Monthly Archives: December 2012

An Introduction to Women’s Health

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I have been kept so busy that I have barely had time to update this blog! After spending a few days as a tourist in Hyderabad, I left Andhra Pradesh and have settled in Coimbatore, Tamil Nadu, where I will spend the next six weeks working at The Womens Center. This small, private hospital is remarkable. Not only does it offer lavish interiors (it’s the most pleasant hospital that I have ever been in–I stayed in a patient room for two nights and it was the nicest place that I stayed since leaving the US), it offers remarkable services at affordable prices. But enough advertisement…

While here, I will be conducting educational outreach projects. I have been busy learning about all sorts of women’s health issues, finding statistics, and trying to figure out how to present my findings to women from a culture where private parts are kept very private and sex is a very touchy subject. My first presentation will be this Friday to a group of educated women working in IT. It will be part of a longer presentation on general health given by a female colposcopist who has just returned to India after practicing for several years in the UK.

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Dr. George Papanicolaou

My talk will be about the importance of the Pap-smear in cervical cancer prevention. India has one of the highest rates of cervical cancer and basically no prevention program, so the aim is to raise awareness around the issue. In this first talk, I will discuss the use of Pap smears in the US and the dramatic reduction in the rate of cervical cancer. For example, with screening, incidences of cervical cancer have been reduced by 75-90% depending on which journal article one reads. This figure is quite remarkable as in 2010, only 73.3% of women in the US had a Pap smear within the last three years. Also of interest is that over half of all cervical cancer cases in the US occurred in women that have never had a Pap smear, where ~25% of cases occurred in women who haven’t had a Pap smear in the last 5 years, and the remaining 25% or so of cases occurred in women who failed to follow-up properly after an abnormal Pap smear. It is estimated that if all sexually active women received Pap smears every 3 years, the incidence of cervical cancer would be reduced by 99%! So, I must find a way to present these promising statistics to women who are very fearful of both cancer and talk of sex (especially as 99% of cervical cancer cases are caused by HPV, a virus transmitted through sexual contact).

(In the US, an estimated 80-90% of sexually active women contract the virus at some point in their lives although the majority are able to clear it to undetectable levels before it becomes a problem)

In discussing these issues with the colposcopist, she told me some startling anecdotes about the female Indian patient. The body clears most abnormal growth on the cervix naturally, so in most cases patients are asked to return for another Pap smear in 6-12 months to check on the condition. However, some patients hear “abnormal,” stop listening there, and nod their heads that yes, they will come back in 6-12 months. But instead they rush to another doctor and, if they have already had their children, they demand a hysterectomy!

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Another issue with this sensitive topic is women wondering HOW they became infected with HPV in the first place. As very few women in India have had more than one sexual partner and their husbands insist that they have both been faithful and were also “pure”  at the time of marriage, this creates yet another problem. I have been thinking about how to answer the questions that I might receive on this topic with something other than  “Your husband is a liar.”

(HPV can be spread without actual intercourse but contact is necessary).

Another project that I will be working on involves visiting orphanages in the area and giving talks on feminine hygiene and sexual abuse. I just did some quick research on feminine hygiene in India and found some pretty startling results. For example, in India, only 6% (around 30 million women) use some sort of hygienic sanitary napkin during their monthly menstruation (compared to the 96% rate seen in developed countries). The remaining women use whatever they can find. Thus, women often endure embarrassment, infection and loss of workdays due to the negative social stigma and discomfort associated with monthly menstruation. Reproductive tract infections are 70% greater among women who lack access to hygienic supplies and as many as 31% of adult women in India note a drop in their productivity levels when they menstruate, resulting in missing an average of 2.2 days of work each month (click here to read more). Aside from these issues, I will also teach simple exercises to relieve menstrual cramps as well as exercises to help combat depression. These presentations will be a challenge as the customs and sexual culture are just so different from what I know (I still haven’t even figured out how people here get by without toilet paper).

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Sketch of a baby with arthrogryposis (Wikipedia)

Meanwhile, I have read about 30 journal articles and reports on different aspects of female health, evaluated sperm for male infertility tests (more observational on my end), watched mammograms and ultrasounds, watched a C-section, spent time in the NICU with preemies including one suffering from arthrogryposis, went on rounds, watched heart scans on newborns… Its been busy but I’ve learned so much and am so excited to learn more!

