The second LSE-UC Berkeley Bangladesh Summit featured a presentation on women’s health narratives within an informal settlement in Dhaka, developed by Sabina Faiz Rashid (BRAC University) and Mikhail I. Islam (Strategy & Design Consultant). Here they explain why public health interventions in Bangladesh can improve by listening to those who need them most.
Photo: An informal settlement in Dhaka | Credit: Momo Mustafa (2017), BRAC JPG School of Public Health, BRAC University.
While public health predominantly diagnoses and treats the physical aspect of being through a disease-based framework, women are compelled to classify, diagnose and manage their own health conditions. Sonya, a recently unemployed 23-year-old woman and divorcee, worked in a garment factory for nearly two years. She lives with her mother and younger sister in the Bashantek informal urban slum settlement in Mirpur, one of the largest in the megacity Dhaka with over 31,000 residents and 9,800 households within about a 1/2 sq. mile. She and her sister had to drop out of school when Sonya’s father passed away. She began working when only 15 years old to partially support her family.
These interviews took place for several weeks, in 2018, as a follow up from prior field visits to informal settlements.
“I recently left my job because it was so low paying and the working conditions are extreme…I have to stand for hours, Sonya remarked. ‘I feel durbol’ which refers to an acute emotional, mental and physical fatigue
Later in the interview, Sonya turned to her sister. ‘Should I tell them?’; to which her sister nodded in assent. ”I felt emotional and mental anguish,helpless…my husband used to beat me all the time…no one listened when I confided about his behaviour….I had to leave him,” she admitted. Despite her family’s stern disapproval, yet no longer able to bear the physical and emotional trauma any longer, Sonya divorced him. She returned to her mother’s house in utter shame,s since divorce within the informal settlements carries enormous social stigma. The most economically disadvantaged young women are expected to remain married no matter how destructive the marriage proves for the wife.
Sonya was constantly taunted and shamed by her relatives, the community and her own family for the divorce. “I didn’t feel like seeing anyone and I drowned out the criticism by listening to music on my phone.” Sonya became so isolated that in desperation, her mother convinced Sonya to work abroad as a migrant worker. She worked in Jordan but returned abruptly within two years, because she admitted, ”I was very alone and missed my mother and my sister.”
Sonya also divulged that her paternal uncles exploited her father’s death by forcibly taking over her father’s business with a local gang’s help. Since it is customary for one’s paternal uncles to take guardianship and provide for the vulnerable widowed family, Sonya’s uncles’ betrayal deeply agonised her. To complicate matters further, they remain her nominal albeit ambivalent guardians living next door; with whom the family must maintain a dependent relationship for survival.
”I came back (from Jordan) and worked for some time in a garment factory but then quit.’ Sonya explained, ‘Í am always anxious and I worry so much and then I begin to get angry, my head starts to hurt, my limbs go numb and I cannot stand properly or control what I do. When this happens, I go lie down in a corner of the bed, looking at my phone and not talking to anyone until I can feel myself calm down. I can’t sleep and I feel ‘durbol’. After that I usually end up feeling extremely weak and spending the entire day in bed.”’
She attributes this to her father’s death, her violent marriage and her uncles’ manipulation. Sonya also shared she was ‘’anxious that her husband will track her down and start harassing her to return to him again, and . . . felt ashamed to meet her family members, especially younger cousins who are married.” As a divorcee she is often mocked by relatives as having a “porra kopal”, literally a burnt forehead, which refers to a cursed future bringing misfortune upon others. When she is by herself, she uncontrollably breaks down and cries at this vicious humiliation.
Sonya’s dire circumstances within the settlement again lead to a desperate aspiration to work in Jordan. Yet she could not accumulate any savings to leave, having spent all her earnings on the family . Her sister apprises Sonya’s health by claiming that ‘órr tho matha noshto”, literally that her head is ruined,, and meaning she ”is psychologically unstable.” Sonya has visited many doctors, but explained that they cannot cure her illness.
A living illness
Sonya’s emotional, mental, physical and social experiences embody her entire life. This multi-dimensional health condition resists simple diagnosis. Similar to Sonya, other women spoke of ”a life of constant struggle, of the feeling of their limbs giving up or losing life…”
In documenting these narratives originally in 2001 during fieldwork in other settlements, women often referred to the precariousness and fragile uncertainties in life as ‘Chinta Rog,’ which literally translates as worry or anxiety illness. Women spoke of, ’’how worries and anxieties grow like a tree inside the body, leading to branches causing all types of ailments, from sleeplessness, loss of appetite, fever, blood pressure and even more serious illnesses like cancer.”
