely she must remember what it was like when she was the DIL, but rather than change, she maintains the status quo. I wonder if it’s the fact that this is the only time in the MILs life when she has some power, and doesn’t want to give it up. Of if there is a perception from the larger community that if the MIL starts changing things by allowing the DIL more freedom, that she will lose status. It seems there is so much desire to change some of these social norms, like dads playing with their children, and MILs and DILs having mutually beneficial relationships, but so little will to change – or perhaps it’s fear of change, and we just have to wait until the one or two brave people can lead by example.
Another one of the things that really struck me was the initiation on discussions about human sexuality. I suppose I’ve taken it for granted because I’ve always lived in North America, where sex is discussed fairly openly. We’re taught the biology and health in school, and other literature on the emotional, psychological, and social aspects of sexuality is widely available. My relatives and friends talk openly too, and men and women will discuss in mixed company. There is certainly a sense of personal space, respect, and privacy, but the topic itself is not taboo. It is hard for me to imagine what it must be like to have that whole idea of sexuality a complete mystery – even after marriage. It made me realize just how revolutionary this approach is, talking with couples about their relationships as a way of improving maternal health.
I loved seeing the CARE staff and the NGO workers, anganwadi workers, and peer educators so engaged in their work, I think that was the best part of this field visit. I had asked to go see these health projects because I wanted to be inspired after spending the last several months in Headquarters and I’m happy to say it worked! After the village I was able to do a bit of sightseeing in Lucknow, then left the next morning for Delhi.
Anyway, I could go on, but I have only half a day left in office and I need to summarize my last six months of work here… so I better get this posted. By the time most of you read this, I will be on a plane. The clock keeps ticking and counting me down here. It’s such a strange feeling to have this all come to an end now, just when I thought I was finally getting the hang of things. I’m so, so grateful to have had this opportunity. As tough as it was sometimes, there were also times of true wonder, insight, enlightenment, and fun. I’m so glad I did this, it’s been a dream of mine for years and while the experience itself is just about over, I know that I’ve changed and I’ve even made some positive change at CARE. I’ve met new people, done crazy things, and learned so much. The world is just such an interesting place – aren’t you glad you live here?!
Finally, thank you to everyone who has followed me on this blog. I know it was sometimes funny, sometimes kinda boring probably, but I’ve appreciated your support and encouragement and having a small audience to report back to really helped me make the most of this adventure. Not sure if I’ll be posting from Hawaii, but in any event, I will see those of you back home soon, and I will cook you some dal and let you dress up in my sari 🙂