An update on my Widows Project:

The first widow I spoke with who was taking care of her orphaned grandson is currently making arrangements to live at the BIRDS farm where here grandson will attend the BIRDS school. On a more upsetting note, the two little boys whose parents died of AIDS and suicide, are both HIV positive. The twelve-year-old girl with tuberculosis does not have HIV. BIRDS is aware of this situation and will be doing all they can in order to get treatment for these children and support for their grandmother.

I am also still plugging along on the development of SHELTER, the non-profit sustainable women’s shelter that I am working on developing with two Indian MBAs.

(Hopefully Not) Lost in Translation

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Every act of human communication requires some form of translation. Even speaking in our own language requires translating what one person meant in his own mind into what one thinks he meant to convey. Body language as well requires translation–but perhaps body language is so engrained in our nature that it requires a bit less translation (although it can add even more confusion to the act of translating for the body often says one thing and words another).

Now move these complexities into a different language and add yet another filter and layer of translation–a translator. And now add different customs that might even obscure some body language (i.e. do people smile because they are happy or because it is their custom?). From all these complexities one can easily see the difficulties of translation–especially when one must use a translator.

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Interview with translator in a tribal village

In my interviews with widows, I had to use a Telugu to English translator. While it was incredible that I could “speak” with the widows, I did run into a few problems (really more minor annoyances) with my translator. For one, he was a man and I was interviewing uneducated women who came from a culture where women are considered less than their male counterparts–and I was asking these women for some fairly personal and gender-based information. Seeing this potential barrier, I had originally arranged for a female translator, but she had an unforseen arranged marriage and was no longer available. So, I had to make due with what I had and now must factor the male translator into the equation. Doing this, I assume that the stories that these women told me were actually more horrific than the information and translations that I received.

Some other issues that I faced with the translator involved him filtering what the women had to say and giving me only what he thought I wanted to hear. While my questions were answered somewhat directly, I had posed the questions as open ended because I wanted to get the women to talk about their lives. And, from what I could not understand but judging from the length of their answers, it worked. However, from the brevity of the translations I received, I know that my translator had his filter on high. I would constantly ask, “What else did she say?” and my translator would respond:

“She is telling me about her sorrows.”

“And…”

“Next question.”

I would receive this frustrating response to my pleas for better translation (or actual translation!) several times each interview.

Another frustration besides the filter set on high was my translator responding “same thing” instead of actually translating what the woman actually said. Yes, every woman that I spoke with suffered from neglect and discrimination. But I wanted to hear their stories and hear what they had to say.

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Interview in a village school

And yet another annoyance which I think actually did affect my research was the translation of the responses to the mental health questionnaire. These questions were a little more direct. Where the first part of my interview asked open ended questions such as “What is your opinion about widowhood in your village?”, the mental health questionnaire asked questions that were meant to get responses more along the lines of “yes,” or “no,” or “sometimes.” But, as these women wanted and needed to talk and share their sorrows, their responses were not quite so direct. For example, their responses to “In the past month, how often have you been feeling sad?” would consist of a long story about what had happened in the past month rather than a response such as “seven times.” Thus, my translator would say “sometimes” or “no” and would look annoyed when I would ask him to elaborate. As each response in this section was meant to generate a number, such inaccuracies in translation do effect my research.

In regards to inaccuracies in the mental health score, towards the end of my interviews, I realized that my translator was adding a little too much of his own translation onto the responses in regards to questions about whether the widows ever thought that life was not worth living. I discovered this issue when a women gave a long and emotional response and my translator simply translated, “No. Next question.” Here, I demanded an elaboration. It turned out that this woman had twice attempted suicide but for the sake of her children did not want to harbor such thoughts. And so, in response to the question: “Have you ever felt that life was not worth living?”, my translator translated the response of a woman who had actually admitted attempting suicide more than once as “no”. Thus, my translator failed to translate the difference between wanting to feel a certain way and actually feeling a certain way.

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Interview at the BIRDS farm

From this point on, I demanded actual translations to these questions. However, for the previous eighty-five or so widows that I had questioned, I cannot fully trust the accuracy of their mental health scores. Thus, I will have to translate and factor these inaccuracies into the mental health scores. Unfortunately, the actual scores are probably actually much higher than those that I have calculated. And, as the previous post states, the average mental health score for the one hundred and eleven widows was 4.47 on a scale from 0-8.

