Majmawalas and Sexual Health Promotion in Bangladesh: an Ethnography of Street Healers in Dhaka City

Majmawalas and Sexual Health Promotion in Bangladesh: An Ethnography of Street Healers in Dhaka City

Md Mujibul Anam BSS (Hons), MSS in Anthropology (Jahangirnagar, Bangladesh), MA in health and society (Heidelberg, Germany)

Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy

School of Public Health and Social Work Faculty of Health Queensland University of Technology 2017

Dedicated to My Parents & My Wife

Keywords

Sexual Health Promotion, Majmawalas, Majma Street Healing, Public Health, Bangladesh, Men’s Sexual Health, Community Resources, Traditional Healing System, Public Health Professionals, Health Workforce, Explanatory Model, Pornography, Sex Education, Men’s Sexual Performance Anxiety, Stress, Mental Health.

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List of publications and presentations

Publications relevant to the thesis but not forming part of it

Ahmed, Z., Anam, M. M. (2015). Gender understanding in village ethnographies in Bangladesh: Some conceptual questions we can raise. In A. Naher, M. M. Anam, S. Parvin, S. Khatun, M. N. Uddin (Eds.), Gender relation, Otherness, and Market-oriented Globalisation, ( pp. 19-32). Dhaka: Novel Publishing House

Anam, M. M. (2014). When sexuality is in a research topic! the methodological challenges in sexuality and street healing research in Bangladesh. The Oriental Anthropologist, 14(1), 27-40.

Presentations relevant to the thesis but not forming part of it

Anam, M. M. (2015, December). Sex and Morality: Dilemmas of Sexual Health Promotion and Traditional Healing in Bangladesh. Australian Anthropological Society Conference: The University of Melbourne, Melbourne, Australia

Anam, M. M. (2015, November). Street healers in Bangladesh and their potential contribution to male sexual health promotion and education. The IHBI Inspires Conference: Queensland University of Technology, Brisbane, Australia

Anam, M. M. (2014, November). The role of ‘evidence’ in successful street healing in Bangladesh. Workshop on Negotiating Success: Ruhr University, Bochum, Germany

Abstract

Bangladeshi sexual health programmes focus their efforts largely via a biomedical lens in which the social dimensions of sexuality are given little consideration. Among the outcomes of this biomedical dominance is a lack of interest in the potential role of informal traditional healing systems that are a prime source of health care for many Bangladeshis. Specifically, there is a group of traditional street healers who provide remedies for male sexual health problems. In a country with limited health care resources, these street healers (majmawalas) are an important part of the health system. Yet, the majmawalas are largely seen as ‘problems’ rather than potential resources within the public health system. Furthermore, the health seeking behaviours of men who access these majmawalas could provide a window of understanding as to the meanings that men attach to their sexual health.

A central contention of this thesis is the importance of working with the majmawalas rather than against them. Sexual health promotion is a challenging enterprise in Bangladesh and all the more challenging if systems are not willing to recognise existing community resources which might help address some of those challenges. Here an ‘insider’ version of male health needs to be understood in order to articulate a more culturally appropriate public health response in

Bangladesh.

The methodology of the research was ethnographic. It utilised the reflexive nature of ethnographic study. Based on street ethnography, this research examined street healing settings from both the perspective of the healers and the audience in order to understand the construction of masculine sexuality and sexual health-seeking behaviour in Bangladesh. Besides the street ethnography, this research worked with public health professionals to explore the majmawalas’ possible engagement in male sexual health promotion programmes in Bangladesh.

The capital of Bangladesh, Dhaka was the research location for the study. This research provided new knowledge on three different aspects of male sexual health seeking behaviours in

Bangladesh: (i) street healers as promoters of male sexual health, (ii) street healers’ clients’ health seeking behaviours, and (iii) possible engagement of street healing in Public Health.

The majmawalas not only fill a gap in health service provision in terms of cost, but also in their focus on the whole person rather than solely on the ‘disease’. Therefore, it is important to examine street healing in Bangladesh to understand male’s sexual health seeking behaviour.

Furthermore, because the Bangladeshi public health authority does not recognise the majmawalas as part of the health system, there is the possibility to facilitate a connection here, and in so doing acknowledge the majmawalas as a potential resource in public health rather than

‘problems’ to be solved. In particular, the results of this study contribute critical knowledge about the potential to harness the majmawalas in sexual health promotion programmes in

Bangladesh.

Table of Contents

Key words iii List of publications and presentations iv Publications relevant to the thesis but not forming part of it iv Presentations relevant to the thesis but not forming part of it iv Abstract v List of acronyms xiii Statement of original authorship xiv Acknowledgements xvi

Chapter 1: Introduction Hasan’s story 1 The need for an insider perspective 8 Research aim 9 Research questions 10 Structure of the remaining chapters 10

Chapter 2: Sexual Health Promotion in Bangladesh

Introduction 14 Bangladesh and its health sector 14 The traditional healing system in Bangladesh and the colonial legacy 19 Enhancing the pluralistic system 25 Sexuality and sexual health promotion in Bangladesh 29 Gender and sexual health 34 Masculinity, masculine sexuality and men’s sexual health 38 Theoretical perspective 44

Chapter 3: The Methodology and the Research Settings

Introduction 47 Preparation for the fieldwork 48 My fieldwork in Bangladesh 52 Fieldwork Phase 1: The majmawalas and their clients and non-client audience 52 Entering in the field 52 Fieldwork with the majmawalas 56 Fieldwork with the majmawalas’ clients, and non-client audience 63 Fieldwork Phase 2: Public health professionals 65 Recruiting public health professionals for the field work 66

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The fieldwork with public health professionals 66 The research settings of my fieldwork in Dhaka 68 The research sites of the majma street healing 72 Mohammadpur Bashbari area 74 The Farm-gate Area 76 Kawranbazar 77 Bashundhara city area 78 Mirpur shrine area 79 Data organisation and analysis 80 After fieldwork: data organisation and data analysis 83 The language issue in data organisation and data analysis 83 Reflection and summary 84

Chapter 4: The Majma Street Healing: A Masculine Space of Livelihood, Performance, and Engaging People

Introduction 88 The process of engaging people in the majma street healing 89 Drawing attention in a majma street healing 91 Selection of time and place for the majma street healing 93 The majma time 93 The majma places 94 Storytelling as a tool for audience’s engagement in the majma street healing 98 The question and answer technique (Q&A technique) 102 Approaching the audience member to sell medicine 107 Producing medicine as part of the session 107 The use of religion in approaching the audience members to sell medicine 114 Showing efficacy in approaching to the audience members for selling medicine 117 The majma street healing – a group consultation method on men’s sexual health 120 Reflection and summary 124

Chapter 5: The Majma Boyan - A Guiding Framework Underpinning Majmawalas’ Approaches to Sexual Health

Introduction 126 Sexual health problems discussed in the majma 127 Premature ejaculation 127 Erectile dysfunction 129 Semen loss concern 130 Size and shape of penis 131

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Sexually transmitted infections and AIDS 131 Causal explanations on men’s sexual health problems 133 Food contamination and poor food habits 133 Everyday stress/tension 136 ‘Inappropriate sexual practice’ 138 Masturbation 138 Sex with sex worker 140 Men who have sex with men 140 Sex during menstruation 141 Symptoms and sufferings described in majma 142 Physical suffering 143 Social suffering 143 Spiritual Sufferings 146 Sexual health support in majma 149 The majmawalas’ advices for different sexual health concerns 149 Eat healthy food 149 Avoid junk food and smoking 149 Enjoy sex without tension 150 Don’t jump into it, allow some time 151 Avoid pornography 151 Use of condoms 152 Medication for managing sexual health problems in majma 153 Reflection and summary 154

Chapter 6: The Meanings of Sexual Health among Bangladeshi Men Introduction 157 Sexual health anxieties 157 Premature Ejaculation 159 Erectile dysfunction 160 Semen loss 161 Penis size 161 Causal explanations 163 Poverty and poor food 164 Everyday stress 165 Sexual practices 166 Accident 167 The characteristics of suffering 167 Individual level (physical and mental) suffering 168 Family suffering 170 Spiritual suffering 173 Seeking support for sexual health problems 173 Reflection and summary 177

Chapter 7: The Challenges and Opportunities in Sexual Health Promotion in Bangladesh

Introduction 181 The public health professionals 182 The challenges in sexual health promotion 185 The potential for engaging majmawalas in sexual health promotion in Bangladesh 192 The supportive view 193 Case Study 1: Rahim Mia and his family planning activities 193 Case Study 2: Tushar Paul and his HIV/AIDS awareness programme 198 Case Study 3: Akbor Ahmed and their adoption of majma street healing 199 Case Study 4: Farukh Hossen 201 The non-supportive view 203 Cast Study 5: Shovon Mia 203 Cast Study 6: Malik Hasan 205 The mixed views 206 The strengths of majma street healing 207 The weakness of majma street healing 209 Summary and reflection 211

Chapter 8: Conclusion: The Importance of the Majma Street Healing in Sexual Health Promotion in Bangladesh

Introduction 213 The majmawalas’ potential contribution to sexual health promotion 214 Valuing the insider perspective 214 Developing essential and culturally appropriate sexual health promotion content 217 Establishing a culturally appropriate sexual health promotion strategy 219 The paradox of not valuing the majmawalas in sexual health promotion 222 The institutional/colonial legacy 223 The influence of reductionist accounts of evidence in health promotion 224 Aid dependency and sexual health promotion in Bangladesh 227 Research aim revisited 229 Final reflection: the plant in the courtyard can be a medicine 232

References 234

List of Figures

Figure 1.1: Man pedaling a rickshaw in front of an HIV/AIDS poster in Bangladesh 4 Figure 1.2: A majmawala and his audience in Dhaka, Bangladesh 6 Figure 3.1: An example of the traditional form of the majma street healing stall 57 Figure 3.2: An example of the street based pharmaceutical drug (potency enchantment) stall 57 Figure 3.3: Kolkata Herbal’s posters on the Dhaka street 71 Figure 3.4: The temporary open market on under constructed road in Mohammadpur Bashbari 75 Figure 3.5: Farmgate bus station 76 Figure 3.6: Bashundhara City area 78 Figure 3.7: Mirpur Shrine area 79 Figure 4.1: A ready majma setup in front of Kawranbazar mosque in Dhaka 96 Figure 4.2: A majmawala conducting a majma in a bus station in Dhaka city 97 Figure 4.3: Beginning of a majma: pedestrians looking to the majmawala 98 Figure 4.4: Audience members looking at the photo album and listening to a majmawala 99 Figure 4.5: Audience members in a majma 100 Figure 4.6: A majmawala’s Q&A session 103 Figure 4.7: Colourful jars in Nawser’s majma street healing session in Dhaka 110 Figure 4.8: The moving spoon 112 Figure 4.9: Live leeches, photo album, and the massage oils on a car hood 112 Figure 4.10: Distributing a free sample to the audience 117 Figure 5.1: The levels of suffering due to poor sexual health 142 Figure 6.1: The eight fingers measurement 162 Figure 7.1: A community health worker promoting condom use in a village in 1995 196

List of Tables

Table 2.1: Health care workforce in Bangladesh 17 Table 3.1: The activity summary of the fieldwork with the majmawalas 62 Table 4.1: The majma sessions 94 Table 4.2: The majma locations 95 Table 4.3: Clients and non-client audiences’ experiences in the photo album stories 100 Table 5.1: Majmawalas’ medication and price 153 Table 6.1: Sexual health concerns among the majmawalas’ clients 158 Table 6.2: The majmawalas’ clients’ perception regarding the standard time for intercourse 159 Table 6.3: The majmawalas’ clients’ views on the causes for their poor sexual health 163 Table 6.4: The majmawalas’ clients’ comments on the efficacy of majma medicine 175 Table 7.1: The public health professionals and the background information 182 Table 7.2: HIV and AIDS status in 2015 184

List of Maps

Map 3.1: The research sites of the majma street healing 73

List of Charts

Flow Chart 4.1: The engagement process of a majma street healing 90

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List of Acronyms

AIDS Acquired Immune Deficiency Syndrome

AIMS Assessment Instrument for Mental Health Systems

AMC Alternative Medical Care (AMC)

BAMS Bachelor of Ayurvedic Medicine and Surgery (BAMS)

BAPSA Bangladesh Association for Prevention of Septic Abortion

BAUMC Bangladesh Ayurveda and Unani Medical College

BHMS Bachelor of Homeopathic Medicine and Surgery (BHMS) BHWR Bangladesh Health Watch Report

BNPS Bangladesh Nari Progati Sangha

BUMS Bachelor of Unani Medicine and Surgery (BUMS)

CCTV Closed Circuit Television

CD Compact Discs

CTC Close to the Community FPAB Family Planning Association Bangladesh GEMT Gabinete de Estudos de Medicina Tradicional HASAB HIV/AIDS and STD Alliance Bangladesh HIMM Health, Illness, Men and Masculinities HIV Human Immunodeficiency Virus infection IDU Injecting Drug Users MA Master of Arts MBBS Bachelor of Medicine, Bachelor of Surgery MDG The Millennium Development Goals (MDG MHFW Ministry of Health and Family Welfare MSM Men who have sex with men NAC National AIDS Committee (NAC) NASP The National AIDS/STD programme NGO Non-Government Organizations PhD Doctor of Philosophy

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Program for Research and Intervention for Development, PIACT Bangladesh Education, Training and IT, Bangladesh Q&A Question and Answer QUT Queensland University of Technology QUTBA QUT Bangladeshi Association QUTHREC QUT Human Research Ethics Committee QUTPRA QUT Postgraduate Research Award Reproductive Health Services Training and Education RHSTEP Programme SRHRE Sexual and Reproductive Health and Rights STIs Sexually Transmitted Infections TWB The World Bank UK United Kingdom UNAIDS Joint United Nations Programme on HIV/AIDS UNDP The United Nations Development Programme USA United States of America USAID The United States Agency for International Development WHO The World Health Organization WSSA Water Supply and Sewerage Authority

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Statement of Original Authorship

The work contained in this thesis has not been previously submitted to meet requirements for an award at this or any other higher education institution. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made.

QUT Verified Signature Signature:

Date: 12th September 2017

xv Acknowledgements

It is really difficult for me to write acknowledgements for my PhD journey. I have received so much support and kindness from so many different people and institutions, and I do not think it is possible to express the full extent of my sincere gratitude to them here. My PhD journey was challenging in many ways but my chronic physical sickness was the real challenge for me. When

I got the scholarship to pursue my PhD at the Queensland University of Technology, I was really excited about my academic engagement and endeavours but I did not know that I would need to spend more time on managing my health than on the study.

I started my PhD in April 2013, and very shortly I was found to have an intermittent leucocytosis. I went to a doctor because of a chronic back pain and they found my white cell count was elevated. With this medical condition, and being away from family living overseas, I had little hope of completing my PhD project. It was my supervisors, Associate Professor Mark

Brough and Associate Professor Ignacio Correa-Velez, who made me regain my hope. You not only contributed to my academic understanding of this PhD project, but also showed me how one could still smile and continue working, even in a very critical condition. I do not think I have the language to express my gratitude for your support.

I am deeply indebted to my respondents in the field. Due to anonymity, I am unable to write your names here, but your wisdom, experiences, and stories helped me succeed in my study.

Very special thanks go to my majmawala respondents. I hope our friendships will continue well after this PhD journey.

The writing of this thesis was supported, edited and critically reviewed by many people: my supervisors, my thesis examiners, Dr Leonie Cox, Dr Julie King. Professional editor Kat

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Bowman provided copy-editing and proofreading services, according to the guidelines laid out in the university-endorsed guidelines and the Australian Standards for editing research theses.

Thank you for your professional advice, support and criticisms that helped make my thesis better.

This project was possible with the support of the QUT Postgraduate Research Award

(QUTPRA) and QUT HDR Tuition Fee Sponsorship. Thank you QUT. I also acknowledge the support of Jahangirnar University, Bangladesh, for giving me leave from work to complete my

PhD. I am deeply indebted to my teachers at the department of anthropology, Jahangirnagar

University. Professor Zahir Ahmed, you have been an outstanding mentor for me since my years as an undergraduate. Thank you sir!

I would like to express my deepest appreciation to my colleagues, friends, and relatives in

Australia, members of the QUT Bangladeshi Association (QUTBA) and their families, my colleagues, friends and students in Bangladesh for their time and moral support. I could not have written my thesis without those coffee and tea times, ghost stories, and your food.

To my family: I love you all.

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Chapter 1: Introduction

I want to be a complete man before returning to my village. I want to marry in the same village. I do not care about money. Money is not a problem for me. - Murad Hasan, a divorced man and a client of a majmawala

HASAN’S STORY I first met Murad Hasan near a majma street healing site in Kawranbazar, Dhaka, Bangladesh. He was waiting for sexual health advice and medicine from Kashem Ali, a street healer (majmawala) of that area. Hasan, a 35 year old divorced man, ran a fruit business in Kawranbazar market. He was earning good money from the business, but he had another kind of problem in his life, which according to him, very much needed the help of a traditional healer specialising in sexual health.

Hasan was extremely anxious about his sexual performance and was also shamed by the public way in which his sexual problem had become a topic of wider conversation in his local community.

Hasan was raised in a rural area in Bangladesh and received primary level education only. He fell in love with Fatema Banu, a local girl. However, the relationship was not supported by either family. In Hasan’s community marriages were always arranged, and therefore boyfriend/girlfriend relationships were not acceptable. Hasan tried to convince his family to allow him to marry Banu but failed. He married Banu anyway, despite the lack of support. Later, both families came to accept the marriage.

At this point, it seemed to Hasan that his life difficulties were behind him. However, a new problem emerged for Hasan in his relationship with Banu. Hasan’s sexual relationship with Banu was not going well. She became unhappy with Hasan’s premature ejaculation early in their married life. She informed her family about the problem and this created conflict with Hasan. The conflict led to divorce. The issue became public knowledge in the village. Neighbours started making fun

1 of Hasan. It was painful for him to live with this shame in his home community. He moved to

Dhaka to escape the shame and to find help for his sexual problem.

Hasan had experienced premature ejaculation before his marriage, and thought that his pre-marital sex life was the cause of his problem. He had been a regular visitor to red light areas and thought sex with sex workers made him sexually weak. He could not share his problem with anybody, but saw marriage as a solution to the problem. He thought marriage would help him to control his sexual desire, and the problem would go away. He did not disclose the problem to his friends; neither did he seek any advice from anyone else. Sharing and seeking advice for premature ejaculation was shameful to him, and he was not sure where to go with this problem. After the divorce, he moved to Dhaka. It took a few years for him to settle in Dhaka and get his fruit business to work well. Now, the income from the fruit business has made him financially comfortable, but the embarrassment of his sex life haunted him all the time. I found Hasan very depressed. He was eagerly looking for a solution from a majmawala for his problem. He was happy to pay any amount to regain his ‘sexual power’. He saw ‘fixing’ his premature ejaculation as the only solution to his ‘shameful’ situation.

Hasan’s story tells us about another aspect of Bangladeshi society. Hasan sought support to increase his sexual power so that he could marry someone from his ex–wife’s village to regain his

‘manhood.’ This shows the typical understanding of the men in Bangladesh and the existence of a strong patriarchal society. In the patriarchal society of Bangladesh, Hasan is supposed to have the ability to control his wife. Therefore, when the voice of a female became prominent, the community saw it as a sign that Hasan lacked the power to maintain the patriarchal norms of the society. He became an incomplete man who failed to control the sexual desire of his female partner. Hasan saw his premature ejaculation as a problem not only for his sexual wellbeing, but also because he found his role of ‘a social male’ was called into question. The crisis in Hasan’s

2 sexual role was not only physical; it was also social and political. Thus, Hasan’s story and his interaction with the majmawala highlight the relationship between patriarchy and sexual wellbeing.

Hasan was not an exception among the clients of majmawalas I spoke with in Bangladesh. The majmawalas provide a service to men like Hasan and this gives them the ability to draw a crowd of men in the busy market places of Dhaka city. Within these encounters, dozens of men crowd around a majmawala listening intently to their explanations of male sexual dysfunction as well as the ensuing advice about the life-changing remedies they can offer. These are daily occurrences on the streets of Dhaka, and represent something of a contradiction in Bangladeshi society concerning the public discourse of sexuality. Sex education and sexual health promotion remain very tightly constrained activities within the education and health institutions of Bangladesh. Sexual health is, therefore, a very difficult issue for the Bangladeshi public health system to advance. It sits beyond the boundaries of acceptable public discourse. The little public health information that is conveyed in mass marketing campaigns is delivered within a strict moral code where explicit information is absent and instead information is heavily camouflaged within messages about the dangers of

Human Immunodeficiency Virus infection and Acquired Immune Deficiency

Syndrome (HIV/AIDS).