In our recent 2018 fieldwork, women shared several newer and additional terms for this health condition, such as ‘Moner Oshanti’, which literally translates as the heart not at peace; and engenders a continual restlessness in one’s entire being and soul. ‘Osthir Osthir Lageh’, an idiom that literally translates as ‘feeling restless, restless’, describes a state of compounded restlessness in one’s body and soul.’’ A woman explained ‘’that an uncertain family life and financial struggles” causes this.
Women in both sets of fieldwork spoke of suffering from ‘Tension.’ ‘Amar onek tension hoy” –I’m experiencing a lot of tension; and “Amar jibonay onek tension” – in my life there is so much tension.” The Bengali colloquial use of tension goes beyond its English usage as a physically oriented ailment (muscle tension, etc) and refers to acute emotional stress and anxiety.
While Public Health predominantly diagnoses and treats the physical aspect of being, through a disease-based framework, women like Sonya are compelled to classify, diagnose and manage their own health conditions. So, how would the Public Health world identify this form of human ailment or illness, since it does not conform to any conventional notions of disease? Perhaps one could begin attempting to classify it as “Chronic Life Trauma” or ‘’Traumatic Life Disorder”, although these terms carry their own cultural biomedical discourses and do not accurately capture these indigenous health conditions. These develop out of a specific South Asian socio-economic growth context incongruous with the modern biomedical models which have evolved from their own particular western socio-economic context.
The social determinants of poor health
These stark realities of life and their corresponding health experiences are not exceptional as the majority of those living in slum settlements is filled with extreme precariousness, managing one crisis after another. Dwelling in small congested makeshift tin and plastic-framed structures without ventilation, overflowing noxious sewage, they face constant risk of eviction or demolishment.
Erratic menial jobs that preclude paying their rent and procuring food, consistently exacerbate their housing and food insecurity. Rationed but inadequate water access and unsanitary, unhygienic broken public latrines render daily dehumanising indignities. All the while with rampant petty crime and the threat of gang violence overshadowing their lives. Such daily chronic stressors don’t simply impinge upon their lives in the conventional ‘fight or flight’ response; but posit their entire state of being in perpetuity, since their very basis of life is ‘stress-centric’.
Public health with a heart
Sonya’s personal determinants of health articulate experienced health conditions which transgress and challenge our conventional notions of disease-based illness. While such communities of supposed health recipients like Sonya struggle to convey what is critically important to understanding their health realities, we overlook and thereby delegitimise their health claims.
This is due in part to our predominant biomedical health models which can only investigate, diagnose and ‘treat’ physical disease, essentially rendering Sonya’s experienced health realities invisible. But also due to this very same disease-centric model constantly reductivising such health phenomena into its own circumscribed definitions of anxiety, depression or cultural syndromes and the like. Both appear grossly inadequate in explaining Sonya’s health ailment and patients’ actual conditions in general, in which case Sonya’s own diagnosis proves more accurate.
This implies an incomplete health framework or perhaps even worldview underlying Public Health. We currently view emotional health and well-being as subsets of the emergent field of mental health, even though there is ample evidence that human emotions dynamically determine or precede mental functioning. More importantly, human experience bears this truth out.
Public Health gives little credence to how human emotions interact with and affect the mental, social and physical dimensions of being; which arguably explains what plagues the medical profession in delivering better patient health outcomes. The only people who seem to understand and profiteer from this primacy of emotions are pharmaceutical companies, branding experts (i.e. advertisers) and social media, who have turned emotional engagement into a formidable science for mass consumer selling.
While modern psychiatry continues prescribing pills to its patients; not ironically, from pharmaceutical advertising and doctors’ sales incentives, these treatments fall extremely short of the real health extremities faced by women living in settlements. Sonya and other informal settlement women in fact regularly purchased tonics and vitamins , promising “to restore vitality, and energy’’ from the local pharmacies; a for temporary but desperate alleviation from their everyday lives.
While Public Health interventions focus parochially on clinical disease factors, the human experiential dimension of health acknowledging, validating and coping with unmet lifelong health needs, remains entirely invisible. Perhaps beginning to incorporate Sonya’s and millions of other informal settlement women’s Personal Health, would make for better Public Health.
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The authors would like to thank Ishrat Jahan and Selima Kabir, BRAC School of Public Health, for their dedicated fieldwork support.
Sabina Faiz Rashid is Dean & Professor, BRAC JPG School of Public Health, BRAC University
Mikhail I. Islam is a Strategy & Design Consultant, BRAC JPG School of Public Health, BRAC University