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Please watch all 4 parts of this documentary series, covering healthcare systems in the US, UK, Switzerland and Australia.

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Assignment Overview

· Case study: PIH ch. 7: “Swasthya: The Politics of Women’s Health in Rural South India,” by Suneeta Krishnan, pp. 128-147.

After reading the assigned text, compose a 400-500 word reflection and submit it to the Canvas discussion board.


Content and Grading

In your reflections, address the following 3 questions.

1. What are the author’s main messages/arguments? What is the main takeaway of this case study? What is the essential background information that we need to understand it? (2.5 points)

2. How does the case study relate to concepts from the course (including lectures, readings and videos)? Connect themes in the case study to at least 2 concepts from the course.  Put these concepts in bold so that we can easily find them when grading, and be sure to explain or elaborate on HOW the case study illustrates, complicates or is connected to that topic. (4 points)

3. Share your personal reaction or stance on the issues developed in the case study. Has it changed your opinion on the topic? Does it relate to your own personal experiences? Does it connect to things you have studied in other courses, or articles you’ve been reading in the news lately? (2.5 points)

4. Proper citations (1 point)

Citations

You must include proper academic citation in your case study reflections. This is a good habit to get into generally. Visit this page for the 
general course citation guidelines.

· When referring to required course material, use a shortened version of the APA’s author-date, in-text parenthetical citation system, e.g. (Marmot 2010). You can abbreviate our course textbooks to RGH and PIH, or use the case study author’s last name. Be sure to spell the author’s name correctly! Lectures can be cited by the number, e.g. (Ryan lecture 4.2). Videos can be cited by the primary speaker or a shortened version of the title, e.g. (Bad Sugar) or (Rosling).

· When referring to outside articles or sources, use the APA’s author-date, in-text parenthetical citation system, e.g., (Washington Post 2021) and include a hyperlink or full citation to your original source at the end of your submission. Connecting the case studies to outside sources is always welcome, but be sure you are also

· You do not need to write a full bibliography for case study reflections.

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

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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.

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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

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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

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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

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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.”

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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

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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.

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“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

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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.

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“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 …

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

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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

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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

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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,

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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.

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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,

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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.”

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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.

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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

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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 …

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