Figure 1.1: Man pedaling a rickshaw in front of an HIV/AIDS poster in Bangladesh

Photo Source: Matthews (1995)1

Figure 1.1 shows the typical style of HIV/AIDS public information conveyed in Bangladesh. The poster shows a skeleton and a few houses in a village. At the top of the poster, it says, ‘AIDS has no treatment and brings premature death.’ At the bottom of the poster, it says, ‘AIDS, death is the only result.’ The billboard conveys a message of fear, but little else. There is no information about how to prevent HIV/AIDS transmission. The symbolism and the text are created to align with moral codes of public discourse in Bangladesh, but in so doing lose the capacity to convey information that might assist people to prevent HIV/AIDS transmission.

Similarly, debate continues in Bangladesh about the appropriateness of HIV/AIDS education in schools (Rob et al., 2006; Sarma et al., 2013; Sarma & Oliveras, 2013) and since the little headway that has been made here only applies to secondary schools, and given most Bangladeshis like Hasan do not get the opportunity to go beyond primary school education, most will receive no education

1 The link of the photo source: http://www.alamy.com/stock-photo-man-pedalling-a-rickshaw-in-front-of-an-aids- poster-in-bangladesh-3373774.html, (last accessed on 17.08.2016) 4 about sexual health. Just as there is little men’s sexual health promotion activity in Bangladesh, there are also few options for anyone concerned about their sexual health to seek diagnosis and treatment. Sexual health clinics are concentrated in the city areas and focus mostly on biomedical concerns such as sexually transmitted infections (STIs) and infertility (Rashid et al., 2012; Hawkes,

1998). Psycho-social concerns such as premature ejaculation, worries about penis size or semen loss2 do not receive much attention in the clinics. These are the concerns that often bring

Bangladeshi men to majma street healing, since the majmawalas respond to a much broader agenda than just ‘diseases’. Moreover, the biomedical clinics are not affordable for many poor Bangladeshi men, nor are they as easily accessible (Pavel et al., 2016). The health seeking process in sexual health clinics is also uncomfortable for many men. Sexual health clinics require the service seeker’s identity and they document the problem. This process can add to the awkwardness many men feel in disclosing their sexual lives to a health professional. Given this context, it is not surprising that

Hasan is an eager client of majma street healing.

My previous MA3 research helped me to understand that the majmawalas are geographically accessible, economically affordable, and morally acceptable, and perhaps most importantly, speak directly to the ways Bangladeshi men frame their sexuality and their sexual health (Anam, 2010).

Gani and his colleagues (2014) observed a very similar context in their research on close to the community health service providers in Bangladesh.

The community is more inclined towards informal service providers than formal providers. The informal providers are more accessible and more easily trusted, making the community think of such providers as their own people, since they are embedded

2 Semen loss has a culturally specific meaning in the South Asian context. Semen is seen as the quintessential fluid of life and source of strength, energy, knowledge and skills (Alter 1992) and therefore, semen loss is associated with loss of men’s masculine power. There is more discussion on semen loss in chapter 2, 5 and 6. 3 I did my MA in Health and Society in South Asia at Heidelberg University, Germany. [Anam, M. (2010) Masculinity in Majma: An Ethnography of Street Healing in Bangladesh. MA Thesis, Health and Society in South Asia, University of Heidelberg. The MA research report is available here http://crossasia-repository.ub.uni-heidelberg.de/1402/]. Under the MA programme, I did six weeks fieldwork on majma street healing in Bangladesh. It was the beginning of my learning journey about majma street healing in Bangladesh. The focus of the research was to understand majma street healing as a means to make a living for the majmawalas as well as to begin to explore concepts of masculine sexuality within majma street healing. That short research experience provided me with an important foundation which I have now been able to build on in this PhD project. 5

within the community. Moreover, the cost of care is an issue that cannot be neglected for marginalized populations, and by providing services at minimal cost, informal providers are more acceptable in the community. (Gani et al., 2014 p. 121)

Hasan’s story about premature ejaculation and his interaction with a majmawala offering various herbal and other remedies is not the place public health authorities in Bangladesh look in their efforts to tackle ‘the real’ public health issues of HIV/AIDS and other STIs. Instead, they do what they can with the limited resources they have within a very difficult set of economic, political and social circumstances. Meanwhile, Hasan and other men like him engage in lively discussions about sex and sexual health in very public spaces, guided by a diverse range of healers who inhabit the streetscapes of Dhaka. Figure 1.2 shows the level of interest a majmawala can generate when they talk about sexual health.

Figure 1.2: A majmawala and his audience in Dhaka, Bangladesh

Photo Source: Fieldwork photograph, 2014-15

The audience here stands in the hot sun for an hour or more as the healer performs his well- rehearsed routine in which he educates and offers remedies to the crowd. The contrast between

6 this scene and the HIV/AIDS billboard could not be more stark. The majmawala speaks explicitly about sex and sexual health. There is a clear message, and a solution is offered.

These majmawalas draw on a tradition of street healing in Bangladesh, but they are not all

‘traditional healers.’ They utilise both ‘traditional’ modalities of healing as well as increasingly incorporating Western medicine within their practice. They are all small-scale healing entrepreneurs who must find ways to engage their clients within their everyday life in order to make a living, as they compete for attention amongst the many other street vendors in Bangladesh.

Their capacity to undertake this activity stands in contrast to the difficulties of the formal public health system to strategically address sexual health promotion in Bangladesh. The majmawalas receive no funding or other support from the public health system. Instead, they are more likely to be derided for their ‘lowly’ social status and their ‘minimal’ education. They are likely to be seen as problems by the public health scholars (such as Nahar et al., 2013), conveying incorrect information and providing remedies unlikely to work.

Yet majmawalas do what the formal system fails to do: they make information and medicine accessible. This thesis takes up the activities of majmawalas as a matter of ethnographic interest, precisely because they may offer a solution rather than a problem for the public health system.

As a child, I first heard the term AIDS not from the media, not from school, nor from a friend or family member but instead from a majmawala. I can still recall that moment. On that day, I went to the Bangladesh central mosque – Baitul Mokkaram, with one of my cousins, to visit nearby markets. There we saw a man surrounded by a large audience. This was not new to me.

In my village markets, I saw this kind of gathering several times. We call this gathering a majma.

I was very interested in that majma. I asked my cousin, whether he was interested in seeing

7 majma. He agreed, and we joined the audience. I cannot recall all of what I heard that day from the majmawala, but I can vividly remember the introduction he gave me to the topic of AIDS.

This scenario is still true for many Bangladeshi boys, who continue to learn about sexual health from the majmawalas. It is not only that the majmawalas talk explicitly about sex; they also

‘perform’ a routine for their audience in which they not only inform, but also do so in a way that is engaging and even entertaining. Their performance attracts everyone from young boys through to old men; street laborers through to passing office based professionals.

As I consider Hasan’s story now as a medical anthropologist, I am struck by the knowledge and skills of majmawalas and the disappointment I feel that instead of being seen in this light, they are ignored and even admonished by the formal health system. I see Hasan’s story and his engaging role with majma street healing as a window to understand how men in Bangladesh discuss, perceive and respond to their sexual wellbeing. In this context, I am interested in majma street healing to find an insider’s perspective to propose better sexual health promotion in Bangladesh.

THE NEED FOR AN INSIDER’S PERSPECTIVE A central contention of this thesis is the importance of working with the majmawalas rather than against them. Sexual health promotion is a challenging enterprise in Bangladesh and all the more challenging if systems are not willing to recognise existing community resources which might help address some of those challenges. Here an ‘insider’ version of men’s health needs to be understood in order to articulate a more culturally appropriate public health response in Bangladesh. This process also involves a recognition of the value of ‘bottom-up’ approaches to health promotion.

As the Ottawa Charter of health promotion states:

Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve

better health. At the heart of this process is the empowerment of communities - their ownership and control of their own endeavours and destinies. (WHO, 2009: 3)

In the Bangladeshi context, I argue that the majmawalas are such a community resource who can contribute to understanding and articulating a more culturally appropriate approach to sexual health promotion. In a country with limited health care resources, these majmawalas are an important part of the health system. They are constructing meaning in the area of sexual health

(especially in the area of sexual performance) in the absence of other information; and they are also creating a particular version of male sexual health and wellbeing. Furthermore, the health seeking behaviours of men who access these majmawalas could provide a window of understanding as to the meanings that men attach to their sexual health.

This study examines majma street healing as a means to understand masculine sexuality and sexual health-seeking behavior in Bangladesh. This thesis draws on an anthropological premise of building bridges between diverse social spaces. In this case, I am interested in how Bangladeshi men think about their sexual health and how the majmawalas respond to their sexual health problems. Based on this ethnographic account of the majmawalas and their clients, this thesis then considers the possibilities of majmawalas as potential contributors to sexual health promotion within the public health system in Bangladesh.

RESEARCH AIM The central aim of the study is to explore majmawalas’ possible engagement in male sexual health promotion within the public health system in Bangladesh. Majma street healing has two aspects, both of which are of significant value to sexual health promotion: i) it is a domain that facilitates the understanding of insiders’ views of sexual health, and ii) majmawalas hold the very practical potential to promote sexual health in a culturally appropriate and effective way. Therefore, in the examination of the potential of majma street healing in sexual health promotion in Bangladesh,

9 the study of majma street healing provides a way into gaining an insiders’ perspective of sexual health.

RESEARCH QUESTIONS Following on from the central research aim I pose the following related questions to guide this research:

(i) What guiding frameworks underpin majma street healing approaches to sexual health promotion in Bangladesh?

(ii) How do the audiences of majma street healing describe their understanding of sexual health problems?

(iii) How do public health professionals in Bangladesh perceive majma street healing? What opportunities do they see for collaboration with the majmawalas?

STRUCTURE OF THE REMAINING CHAPTERS

Chapter 2: Sexual health promotion in Bangladesh

This chapter reviews the literature on Bangladeshi sexual health to outline the broader context of this research. It describes the Bangladeshi health system in order to establish the potential significance of the majmawalas within this system. The conceptual premise of the thesis is also established in this chapter as a means to make sense of the challenging circumstances presented.

Chapter 3: The methodology and the research settings

Chapter Three introduces the research settings and describes the research methodology. The ethnographic approach employed in this research is described, including its critical value for

10 addressing the objectives of this study. Issues of ‘insiderness’ and ‘outsiderness’ are discussed from my perspective as a male Bangladeshi medical anthropologist undertaking this research. Besides the street healing settings, my ethnographic approach also encompassed relevant public health professionals, as it only with their endorsement and partnership could majmawalas be effectively engaged in a broader sexual health promotion strategy. This chapter also discusses the methodological issues associated with doing advocacy as part of ethnography.

Chapter 4: The majma street healing: A masculine space of livelihood, performance, and engaging people

This chapter sets the scene of majma street healing. Majma street healings are at once small businesses, theatrical performances, and health services. They are also exclusively male spaces, though they exist within a broader public space occupied by both men and women. It is not an easy task to gather random men from the street and engage them in a conversation about their sexual health and then convince them to purchase remedies, however, this is precisely what happens in majma street healing. This chapter describes the processes which underpin this capacity, including the meanings attached to the performance of majma street healing. In addition, this chapter provides an insight into the audience’s perspective of majma street healing, bringing to light the dialogical nature of majma.

Chapter 5: The majma boyan – a guiding framework underpinning majmawalas’ approaches to sexual health

The majma boyan (বয়ান) is the healing speech. The majmawalas discuss their understanding of sexual health in the speech. They articulate a framework of meanings which draws together ideas about the body and male sexuality within the Bangladeshi socio-cultural context. The meanings they articulate both map onto existing ideas among Bangladeshi men as well as advancing new

11 ways to think about changes in the social landscape, including the influence of the west and, in particular, biomedicine. The majma boyan thus resonates with existing belief systems and also accommodates and appropriates a diverse array of ways to think about sexual health. This chapter analyses the content of the healing speech and describes the explanatory framework which gives coherence to this content.

Chapter 6: The meanings of sexual health among Bangladeshi Men

This chapter describes sexual health anxieties of Bangladeshi men. The main focus of Bangladeshi sexual health promotion is on HIV/AIDS and other sexually infectious diseases. On the other hand, many men in Bangladesh are more concerned about their performance related sexual health.

Thus, erectile dysfunction, premature ejaculation, semen loss, and penis size are the major concerns among the clients of majmawalas. This chapter gives an account of Bangladeshi males’ sexual health anxieties in order to rethink the context in which ‘the diseases’ of sexual health are made sense of by Bangladeshi men.

Chapter 7: The challenges and opportunities in sexual health promotion in

Bangladesh

There are two different parts in this chapter. It starts with the discussion of the public health professionals’ thoughts and experiences of their sexual health promotion programmes in

Bangladesh. Sexual health promotion in Bangladesh has been mostly dependent on foreign aid.

Therefore, changes in sources of foreign aid can at times lead to significant changes in programme direction. Such changes have little to do with a strategic assessment of needs and have little likelihood of producing a cohesive or sustainable approach to sexual health promotion. At the same time, public health professionals must also face the practical challenges of how to go about sexual health promotion, a highly-stigmatised area of practice, where there are major constraints

12 in public communication and a shortage of a skilled health promotion workforce. In the second part, the chapter explores the Bangladeshi public health professionals’ views on majma street healing and the extent to which they see this healing system as a problem or a resource. Thus, I brought my understanding of street healing to the public health professionals as an act of advocacy for the majmawalas’ engagement in sexual health promotion. This is presented as part of my ethnographic journey too. I experienced both appreciation and rigidity to this idea, which I explore here both as a practical challenge in sexual health promotion as well as another window into meanings and contestation of ideas which continue to play out in the Bangladeshi health system.

Chapter 8: Conclusion: the importance of the majma street healing in sexual health promotion in Bangladesh

Based on the research findings from different actors in the study, this chapter discusses the rationales for the possible engagement of the majmawalas in sexual health promotion in

Bangladesh. It includes implications of the possible engagement of the majmawalas for public health policies and programmes in Bangladesh. Conclusions are drawn here, and a summary of key findings in relation to the objectives of the thesis are provided. This chapter also comments on further research possibilities.

Chapter 2: Sexual Health Promotion in Bangladesh

INTRODUCTION In this chapter, I contextualise the central concepts of this thesis, namely sexuality, sexual health and health promotion in Bangladesh. I also contextualise the importance of street healers

(majmawalas), a traditional ‘close to community’ health provider group. The crisis of sexual health promotion in Bangladesh is in many ways rooted in the overall health sector of Bangladesh, where resources, more specifically the formal and professional health workforces, are in a critical shortage. In addition to the professional health workforce crisis, the external aid and expertise dependent development approach is also contributing to the crisis. In this context, firstly, I give an overview of the Bangladesh health sector, and in particular trace the dimensions of the formal health workforce crisis in Bangladesh. This section discusses that the overemphasis on the biomedical health care system has resulted in the neglect of the traditional health system. This section also discusses the importance of enhancing pluralist health care systems. Secondly, I examine how sexual health anxieties are constructed within the dominant heterosexual discourses and discuss how an insider perspective is important to understand dominant heterosexual discourses. Finally, I discuss the theoretical framework of the thesis to describe how I envisage culturally appropriate sexual health promotion for men in Bangladesh.

BANGLADESH AND ITS HEALTH SECTOR The Bangladesh health care sector has four major players: government, private sector, Non-

Government Organizations (NGOs) (private and non-profit) and donors (Ahmed et al., 2013).

The government health sector has very limited resources to ensure health care for its people in

Bangladesh. Under the Ministry of Health and Family Welfare (MHFW), the Government of

Bangladesh provides country-wide preventive and curative services (MHFW, 2014). The ministry is responsible for policy formulation and implementation of health care regulations. The estimated number of health workers in this sector (see Table 2.1) is just 20,234 doctors, (Islam and Biswas,

2014), 15000 nurses, 10,000 paramedics and 54,595 community health workers (Ahmed et al.,

2013) for a national population of 153 million people (Chowdhury et al., 2013). The clinical facilities are also poor. In the subdistrict4 level, there are 459 hospitals with 18,340 beds (Ahmed et al., 2013). In the secondary and tertiary levels, the Government of Bangladesh has established only 124 hospitals with 41,655 beds (Ahmed et al., 2013). Policy researchers (Adams et al., 2015;

Adams et al., 2013; Ahmed et al., 2013; Chowdhury et al., 2013; Darkwa et al. 2015) find the government health care sector to be extremely centralised. The shortage of resources and centralisation are responsible for the poor capacity of the sector (Adams et al., 2013).

The private sector in Bangladesh provides the major proportion of health care. Ahmed et al. (2013) categorise two different actors in this sector: formal and informal. The formal contributors to the health sector are mainly profit-based health businesses where health coverage is concentrated only in high-end secondary to tertiary health care levels. It is a rapidly growing sector with limited regulation. It has approximately 40,000 doctors and 5,000 nurses (Ahmed et al., 2013). The clinical facilities predominately include diagnostic centres, with a total of 5,122 centres. The number of hospitals and clinics demonstrate the business prospect of this growing sector. It has 2,966 registered hospitals and clinics with 53,448 beds.

The informal component of the private health sector in Bangladesh incorporates a mix of traditional healing systems, village doctors, and drug shop attendants (BHWR, 2008, 2012). This

4 A subdistrict is a second lowest administrative unit in Bangladesh. There are 490 sub districts in Bangladesh under 64 Districts and 8 Divisions. The lowest administrative structure in Bangladesh is the Union. 15 part of the private sector is rarely registered with any government regulatory body (Ahmed et al.,

2011). The estimated workforce of this sector includes 50,000 traditional medicine practitioners,

90,000 homeopathic practitioners, 170,000 drug-shop attendants5, and 185,000 village doctors6

(Ahmed et al., 2013).

The third player in Bangladesh health care includes those Non-Government Organizations (NGO) involved in the provision of health care. NGOs are private, non-profit organizations. A significant number of programmes are focused upon providing primary care to the poor (Adams et al., 2013;

Ahmed et al., 2011; Chowdhury et al., 2013) as well as the establishment of clinical services, mostly aimed at maternal, newborn, and child health and family planning issues. This sector accounts for the major proportion of health research in Bangladesh (Chowdhury et al., 2013). Although NGOs contribute to the health care of the Bangladesh population, there are not enough long term direct health care programmes.

The fourth sector in Bangladesh health care is the external donor agencies, such as the World

Bank. The NGO sector is connected with these donors for their financial and logistic support.

These donors also support infrastructure development for the overall health sector in Bangladesh.

5 These are not trained pharmacists. They learn about drugs form their sales experience in drug shops. 6 These village doctors are not bio-medically trained. As they provide treatment, which they learn informally, villagers call them doctor. 16

Table 2.1: Health care workforce in Bangladesh Estimated number in the health workforce Estimated number in the health workforce (Formal Sector) (Informal sector)

Government ~ 20,000 doctors Informal ~ 50,000 traditional medicine ~15,000 nurses Health practitioners ~10,000 paramedics Workforce ~ 90,000 homoeopathic practitioners 124 secondary and tertiary > 170,000 drug-shop hospitals with 41,655 beds attendants > 185,000 village doctors Private ~ 40000 doctors NGO ~ 5,000 paramedics ~ 5000 nurses Supported > 105,000 community health workers 2,966 registered hospitals Government ~54,595 community health and clinics, 53,448 beds Supported workers

Source: Adopted from Ahmed et al. (2013), BHWR (2012), Islam and Biswas (2014)

Table 2.1 clearly shows a high level of health workforce shortage if we only consider the formal sector health workforce in Bangladesh. Adams et al. (2013) state such deficits have resulted in a

‘crippled’ health system. ‘The state of health in the Bangladesh 2007’ report (BHWR, 2008) shows a similar crisis of workforce. The Bangladesh Health Watch Report (BHWR, 2008) notes that qualified modern practitioners account for a small proportion of the entire workforce, making up just 5% of all health care providers with just 7.7 physicians, dentists and nurses together per 10,000 population (BHWR, 2008: ii). The recent reviews of the Bangladesh health system (Islam and

Biswas, 2014; Khan et al. 2015; Darkwa et al. 2015; Khatun et al. 2015) echo the similar critical shortage of professional health workforces. All of these recent studies confirm that there is no significant change in the number of the professional health workforce in recent time in Bangladesh.

