On the Front Lines of Global Women's Health
Yingzi left home at 13 with a hope of making money for her farming family in rural Jinping County, Yunnan Province, China. Her friends told her she should go to a big city to find work. So when she had the opportunity to leave Jinping, Yingzi made her move. She went to Mengzi City.
When she first arrived, Yingzi took various jobs in restaurants and clothing shops and as a nanny. But with a salary of 400 or 500 yuan a month, she couldn't afford to eat well and still support her family. When she was 16, she decided to get a job at a karaoke bar, or a KTV, as they're commonly known. Karaoke bars in China are at the heart of the country's sex industry. Customers are usually groups of men who want to sing and drink in the company of young women.
"Looking back, I think the friends that told me to come to Mengzi were sex workers, but when I first arrived, I didn't know what they were doing," Yingzi says. "In the beginning, I didn't do sex work. But later, for economic reasons and because my family was poor, I started to."
It wasn't long before Yingzi realized the risks associated with living life as a sex worker. She saw many girls, some as young as 15 years old, with reproductive health problems, including severe abdominal pain. Like Yingzi, they had no family members around who could take them to the hospital for treatment. "Knowing these women's health conditions made me realize how hard life can be."
In 2009, Yingzi got acquainted with PSI through the Mengzi Sisterhood Health Home (SHH), a drop-in center for female sex workers that was launched in August 2005 as a focal site for PSI's outreach program. In December 2009, Yingzi became a part-time staff member at PSI/China.
Yingzi does outreach work in brothels and KTVs. She also works at SHH as a peer educator. The program, funded by the U.S. Agency for International Development, reaches female sex workers, a particularly vulnerable population in Mengzi, through quality outreach and interpersonal communication methods. HIV prevention activities are peer-based using carefully tailored behavior change messages that are evidence-based and determined through exhaustive research. SHH provides free checkups for sexually transmitted infections (STIs) by a local doctor, who can also make referrals for other testing and/or treatments at the local maternal and child health hospital.
After working in the sex industry for several years, Yingzi has come a long way. As a PSI/China peer educator, she has not only learned how to protect her own health but is also actively engaged in helping her peers do the same for themselves. "I've learned a lot from working at PSI. Now I know about women's health, reproductive health and how to protect myself. Take condoms as an example. I used to not know how condoms could protect me. But I've learned a lot here, especially as a girl from a rural village. I think PSI is a good place."
"My sons keep me grounded," María Paz Callejas says with a smile. "Whenever I feel like giving up, they snap me right out of it." Marípaz, as she is affectionately known, has felt like giving up a few times in her life. She was diagnosed with HIV in 1996, several months after her husband died of AIDS-related causes. Without proper counseling or anyone to turn to, Marípaz returned home with her test in hand. "I locked myself in my bedroom because I didn't want my children to see me crying."
Marípaz was born the youngest of 12 in the outskirts of San Agustín Usulután, a town in a southeastern region of El Salvador. According to statistics from the United Nations Joint Programme on HIV/AIDS, adult HIV prevalence is still relatively low (less than 1 percent) in this small but densely populated country of about 6.2 million. Nevertheless, approximately 35,000 people are estimated to live with HIV and many, like Marípaz, may not have received adequate counseling before and after taking an HIV test.
It wasn't until a friend referred her to a local nongovernmental organization, Fundasida, that Marípaz took another HIV test and finally received professional counseling. "I had so many questions," she says, "and I finally had someone to answer them." After several months of continued counseling, Marípaz joined a support group for people with HIV. She started two other groups for youth—both positive and negative—and for family and friends of people with HIV. She then went on to volunteer at the foundation's confidential hotline and prepared meals for people who came to receive treatment, care and other services.
In 2002, Marípaz received a phone call about a job opening at PASMO, PSI's Central American affiliate. "When I interviewed her, she didn't have a lot of experience in education," says Susan Padilla, PASMO's HIV manager. "But I saw a lot of potential in her, and I told her that she was completely capable of carrying out the work." A few days later, she was hired to do interpersonal activities with groups particularly vulnerable to HIV. At the end of the day, Marípaz says her family and children are what motivate her to keep going each day. Her three sons, none of whom tested positive for HIV, are healthy and in school.