Despite my issues with my translator, I do feel that my research is fairly accurate and am thankful that I had a translator. Unfortunately, the inaccuracies and issues due to the gender of my translator and his actual translation only make my results even more depressing.

Portraits of Indian Widows

I have completed my research and have now interviewed one-hundred-and-eleven of India’s poorest rural widows. I have entered some findings into a spreadsheet and now have some basic statistics. I interviewed women ages nineteen to eighty-nine with an average age of fifty-one. Sixty-four of these women live alone or are the sole supporters of their families (only forty-four report receiving support at all). Of these one-hundred-and-eleven women, the average age of marriage was just 14.48, with the youngest being married at just ten years and the oldest at twenty-five. The mental health scores from the mental health questionnaire, with a range of 0 to 8, averaged 4.18 (and I am not sure how accurate this number is as I always had trouble with my translator here–but I will go more into that issue in a later post).

This experience has been transformative to say the least. I have been deeply moved by these women and amazed at their strength and endurance for life at its worse. I have loved my time here and feel honored to have had so many women share their lives with me. I know that I will somehow continue this work in the future.

Below are portraits of thirty-four of the widows, including the nineteen year old and the eighty-nine year old.

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Freedom and Choice

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The last month in India has tested my independent nature. For the past several years, I have experienced the luxury of living alone and, My!–what a luxury! I could do whatever I wanted whenever I wanted and I could eat what I liked whenever I liked (the only constraints being whether New Seasons was open or if I could find a restaurant suitable to my tastes, which happens all too frequently in Portland). I could exercise as much as I liked and however I liked. And, most importantly perhaps, I could go on long walks alone through the city or woods.

But in my experience of India?

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Some of this strain is due to my gender–for even as a westerner, I am still a woman alone in India (and rural India at that). As this trip is just a short portion of my life, I have surrendered to the customs of rural Andhra Pradesh. For the most part, I have given up my pants and I do not show my ankles. I am OK with this as I know that in a few short months, I will be prancing around in a bikini in Thailand. But at times, the constraints placed on me by my gender irk me. I am not expected to be alone or to want to be alone. I must have someone accompany me wherever I go (and if I do manage to sneak off, I am left with lectures about danger and the guilt of having made someone worry). And exercise? Practically forbidden (although I have managed to get some in). At times, part of me wishes that I were a man–able to enjoy a solo run through the fields and the other luxuries afforded by the gender. But, still happy to be a woman, I sometimes wish that I were traveling with a man, as even in cities the security opens so many possibilities…

(As a young woman who has traveled alone quite a bit, I know the need for caution and have so far managed to avoid trouble–I do have sharp elbows after all! Surprisingly, the time I felt most threatened by “the weakness of my gender” was back in Oregon, sitting by a waterfall…)

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The other struggles that I am having are experienced universally by other Type-A personalities. I cannot set my own schedule. I eat when I am called and have little to no choice about what I put into my body. I know that I have gone above and beyond my self-imposed sugar intake of 30 g/day and I know that there is nothing I can do about it. My body has started to reject rice once again (after allowing me to enjoy it for just three short weeks) but I must still eat it (rice makes up the majority of the diet here so I have resigned to my fate of eating it two or three times per day–I love it, but it hurts).

While I may feel a tad constricted, I do not feel trapped here (how could I when I love what I am doing so much?). I cannot wait until I again have the opportunity to visit this wonderful place and see my BIRDS family–this adventure has been truly spectacular. I am, however, looking forward to moving on to someplace where I can exert a little more control over my daily life. I do realize that the experience and struggle has been good for me as I cannot always have my way–it is important for me to continue to learn to let go and to let someone else take the reins for once (but I am so happy that my project affords me the little luxury of letting me be my Type-A).

This experience has also brought to mind the relation of choice to freedom and happiness. One theory suggests that choice (and the concept of freedom) actually makes us less happy and free. I guess that having no choice lets us enjoy the moment and not regret our decisions or worry about whether we should have opened Box A instead of Box B (it shifts the blame of our actions from ourselves). Perhaps. But after knowing choice and experiencing freedom and the delicious agonies they cause, is it possible to feel happy and free in their absence?

Note: Even without the luxury of total freedom of choice that I am currently experiencing after knowing its torturous pleasures, I am quite happy here (possibly because I know that I do not have to eat and endure rice endlessly).