The World Health Organization (WHO) also finds the critical shortage of trained health workers to be hampering the delivery of health services in Bangladesh (WHO, 2012). Based on data from the Ministry of Health and Family Welfare’s human resources development unit, WHO (2016) shows that Bangladesh has been suffering from both an overall shortage as well as a geographic

17 mal-distribution of the health workforce. WHO (2016) estimated that in 2011, the number of physicians per 10,000 Bangladeshi population was only 3.05, and the number of nurses per 10,000 population was just 1.05. The World Bank’s World Development Indicators: Health System (2013) shows a similar status in Bangladesh. According to this report and other studies (such as Islam and

Biswas, 2014), from 2006 to 2011, there were only 0.4 physicians and 0.2 nurses per 1,000 population in Bangladesh, whereas in Australia, there were 3.9 physicians and 9.6 nurses, and the

World averages were 1.4 physicians and 2.9 nurses per 1,000 population. Furthermore, the World

Bank found a significant gap between sanctioned and filled health worker positions in Bangladesh.

Thus, there is both a lack of positions and a lack of people to fill the positions.

The World Bank Report (2009) indicates the overall vacancy in government sanctioned health worker positions to be 36%. They further note that almost two-thirds of the total facilities operate with less than 75% of the sanctioned staff working in the facilities. Facilities in rural areas suffer more than urban areas as professionals are less inclined to stay in rural areas (Darkwa et al. 2015;

Ahmed, 2005; Cockcroft et al., 2007; Cockcroft et al., 2004; Mahmood et al., 2010). Conversely,

70% of the Bangladeshi population live in rural areas (BBS, 2012). Therefore, this geographic mal- distribution limits rural health care access for its clients. These statistics clearly indicate that the

Bangladeshi health care system has a significant shortage of health professionals, with significant negative repercussions for communities.

The situation is even worse in the case of mental health care facilities. WHO (2007a) claims that there is no specific mental health authority in the country. According to WHO:

There are 50 outpatient mental health facilities and no facility provides follow-up care in the community. There is no day treatment mental health facility in the country. There are 31 community-based psychiatric inpatient units for a total of 0.58 beds per 100,000 population (WHO 2007a: V).

The Bangladesh government has publicly noted a similar ‘crisis’. Cited from the Bangladesh

National Mental Health Survey (2003-2005), the World Health Organisation Assessment

Instrument for Mental Health Systems (WHO-AIMS) report (2007 a) states that approximately

16% of the country’s adult population suffer from mental disorders. The report also says that there are fewer than 100 qualified psychiatrists and 1,000 psychiatric beds available to the 153 million citizens.

Table 2.1 also shows that Bangladesh has a very diverse set of health providers and that the informal sector which includes traditional healers (such as majmawalas) is a very substantial part of the overall system. In this context, it is important to see how we utilise that diversity in

Bangladesh health sector. The following section focuses on that aspect.

The Traditional Healing System in Bangladesh and the Colonial Legacy The Government of Bangladesh acknowledges the shortage of resources in its health sector. The

Ministry of Health and Family Welfare (MHFW) notes in its recent health policy that Bangladesh is one of fifty-seven countries which have been running their health sector with a critical shortage of resources (MHFW, 2011). It also notes that the government and formal private sectors are not capable of ensuring health care in Bangladesh. Hence it is not surprising that the majority of

Bangladeshi people seek their health care from informal traditional healing sectors.

The government has accepted its failure to ensure health care for its citizens, and proposed a policy for human resource development and management of the health system to improve health care conditions. To do so, the government’s policy endorses the development and recruitment of

Unani, Ayurveda and Homeopathy medical systems as alternative approaches to enrich the health system in Bangladesh. According to the national health policy:

Alternative health service systems, such as Ayurvedic, Unani and Homeopathic practices will be incorporated into the National Policy. Encouragement will be given to the principle of making these three disciplines of medical science more scientific and time-worthy towards enabling the practitioners in these disciplines to contribute to the country’s health service. Government will provide appropriate support to these systems through enhancing grants and arranging proper training in these areas, and ensure monitoring of the quality of services rendered through these systems. (Policy Strategy – 18 of Bangladesh National Health Policy -2011)

However, in reality, the government has not shown enough commitment to incorporate these medical systems into its health sector. According to the government of Bangladesh health bulletin, published in June 2012, more than 90% of Unani, Ayurveda and Homeopathy medical officers’ posts were still vacant (Azad, 2012). Azad (2012) further notes that only 15 Unani, 14 Ayurveda and 15 Homeopathic medical officers are working in the government health sector7. This statistic indicates that although the government’s health policy is interested in fulfilling its health workforce with alternative medical systems, in reality, there has been no evidence of commitment to undertake such a process.

The failure to support an alternative health workforce framework for graduates of Unani,

Ayurveda, and Homeopathy institutions is further complicated by a complete absence of thinking in regard to the many other forms of traditional healing practice. Both government and non- government organizations do not acknowledge the informal traditional health sector, which is viewed as ‘semi-qualified’ or ‘non-qualified’. However, the surveys on Bangladesh health care

(BHWR, 2008, 2012) show that these informal traditional healing sectors account for the major proportion of health care services in Bangladesh.

7 In 1990, the only government Unani and Ayurvedic Medical College and the only government Homeopathic Medical College were established in Mirpur, Dhaka. Both ocolleges follow similar admission and academic criteria like MBBS degree programme. The government Unani and Ayurvedic Medical College offers two different types of Bachelor degrees: Bachelor of Unani Medicine and Surgery (BUMS), and Bachelor of Ayurvedic Medicine and Surgery (BAMS). The government Homeopathic Medical College offers Bachelor of Homeopathic Medicine and Surgery (BHMS). All of these programmes require five years of coursework and a yearlong internship. Please see Siddique, Abu Bakkar (2015). An overview of alternative medical care in Bangladesh. Dhaka: Office of the director Homeo & Traditional Medicine and Line Director Alternative Medical Care (AMC). 20

The Bangladesh Health Watch Report (BHWR) (2008) shows8 that the informal traditional healing sector is the largest sector in Bangladesh health care. They further note that ‘the largest group is the traditional healers who include kobiraj9 (কবিরাজি), ,herbalists, and totka (টোটকা), faith healers, and have a density of 64.2 per 10,000 population’ (BHWR, 2008: 7). On the other hand, the proportion of all types of qualified biomedical practitioners’ (physicians, dentists, nurses) density is extremely low – 7.7 per 10,000 population (Islam and Biswas, 2014). Although informal traditional healing practitioners contribute significantly to Bangladesh health care, there exists limited initiative to incorporate or acknowledge them within the Bangladesh health system.

Like the traditional health workforce scenario, there is a similar lack of support regarding the overall research and development of traditional healing in Bangladesh. The National Drug Policy

1982 acknowledged the importance of traditional medicine in Bangladesh (Chowdhury, 1995), yet, there are only two Government Degree Colleges and one Private Degree College in traditional medicine (Azad, 2012) for a population of 153 million. However, the government’s lack of support has not stopped the rise of traditional medicine in Bangladesh; the Bangladesh Health Watch

Reports and mainstream pharmaceutical researchers have acknowledged the Bangladeshi people’s dependence on traditional medicine. For example, Ghani (2002), a professor of Pharmaceutical

Science in Bangladesh, shows people’s dependency on traditional medicine. He has categorised

Bangladeshi traditional medicine into two different sections – (i) ‘the old and original form’, and

(ii) ‘improved and modified form’. According to Ghani (2002) the old and original form has three different types of medicines: folk medicine, religious medicine and spiritual medicine10, and the

8 I could not find any updated survey on that aspect. Even the very recent publications refer to this report. For example, Islam and Biswas (2014), Bangladesh Health System Review (2015) show similar statistic to the Bangladesh Health Watch Report (BHWR) (2008).

9 Majmawalas are part of the kabiraji system.

10Ghani (2002) gives the following examples of the old and original form of traditional medicine: Folk medicine, which uses mainly plant and animal parts and their products as medicines for treating different diseases and also includes treatments like blood-letting, bone-setting, hot and cold baths, therapeutic fasting and cauterisation. 21 modernised Unani and Ayurvedic systems produce the improved and modified form of traditional medicine (Ghani, 2002). Although the government of Bangladesh does not have the initiative to improve and regulate traditional medicine, Ghani (2002) estimates that the traditional medicine system has more than four hundred factories in Bangladesh, using local and imported raw materials. This estimation emphasises the total business volume of traditional medicine in

Bangladesh as well as peoples’ reliance on traditional medicine.

The neglect of the traditional healing system is rooted within the colonial legacy of displacing local knowledge in favour of western knowledge. The establishment of biomedicine in the colonial period started with the idea of disease control. Disease control was not only a medical intervention in the Indian sub-continent but was also the beginning of oppressing all other forms of local medical systems as well as peoples’ understanding about their body and health. During the colonial period of disease control, biomedicine also colonised the body. Based on the historical context of controlling three epidemic diseases- Smallpox, Cholera and Plague; Arnold (1993) shows that the biomedical establishment was possible due to the strong political and administrative support from the colonial state. It was not only the medicine but the colonial power that was used to convince the locals to follow the instructions of biomedicine rather than their own knowledge system.

Biomedicine was not in this superior position all the time. Before 1800, it had made few inroads into South Asia and was largely confined to European enclaves and ports (Arnold, 1993: 11; Bala

1991). Even Europeans sometimes turned for help to local traditional healers such as Hakim and

Vaidys. The cause, for seeking this assistance, was a belief that local healers would be more familiar

Religious medicine, which includes use of verses from religious books written on papers and given as amulets, religious verses recited and blown on the face or on water to drink or on food to eat, sacrifices and offerings in the name of God and gods, etc. Spiritual medicine, which utilises methods like communicating with the supernatural beings, spirits or ancestors through human media, torturous treatment of the patient along with incantations to drive away the imaginary evil spirits and other similar methods.

22 with the disease of that climate and with the locally occurring medicines. However, a hundred years later, a dramatic transformation had occurred in both the character and the relative position of western and indigenous medicine in India (Arnold, 1993: 11). At the end of the nineteenth century, western medicine enjoyed a formidable degree of authority over British India, within the councils of government and over the lives of its 300 million subjects. This establishment of authority over British India was interrelated with a series of momentous changes that were taking place in Western medicine at the time. These changes included vaccination against smallpox in the

1800s, the Contagious Diseases legislation of the 1860s, the public health movement, and the germ theory of disease which contributed to the establishment of biomedicine in the region (Arnold,

1993: 290).

One of the major consequences of germ theory was to control ‘the disease’. Therefore, the intended interventions towards epidemic control involved examining the human body for germ identification, separating affected bodies from the healthy ones, hospitalization of affected people and destroying affected property (Arnold, 1987, 1993). Conversely, Indian understandings of epidemics were rooted in its own cultural beliefs of diseases often concerned with curses of supernatural power. At the same time, investigations of the body and the hospitalisation process were considered by the local people as humiliating (Arnold, 1987, 1993). In other words, local people believed that the western processes of bio-medicinal examination of human body were dishonourable for them, and started resisting these new examination processes.

The early years of the Indian disease control provides an important illustration of the complex interplay of coercion, co-operation, resistance and hegemony, as well as class and race in the colonial situation (Arnold, 1987: 90). This illustration also reflects the different South Asian conceptions of the body from western concept of the body. Investigating the body for germs,

23 separating the ill body from the healthy one, hospitalisation of the ill body reflected British colonial interventions.

In post-colonial Bangladesh, biomedicine remains a dominant force. While there is only one government Unani and Ayurvedic Medical College and one government Homeopathic Medical

College, there are 30 government and 6 semi-government Biomedical Colleges in Bangladesh. In addition to the government Biomedical Colleges, more than 50 private Biomedical Colleges are offering graduate programmes in biomedicine in Bangladesh11. Therefore, the national health budget and the investment in health care mostly go to biomedical health care. Like any other country, biomedicine runs as unchallenged health care system and centre of focus of all kind of medical research and innovation in Bangladesh. Even the institutionalised format of traditional medical systems in Bangladesh follows the biomedical system as a survival strategy12.

The dominance of biomedical systems could not ensure an accessible health care for all. The current professional health workforce crisis makes it clear that even if we stopped re-examining the colonial legacy of biomedicine and wanted to utilise this system for everybody’s health care, right now in Bangladesh it is not possible. If I focus on mental health services only, as I am considering that the closest health care support for people with sexual performance anxieties, it is in no way possible to address such a health problem. In a system review on mental disorders in

Bangladesh, Hossain et al. (2014) show that only 16% of the total number of people with mental disorders seek mental health support from the mental health professionals. Like the other health support, Bangladeshi people rely highly on traditional healing (Giasuddin et al., 2012; Islam et al.,

2009). It is therefore clear that men who experience anxiety or distress in regards to their sexuality

11 See http://www.mohfw.gov.bd/ (last accessed on 24.11.2016)

12 See Siddique, Abu Bakkar (2015). An overview of alternative medical care in Bangladesh. Dhaka: Office of the director Homeo & Traditional Medicine and Line Director Alternative Medical Care (AMC).

24 have negligible options outside of the informal system. The following section discusses a possible solution to this problem.

Enhancing the Pluralistic System The Bangladesh health system overview shows a pluralistic health care system in Bangladesh.

Although there is significant government neglect of the traditional healing systems, it is unlikely that the Bangladesh health care authority can ensure universal health coverage without them. In many countries, traditional healing systems are often used in parallel with biomedicine, and medical authorities have recognised that traditional healing systems do have some obvious advantages to health care (Helman, 2007). For example, WHO emphasises the involvement of every actor in both the formal and informal health workforce in any health system. The World Health

Organisation’s reviews (WHO, 2012, 2014) on health systems give top priority to both the formal and informal health care workforce. According to WHO, the health workforce is identified as one of the six building blocks (WHO, 2007b). WHO states that health is everybody’s business. WHO

(2007b) sees a health system as more than:

…the pyramid of publicly owned facilities that deliver [sic] personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation (WHO, 2007b: 2).

The World Health Organisation’s explanation of the health system helps us to acknowledge the role of traditional healers in health care. This explanation of engaging traditional healers into the health system is reinforced by WHO’s strategic papers (WHO, 2002, 2013) on traditional medicine.

These papers emphasise the harnessing of traditional healers, noting that traditional medicine is the first and only source of health care for many people in the world. In most cases, it is affordable for the people as well as rooted within a cultural and historical context. Therefore, it has cultural acceptance, and people are more inclined to trust it. Thus, WHO justifies the need for a proper strategic plan for traditional medicine and its implementation in the health system. In the

Traditional Medicine Strategy 2014-2023 (WHO, 2013), WHO endorses the harnessing and promotion of traditional healing practices. It also suggests a national policy and implementation framework for traditional healing for its member states. WHO (2013) considers the harnessing and promotion of traditional healing as an important measure in ensuring proper health care.

Similar to WHO, Ahmed et al. (2013) propose ‘harnessing pluralism’ as a strategy for the betterment of health care in Bangladesh. They suggest that though Bangladesh has limitations in its health infrastructure and health workforce, it has achieved remarkable progress in some cases.

This was possible due to its pluralistic health system. Ahmed et al. (2013) argue that the Bangladesh health authority did not plan for the strategy but did incidentally receive the benefits of a pluralistic system. They are in favour of the idea of pluralism due to the ‘largely positive health effect because of a dynamic combination of forces ranging from the legacy of traditional care systems, to the enterprise of the private sector and a permissive and weakly regulated public sector’ (Ahmed et al.,

2013: 1). The Bangladeshi peoples’ reliance on traditional health care demonstrates the need for an immediate course of action to integrate traditional systems into the Bangladesh health system as well as into sexual health promotion.

In the African context, tradional healing systems have been successfully incorporated within the larger health system. Specifically in sexual health promotion, African tradional healers started working from the beginning of the AIDS epedimic. For example, the Department of Traditional

Medicine in Mozambique, locally known as GEMT (Gabinete de Estudos de Medicina

Tradicional) initiated a pilot programme to engage traditional healers in the prevention of AIDS and STIs in the early 1990s. Green (1999) claimed that despite some shortcomings, the collaboration with the traditional healers provided a pathway to work with traditional healers in a culturally sensitive way. Green (1999) believed that the majority of healers could learn about AIDS and STIs from the programme and they shared their understanding with local people. A similar

26 initiative was taken in Bangladesh in 2007. In that year, the United Nations Development

Programme (UNDP) conducted a study that found that the local traditional healer could be an important factor in the HIV/AIDS prevention programme in the locality. The local people held strong faith in traditional healers, and therefore the UNDP recommended that its medical team should work with traditional healers, although no further work on this issue appears to have taken place beyond an initial health pilot initiative (Islam & Moreau, 2009).

A more sustained example of working with traditional healing knowledge in Bangladesh is the successful collaborative work with traditional birth attendants. This collaborative programme contributed to a significant reduction of the maternal mortality rate in Bangladesh. The World’s

Midwifery Report (2011) shows that in 1990, the maternal mortality rate in Bangladesh per 100,000 live births was 870, decreasing to 340 in 2010. One contributing factor to this success was a community based birth attendant programme (Ahmed & Jakaria, 2009). In 2003, the government of Bangladesh started this program with local level birth attendants. Under this programme, traditional birth attendants were identified as an important part of the health care workforce, and received training from the program. Nearly a decade later, traditional birth attendants are responsible for approximately 85% of deliveries in Bangladesh (Ahmed & Jakaria, 2009), and hence are not so much an ‘alternative’ to centralised biomedical systems, but rather the biomedcal systems are an alternative to the dominant traditional system.

The birth attendant program shows the value of working with the informal sector rather than against it. A similar community based approach is also used in a family planning programme, an oral rehydration therapy programme, and an expanded programme on immunisation in

Bangladesh (El Arifeen et al., 2013). Therefore, we see good prospect in utilising traditional healing in the Bangladesh health system.

Given the workforce shortages in the biomedical systems in Bangladesh, the value in utilising established traditional health workforces cannot be overstated. Indeed, the shortage in the health workforce is the prime issue in universal health coverage, impacting upon the achievement of the

Millennium Development Goals (MDG) for health (WHO, 2012). The Joint Learning Initiative has found similar issues in human resources for health care, stating that the health system performance is grounded its human workforce (Chen et al., 2004). They further note that ‘the density of workers in a population can make an enormous difference in the effectiveness of MDG interventions’ (Chen et al., 2004: 1984). Scholars (Adams et al., 2013; Ahmed et al., 2013; El Arifeen et al., 2013) advocate a human resources policy and action plan to address this issue in Bangladesh.

Adams et al. (2013) recommend a careful mixing of informal health forces in human resources, with one of a number of suggested strategies being ‘to extend the remit of community health workers to include a full range of health promotion and prevention interventions’ (Adams et al.,

2013: 2107).

The shortage in the professional health workforce shows the necessity of utilising community/alternative resources in health care and health promotion, but this is not the only reason for engaging the traditional health workforce in mainstream health care. I see strong evidence for engaging the traditional healing system in health promotion in Bangladesh, particularly in the case of sexual health promotion. The cultural sensitivity and the socio-cultural meaning of sex and sexuality are important aspects in sexual health promotion. Engaging traditional healing systems will be useful to address the sociocultural context and identify appropriate sexual health promotion. In the following sections, I discuss the gaps in sexual health promotion in Bangladesh and arguments for engaging traditional healing systems in sexual health promotion.

SEXUALITY AND SEXUAL HEALTH PROMOTION IN BANGLADESH The official discourse on sexuality in Bangladesh is that sexuality is perceived as very secret and a matter of shame, with any kind of discussion of the topic perceived as immoral (van Reeuwijk et al., 2013). Therefore, the mainstream view (such as Bhuiyan, 2014; PLAN, 2010) is that there exists very limited scope in Bangladeshi institutions, such as schools, to run a curriculum on sexuality or sexual health. Following this mainstream view, many scholars (such as Bhuiyan, 2014; Nahar et al., 2013, van Reeuwijk et al., 2013) see the institutional intervention, such as school curriculum or mainstream public health interventions, as the only solution to address the problem. Therefore, when they find constraints in running a school programme or a mainstream public health campaign they come in to the conclusion that the society is not ready for those kinds of discussion. In this perspective, I find an extension of biomedical/ Western institutional domination to understand

Bangladeshi society. This dominating perspective examines the social understanding of sexuality from an external point of view. They do not try to understand how people in the community discuss and share their knowledge about sexuality. They (Bhuiyan, 2014; Nahar et al., 2013, PLAN,

2010 van Reeuwijk et al., 2013; UNESCO, 2009) also fail to understand that institutionalised schooling, formal sex education or the existing public health interventions may not be the appropriate way to discuss sex and sexuality in a non-Western context. However, they prefer to keep trying, with an approach where they see community as a receiver of their ideas. Therefore, not surprisingly, the contemporary dominant public health campaigns reproduce the idea of germ theory for promoting sexual health, and sexual health campaigns mostly limit their scope within the boundary of STIs. Culture-bound sexual health concerns are generally ignored (Khan et al.