Her eldest, José Luis, is studying psychology at the university level and says he would like to work at PASMO helping others. He has also given Marípaz the chance to be a grandmother, and she proudly shows the pictures of her granddaughter on her mobile phone. "I always wanted a little girl, and now I finally have that chance."
Every day, Agnes Phiri Kornika wakes up at 5 a.m. to pray for the rural women of Zambia. She prays for women who have multiple children, for women struggling with unwanted pregnancies, for women who have no access to family planning. Then, she puts on her dancing shoes and does something about it.
Agnes—Aggie for short—has six children of her own between the ages of 11 and 39 and has been a midwife for 34 years. She knows a thing or two about reproductive health. Her passion for helping the underserved has brought her to the far reaches of rural Zambia. "My family lives in Lusaka, but at the moment I am in an eastern province of Zambia, where I am helping, or rather saving, the rural women with a long-term family planning method," she says.
Aggie provides family planning counseling and insertion of long-acting reversible contraception, namely intrauterine devices (IUDs) and implants. She considers her work for PSI's local affiliate, Society for Family Health (SFH), her God-given profession not only because she is committed to helping women take control of their reproductive health, but also because she is a gifted communicator. She speaks multiple languages and has a way about her that puts people of all backgrounds at ease. "I don't really have a problem in communicating with anybody, be it young, old or middle aged. They find me accommodating, and I also find them accommodating," she says.
Aggie takes an active interest in the women she serves. One woman she helped had been pregnant 16 times. "A rural woman gets married at 14. This rural woman, at 42, had been pregnant half of her life. Because her children were dying of malnutrition, she kept on producing every year," Aggie says. "I was really affected; I've never seen a 16th child from the same woman and man in my life."
Aggie counseled the woman on her family planning options, and she chose an IUD, which Aggie inserted. Both the woman and her husband came back to thank Aggie and have served as role models for other couples in the community by dispelling myths about IUDs. While access to family planning can be a matter of life or death, Aggie educates women and men in a positive and engaging manner by dancing, singing and talking about the real reason people need family planning: sex.
"I've come to discover that, in a woman's life and a man's life, the best thing is sex. So as a part of my sensitization, I always say that what you have to enjoy is your sex," Aggie says. "I tell them to enjoy sex with the partner God has given you rather than you trying to find satisfaction from someone else. And this has also helped them to maintain their relationships. Even the men have come to appreciate it. They come personally to say thank you."
Aggie discusses how using long-acting, reversible methods of contraception will help relieve a woman's anxiety about becoming pregnant, thereby freeing her from worry during sex. "With this long-term family planning method, which is never forgotten, you can go anywhere anytime. You won't forget to take your pill; you won't forget the date of your next injection, because you already have the device in you. That brings a lot of comfort to a lot of women."
Aggie's smiling face and upbeat personality undoubtedly bring a lot of comfort to a lot of women as well. In these rural areas, SFH, working in partnership with the Ministry of Health, is one of the few organizations that have been able to successfully increase informed demand for and use of IUDs. "I would say our program is doing the best and it is the best, especially for rural women. It has never been done there," she says. For Aggie, there is no uncertainty about how these rural women view SFH's program. "When you see them dance, you know they really appreciate the service."
Vongphachanh "Khom" Temmelath lives in Sythane Tai Village, in Vientiane, the capital of Laos. Born a boy, Khom knew from an early age that she was different. Growing up, Khom had a group of friends who were also born and raised as boys but identified as girls. As they grew older and began to express their identities, their families reacted with anger, often hitting and abusing them. Early on, Khom's family was deeply embarrassed and worried that their small community would judge them.
They urged her to wear men's clothes and to act more masculine, but she insisted this was how she felt in her heart. At the age of 10, Khom lost her father. With time, Khom's family accepted her identity as a male-to-female transgender, or katoey. In high school, Khom began wearing makeup but still dressed as a man and kept her hair short.
By the time she went to college, she had grown her hair long and wore women's clothing. She became an active part of social events on campus, volunteering and organizing events. But the school authorities challenged her repeatedly. Eventually, the constant pressure from the school and the discrimination from fellow students caused her to drop out of school.
Khom says it's nearly impossible to find a job in Laos as a transgendered person. "Companies look at your picture, your long hair, and then they see that you are born male, and they toss your CV out." Unemployed, she felt alone and adrift.