2006).

Sexually Transmitted Infections (STIs) have been given much attention by external donor agencies and government public health programmes in Bangladesh (Alam et al., 2013; Azim et al., 2006;

Khan et al., 2008). These programmes mainly focus upon the alleviation of possible threats of increased prevalence of sexually transmitted infections. For example, HIV/AIDS is at the centre of sexual health related public health programmes. Bangladesh has a high profile National AIDS

Committee (NAC) and the National AIDS/STD programme (NASP) to protect its people from the disease (Azim et al., 2008). Alongside the Government’s efforts, there are also 235 NGOs working in this area. These programmes are funded by the Ministry of Health and Family Welfare, the Global Fund, World Bank, Department for International Development, German Technical

Cooperation, USAID and others (Azim et al., 2008: 312), and conduct many initiatives for national

HIV/AIDS prevention in Bangladesh. However, these prevention programmes concentrate on transmission and behavioural change in the most at risk population groups such as sex workers, injecting drug users (IDUs), men who have sex with men (MSM), and transgender people (Azim et al., 2008). Therefore, the National AIDS/STD programmes in Bangladesh have stigmatized

HIV/AIDS as a disease (Sultana, 2012), and do not consider the problem from a more holistic standpoint.

Not only the intervention programmes, but also the surveys on sexual disease create stigmas. Most of the national surveys connect sexual disease with sex workers, and are mostly interested in counting the prevalence rate of sexual STIs mostly among sex workers. For example, the National

HIV Serological and Behavioural Surveillance found sex workers, male, female and transgender, to be the most at risk groups, and its technical reports concern mostly sex worker groups.

According to the NASP’s 7th round technical report NASP (2007) the prevalence of HIV infection was less than 1% among the sex worker groups. Similar attention is exhibited in the case of other sexual diseases. For example, studies of syphilis (Azim et al., 2000, Rahman et al., 2000, Nessa et al., 2000) blame female sex workers for spreading the disease. This patriarchal approach does not critically examine the role of men in spreading sexual diseases. This perspective also established sexual disease as a result of immoral sexual behaviour. Therefore, this perspective can influence symptomatic patients with sexual diseases to not seek health care.

Like other South Asian public health authorities, authorities in Bangladesh show little attention to the general discourse of sexuality in sexual health promotion. Hawkes and Collumbien (2007) have described public health programmes in South Asia as not concerned with the construction of masculinity or its consequences for men’s sexual health. Rather, they focus mostly on managing sexually transmitted infections. However, men in South Asia are more worried about their masculine sexuality; they are concerned about their discharge syndromes, weakness and erectile dysfunction (Hawkes and Collumbien, 2007). In a similar vein, Schensul et al., (2006) have suggested that men are more concerned with ‘men’s performance’ rather than sexual diseases.

Khan et al. (2008) find a similar attention to the inadequate focus upon masculine sexuality as a sexual health concern in Bangladesh. However, there has been little attention given to masculine sexuality (Collumbien & Hawkes, 2000; Hawkes & Collumbien, 2007; Schensul et al., 2006). This biomedical approach fails to explain how men’s health is connected to masculine sexuality.

Verma et al., (2001) have examined the vocabularies that men use in India to describe their sexual health problems. The authors have explained cultural perspectives and local health practitioners’ views on the vocabularies. Two major men’s sexual health problems, Kamjori and Garmi, are highlighted. Kamjori refers to sexual weakness (which is considered to be one of the more worrisome men’s sexual health problems) and Garmi refers to ‘heat’ and its representative sores and various forms of pus discharges, as well as the appearance of boils and pimples. The first health problem, Kamjori, show us South Asian men’s anxiety about having lowered masculine sexuality. Although everyday vocabularies show people’s anxiety about masculine sexuality, the public health authority does not appear to be aware of the problem (Verma, et al., 2001).

Having conducted their research both in urban and rural Bangladesh, Khan et al. claim to

“understand men’s emic views about sexual functioning” (Khan et al. 2008: 38). They analyse perceptions of the penis and the links with masculinity. According to them, size, shape and action

31 of the penis are related to men’s sexual power in the Bangladeshi context. Therefore, “in order to be a sexually powerful man, most men wanted to have a good sized and shaped penis” (Khan et al. 2008: 41). The researchers have argued that the penis is situated at the core of masculinity and penile erections equate to men’s power and potency. Further, failure to have prolonged sexual intercourse and premature ejaculation are reported to be two major threats for men’s sexual performance.

Noting that there is limited HIV/AIDS based sex education offered in school education programmes in Bangladesh, Cash et al., (2001) show the importance of sex education in different educational organizations in order to reduce the risk of and vulnerability to sexually transmitted diseases. Similar studies by Nahar and her colleagues show that this situation of limited access to sexual education also contributes to sexual violence (Nahar et al., 2013). Thus, we see the necessity to break the silence. In a sense, though, the silence is already broken among men interacting with majmawalas and a growing commercial trade of pornography (Nahar et al., 2013). The widening availability of the internet and mobile phones has significantly changed the landscape of possibilities for Bangladeshis to consume a diverse and globalised set of images/narratives about sex and sexuality. Not least among these is the heightened accessibility of pornography (Akhtar,

2010; Hasan, 2010). Printed pornography magazines and pornographic video compact discs (CD) are also easily available in roadside terminal markets (Rashid et al., 2012). Yet, this reality has not been tapped into by public health professionals operating with ‘etic only’ models of practice.

One example of these ‘etic only’ models of practice are the NGO’s sexual and reproductive health and rights programmes in Bangladesh. NGOs such as Program for Research and Intervention for

Development, Education, Training and IT, Bangladesh (PIACT Bangladesh), Bangladesh Nari

Progati Sangha (BNPS), HIV/AIDS and STD Alliance Bangladesh (HASAB), Reproductive Health

Services Training and Education Programme (RHSTEP), Bangladesh Association for Prevention

32 of Septic Abortion (BAPSA), and Family Planning Association Bangladesh (FPAB) have been working on Sexual and Reproductive Health and Rights (SRHRE)13. The programmes on SRHRE are dependent on external donors and the extension of HIV/AIDS based sexual health promotion.

None of the programmes focus on community level resources as part of their working goals.

Rather, from the beginning, these programmes work from the premise that community views are a problem to be solved, thus acting as a constraint on establishing sexual and reproductive health and rights. For example, PIACT Bangladesh sees community people as a blockage to developing textbooks on HIV/AIDS education14 .

The ideas of sexual and reproductive health and rights are very western centric and the programmes operate on the assumption that the community needs an intervention to accept western ideas. On the other hand, they do not want to see how the community itself understands sexual and reproductive health and rights and addresses those issues among themselves. Therefore, though these programmes raise the notion that proper sexual health awareness would be useful to establish gender equity, the programmes place western knowledge as the core of their purpose.

The context of sexual health promotion in Bangladesh illustrates that most of the public health research and programmes are grounded in a biomedical gaze of disease; they look for biomedical causation of sexual diseases and not to engage with community meaning of sexuality. The biomedical construction of disease here is an ‘outsider’ or etic framework15 which, when applied

13 Please see the social empower programme website page of Bangladesh Nari Progati Sangha (BNPS) http://www.bnps.org/social.html; DOEL campaign page of HIV/AIDS and STD Alliance Bangladesh (HASAB) http://www.hasab.org/about_doel.php; Reproductive Health Services Training and Education Programme (RHSTEP)’s website http://www.rhstep.org/ ; Bangladesh Association for Prevention of Septic Abortion (BAPSA) website http://www.bapsa-bd.org/; Family Planning Association Bangladesh (FPAB)’s core programmes page http://www.fpab.org.bd/Core.

14 See details on PIACT Bangladesh website http://www.piactbangladesh.org/programs/education/school- education-of-hiv-aids/76-behru.html and in Chapter 7. 15 Harris (1976) has differentiated Etic and Emic perspectives. He states, ‘The difference between etic meanings and emic meanings is the difference between the first level surface meaning of a human utterance and its total psychological 33 without connection to the ‘insider’ or emic view, creates a major disjuncture. The need for ‘bridge- building’ between these two spaces is a role very suited to a medical anthropology lens. A central contention of the research proposed here is that this ‘insider’ version of men’s health needs to be understood in order to articulate more culturally appropriate public health programmes in

Bangladesh. This ‘requires an understanding of the holistic relationship between sexuality, gender and health. In the following section I describe that perspective.

Gender and sexual health Gender relations are an important area for understanding human health. The term ‘gender’ refers to the differences between socially and biologically determined sex (West & Zimmerman, 1987).

It is argued that gender relations are simultaneously produced and reproduced by social practice

(Ortner, 1972; Whitehead, 1981). Broadly, gender is a product of socio-political processes which produce and institutionalize asymmetries on the basis of sex (Tienda & Booth, 1991). In these socio-political processes, a man can assume particular thoughts and practices to define himself as a man. These perceptions and practices are mostly conceptualized with the idea of ‘maleness’ or

‘masculinity’. Therefore, the perceptions on masculine ideas can influence men for practicing particular sets of ideas in their life. Masculinity is thus important to consider within this research.

Gutmann (1997) classifies four characteristics of masculinity. These four characteristics are: (i) anything that men think and do, (ii) anything men think and do to be men, (iii) anything that makes some men ‘more manly’ than other men, and (iv) anything ‘that’ - women are considered ‘not’

(Gutmann 1997: 386). Although Gutmann’s typology here is useful for drawing some boundaries around the category, it is critical that we do not allow these boundaries to become reified.

significance for speaker and hearer respectively’ (Harris 1976: 345). In this study, I am using an etic perspective to show the external perspectives on men’s sexual health problems. 34

Brittan (1989) argues that any assumption which characterises men with some ‘‘discoverable dimension,’’ is problematic:

Masculinity must begin with its place in the general discussion of gender. Since gender does not exist outside history and culture, this means that both masculinity and femininity are continuously subject to a process of reinterpretation (Brittan 1989: 1).

In this context, masculinity does not refer only to men but also to gender relations and politics and unequal power structures embedded in those relations. Gilmore (1990) critiqued the obscure or exclusionary image of manhood through a particular cultural setting and arrangement. He examines cultural sanctions, rituals, and endurance as means of manhood-making processes in different societies. In their examination of manhood-making processes, Gilmore was interested in the constructions of a ‘real man’ in different societies. Gilmore found that a culturally sanctioned stress on ‘manliness’ is almost universal.

The process of manhood-making has a huge impact on men’s health. Scholars (Courtenay, 2000;

Courtenay, 2002; Evans et al., 2011; Gannon et al., 2004; O’Brien et al., 2005; White & Cash, 2004) have analysed the gendered aspect of health; they have found that perceptions and practices based on patriarchal gender constructs can lead to potential damage to men’s health. Men’s patriarchal power is thus both a problem for women and, somewhat ironically, also for men. Men’s desire for

‘masculinity’ at times pushes them towards a risky lifestyle. The desire to achieve a particular level of ‘masculinity’, referred to as hegemonic masculinity16, brings men to become involved with practices which might not bring positive outcomes for their health.

Scholars have explored the desire for hegemonic masculinity in different parts of the world, and have noted the consequences for men’s health. For example, Courtenay (2000) addresses this issue

16 I discuss the concept of ‘hegemonic masculinity’ in the next section.

35 in the context of the United States. Compared with women, he shows that men in the US suffer more severe health problems and die seven years younger than women. He explores the causes behind this scenario, and argues that the cultural construction of masculinity in the US influences men’s poor health status. Thus, men engage with particular health-related beliefs and behaviours to ensure their social power and status but which may be health harming. Evans et al. (2011) have described a similar cause behind Canadian men’s poor health status. They suggest that a number of studies acknowledge gender as a determinant of health, but those studies do not explain, ‘… the mechanisms by which gender influences men’s health’ (Evans et al., 2011: 8). Therefore, they have proposed a framework, Health, Illness, Men and Masculinities (HIMM), where masculinity intersects all other social determinants to understand men’s health.

Similar positions have been reported in Europe. White et al., (2004) have examined the state of men’s health in European countries by comparing life expectancy, death rates and cause of death.

They have found that due to lifestyle choices and risky behaviours, European men have a poorer health status than women. Similarly, O’Brien et al. (2005) have observed this connection between masculinity and men’s health seeking behaviour. Based on their research in Scotland, they have found that many Scottish men are reluctant to seek help as to do so could be interpreted as a symbol of lowered masculinity.

Gannon et al. (2004) have stated that the construction of infertility can be a challenge for men’s health. They investigated media reports in the UK to understand the process of males’ construction of infertility. They have found that the construction of infertility can produce stigma for men, and infertile men may consider themselves less masculine. The authors comment, ‘one reason that infertile men are stigmatised is because they are perceived as being deficient in a defining component of masculinity’ (Gannon et al., 2004: 1174). Media reports reproduce the image of a hegemonic masculinity, and men’s fertility can be one of the symbols for that. Popular media

36 reinforces the idea that a real man should have ‘reproductive capacity’. Thus, we see the role of masculinity in men’s health and wellbeing in America and Europe.

Scholars in Australia also emphasise the idea of masculinity for the betterment of men’s health.

Saunders and Peerson (2009) have advocated for incorporating the idea of masculinity in national men’s health policy to address Australian men’s health properly. They have argued that much of the discussion of Australian men’s health does not address masculinity. Equally, there exists limited interest in the understanding of men’s health through this lens of hegemonic masculinity in Asia, especially in Bangladesh. There exists a strong patriarchal system in Bangladesh (Arefeen, 1986;

Islam, 2005; White, 1992), which also influences men to perceive and carry out particular masculine practices to establish themselves as ‘real17’ men (Arens and Van Beurden, 1977; White, 1992).

Arens and Van Beurden (1977) find a strong patriarchy in Bangladesh that reproduces a set of masculine sexual ideas and practices for exploiting women in different ways. Men’s perception about ownership of women and their bodies are key aspects of the patriarchy. This perception provokes men to think about particular masculine practices where they see the female body as a subject of sexual penetration (Islam & Karim, 2011; Nahar et al., 2013; Rahman et al., 2013).

Current Bangladeshi public health programmes tend to concentrate on diseases; thus, there is a privileging of biomedicine and a consequent dismissal of social forces in health including gender.

Biomedicine acknowledges biological differences in health between men and women, but struggles to connect these differences with the socio-political dynamics of gender.

17 The idea of ‘real’ men refers to masculine sexual men. In the following section, I discuss masculine sexuality. 37

Masculinity, Masculine Sexuality and Men’s Sexual Health Masculinity in general does not only refer to the understanding of male sexuality18. Masculinity is understood as the cultural construction of men’s identity and its relation to society. Donaldson

(1993) has noted in his writing on ‘hegemonic masculinity’ that the notion of masculinity is associated with dominating others. Donaldson’s ‘hegemonic masculinity’ explains the process of establishing hierarchical relationships among men. Hegemonic masculinity also opposes the idea that masculinity is solely a form of men’s dominance over the women. Rather it is noted the hierarchical forms of dominance among and between men and the world around them. Hegemonic masculinity, which shares Gramscian views of hegemony19 (Ghosh, 2001), helps us to understand masculinity as a culturally constructed phenomenon. As Donaldson has stated, ‘the crucial difference between hegemonic masculinity and other masculinities is not the control of women, but the control of men and the representation of this as universal social advancement’ (Donaldson

1993: 655). Thus, there is a performative role amongst men to establish themselves as men. This is not only a matter of sexuality but also of men’s performance of masculinity.

In Bangladesh, men hold strong ideas of masculine performance in regards to their sexuality. The capacity for sexual performance bound to a limited construction of sexual activity involving penetrative sex with a woman and lasting a significant period of time defines men’s ideals of being not just a satisfying sexual partner but also being a man. Men conceptualise themselves as real men based in part on their sexual capacity. This desired sexual power of men is thus not only a desire

18 In this research, I am mostly referring to sexuality as heterosexual practices. However, I am aware of other sexual behaviours and gender identities, and I have respect for all kinds of sexual identities and their practices.

19 Gramscian views of hegemony examine the process of dominance in the society and the state. The capitalist states do not only rule through force, such as police, military institution; rather they rule through consent. The Italian communist Antonio Gramsci’s influential notions of ‘hegemony’ describes how the capitalist states are being made up of two overlapping spheres, a ‘political society’ (for rules through force) and a ‘civil society’ (for rules through consent). Please see (Heywood 1994: 100-101).

38 for performance with their female partner but also needs to be understood as part of a broader performance of masculinity.

The hegemonic masculine sexuality influences men to see their sexuality as a domain of controlling and dominating their sexual partners. Thus, sexual intercourse could be interpreted as a test of the man’s ability in this regard. Duration of ejaculation period, penis size and shape, and fertility are the parameters of measuring sexual performance. Thus, a man may see his sexual performance as an ultimate way of proving his masculinity. Kirchwey20 (2008) referred to such men as members of the Viagra Nation. As a further exploration of this issue Kirchwey’s (2008) poem, Viagra Nation, invokes hegemonic masculine sexuality in a performative mode.

promising “steel-hard erections,” orgasms “longer and more intense than any you’ve ever known,” ejaculations (as to volume? force?) “like a porn star,” and increases in length just short of serpentine (Kirchwey, 2008: 173)

The above four short lines of Kirchwey’s poem illustrates men’s desire to be a ‘real man’. In this desire, they need longer and intense orgasms; ‘porn star status’ is seen as the ideal. Thus, we find

Viagra as a symbol of hegemonic masculine sexuality. Whilst Viagra is a product of the West, it is now part of a globalised imagination of men’s sexual capacity.

The key focus of the business of the Viagra nation is maximising men’s sexual performance.

Therefore, Kirchwey (2008) sees Viagra not only as a pharmaceutical product but also a reflection of a particular ideology. Manderson (2012) has commented that this age is one of ‘material worlds, sexy lives’, and men’s desire to have ‘steel-hard’ erections and long voluminous ejaculations in order to prove ultimate performance. Failure may result in men feeling anxious, and therefore

20 Karl Kirchwey is an academician and American poet. Please see details http://www.bu.edu/creativewriting/karl- kirchwey/ (last accessed on 29.09.2016) 39 seeking performance enhancement materials. Manderson (2012) has examined the connections here between business and profit:

Companies market sexual products, particularly for enhanced sexual performance, through email and on various websites, creating pathologies of sex in order to build market demand. Science, primarily conducted within the commercial sector, plays a role in this, improving on products to enhance effectiveness (and safety) to replace and grow existing demand; others gain employment in this field by improving advertising techniques, and harnessing people’s anxieties about sex and so their interest in products, in diverse settings (Manderson, 2012: 2).

This production and distribution of sexual technology reinforces men’s performance centric sexual life. This process shows ultimate performance as the path of extreme pleasure, which may encourage men’s dependence on sexual products. Thus, this techno-dependency defines sexuality within men’s sexual performance with men becoming increasingly anxious about any signs of their

‘poor’ performance.

Vares and Braun (2006) have analysed Pfizer’s advertisement for Viagra. They have argued that since their release in 1998, the advertisements for Viagra have been influencing the perception and practice of sexuality in popular culture. It has been narrowing even further the discourse of masculine sexuality, putting emphasis on penile performance and enhancement. One of the agendas of Pfizer’s advertisement for Viagra was to establish erectile dysfunction as a serious medical condition, so that it could prove the importance of Viagra for ‘the health and happiness of millions of men and couples worldwide’ (Vares & Braun, 2006: 322). The legitimatization process of Viagra has a strong influence on all age groups.

Vares and Braun (2006) have concluded that Pfizer’s advertisement for Viagra in New Zealand was founded on the goal of establishing it as a ‘necessity.’ This is also true for Australia. The erectile nasal spray debate in Australia (Battersby, 2013) is an example of the demand for this penile performance enhancement in the country. Many men in Australia use the erectile nasal spray for

40 enhancement of their sexual performance, however, Battersby (2013) has reported that the erectile nasal spray did not work; despite this, we see continued demand.

The debate regarding the use of these enhancement drugs is ongoing (Åsberg & Johnson, 2009;

Grace et al., 2006; Loe, 2004). In this context, it is important to note that men’s health cannot be examined without an understanding of men’s notion of sexual performance. The dominant notion of sexual performance is hegemonic, where men search for their optimum capacity to prove the highest level of masculine sexuality. In this regard, sexual products are a popular option for many men.

Men’s dependency on sexual products to enhance their ‘sexual power’ is also an increasing issue in Asian societies. Ho et al. (2011) have reviewed the status of Asian men’s sexual dysfunction.

They comment that the production and advertisement of Viagra broke the silence of sexual taboo in Asia. Prior to this time, sex was a highly taboo issue in most Asian countries. Therefore, it was hardly possible to discuss men’s sexual dysfunction openly. Ho et al. (2011) have found that the

Viagra discourse made it possible to address men’s sexual dysfunction publicly. Furthermore, they have noted a rapid development of sexual medicine in Asia. Ho and Tan (2011), note that there is a long history of using herbal medicine to resolve men’s sexual dysfunction in Asia and that the use of herbal medicine for treating sexual dysfunction has been rising in the region. Thus, it needs to be acknowledged that while men’s sexual anxiety is partly enhanced through the biomedicalisation of ‘erectile dysfunction’, and is strongly connected with ‘modern’ pharmaceutical products like Viagra, it also has the capacity to reinvigorate traditional remedies. This overall context of men’s sexual dysfunction in Asia is similar to the South Asian context of masculine sexuality.

According to various researchers, men in South Asia are concerned about semen loss. They see semen as central to their masculinity (Alter, 1992, 1997; Cohen, 1997; Roy, 2001). Roy’s

41 ethnographic documentary Majma (2001) shows this element of masculine performance. Based on the everyday life of two men - Aslam and Khalif Barkat - Roy has explored lay perceptions of men’s sexual performance. Aslam sells traditional potency enhancement medicine for sexual problems on the footpath of old Delhi’s Meena Bazaar. Khalifa Barkat is a guru of an akhara21 in the park adjacent to Meena Bazaar and puts a group of young men through the moral and physical grind of wrestling on a daily basis. The documentary shows the anxiety, fear, and stress about

‘performance,’ that are all prevalent concerns related to men’s sexuality. Wrestling is considered to be a means of bodybuilding that enhances later sexual performance, although the required training is long and arduous. However, potency enhancement medicines are often considered as treatments for those who feel less sexually capable. Thus, this documentary depicted the concern of men’s sexual anxiety and its local management.

Alter’s ethnography (1992) provides a thick description of men’s perception of masculine sexuality in a South Asian context. Although this ethnography primarily deals with Indian wrestling as a form of identity formation, his definition of a healthy body aids in understanding the relationship between health, domination, and sexuality. Alter observed that as, ‘‘a healthy body is made to shoulder the burden of certain ideals it also becomes subjected to a microphysics of domination and control. Technologies intrude into the body and mould perceptions of health, fitness, sexuality, and aesthetic beauty’’ (Alter, 1992: 91). Therefore, the idea of masculine sexuality is both ideological and contextual.

The battle for domination and control in a man’s attempt to achieve a healthy body may be marred by uncertainty, which can in turn be destructive for health and wellbeing. Alter (1992) explained the Brahmacharya notion of celibacy and self-control in order to understand the uncertainty of

21 A common place for practicing Indian wrestling and body building. 42 masculine sexuality as well as the path away from that uncertainty. Because practicing Brahmacharya is the only way to protect against semen discharge (Alter, 1992, 1994, 1997), Indian wrestlers regard semen not only ‘‘as the quintessential fluid of life, they also regard it as the very cornerstone of their somatic enterprise. It is the source of all strength, all energy, all knowledge, all skill’’ (Alter

1992: 129). It is important to understand then that in many South Asian contexts semen symbolises men’s health as a whole. It is not just an aspect of sexual health but an indication of their ‘total’ health. Men follow a particular life-style to keep their semen for a certain period so when the time comes they can prove their ability. If they fail it creates anxiety. The ‘Viagra Nation’ is most certainly now at work in South Asia, but, as the preceding discussion shows, it must be understood as intertwined with a particular South Asian version of hegemonic masculinity which has synergies with Viagra.

Rashid et al. (2012) have explored Bangladeshi men’s dependency on sexual products. They describe sexual medicine as a rising business in Dhaka’s informal market. In their examination of city life in Dhaka, they observed a growing consumerism within the sex trade. According to them, shops on the street sell pornography, printed magazines, and CDs/video clips of local and international films, as well as local Bangla ‘X-rated’ films. Like other Asian countries, sex is a taboo issue in Bangladesh, but these trades of sexual products in an open place show that this ‘taboo’ is neither monolithic nor absolute. The new liberal economy in Bangladesh has allowed for the production and distribution of sexual products (Rashid et al., 2012), and so in turn is promoting a particular culture of hegemonic masculine sexuality. Thus, we see the Viagra discourse all over the world, including Asian countries like Bangladesh.

In the context of Viagra discourses, it is important to understand how this influences the everyday life of men’s in Bangladesh and how they response with that context. It is, therefore, the social context of sexual life which needs more attention. Without considering the insiders’ perspectives,

43 it is not possible to formulate an appropriate sexual health promotion. But, there is a dominant etic perspective in regard to sexual health in Bangladesh where we see both government and non- government organisations actively advocating preventing ‘sexual disease’. On the other hand, we see an emic perspective where the perception towards sexuality has a significant impact on gender relations and men’s health. This emic perspective receives little exploration, and there are currently no initiatives to utilise this perspective to address sexual health in Bangladesh.

THEORETICAL PERSPECTIVE In the context of sexual health promotion in Bangladesh the judgements come from the science, and in particular more especially, biomedical science. Therefore, as in the global context Nichter

(2008), the major sexual health research and intervention programmes in Bangladesh either look for information gaps or see local cultural barriers as their challenges. This approach does not see peoples’ knowledge and their strengths in health promotion, but rather it promotes a biomedical understating of an individualistic model (Parker & Aggleton, 2003) in health promotion. The dominant sexual health intervention programmes in Bangladesh are the continuation of the individualist model where sexual health related sufferings and their social-cultural context is not the part of sexual health promotion. Thus, cases such as Hasan’s, discussed at the beginning of this thesis, are not at the centre of sexual health promotion in Bangladesh.

In contrast to dominant public health interventions, medical anthropologists have shown the importance of cultural perspectives in health promotion. For example, in the south Asian context,

Nichter has been advocating for incorporating cultural perspectives in health promotion for a long time (Nichter and Nichter 1996, Nichter and Lock 2002, Nichter 2008). Therefore, the theoretical perspective of this study relies on the understandings which promote cultural perspectives in health promotion. There are significant reasons for this position. Firstly, this study examines the context

44 of men’s sexual health concerns in Bangladesh; secondly, it talks about a particular community health provider, and thirdly, this study focuses on insiders’ perspectives in sexual health promotion in Bangladesh. These three aspects are interconnected and rooted in a cultural context.

In this study, I utilise the cultural perspective to explore an insider perspective in sexual health anxieties and to recognise local knowledge in sexual health promotion. Kleinman (1980) provides a framework to incorporate cultural perspective in my study. His explanatory models are in the centre of the theoretical framework of this study. Explanatory models are ways to understand how illness is patterned, interpreted and treated in a cultural context. This framework provides a similar outline to understand both patients and practitioners’ perspective.

Explanatory models are held by patients and practitioners in all health care systems. They offer explanations of sickness and treatment to guide choices among available therapies and therapists and to cast personal and social meaning on the experience of sickness. (Kleinman, 1980: 105)

Kleinman’s explanatory models do have some shortcomings. Even Kleinman (1995) realised that his explanatory models are uncomfortably symbolic and structuralist. Therefore, he suggested some changes to his original conceptions of the explanatory models.

Today, I am uncomfortable with the style and even the preoccupation of “models,” ethnocultural or other, which imply too much formalism, specificity, and authorial certainty, but models were definitely in my mind in the 1970s, a residue of symbolic and structuralist readings… I, like many others…have become less impressed by systematic connections and more by differences, absences, gaps, contradictions, and uncertainties. (Kleinman, 1995:7-8)

Perhaps Kleinman was concerned about the mechanical use of explanatory models. As we can see,

Kleinman’s explanatory models are now used largely by clinicians to identify ‘causal links between beliefs and risk behaviours’ (Rodgers, 2012: 6). Therefore, in this study Kleinman’s explanatory models are my primary analytical tool which guides me to organise the thoughts of majmawalas and their clients. With these explanatory models, I combine other medical anthropological perspectives for a holistic insiders’ perspective in which men in Bangladesh and the majmawalas provide their explanations about sexual health. For example, in my study, critical medical

45 anthropological ideas help me understand the local and global political economy and its relation to men’s health. Nichter’s works contribute to my understanding of the meaning of community resources and their potential contribution in health promotion. Therefore, in general, the theoretical perspective of the study is a medical anthropological understating of the cultural perspective to explore the insider perspective for an appropriate sexual health promotion for men in Bangladesh.

Chapter 3: The Methodology and the Research Settings

INTRODUCTION In this ethnographic study, I examine a close to community health provider, the majmawala, in order to consider their current role and potential roles in sexual health for men in Bangladesh. In my study, I looked for a research area where I had access to both majma street healing and health professional settings. Dhaka, the capital of Bangladesh, provides this opportunity since it has a rich street vendor culture as well as being the head office of many government and non- government agencies related to public health. Due to the nature of my ethnographic study, there were two different phases in my fieldwork. In the first phase, I worked with the majmawalas and their clients as well as their non-client audience22. In this phase, I was interested in the majmawalas’ engagement with the clients and non-client audience and in the healing process. The focus of this phase was the thoughts of the members of all three groups about men’s sexual health. In the second phase of my fieldwork, I worked with public health professionals to explore the challenges in sexual health promotion and the prospect of involving the majmawalas in sexual health promotion in Bangladesh.

In this chapter, I describe the fieldwork process and the research settings. The chapter consists of six sections. The second section describes my preparation for the fieldwork. The third section discusses my fieldwork journey, research procedure, and experiences. The fourth section describes

22 A non-client audience member is not a buyer of majma medicine but they are audience members of a majma. They listen to the majma and learn different sexual health issues from the majmawalas. 47 the research settings. The fifth section is a description of data organisation and data analysis.

Finally, the sixth section is a reflection and a summary of the fieldwork.

PREPARATION FOR THE FIELDWORK In an ethnographic study, it is critical to be well prepared for both data collection and analysis.

Ethnographic data can come from many sources and is not only the outcome of interviews which have come to dominate qualitative inquiry. Observational notes, audio and video recordings, photographs and any other useful media, such as collected texts of myths, events, music, and gossip, can all be important aspects of fieldwork (O’Reilly, 2012). However, these sources can produce only a factual account of culture, which Geertz calls as a thin description (Geertz. 1973).

A thin description does not relate and describes the findings with the local social codes of those events. Therefore, Geertz expects thick description in an ethnographic study. Geertz’s interest in thick description shows the desire for an insider’s perspective. The majma street healing that is the centre of this study can only be fully understood within a broader relational context of the

Bangladeshi health systems and social context.

To produce a thick description in my ethnography, it was essential for me to carefully prepare for fieldwork. Some of the preparations were already accomplished due to my background. For example, it is important to know the language of the field to enrich the data quality (Beattie, 2013;

Spradley, 1979). As a Bangladeshi anthropologist, I speak the same language as those in my field of study, and I have had previous research experience in doing ethnography in Bangladesh.

Particularly, my MA research (Anam, 2010) was an essential preparation for working in the field of sexuality and sexual health. Therefore, I was in a position to undertake a ‘native’ ethnography.

I was conscious about the factors which are associated with insider-outsider status. According to

Narayan (1993), those factors can be “education, gender, sexual orientation, class, race, or sheer

48 duration of contacts” (Narayan, 1993:672). I was also conscious that the ‘native’ does not essentially provide an advantage in the field. On the contrary, it can also produce a range of disadvantages (Ahmed, 2000). Ahmed was challenged by the local leaders for conducting fieldwork in his locality in Bangladesh. Those leaders found him a possible threat to their dominating role in the community. There can be other limitations too for the native ethnographer. For example, one can fail to notice important phenomena during the fieldwork due to the everydayness of what is being observed. Therefore, in my preparation for this fieldwork, I made a checklist for myself which helped me to recall my role as a native ethnographer in the field. I was aware of my social and professional positions in Bangladesh. The checklist was a reminder to ensure a balance between social life and the field work. At the same time, the checklist23 was a reminder to ensure a balance between my focus on the majmawalas and on public health professionals.

I made the checklist to overcome possible limitations in ‘native’ ethnography. The checklist was useful to remind me of the potential limitations of my work. However, I knew that the challenge of ‘native’ ethnography was not only on the field, but also the historical legacy of ethnography or anthropology was necessary to understand my position as an ethnographer. The anthropology discipline is never stable and steady. This is a discipline with many debates about the subject of ethnography and the ethnographic writings. Morris (1997) says, ‘Anthropology has never been a monolithic discipline. It has always reflected a diverse range of theoretical perspectives, but seen

23 The checklist included the following concerns: 1. I need to make a balance between my family, social life and the fieldwork. I will go to fieldwork as well as to my family. Therefore, I will need to make a balance between these two domains. 2. My professional identity in Bangladesh as an academic staff member in a public university can be an issue in my field. My majmawala respondents and their audience might feel a distance from me. I will need to make sure that my professional identity will not be an issue. I would like them to see me as a PhD student who is eager to learn from them. 3. My conversations with public health professionals might raise debates. I need to be very careful about my role. Again, I will be there as a researcher who is eager to learn from them. 4. I will need to share my findings with my supervisors in regular Skype meetings. Their feedback will be useful to see my fieldwork from an external point of view. This internal and external combination will be helpful to ensure a balance between my native position and my researcher position.

[sic] as a critical movement within anthropology’ (Morris, 1997: 313). There are debates even on the geographical location of ethnographers’ work. For example, Esteban Krotz’s (1997) proposal on ‘Anthropologies of South’ starts a debate on the geographical position of ethnographer’s fieldwork and the geographical position of ethnographic production.

One of the characteristics which, at first glance, distinguishes ‘classical’ anthropology from the one practiced at the present time in the South is that, in the latter, those studying and those being studied are citizens of the same country. This is obviously not a matter of geography, although often the physical closeness between the places where the empirical information is being collected and the places where this [sic] materials are being analyzed, [sic] discussed and the results of the research published, is important. (Kortz, 1997:244)

In the context of ‘Anthropologies of South’, my position as ‘native’ ethnographer is not fully secured. I conducted fieldwork in Bangladesh in the local language, but most of my writing was in

Australia, in English.

There were also institutional issues in my preparation for the fieldwork. One of the aspects was ethics clearance. The QUT Human Research Ethics Committee was the primary ethics committee reviewing the research proposal. As my field was in Bangladesh, the ethics clearance from

Bangladesh was equally important. However, there was no ethical review system in Bangladesh equivalent to the one operating in Australia, apart from a national committee which deals with clinical trials24. The ethics review process was a very helpful preparation for my fieldwork. It helped to organise the data collection tools and generated an organised plan for my fieldwork in

Bangladesh.

My study involved three types of participants: street healers (majmawalas), their clients/non- client25 audience and public health professionals. They were from different backgrounds, and from

24 Please see details on Bangladesh medical research council’s website http://www.bmrcbd.org/research.html (last accessed on 10.09.2016) 25 In this study, clients refer to men who bought medicine from majma street healing and non-clients refer to men who did not buy medicine from majma street healing. 50 different places. Even the majmawalas were from different backgrounds. They did not belong to a particular community; their residence and socio-economic backgrounds were different from each other. They worked in different areas. This was also true for the clients, non-client audience, and public health professionals. Therefore, another aspect of the pre-fieldwork preparation was considering different ways to approach these diverse groups of participants. For example, one of the aspects of the research was gaining permission from the participants for the ethnographic interviews. There was a high chance of low or no literacy among the participants and therefore being unable to read and sign a consent form. In addition to that, written consent may be seen as a potential threat in the Bangladeshi context as participants may feel that an obligation is being imposed on them when signing a written document.

One can see the complexity and limitation of written informed consent. I knew the complexity of written consent due to my Bangladeshi background. Someone from a different background might not know the challenge of written consent in Bangladeshi context and might realise the complexity once in the field. Therefore, I had to work out a strategy before the fieldwork so that I could resolve the issue of consent. I used verbal consent for the majmawalas, clients and non-client audience and written consent for public health professionals. In this regard, I found that a prior understanding about the research area before finalising the research tools and techniques was useful.

I wanted to investigate the potential role of the majmawalas in health promotion through this ethnography. Therefore, the fieldwork was not limited to data collection; rather it was important to work with a particular set of findings from the majmawalas first, and then explore the perspectives of another group, public health professionals, for promoting the relevance of a community resource in health promotion. Equally, my accessibility among different participants was not only my access to them as a researcher; rather the access was an approval for discussing

51 and allowing or rejecting a proposal from their professional perspective. Thus, the fieldwork was not only interested in the traditional form of ‘data collection.’ It was more interested in the context of data and its relation to the participants. So, the journey of my fieldwork required an open and easy access to participants, their trust of me and of my proposal. In the following section, I describe the journey of my fieldwork in Dhaka, Bangladesh.

MY FIELDWORK IN BANGLADESH The journey of my fieldwork in Bangladesh began after the confirmation of my research proposal and research ethics approval from my school at the Queensland University of Technology. At the beginning of the fieldwork, I saw two different phases in the fieldwork. The first phase was with the majmawalas and their clients and non-client audience, and the second phase with public health professionals. Before the fieldwork with public health professionals, I wanted to gain an in-depth understanding about the majma street healing and its importance to men’s sexual health in

Bangladesh. Therefore, the idea behind these two phases was to conduct the systematical fieldwork and to prepare for the second phase of fieldwork while doing the fieldwork in the first phase.

I was in the field from May 2014 to April 2015. At the beginning of the fieldwork, I made a tentative timeline for the two phases of the fieldwork. The following sections provide a detailed description of the fieldwork and the fieldwork schedule.

Fieldwork Phase 1: The majmawalas and their Clients and non-Client Audience

Entering in the field The centre of the study was the majma street healing. An open and trustworthy relationship was critically important for me to be able to undertake this research. My previous research experience

52 and Bangladeshi background were useful to establish strong relationships, however, there should be no assumption that this made the task ‘easy.’ At the beginning of my fieldwork, I spent much time in the majma street healing hubs. I observed and listened to the majmawalas’ healing sessions as a viewer. At this stage, I tried to introduce my study and establish contact with the majmawalas.

I described my research plans and sought their permission to work with them. I went about this task at a steady pace. I did not wish to ‘hurry’ the relationships.

Initially, none of the majmawalas were trully convinced about me and my research. I identified myself as a PhD student at an Australian University and as an academic staff member at one of the public Universities in Bangladesh26. These roles positioned me initially as someone to be suspicious about. None of the majmawalas had had previous experience of academics, nor had they taken part in research, so the whole idea of me and my study was a new phenomenon for them.

The idea of research was a new phenomenon, but they were familiar with other professions, some of whom were not always respectful of them. For example, journalists, police officers and even local gangsters came to them regularly for money (almost every day for some of the majmawalas).

The ‘journalists’ were extorting money in order not to publish negative news about them, police officers were extorting money on the basis of threatening forceful evacuations of them from public spaces, and local gangsters extorted on the basis of threats of violence. These sorts of oppressive circumstances meant that majmawalas were understandably wary of me at first.

26During my preparation for the fieldwork, I thought about the possible risk of disclosing my identity, as mentioned in my checklist. I wanted to make sure that my identity would not be an obstacle for the fieldwork, but at the same time I have had to disclose my identity to ensure my ethical position. I knew that my identity as an academic staff member could create a distance between me and my majmawala respondents. Therefore, I emphasised my identity as a PhD student, and gradually I established that as my primary identity.

The majmawalas’ businesses were on the street. They needed to be set up and taken down quickly.

They could be moved on at any time by police. Like other street vendors, they have no permanency, no certainty of the occupation of space, and must compete with many other street vendors for both space and the attention of passers-by. Not surprisingly when I introduced my research to them, they thought I was probably a journalist who would eventually ask for money from them. They thought I was pretending to be a researcher. At that stage, they did not trust me, but they did allow me to observe their healing sessions and were answering my questions. As a fellow Bangladeshi, I felt the absence of a true welcome, but I understood that their fears were well founded and that I needed to be patient to gain their trust.

The first month of fieldwork was frustrating due to the absence of a proper rapport with the majmawalas. However, I knew, I would be able to establish rapport, and I knew, I would need to wait and spend time in the field. Eventually, I got their warm welcome.

One particular incident contributed to breaking the ice and building rapport. At a random majma street healing session, I was taking notes of a speech of Didar27 – a Dhaka-based majmawala.