Khom's health was also at risk. At 0.1 percent, HIV prevalence among the general population of Laos is relatively low, but a recent survey established the HIV prevalence among men who have sex with men, including transgendered men, to be 5.6 percent. Among that group, there is a self-reported prevalence rate of STIs at around 42 percent.
In response, PSI/Laos opened three New Friends Drop-In Centers in 2008 in the country's largest urban areas, providing a range of HIV and STI prevention education and services for an estimated 6,000 transgendered people and their partners. After being isolated for so much of her life, Khom found a sense of community through PSI. She helped with a research survey and became more and more involved in the New Friends Drop-In Center activities. Eventually, she began working as a peer educator. Now, she mentors youth who visit the drop-in center. She urges her peers to focus on their studies and to finish their degrees. She also gives them the emotional support they need in order to face the discrimination they feel at home and at school.
"Not even in my dreams did I imagine I would be able to do this kind of work," Khom says. Before working at New Friends, she had heard of HIV and STIs but did not know how important it was to keep herself healthy and to prevent these diseases. Fearing discrimination, she rarely saw a doctor and had never been tested for HIV or STIs. Now, she says, "I can protect myself and protect others."
When she was younger, Tarisai "Tears" Wenzira dreamed of being a nurse like her mother. After Tears' parents died when she was 15, she went to live with her grandmother, a farmer, along with three siblings and her late aunt's three young children. When she was forced to drop out of secondary school to help her grandmother support their large family, Tears felt the dream of becoming a nurse slip away.
With little education and a lack of job opportunities, Tears drifted into marriage and motherhood at 17. After three years of struggling to cope with both, she divorced her husband and returned to her grandmother's home in rural Wezda, this time with her two young daughters.
Again she found herself in search for a job to help support her family. This time, she found one as a hairdresser. It was at the salon that she was first approached and trained by PSI to promote and sell female condoms to her clients.
"I remember learning about PSI when a field officer visited our salon and introduced the care female condom and its role in HIV prevention. She demonstrated how it is used and coached us on how to teach our clients on correct use of the condom as well as negotiating for its use with their partners," Tears says. "She sold some condoms to us for resale to our clients, and when I realized some profit from the sales, I became interested and agreed to continue."
Twenty-one percent of Zimbabwean women and 14 percent of men are HIV-positive. Yet, cultural and gender dynamics often prevent women from purchasing and initiating condom use. PSI found that hair salons can break through these cultural barriers. According to research, a majority of women in Zimbabwe visit a hair salon at least once a week and spend about 45 minutes to an hour there each visit. Clients often become friendly with their hairdressers and discuss social issues.
Tears became one of the more than 2,000 hairdressers in Zimbabwe who work closely with PSI as part of a program—co-funded by the U.S. Agency for International Development and the U.K. Department for International Development—to prevent HIV transmission by promoting the use of female condoms to their clients. During discussions with their clients, hairdressers show women how to use the product and let them touch and feel it. Research also showed that lack of knowledge about how to insert the female condom correctly and fear of its size were also barriers to use.
Today, Tears, a radiant 28-year-old with beautiful hair and a welcoming smile, has remarried and has a third daughter. She has moved to Chitungwiza, a small town 19 miles from Zimbabwe's capital, Harare, where she continues her work as a hairdresser, advocate and educator. Tears sells 100 female condoms per month and makes a profit of $4—enough to buy basic groceries like bread and milk for her family. In 2009, PSI sold more than 2 million female condoms, and more than 50 percent of them were distributed through the network of 1,700 hair salons across the country.
Tears is proud of her confidence to talk about the female condom, even to clients who are more educated than herself. "My work with PSI has been an eye-opener. Despite my incomplete secondary education, I can confidently speak about the care female condom to women and men, some of who are professionals." She also feels her work with PSI has benefited her family. She introduced her sister, who is HIV-positive, to the female condom. Her sister is happy and now enjoys a normal sexual life.
Tears' strength to overcome her life's hardships has made her a powerful advocate for PSI's HIV prevention and family planning efforts.
PSI Ambassador Debra Messing met Tears during her visit to Zimbabwe in December 2009. Visit PSI.org to see the photos.
PSI is a leading global health organization with programs targeting malaria, child survival, HIV and reproductive health. Working in partnership within the public and private sectors and harnessing the power of the markets, PSI provides lifesaving products, clinical services and behavior-change communications that empower the world's most vulnerable populations to lead healthier lives. Learn more at PSI.org.
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