Suddenly, a ‘journalist28’ and his assistant came, and started filming the session. They did not ask for any permission to film the session. Though it was a disruption for Didar, he continued the session. The ‘journalist’ and his assistant completed their filming and went to the assistant of Didar.

I followed them. They asked for money from Didar’s assistant. The assistant suggested they wait until the end of the session, and said he was not able to give them any money. The ‘journalist’ was angry and repeatedly asked for money.

27 Didar is a pseudonym of one my majmawala participants. The names I use throughout thesis are pseudonyms.

28 I am not sure whether they were a journalist or not. They claimed but did not confirm their engagement with any news agency. Their only purpose was extorting money. 54

I intervened. First, I gave my identity and described my purpose of staying in the area. Then, I wanted to know about their identities and the reason for filming the session and demanding money from the assistant. Initially, the ‘journalist’ and his assistant did not believe me and thought I was a majma man too. The ‘journalist’ started describing his power and network in the media and claiming himself as an important journalist of multiple newspapers and television channels, but failed to provide any explanation for asking for money. Rather, the pair now started asking for money from me. I showed them my identity card and they realised that I was actually a University academic who was there for legitimate research purposes. The ‘journalist’ and his assistant did not confirm their involvement with a particular newspaper or television channel. They did not explain their reason for filming the session or for asking for money. When I started talking about the potential of majma street healing and requested that they consider covering the positives of majmawalas in their news, they left the place. It was clear their only purpose was blackmail.

Didar’s assistant and a few other people of the area observed my encounters with the ‘journalist’ and his assistant, and Didar also saw the end of our interaction. This helped convince Didar that

I was there for true research purposes, and that I would not do any harm to them or their reputations. If necessary, I would raise my voice for them.

Didar told the story to other majmawalas of his circle. A good number of majmawalas started trusting me and my study plan after this incident. This episode made me the majmawalas’ aponjon

(আপনজন) – the dearest one. It opened the door for me to gain entry with a proper welcome into the majmawalas community and made things much easier for me in the field.

Being accepted by the majmawalas also helped me gain access to their clients and audience. I could now easily participate in the session to observe the audience and clients and establish contact with

55 them for ethnographic interviews. Sometimes, the majmawalas even helped me to approach their clients by introducing me to them.

My experience with the ‘journalist’ had several implications in my research. From the methodological point of view, my intervention had a significant contribution to the rapport building with majmawalas. It gave me an opportunity to take a stand for my majmawala participants, and was my first chance to justify/speak in favour of the majmawalas contribution to the Bangladesh health sector. That incident also gave me evidence of the oppressive circumstances that majmawalas were dealing with in their everyday lives.

Fieldwork with the majmawalas At the time of this research, there were two different kinds of informal medicine markets in Dhaka city for potency enhancement supports. One group described the various aspects of men’s sexual health problems and prepared their medicine in front of the audience (see Figure 3.1). They were the majmawalas - traditional street healers. The other group sold drugs made by pharmaceutical companies. Many in this group used recorded lectures, but some just organised their medicine on a table and sat and waited for the customers (see Figure 3.2). This latter group was similar to other market stalls which sold products on the street. The first group, however, interacted with people and communicated their understanding of sexuality and sexual health. They positioned themselves not merely as ‘sellers’ but as healers with capacities to diagnose and treat with medicines they made themselves. They presented the overall process of traditional medicine in their sessions. It was this first group that I was interested in working with. They are the majmawalas of my study. I worked with seven majmawalas from this group in different parts of Dhaka city.

Figure 3.1: An example of the traditional form of a majma street healing stall

Photo Source: Fieldwork photograph, 2014-15

Figure 3.2: An example of the street based pharmaceutical drug (potency enchantment) stall

Photo Source: Fieldwork photograph, 2014-15

The centre of my fieldwork with the majmawalas was to understand the process of engaging people and their explanation of men’s sexual health problems. At the same time, I was interested in the interaction between the majmawalas and their audience. In this context, the reflexive and spontaneous nature of ethnography was useful for me. Prescribed tools and techniques could never achieve my goals. I utilised the strengths of participant observation and unstructured ethnographic interview technique during my fieldwork to learn iteratively with the majmawalas.

The main strength of ethnographic research is the participant observation method. In participant observation, an ethnographer stays in a particular community for an extended period of at least a year (Beattie, 2013) and participates in their everyday life. Beattie (2013) noted, ‘unless we understand how the people we are studying think about them, we simply replace their conception with ours’ (Beattie 2013, 83). Therefore, I spent much time with the majmawalas to understand their profession of majma street healing and its meaning to them (see Figures 3.1 and 3.2).

My Bangladeshi background and the incident that led to my being welcomed were useful for my participation in the majmawalas’ healing sessions. My ability in the local language was, of course, of prime value in helping me understand the healing sessions, as I could accurately follow the discussions of the majmawalas and their audience. During my participation in any majma street healing sessions, I observed the majmawalas’ practice, performance, and engagement while they delivered their narratives about sexual health, which would not have been possible in an interview using an interpreter (as a non-Bangladeshi would likely require). Similarly, it was possible to observe the responses and reaction of the clients and the non-client audience of the street healing during the time of street healing sessions. By utilising the observation method, it was possible to explore which part of majma made its audience more attentive and which part of the healing session influences clients to buy medicine. Similarly, some of the audience were only listening to the majmawalas and did not buy medicine; the observation method was useful to see their

58 responses as well. My broader cultural knowledge of the street context, as well as the surrounding context of the other vendors, and the potential roles of police or religious figures was critical to the success of my fieldwork.

I observed the majma street healing like other audience members of the majma sessions. Most of the time, I was part of the gathering, standing with other men, listening to the majmawalas’ narratives. The majmawalas’ different activities and their interactions with the audience were also part of my observation, as were the responses of the audience. During the observation, my role as a researcher was always in my mind. I never participated or volunteered in any aspects of the majma street healing, nor did I ask the majmawalas any questions during that time. In some of the observations, I kept a distance from majma street healing session, as this gave me an opportunity to see the whole majma setting.

Part of the observation was to document majma narratives. These were important to understand the process and perceptions of the healing system. The majmawalas draw upon their past in the healing sessions. They narrate their life experiences and family heritage to show their past involvement with the profession. They also raise problems relating to men’s health and possible healing for these issues. They have their own aetiologies to explain men’s sexual health problems, and treatments to cure those health problems.

The majma narratives were important areas to understand the street healing; the narratives provided by the majmawalas were the result of both specific knowledge about health as well as being drawn from wider experiences in Bangladeshi society. Therefore, it was important to examine the majmawalas’ narratives to appreciate the socio-historical, as well as aetiological and treatment aspects of street healing.

The majmawalas were fluent in delivering the majma narrative. It was not possible to listen and then write the narratives. That could be a distraction in the majma street healing too. So, with the permission from majmawalas, I preferred to record audio of the majma narratives. I kept a voice recorder with me, and the majmawalas knew that I was recording their speech during the majma street healing.

The observation and documentation of the majma street healing gave me an understanding of the healing profession. At the same time, it was important for me to understand the people of the profession too. The majmawalas were more than their profession, and over time I came to know something of their backgrounds, their families and their personal histories and aspirations. I saw that the whole process of street healing and the ideas that accompany street healing were linked to the majmawalas’ lives. Therefore, utilising the ethnographic interview29 method allowed me to understand the contexts that influence the majmawalas to talk about different aspects of men’s sexual health. A professional explanation from the majmawalas themselves was also necessary in order to interpret their narrations. Through the ethnographic interviews, I came to know their explanation of male sexuality and health, which they delivered in their healing sessions. In those ethnographic interviews, we discussed the medicinal and healing methods that they offer, intermingled with everyday talk about their daily life circumstances.

Depending on the context of the discussion, I conducted the interviews in different stages with all of the seven majmawalas. I was not the only one who asked questions in those interviews. Rather, my majmawala participants asked questions too. They were interested to know about my experiences in Australia. They were also interested to know about my plans for the research

29 The ethnographic interview is not a formal, structured interview. Instead, it is informal and conversation based (Bernard, 2006; O’Reilly, 2012; Spradley, 1979). O’Reilly (2012) commented on the process of the ethnographic interview: ‘A good ethnographer will take any opportunity to listen and to ask questions of individuals and groups whilst participating and observing’ (O’Reilly, 2012: 118). 60 findings. Therefore, informal chatting was the primary mode of the interviews. I found the informal nature of the ethnographic interview very effective.

Not all the chatting was directly relevant to my study. Often, we discussed street violence and

Bangladeshi politics. My majmawala participants and I shared a level of uncertainty about the political and economic conditions in Bangladesh. Therefore, those topics came into our discussion spontaneously.

I met with the majmawalas before or after majma sessions. Usually, we went to nearby tea stall, had tea together and continued our discussion. These were places near to the majma street healing sessions, and the majmawalas gave me time during gaps in their sessions. Those were short conversations, as they had to go back to continue their sessions. For longer conversations, I met with them in their homes, usually, in the morning. During those long conversations, I followed a checklist that I was developing from my participation in their majma street healing. The checklist contained my points for the discussion, where I was interested in majmawalas’ further explanations about their majma speeches. Their engagement with the profession was also an important part of that checklist.

Throughout the fieldwork period, I extensively photographed the majma settings and locations.

These photographs are a visual presentation of the majmawalas’ acts and the majma street healing.

They document the nature of engagement in the healing sessions. I utilised my phone camera as it was both handy and effective in avoiding disruptions to the field research, although it did mean I had to compromise on the quality of the photographs.

Among my majmawala respondents, five were mobile and conducted their majma in different parts of Dhaka city. They maintained a weekly schedule, and they were aware of each other’s majma

61 locations. The other two were mostly permanent in their location30. The majmawalas’ mobility was important for the availability of space for conducting sessions. The busy Dhaka Street was not available every day, and therefore most of the majmawalas used the weekly day off for the market.

At the same time, they were aware of the times and places which were suitable for gathering an audience.

During my fieldwork, I followed a set of common steps for all seven of the participating majmawalas. I developed a strategy to work with all of them across my year of fieldwork. This enabled me to ‘take turns’ with different majmawalas at various times of the day and week. During the second month of my fieldwork, I was able to establish a proper rapport with the majmawalas, after which I followed a schedule for each majmawala. I met with every majmawala at least once a week. In weeks 5 and 6, I spent time observing and trying to understand the majma settings. From week 7, I started audio recording majma street healing sessions in addition to my regular observation and informal discussion with majmawalas, and this continued until week 11. The ethnographic interviews started from week 13 and were completed at the end of week 20. Thus, in the first five months of my fieldwork, I worked mainly with the majmawala participants. The timetable shown in Table 3.1 is a summary of my fieldwork with majmawalas.

Table 3.1: The activity summary of the fieldwork with the majmawalas Month Week Fieldwork Activities with the majmawalas Month 1 Week 1 Mapping of majma street healing in Dhaka city Week 2 Mapping of majma street healing in Dhaka city Week 3 Mapping of majma street healing in Dhaka city, and establishing contact with the majmawalas Week 4 Mapping of majma street healing in Dhaka city, and establishing contact with the majmawalas Month 2 Week 5 Observing majma Week 6 Observing majma Week 7 Observing majma, and audio recording of the majmawalas’ majma speech, informal discussion with the majmawalas Week 8 Observing majma, and audio recording of the majmawalas’ majma speech, informal discussion with the majmawalas

30 I described majmawalas’ weekly schedule and locations in the next chapters. 62

Month 3 Week 9 Observing majma, and audio recording of the majmawalas’ majma speech, informal discussion with the majmawalas Week 10 Observing majma, and audio recording of the majmawalas’ majma speech, informal discussion with the majmawalas Week 11 Observing majma, and audio recording of the majmawalas’ majma speech, informal discussion with the majmawalas Week 12 Finalising checklist for the ethnographic interview with the majmawalas Month 4 Week 13 Ethnographic interview with the majmawalas Week 14 Ethnographic interview with the majmawalas Week 15 Ethnographic interview with the majmawalas Week 16 Ethnographic interview with the majmawalas Month 5 Week 17 Ethnographic interview with the majmawalas Week 18 Ethnographic interview with the majmawalas Week 19 Ethnographic interview with the majmawalas Week 20 Ethnographic interview with the majmawalas Source: Fieldwork 2014-2015

From month 6, I concentrated on the majmawalas’ clients and their non-client audience, and from month 8, I started working with public health professionals. However, during my fieldwork, I was always in contact with the majmawala participants.

Fieldwork with the majmawalas’ clients, and their non-client audience The role of a majmawala was not only to sell medicine but also to promote and disseminate certain ideas. Therefore, both clients and non-client audience groups were internalizing information, which influenced their understanding of sexuality and health. Conducting ethnographic interviews with these groups provided invaluable insight into the aetiology of lay perceptions and influences.

With this approach, I conducted ethnographic interviews with both clients and non-client audience members, focusing on their interactions with street healing itself as well as with the majmawalas and their narrations. I asked about their perceptions and practices of sexual health. Furthermore,

I talked to the clients about their reasons for taking healers’ medicines.

I established contact with clients and non-client audience members during the course of the healing sessions, sometimes with the help of the majmawalas. After the initial contact, I spent time with the participant to establish a good rapport before interviewing them. In most cases, I did not do

63 any interview in our first meeting, but instead organised a second time and place for the interview.

None of the interviews could be completed in one session, and so I met with each participant multiple times, based on their availability. I observed their responses and reactions during the healing sessions, but I conducted the interviews without the majmawalas being present, in order to ensure privacy and confidentiality.

I used a purposive sampling approach in selecting the participants from the client and non-client audience groups. I did not try to filter who I would interview. In my first meeting with the participants, I approached them to explain my intention and the study. Not all of them were comfortable with a conversation on sexuality and sexual health and so these clients self-selected out of my study group.

My interviews with the clients and non-client audience members were informal, reflexive and conversational. In my conversation with both the client and non-client audience the perception of men’s sexual health and anxieties were discussed. In those conversations, some of the participants were equally interested in my own experience, which I shared with them. My childhood story of a

Dhaka majmawala was shared in our discussion. They described their interactions too. So, the ethnographic interviews with clients and non-clients were often reciprocal in nature, to an extent.

I was careful not to lead participants, but I needed to utilise my strength as a local who shared some of their experiences in order to develop rapport. We shared each other’s stories. However, I had not had any experience of taking medicine from majmawalas. In this regard then I could quickly move the conversation to one of me being the ‘learner.’ Some of them were interested in my own sex life, as it was one of the important topics of our conversation. I was open with them, which helped make them more comfortable disclosing their sex life.

The conversation with both clients and non-clients did not work according to plan all of the time.

Eleven participants did not want to continue the conversation due to the nature of the topic. They were shy and felt uncomfortable disclosing their perceptions and practices regarding sexuality. In these cases, we stopped the conversation immediately, and they withdrew themselves from the interview.

I started ethnographic interviews with the clients and non-clients in the 6th month of my fieldwork in Bangladesh. It took three months for the ethnographic interviews with 17 clients and 16 non- clients to be completed.

Fieldwork Phase 2: Public Health Professionals The goal of my work was to explore majmawalas’ possible engagement in male sexual health promotion programmes in Bangladesh. To do so, it was necessary to develop an understanding of public health perspectives on the majma street healing and sexual health promotion in Bangladesh.

Relevant public health professionals were important sources of these perspectives and for possible linking of the majmawalas in public health. Therefore, after the first phase of fieldwork with the majmawalas, their clients and non-clients, I conducted fieldwork with public health professionals.

In November 2013, the first year of my PhD, I met and informally shared my research ideas with a few public health professionals who were working in the sexual health area in Bangladesh.

Although this was before I had started my proper fieldwork, it afforded me the opportunity to make an initial connection to this group.

Recruiting public health professionals for the field work Public health professionals were experienced in sexual health promotion and health sector management. Based on my previous communication in 2013 with health professionals, I was able to establish contact with them. I had assistance31 from my friends and colleagues to reach out to a few of the health professionals. Thus, when the time came to do my fieldwork with this group, I already had some starting points in terms of contacts and a level of trust and familiarity with this group. The recruitment of the public health professionals was, however, more formal than for the healers’ group or the clients’ group. The professionals were recruited in a formal way via targeted telephone and email communication using a participant flyer and information sheet. In the case of majmawalas, and their clients and non-client audience, I had to rely on verbal consent, but in the case of public health professionals I got their written consent.

The fieldwork with public health professionals During my fieldwork with public health professionals, I again utilised ethnographic interviews. In these interviews with public health professionals, I sought their thoughts on sexual health care services, health seeking behaviour, and their views on the possible engagement of the majmawalas in Bangladeshi public health programmes. They also discussed the current challenges of sexual health promotion in Bangladesh.

In most cases, I went to the public health professionals’ offices to conduct the interviews. This was convenient for them, and also gave me a sense of the very different context in which they worked compared to the street-based work of the majmawalas. Most of the offices had air- conditioned facilities, which created a complete distance from the street noise. A security check

31 Some of my friends and colleagues introduced me and my research to some of the public health professionals. In the Bangladeshi context, this was particularly useful for me, and helped me get access to them. 66 was common, and I had to get a visitor’s tag before entering the offices. My signatures on the office registers kept a record of my sign in and sign out time.

In each office, I observed the presence of CCTV surveillance and a level of concern for the safety and security of the staff. The political violence on the streets of Dhaka city was so threating that it even hampered normal office movements. Therefore, most of my public health participants had to maintain security protocols. Most of them avoided strike32 days, and went to the office on the weekends instead. Due to the street violence and blocked roads, they used a rickshaw to get to their office instead of using buses or cars. These uncertainties and anxieties were part of our discussion. They repeatedly advised me to follow similar security protocols.

I met with some of the public health professionals in a café. The café culture in Dhaka is gaining popularity. It is already established as a suitable meeting place for the middle class and upper- middle class in Dhaka. Researchers and professionals often meet at cafés, and my meetings with public health professionals in cafés were more like social events. It gave me and my participants an opportunity to get to know each other. Like the majmawalas and their clients and non-client audience, the public health professionals were also interested in my future plans, and were particularly curious about my post PhD plans. Some of them were insecure about the political uncertainty, and their jobs. Those who were working on short-term projects were even more insecure in their jobs due to the temporary nature of their employment contracts. Often, they discussed this uncertainty in our café meetings but not in their offices.

32 Strike is a form of political demonstration in Bangladesh. Often it is a call from the opposition political parties. Usually it calls for the whole shutdown of the city areas where picketers often block all vehicles. They also try shutdown all kinds of business activities and offices. During my fieldwork, there was a high risk of arson attack on vehicles during strike days. 67

This fieldwork with public health professionals had a very particular agenda. It allowed me to explain the role of the majma street healing in health promotion and to understand the responses of public health professionals regarding engaging the majmawalas in sexual health promotion.

After the fieldwork with public health professionals, in the last month of my fieldwork, I returned to the majmawalas. I spent that month getting clarifications on topics previously discussed, and saying goodbye. However, in my eleven months of fieldwork, I was always in communication with them. Either they would call me, or I would call them on various occasions. After returning to

Australia, I kept up that communication. During my data analysis and thesis writing, I called them several times, sometimes for clarification, or to exchange greetings at different festival times. I think this communication is necessary to maintain the possibility of further collaboration with them. At the same time, it reminded them that someone in Australia was still working with their ideas.

THE RESEARCH SETTINGS OF MY FIELDWORK IN DHAKA In this study, it was important to have a research area with access to both majma street healing and health professionals’ settings. Dhaka, the capital city of Bangladesh, was the best research setting for me due to the availability of both majma street healing and public health agencies.

Dhaka has a population of 17 million people33. Every day people arrive in Dhaka city from rural centres with a dream of a better life. Due to the centralised politico-administrative systems in

Bangladesh, Dhaka is the centre with the most opportunities. Dhaka-based domestic and foreign

33 Sector assessment (summary): urban transport. For details, please see details ADB (2011) http://www.adb.org/sites/default/files/linked-documents/42169-013-ban-ssa.pdf, (last accessed on 10.08.2016)

68 investments also increase employment opportunities in the city. Although there is limited access for the urban poor (Hossain, 2006), employment, education, and the availability of health care are attracting migrants from all over Bangladesh. However, the city struggles to live up to these dreams for many, with an unemployment rate of 23% in 201334. Moreover, the city is very crowded and has very limited public infrastructure proportional to the population of the city. Slums are familiar places for shelter for many of the ‘dreamers’ who come to Dhaka to change their life. Hossain

(2008) shows that significant portions of the city’s population are living in Dhaka slums. He also states that the slums’ dwellers are ‘experiencing extremely low living standards, low productivity and unemployment’, and says they ‘mostly live below the poverty line in terms of both calorie intake and the cost of basic needs’ (Hossain, 2008: 1). The substantial poverty within Dhaka is most acute for lower tiers of employment or unemployment. However, life for the more affluent middle classes also presents many difficulties.

Job scarcity, contaminated food, transportation problems, shortage of safe water and power cuts are everyday experiences for everyone in Dhaka. Sometimes, it is very difficult to identify which formal authorities might resolve these sorts of everyday issues. People need to search hard for solutions to their problems. For example, the crisis of safe drinking water in Dhaka city is so critical that the Dhaka Water Supply and Sewerage Authority (DWASA) asks people to boil tap water before drinking35, but they do not take on the responsibility of solving the safe drinking water crisis. It seems to me that the city dwellers themselves are responsible for finding a way to overcome those problems.

34 Please see details Dhaka south city corporation (2016) https://web.archive.org/web/20130115171206/http://www.dhakacity.org/Page/Search_item_details/Search/Item _id/31/Item/employment/Dhaka_City_At_a_Glance, (last accessed on 10.08.2016) 35 For more details, Islam (2015), see: https://www.thethirdpole.net/2015/11/12/living-with-unsafe-water-in-dhaka/ (last accessed on 09.09.2016) 69

Due to a lack of formal services, a number of informal sectors are the reality of Dhaka city. I see these informal sectors as the nucleus of Dhaka life. This characteristic also applies to the health service provision. Like the other areas in Bangladesh, informal health services are the most prevalent form of health service provision in Dhaka (Adams et al., 2015). Even, the informal providers are part of the street landscape. For example, it is possible to get blood pressure and blood sugar tests done in the park of Dhaka city even at the morning walk time of city dwellers.

These informal providers are the most accessible group for most of the communities in the Dhaka city. In a nutshell, the majority of the Dhaka dwellers rely heavily on different informal sectors.

The majma street healing is, therefore, a strong reality in Dhaka city.

The street sex culture in Dhaka is another important aspect to understand the research settings.

The street-based sex trade is quite active in the context of the sex industry in Dhaka. In 2000, a

Bangladesh court declared that brothel-based female prostitution as a livelihood was not illegal36, but, there are only 14 legal brothels in the country, and the largest, Daulatdia brothel village, has about 1,600 sex workers. On the other hand, it is estimated that the total number of female sex workers in Bangladesh is more than 100,00037. Non-brothel-based sex workers are transient, and sell sex informally in various areas of the country. Dhaka City is not an exception, as the floating sex workers in Dhaka are either hotel-based or street based (Islam and Smyth 2012).

During my fieldwork, I observed street-based sex workers looking for clients on the street. They were present at various points. Though they were on the street, they were careful not to disclose their identity. Many of them wore a burkha, the religious veil often worn by Muslim women, to keep their confidentiality. The burkha, the veil often worn by Muslim women, is often worn to

36 For more details, BBC (2000) see: http://news.bbc.co.uk/2/hi/south_asia/677280.stm (last accessed on 09.09.2016)

37 For more details see US Department of State (2009) reports on Bangladesh human rights practice. 70 hide their identity, regardless of religious background, which is an interesting additional use of the

Muslim head covering. In their study on sex, pornography and Medicines in Dhaka, Rashid et al.

(2012) also observed the high presence of sex workers on the streets and bus terminals.

Street posters on potency drugs are another example of the street sex culture in Dhaka city. These are posters of different companies who use the medium to advertise their potency enhancement drugs. I took a photograph (Figure 3.3) of one of those advertisements during my fieldwork in

Dhaka. A company calls Kolkata Herbal Medicare posted four copies of a poster at an entrance of a street. These colourful posters display the existence of men’s sexual health concerns and the high presence of the informal providers. Along with the posters, the distribution of leaflets with similar content is also common on the Dhaka streets.

Figure 3.3: Kolkata herbal’s posters on the Dhaka street

Photo Source: Fieldwork photograph, 2014-15

Along with street sex workers and the advertisements on potency enhancement drugs, the vast street pornography markets in Dhaka sell printed and electronic pornography where both local and international pornographic movies are available.

The research sites of the majma street healing In this busy space of male heterosexuality in Dhaka city, the majmawalas create their own spaces, and are available in different parts of Dhaka city. In my study, I worked in five different locations to understand the diversity of the majma street healing settings. The sites were Mohammadpur

Bashbari area, Farmgate cinema hall compound, Kawranbazar area, Boshundhara City area, and

Mirpur Shrine area (see Map 3.1). These were the places where my majmawala participants conducted their majma. I followed them and their majma street healing sessions in those areas.

Map 3.1: The research sites of the majma street healing

Source: Modified from Banglapedia, National Encyclopaedia of Bangladesh, link http://en.banglapedia.org/index.php?title=File:DhakaPresent.jpg (last accessed on 10.09.2016)

Mohammadpur Bashbari area The Mohammadpur Bashbari area is located in Ward 33 in Dhaka North City Corporation. In the pre-independence era, Mohammadpur was a popular place for non-Bengali and Urdu speaking people. They started living in this area after the India-Pakistan partition in 1947. After the independence of Bangladesh in 1971, the majority of them moved to Pakistan. However, a good number of Urdu speaking people still live in Geneva Camp in Mohammadpur. Along with Geneva

Camp, the names of many roads in the area show the historical legacy. In recent times, a greater proportion of the local population is middle-income Bangle, however, it has also a mix of lower income and higher income populations.

There are a number of private housing groups operating in this area, such as Japan Garden City,

Mohammadia Housing Society, Mohammadia Housing Limited, and Chanmia Housing.

Mohammadpur Bashbari is one housing pockets where the private housing groups are active.

Therefore, building and road construction is common in this area.

During my fieldwork, the construction of Bashila road was underway in Mohammadpur Bashbari

(see Figure 3.4). This was the expansion of a narrow road to Bashila which required the roadside building and establishments to be removed. The slow progress of the road construction provided the opportunity to continue trading for many of the people who had a business in that area. Near to the Bashila tempu stand38 in Mohammadpur Bashbari, a temporary open market existed on this road while it was under construction. There were mobile street vendors there on most days, and on Fridays it was full of vendors and their customers. One could buy everyday groceries, kitchenware and even clothes. It was convenient for many of the locals and passers-by. A newcomer to the area could easily misunderstand and think that it was a regular market place. The scarcity of marketplaces and business options in Dhaka city push the street vendors to make use

38 A tempu is a kind of auto rickshaw. This mode of transport is popular in Dhaka city. 74 of such opportunities, and two of the particpant majmawalas, Didar and Abbas, made use of this opportunity to conduct their majma street healing sessions.

Figure 3.4: The temporary open market on under constructed road in Mohammadpur Bashbari

Photo Source: Fieldwork photograph, 2014-15

Didar and Abbas were usually in the temporary market in Mohammadpur Bashbari for the whole day every Friday. Because Fridays are holidays in Bangladesh, there was no construction work, and that allowed them enough space to conduct their sessions. While Didar and Abbas took the opportunity provided by this unofficial marketplace, they had to pay to do so as the traffic police of the area collected money from them for protection money (pay or we close you down).

This shows the independent character of the informal sectors of Dhaka city. The vendors started their business when they found a place where was possible. They knew that they would eventually have to leave the place, but they wanted to continue their business as long as possible. They even

75 worked with the local power brokers. This is an example of everyday Dhaka, where dwellers often compromise with authority (eg. the police) for their survival. They know that they need to manage their problems with their own networks and connections.

The Farmgate Area The Farmgate area is one of the busiest area in Dhaka city (Figure 3.5). This is a centre of different business, shopping malls, communications, recreation, accommodation, and education. It is a highly commercial area, but due to the unplanned nature of development work, it is hard to categorise Farmgate with a specific area type and describe every aspect of the locality.

Figure 3.5: Farmgate bus station

Photo Source: Fieldwork photograph, 2014-15 The Farmgate bus station is connected with bus routes all over Dhaka city. It makes the place an everyday destination for many city dwellers. It is a very vibrant place where street vendors are also very active. Their business activities continue from early morning to late at night.

Ananda cinema hall, one of the famous cinema halls of the city, brings movie lovers to the area.

From under their veils, street-based sex workers try to communicate with their potential clients.

They often wait for clients coming out of the cinema hall compound. One of my majmawala participants, Fajol Mia, regularly conducted his majma street healing near to the cinema hall. This area is an interesting combination of different realities – a cinema hall where local movies are often screened and its wall full of erotic movie posters, veiled sex workers searching for clients, majma street healing, and the busy passers-by who may be going to a movie or catching bus, and who are also potential clients for both the sex workers and the majmawalas. .

Kawranbazar Kawranbazar has two different characteristics. During the day, it is an office area, dominated by different news offices, butat night, a wholesale market for vegetables, fruit, and fish takes over the area. From late evening, the vendors start organising their stalls and prepare to receive goods from all over Bangladesh. The trucks start arriving at midnight, and continue until early morning, and hundreds of porters work to unload them. Vegetable, fruit and fish sellers from all over Dhaka city come to Kawranbazar to buy goods at a low wholesale price and sell them in their own stores all over the city. In the morning, this night market finishes the majority of trading before the office hours of the area commence. During night Kawranbazar is also well known for the sex trade.

Along with street-based sex workers, some residential hotels operat the sex trade in this area

In the day time, the area is very different. The street tea stalls are full of reporters, who smoke and take tea and discuss different news stories. Some of the porters are still available for carrying goods, while the homeless and street children sleep wherever they can.

Bashundhara City Area Bashundhara City is a complex shopping mall, and one of the largest shopping complexes in

Bangladesh (Figure 3.6). It is located at Panthopath in Dhaka. Its recreational facilities make it the most popular meeting place for Dhaka city dwellers. The Star Cineplex in this shopping mall screens the latest Hollywood movies. The food court on level 8 serves plenty of national and international foods. The centralised air conditioning brings comfort for the visitors. Therefore, visitors come to this shopping complex for multiple purposes. Even on Tuesdays, when the shopping mall is closed, it is a destination for many of the city dwellers. Due to the lack of space, it is almost impossible to get an available meeting place in the area. Therefore, many of the city dwellers come and spend their time in front of the shopping mall. That brings an opportunity for the street vendors to set-up on the side of the road opposite the shopping mall. One of my majmawala participants, Abu Bakkar, conducted his majma there every Tuesday.

Figure 3.6: Bashundhara City area

Photo Source: Fieldwork photograph, 2014-15

Mirpur shrine area The Shrine of Hazrat Shah Ali Bogdadi at Mirpur, locally known as Mirpur shrine (see Figure 3.7), is situated beside the Mirpur-Gabtoli road. The shrine is full of devotees all year, some of whom even live in the compound. Every Thursday, this shrine offers special prayers and programmes which start in the morning and continue until late night and attract thousands of devotees and visitors. Thursday’s activities also increase local business. Though the Mirpur shrine is a place for believers, the sex trade continues in the area.

Figure 3.7: Mirpur Shrine area

Photo Source: Fieldwork photograph, 2014-15

DATA ORGANISATION AND ANALYSIS The ethnographic method does not have any particular tool to organise and analyse data. However, a specific data organisation and analysis plan can be useful for ethnographic research. Some scholars (Barnard, McCosker, & Gerber, 1999; Dahlgren & Fallsberg, 1991; Ellingson, 2011;

O’Reilly, 2012; Peräkylä & Ruusuvuori, 2011; Spradley, 1979) recommend reliance on a particular plan for organizing and analysing qualitative data. For example, Spradley (1979) found that ‘analysis of any kind involves a way of thinking’ (Spradley, 1979: 92). That is to say, in any analysis we need a plan for dealing with our field experiences and its outcomes. Spradley (1979) preferred to depend on a ‘systematic examination’ where an ethnographer would be able to see the relationship between different parts of their research. For instance, in my case, I had majmawalas, their clients and non- client audience, and public health professionals as different participants, and I had different domains in my study – a domain of street healing, a domain of its audience, and the public health domain. It required a clear plan or a way of thinking about the relationship between these different actors and their different domains. I had to see the importance of majma street healing in majmawalas’ lives as well as in the lives of their clients and audience members. Then, I was able to understand the importance of street healing in sexual health as well as in Bangladeshi public health.

Like Spradley (1979), O’Reilly (2012) describes ethnographic data analysis as ‘iterative-inductive’ analysis. This ‘iterative-inductive’ analysis does not follow a linear model of first data collection and then data analysis. It is a process of continuous engagement in the field: ethnographers go back and ask people something again, or they can find the person they missed or they can look for some more information and collect more data, because they do not gather blindly then bring it all home and see what they have got (O'Reilly, 2012: 183). Thus, she stated ‘analysis and data collection are interlinked’ (O’Reilly, 2012: 180). Although ‘iterative-inductive’ analysis is a continuous process, it has a plan. O’Reilly (2012) suggested following links for chasing up ideas or facts. Therefore, ethnographic analysis is flexible and systematic in nature, but in this context, it

80 was necessary to have a plan to organise and analyse data. This plan assisted me in organizing my ethnographic data, and in writing my ethnography. I utilised the followed plan from the very beginning of my fieldwork.

During my fieldwork, I kept a field diary. This diary consisted of my everyday feelings, perceptions, and attitudes in the field, and my own perceptions of an informant, event or particular constraint in the field. As Spradley (1979) pointed out, ‘a journal represents the personal side of fieldwork; it includes reactions to informants and the feelings you sense from others’ (Spradley, 1979: 76). The field diary was a record of my field experiences.

The diary recorded my personal experience, but the description of my field data was in my field notes. A detailed account of observation of events in the field or conversation or interviews with informants was the content of these field notes. I had two types of field notes – condensed and expanded (Spradley, 1979). Condensed field notes were the shorter descriptions of an immediate act; it consisted of signs, symbols or part sentences. Although brief, I wrote it in such a way that I could retrieve the full message when I wrote the more detailed, expanded notes. Writing condensed notes was useful to keep a record of a conversation or for when observing a particular event, but it requires immediate work to expand to more complete notes as soon as practicable. Otherwise,

I risked not being able to discern or remember the full message of the condensed notes. That is why I wrote expanded notes at the end of every fieldwork day. In the case of audio-recorded interviews, a full transcription represented my expanded notes for the interview.

In an ethnographic study, it is important to understand the meaning of evidence in the context of the field, and its relations with the participants. Spradley’s (1979) diagram on feedback loops in the ethnographic method is a good way to represent the process of understanding taking place. Like

O’Reilly’s (2012) ‘iterative-inductive’ analysis model, Spradley (1979) shows the layered way in which understanding builds through reflection over time.

Ethnographic Making an Ethnographic discovery ethnographic record description

Source: Spradley, 1979: 70

Ethnographic discovery and ethnographic description are connected and making an ethnographic record acts as a bridge between them. Therefore, ethnographers have to think about both discovery and description when they write an ethnographic record. They need feedback from the discovery and from the ethnographic description in recording their ethnographic data. For example, re-reading of field notes during the fieldwork may lead to additional discovery; one may need to work with the same ethnographic discovery to get a detailed description. ‘Discovery’ in an ethnographic sense is not a fixed positivist accomplishment. Rather, it is an accomplishment of interpretation built on a steadily building growth of understanding which leads to new questions and new interpretations. Reading my field notes assisted me to think more deeply about my ethnographic data. For example, when I wrote an ethnographic record on the majmawalas, I needed to also consider the majmawalas’ client and non-client audience, so I was not able to write the full ethnographic descriptions before doing ethnographic fieldwork with the majmawalas’ client and non-client audience. In a number of cases, I had to go back to the majmawalas and check my growing interpretations. This was similar in the case of my work with public health professionals. Ethnographic records of street healing helped me start a dialogue with public health professionals, but I also had to go back to the street healing settings for further clarification afterwards. Therefore, ethnographic data recording is itself a process of data analysis.

Along with the observation and interview notes, as well as any other ethnographic evidence, the analyses of collected data are never static. Across the period of fieldwork, new questions can arise, and interpretations can change. For example, photographs can be important ethnographic evidence. The process of engagement of the people in the majma was an important aspect of the majma street healing, and so I took photographs of that engagement process. Those photographs

82 show moments in the majma. Whilst the photographs themselves do not change over time, my interpretation of their meanings changed as my understanding grew.

After fieldwork: data organisation and data analysis During my fieldwork in Bangladesh, reading and re-reading my field diary, field notes and making connections within my findings were the core processes of the data analysis. From this field level analysis, I created an initial structure for my thesis. After the fieldwork, I presented my findings at several events. I got comments from my supervisors and colleagues. Based on those comments, I did a second level of analysis of my field data. Even at this more advanced stage of my thinking I continued to re-read my field diary and field notes. Thus, the analysis was always ongoing and was continually refined as I wrote the thesis itself.

The language issue in data organisation and data analysis Translation is always an important issue in ethnography. Asad (1986) describes the inequality of languages, and suggests asymmetrical cultural translation.

I have proposed that the anthropological enterprise of cultural translation may be vitiated by the fact that there are asymmetrical tendencies and pressures in the languages of dominated and dominant societies. And I have suggested that anthropologists need to explore these processes in order to determine how far they go in defining the possibilities and the limits of effective translation. (Asad, 1986: 164)

Asad’s concern regarding the inequality of languages is relevant for ethnographers who do their fieldwork in other cultures. It is quite the opposite in my case, as I did my fieldwork in my culture, and the language of the field was my first language, Bangla. My respondents spoke Bangla only.

Therefore, first I had to work in Bangla, and then in English. In this process, I did the data organisation and analysis in Bangla. Based on the analysis in Bangla, I wrote my thesis in English.

It was always a challenge working in two different languages. Exact translations were not possible all the time. For example, it was not possible to translate of few of the sexual health problems from Bangla to English. It that case, I described those sexual health problems as best I could in

English, knowing that some of the nuances could not be fully grasped. My limitation in the exact translation clearly shows that even for the native ethnographers language is a big methodological challenge.

REFLECTION AND SUMMARY I began to conduct research on street healing because I was fascinated with the potentiality of the majma street healing in Bangladeshi public health programmes. Apart from my personal fascination, there was an academic purpose behind my choice of this topic for my research: there exists little research on street healing, despite the fact that it is an extremely important element in

Bangladeshi society. One potential reason for the lack of research on this topic may be the majmawalas’ main area of healing, male sexual potency issues.

Due to the methodological challenges, sexual health research is not a popular research area. Lindau and colleagues show that even in the United States, the sexual health problems of aged people have not been thoroughly explored (Lindau et al., 2007). Researchers may face significant challenges when working on this topic. Even teaching experiences on this topic can be very challenging (Ashcraft, 2012; Valentine, 2001). Educators may find it difficult to talk about the topic in a classroom, and it can be difficult for some teachers to find an appropriate way to teach teens about sexual behaviour (Ashcraft, 2012). Similar challenges exist at the university-level in teaching a course like human sexuality, where there can be the risk of negative student reactions, and it can even result in professional stigma (Valentine, 2001). Both Valentine (2001) and Ashcraft (2012) experienced this challenge in the US context, where there is well-facilitated provision for classroom

84 teaching on human sexuality. This problem begs the question: What are the potential methodological challenges for a researcher to work on the topic of sexuality in Bangladesh, where the discussion of such matters is highly stigmatised?

My previous research and Bangladeshi cultural background have led me to think about the potential methodological challenges of my study topic, and has also influenced me to do research on sexuality in Bangladesh. If I decided to not to work in this area, I might avoid the threat of academic stigma. On the other hand, this was an important area to investigate. Therefore, I decided to ignore he academic stigma and to take on the challenge of ethnographic work on sexuality in

Bangladesh. I saw it as my ‘hermeneutic duty’ (Sayer, 2000) to work on this topic.

The second challenge arose from my aim to build a bridge between the majmawalas and the public health professionals. The encounters with public health professionals were critical to understanding the challenges of incorporating street healing in public health promotion. For me, this was at times particularly challenging, as my ethnographic ‘evidence’ was not a familiar basis for health policy for some of the public health professionals. Moreover, my interest in valuing street healers’ knowledge further eroded the potential authority of my knowledge base for those who had come to idolise only certain forms of health ‘evidence’.

My background, being a native in Bangladesh, helped me in many aspects. However, it was a challenge for me as well. For example, at the beginning of my fieldwork, it was difficult for me to narrow down the precise field of study. I was trying to include many things which were not directly involved in my research, such as the many street children in the areas around of my research sites.

I decided to spend time with them, as it could be useful to understand the street culture in

Bangladesh.

While this move was useful for my understanding of the street culture, especially that of the street children, it was not the focus of my study. I had to make a balanced judgment about how much time I spent coming to terms with the wider context of the street versus time with the majmawalas and their clients. There were other incidents too. One of my sites was in Kawranbazar, which is a hub for newspaper offices and television networks. I had a good number of friends who worked there as reporters, and they could easily run in to me on the street while I was conducting my fieldwork. In a Bangladeshi context, it was hard to avoid a tea and a friendly discussion, which was sometimes time-consuming. While this impacted on my fieldwork, being a Bangladeshi, I could not avoid these friendly meetings.

During my fieldwork, Dhaka was violent, and the streets of Dhaka city were unsafe. The political violence on Dhaka streets brings another challenge in the research. I went to Bangladesh in May

2014 for my fieldwork. A level of political violence was always there in Dhaka during the course of my fieldwork, and a period of extreme violence started in late December 2014, and continued until May 2015. During this time, arson attacks on vehicles were a common phenomenon. Most of my fieldwork activities were in the public spaces of the street – observing street healing and interviewing the majmawalas and their clients. Due to the extreme violence, I had to plan all of my movements very carefully. I had to spend hours moving from one place to another. Due to the risk of an arson attack, most of the time I did not use motor vehicles. Mostly, I walked or took rickshaws to reach my participants. An interview which would take an hour in a normal situation often took a whole day. In addition, I had to change the interview schedule many times due to the safety of my participants and myself. Overall the fieldwork was full of uncertainty and surprises.

However, those difficulties also brought some extraordinary experiences which inspired me to continue my work in the area of public health. One of the experiences was my meeting with Joynal

Abedin, a rickshaw puller in Bangladesh. I had no idea that a rickshaw puller in Bangladesh might run a free health clinic in his village. His income from rickshaw pulling in Dhaka city was the

86 source of money for the free treatment offered inthat clinic. I came to know about Joynal Abedin and his clinic when I was waiting in a tea stall for one of my respondents who was late due to a strike on that day. Joynal Abedin was also taking tea and the tea stall owner introduced him to me.

Joynal Abedin started saving money for a clinic when his father died without having access to treatment in his locality, but it took thirty years to save an initial deposit and establish the clinic.

After doing some research on him, I found that Joynal Abedin’s story was already in the national and international media39, but he continued his pulling his rickshaw to earn money for the clinic.

Joynal Abedin’s story gives us two different perspectives: a perspective on the critical resource constraints in health care services in Bangladesh, and another perspective where we see that even a rickshaw puller can contribute to the health system. Certainly, Joynal Abedin’s story helped motivate me to continue my fieldwork at that difficult time, and also helped me to keep searching for community strength in the health care system in Bangladesh. The following chapter on the majma street healing is further evidence for the Bangladeshi community strength, which could be a valuable resource for sexual health promotion.

39 International media such as BBC, Aljazeera also covered Joynal Abedin’s story. For Ethirajan BBC’s (2012) story please see http://www.bbc.com/news/world-asia-18195227 (last accessed on 28.09.2016) and for Aljazeera’s (2012) story, please see http://www.aljazeera.com/video/asia/2012/02/2012219114012469822.html (last accessed on 28.09.2016)

Chapter 4: The Majma Street Healing: A Masculine Space of Livelihood, Performance, and Engaging Men

INTRODUCTION Majma street healings are at the same time small businesses, theatrical performances, and health services. The majmawalas earn their living through majma, and need to make good sales to live well. Unlike most of the other sellers, majmawalas’ clients do not necessarily come with the intention of buying their products. The majmawalas use their skills to draw the attention of locale men40 and engage them in the process of majma street healing, and finally, sell their medicine.

From this perspective, the majma street healing has the core characteristic of being a small business, and every successful majmawala is a good salesperson. But majma street healing is more than just business. It works with an important topic, sexuality, and engages people by describing various aspects of men’s sexual health problems.

I see two different points in a majma street healing, which are equally important in engaging participants. Firstly, the process of majma street healing is an attention seeking technique, and secondly, the content of the discussion provides a focus on sexuality and sexual health. In this chapter, I discuss the process of the majma street healing in order to explore its different aspects and its capacity to engage people. I describe the process of majma street healing, and how that process engages its audience members. In the next chapter, I discuss the contents of the majma

40 These are the men who have some business near to the majma. They are passers-by including office workers, travellers, students, shoppers, rickshaw pullers, drivers, security workers, men returning from Mosque, business owners and shop workers of the locality. 88 narratives. In these two conjunctive chapters, I show the majmawalas’ability to educate random men on the street.

THE PROCESS OF ENGAGING PEOPLE IN THE MAJMA STREET HEALING The majmawalas demonstrate their skills from the beginning of the process, with the selection of the time and place for majma, through to selling medicines at the end. At every step, they gather more participants and work towards selling medicines, by using a number of strategies and techniques to attract the attention of busy, passing pedestrians and engage them in their majma.

The success of a majma depends on convincing a passer-by to purchase medicine. Therefore, it is important for a majmawala to be highly skilled in strategies of persuasion. There are three major steps in the process of engaging men in a majma. These are i) drawing attention, ii) approaching medicine and iii) the consultation. These steps are interconnected; one-step contributes to the other steps. In Flow Chart 4.1, I illustrate a majma process41.

41 The process is not linear but moves back and forth. Therefore, this illustration may not correspond to the true nature of the engagement process. However, I provide a detailed explanation of the process in the text. 89

Flow Chart 4.1: The engagement process of a majma street healing

Locale men

Approaching medicine •Selection of appropriate time and • Group •Making medicines in consultation place public •Storytelling •Utilising religious •Q&A session beliefs •Showing evidence of Drawing efficacy Consultation attention

Source: Drawing from reflection of the relevant data of the chapter

In the above diagram, I briefly show how the majmawalas engage men in their majma. Majma street healing starts with seeking the attention of the locale men. The majmawalas select the appropriate time and place to ensure the availability of an audience. Besides the time and space, the majmawalas’ storytelling strategy plays a major role in drawing the attention of locale men and engaging them. Once there is an adequate number in the audience, the majmawalas start approaching their medicine. In this step, they make different medicines as the men watch, and then offer them to the audience.

The whole majma process is group focused. It does not rely on an individual audience member’s background or individual consultation. The unique group-centric nature of the majma process

90 creates a comfortable zone for men in Bangladesh to understand and seek sexual health care. The majmawalas discuss various aspects of men’s sexual health. They do it publicly. Usually, they do not ask for individual information. The clients of the majma street healing do not necessarily need to disclose their problem to majmawalas or their associates when purchasing medicine. In this way, the audience members are not necessarily perceived to be men with sexual problems. They may be just men who are curious about the topic. Thus, the potential for the audience to be associated with the stigma of sexual health concerns is strongly mitigated. The male audience participates as a group and receives a group consultation. In the following sections, I describe the whole process of a majma street healing from my field notes.

Drawing attention in a majma street healing

Today, I went early to Abu-Bakkar’s majma street healing location. I planned to see the audience gathering from the very beginning. When I arrived, I found the place for Abu- Bakkar’s majma was empty. A nearby tea stall was running. People were coming to drink a cup of tea. They tried to drink tea in a minimum time. Busy pedestrians were passing me. Everybody was busy. It seemed to me that they had not the time even for exchanging greetings.

Around 3 pm, Abu-Bakkar came to his majma street healing place. Like any other day, his assistant Shohag helped him to organise all the equipment, jars on a rickshaw van. Abu- Bakkar has a rickshaw van for transporting everything he needs for the majma from his home to the majma place. It is Shohag’s duty to pull the rickshaw and to assist Abu-Bakkar to organise and set up majma. It took an hour to organise everything on the rickshaw van. Then, Abu-Bakkar went to a nearby Mosque for his Ashor42 prayer. He started his first session just after the prayer.

When he started the session, there was not a single audience member near to him. At the beginning of the session, he tested the voice of his microphone with his usual melodic words, ‘hello microphone testing 1 2 3 4, hello microphone testing 1, 2, 3, 4’. This microphone testing is a common practice in Bangladesh. They use it to check that the speakers are working. Abu-Bakkar’s microphone was good. Still, he was testing the microphone. He does it for every majma. He starts with a low voice and goes to a high voice. While he was testing the microphone, busy pedestrians started noticing him. Tea drinkers in the nearby teashop also started looking at him.

After testing his microphone, he began inviting people to see some photos. “Brothers, come to my rickshaw van and see some pictures. You can see and learn many things which are important for you. Brother come here and listen.” Abu-Bakkar was pointing to a photo-

42 Late afternoon prayer for Muslims 91 album and inviting people to see the photos of the album. The invitation worked. Some of the busy pedestrians walked to him. A few people from the teashop joined him. Others joined him from nearby shops. Gradually, he gathered a crowd of twenty to thirty people.

Abu-Bakkar opened the photo album, and, pointing to the first page with his tiny pointer stick, started a story. The first page was a cutting from a newspaper about a woman who left her husband to join her new lover. He pointed to the newspaper clipping and told another story of a man who suffered from premature ejaculation. The man in Abu- Bakkar’s story was one of his clients who came to him with a premature ejaculation problem. That client was looking for a solution to avoid humiliation in his conjugal life. Abu-Bakkar did not complete the story here. He stopped without telling the full story of his client. I had the feeling of ‘what happened to this man? Did he manage to solve the problem?’ I could see similar curiosity among people in the crowd. They were looking at the photo album and at Abu-Bakkar’s face.

Abu-Bakkar turned the page of the album politely and went to the second page. The second page had a picture of a tree. Again, pointing to the tree, Abu-Bakka started a new story. It was from his story of learning the traditional healing. He recounted that he was the first person in his family to join the street healing profession. None of his family members wanted him to be a healer. His affection for the occupation brought him here. He had a guru who taught him about the profession and the world of herbal healing. He said to the audience that he would tell the story of his guru at a later stage.

He went to another page, where I saw photos of different medicinal plants. He started a new story - how he collected and preserved the herbs. He claimed that due to rapid urbanisation, it was difficult for him and his colleagues to collect medicinal plants. He blamed that the urbanisation was demolishing forest, which was the primary source for medicinal plants in Abu-Bakkar’s profession. In the early days of his profession, it was not difficult for him. However, Dhaka and its nearby areas are now losing natural forest quickly and making Abu-Bakkar’s profession vulnerable in terms of supply of appropriate forest plants.

After telling the story of Dhaka, Abu-Bakkar went to his first story again. He told the audience how he treated his client. As part of the story of the treatment, he also completed the story of his guru. After that, he moved on to the medicine he made for the client of his story.

In this stage of storytelling, he invited the audience to see his medicine (halua) making process. None of the audience left the place. Rather, I saw a few newcomers join the group. Abu-Bakkar kept telling his story while he was making medicine. I observed a group of enthusiastic audience members in front of Abu-Bakkar, who were attentive to his stories and his action of medicine mixing.

I saw the energy in Abu-Bakkar’s story. He was telling the story as if he was acting on a stage. His voice was following the story line. When needed, he would raise the tone of his voice. It appeared as though street theatre was being performed.

- Source: Field note 2014

The above field note describes the scenario of the beginning of a majma. The starting part of a majma is of critical importance for a majmawala. Starting with the zero audience, they need to create a large crowd. A dramatic start is necessary for generating attention and gathering people.

To capture peoples’ attention, majmawalas must plan carefully. They select places which are suitable for crowds to gather easily. They combine the selection of place with an appropriate time.

In the following section, I discuss how majmawalas select their majma places and majma time, and how this is important for gathering and engaging audience.

Selection of time and place for the majma street healing Selection of time and place is important for the availability of a targeted group. In the case of majma, the appropriate selection of time and place ensures a large audience. The majmawalas carefully select a crowded time and places. One strategy adopted by all seven majmawalas was to schedule majma around different religious activities and events. This ensured a good gathering. In the description of Abu Bakkar’s majma, we saw that he started his majma after a prayer, and his majma place was near to a mosque, which was a common tactic among the majmawalas. Other places that are suitable for majma street healing include bus stations and cinema halls, but most of my majmawala respondents preferred places near mosques that guarantee pedestrian traffic.

The majma time Bangladesh is a predominantly Muslim country. Muslims have five prayer times in a day – Fajor,

Jahor, Ashor, Magrib, and Esha. Depending on sunset, the time between Ashor and Magrib can be between 65 minutes and 2.5 hours. During the time between those two prayers, I observed

Musollis43 spending time in places nearby. The majmawalas used that leisure time. On an average day, all of the seven majmawalas conducted their first majma session after the Ashor prayer. Table

43 Musolli refers to a Muslim who is regular in his prayer and his religious obligations. 93

4.1 shows the average timetable that I followed to attend majma street healings during the fieldwork:

Table 4.1: The majma sessions Healers’ Name Day Majma 1 Majma 2 Majma 3 Abbas Friday After Ashor After Magrib After Esha Didar Friday Morning After Jumma44 1 After Jumma 2 Fajol Mia Sunday Morning After Ashor After Esha Baktiar Monday After Ashor After Magrib After Esha Kashem Ali Tuesday After Ashor After Magrib After Esha Abu Bakkar Wednesday After Ashor After Magrib After Esha Nawser Thursday After Ashor After Magrib After Esha Source: Fieldwork 2014-2015

Friday is a holiday for Muslims. On that day, they pray their important weekly prayer, called

Jumma. This is also the weekend in Bangladesh, and the majmawala respondents were very active on that day. All seven majmawalas consistently prepared carefully for Friday sessions, and usually had good sales.

On other days, the majmawalas usually began their majma after Ashor prayer. In the time between

Ashor and Magrib, they tried to conduct at least two sessions, and another two sessions between

Magrib and Esha. After Esha, the majmawalas usually held one session, unless there was still the possibility of gathering enough participants, in which case they would hold a second session.

The majma places Similar to prayer time, conducting the majma near a mosque or a Shrine is another aspect of utilising religious or faith events. Majma near a mosque or a Shrine can quickly reach the followers.

I found that all seven majmawalas preferred to set up the majma in those places. In my weekly

44 Jumma is Friday’s noon prayer 94 schedule, six out of seven of my weekly sessions with the majmawalas were either near to a mosque or near to a Shrine, and only one was near to the cinema hall in the Farmgate area (see Table 4.2).

Figure 4.1 is an example of a ready majma set-up in front of Kawranbazar mosque in Dhaka.

Table 4.2: The majma locations Healers Day Location Didar Friday Mohamadpur, near to Mohamamdpur Bashbari mosque Abbas Friday Mohamadpur, near to Mohamamdpur Bashbari mosque Fajol Mia Sunday Farmgate, near to Farmgate cinema hall Baktiar Monday Near to Mirpur shrine Kashem Ali Tuesday Kawranbazar, near to Kawranbazar mosque Abu Bakkar Wednesday Opposite to City Boshundhara, near to a mosque Nawser Thursday Near to Mirpur shrine Source: Fieldwork 2014-2015

The majmawalas followed a schedule for going to their various majma locations. They generally preferred the market closing days of different places, because it was only on those days that there was enough space for majma. For example, Didar conducted majma five days of the week. He worked on Fridays in Mohamadpur area in Dhaka, and for the rest of the four days in four different areas of Dhaka city. Abbas, Baktiar, Abu Bakkar and Nawser followed a similar rotating place to that of Abbas’.

Fajol Mia and Kashem Ali did not rotate their majma locations. Instead, they conducted majma each day in the same place. It is important to note that, although majmawalas prioritise mosque areas, this did not necessarily mean that their audience were only those attending the mosque.

Passers-by or other people who frequent those areas would also join them.

Figure 4.1: A ready majma setup in front of Kawranbazar mosque in Dhaka

Photo source: Fieldwork photograph, 2014-15

The majmawalas deviate from their regular schedule when there are special religious occasions and instead position themselves near the event. Special religious events, such as Bishwa Ijtema45, an international gathering of Muslims, create scope for many majma sessions. During the annual

Bishwa Ijtema , Muslims from all over Bangladesh and overseas join for prayer in Tongi, a place close to Dhaka city, where they remain for three to five days. The annual days of the Shrines46 or

Orosh Sharifs are a similar opportunity. All seven majmawalas went to Bisho Ijtema and to the different Orosh Sharifs.

45 Please see detail Matthews (2016).

46 On the annual day of the shrines, followers gather for special prayers. They also celebrate the legacy of the Shrine. They also call the day Orosh Sharif. 96

Majmawalas also conduct their majma street healings near to cinema halls and bus stations.

Commuters attend the majma while waiting for their buses (see Figure 4.2), and movie watchers join before or after their films.

Figure 4.2: A majmawala conducting a majma in a bus station in Dhaka city

Photo source: Fieldwork photograph, 2014-15

This selection of time and location is the primary issue for the majmawalas. They need a place with enough space for a crowd at a time when there are enough people passing by to form an audience.

The majmawalas use their best judgment to select the best time and place. After majma set-up, the majmawalas need a way to get the attention of the busy people. In the following section, I discuss how the majmawalas attract the busy passers-by and invite them to join their majma.

Storytelling as a tool for audience’s engagement in the majma street healing The majmawalas use storytelling to engage their audience. It is important to keep the attention of the audience and establish the importance of their medicine through their storytelling. My majmawala respondents used various strategies to engage audience, but they all used the same technique when telling those stories. They told stories and interpreted those stories in relation to their healing process. The audience would hear the story first and the interpretation later. During the explanation of the interpretation, the majmawalas would also weave in the beginning of another story, which would keep the audience engaged and prevent them from leaving (see Figure 4.3 to

4.5). Thus, their skill at storytelling was vital for keeping the audience engaged.

Figure 4.3: Beginning of a majma: pedestrians looking at the majmawala.

Photo source: Fieldwork photograph, 2014-15

In the second section of this chapter, I shared Abu Bakkar’s storytelling strategy. He delivered a series of stories in which the actors and events were different, but which were all part of a wider story. This method of storytelling meant that whether a man arrived at the beginning or the middle of the majma, he could hear the single theme of the story. In other words, newcomers who joined the majma street healing in the middle of a session could easily follow because they were able to listen to the next full story and interpretation.

It is important for majmawalas to have an extensive collection of stories. A photo album is a traditional form of keeping photographic prompts for different stories, and all of the seven majmawalas in this study used a photo album during their storytelling, usually with colourful photos. Every page of the album had a story, sometimes based on news, or other things, such as a particular food. They used the albums to maintain a chronology of their stories and to help the audience visualise the story as they listened (see Figure 4.4). As the majmawalas never completed one story at a time, but rather moved from one story to another and back again. The photo-album kept the audience focussed and helped to show the themes that connected the stories. It also guided the majmawalas in what to say and when to say it.

Figure 4.4: Audience members looking at the photo album and listening to a majmawala

Photo source: Fieldwork photograph, 2014-15

Figure 4.5: Audience members in a majma

Photo source: Fieldwork photograph, 2014-15

In my conversation with majmawalas’ clients and non-client audiences, I wanted to know about their memorable encounters with majmawalas. Interestingly, half of them mentioned the photo album and the role of the photo album stories in quickly drawing their attention to the majma.

Table 4.3 shows some of their comments about the influence of the photo album stories.

Table 4.3: Clients and Non-Client Audience’s experiences in the photo album stories

Participants47 Comments on the memorable encounters with majmawalas C1 I saw a man was talking. There was an album in his hand. I was curious to know about the album. C5 Majmawala was talking about the sexual problem and showing an album. The way he was talking and showing the album, it made me interested in majma. C8 When I was passing a majma, I saw a group of people looking at the album, and listening to majmawala. It made me curious about the gathering, and I joined there. C12 A majmawala showed some pictures of the human body. He was also explaining the function of the body parts. I thought it would be useful to me.

47 C for Client and NC for Non- Client Audience 100

C15 I was at a bus stand, waiting for the bus. A majmawala showing pictures and telling some stories there. It made me curious about him. NC2 A majmawala was showing some important news from his photo album. He was also telling stories. It was interesting. NC5 I have been listening to majma from my childhood. Always, I have an interest in their photo album and the stories. NC11 I was on my way home. I saw a group of people was looking something on a table. I came close and saw a photo album. The man in the middle was telling stories of the album. It was so interesting that I stopped for a while and kept listening to him. NC15 I was drinking tea in a teashop. Suddenly, a majmawala started talking about some photos. I was curious what kind of pictures he would show. I went to see the pictures. Source: Fieldwork 2014-2015

Most of the respondents did not intend to join and listen to majma. They had other business to do. It was the majmawalas’ photo-album and its series of stories that influenced them to join the audience. The colourful photos and the stories that the majmawalas shared with the audience made the photo album strategy very effective in engaging an audience. They also created a very memorable experience, such that half of the client and non-client respondents could recall the stories they had heard and their interaction with the majmawala. Some of the audience came only to listen to the story. One of these was Ripon.

Ripon was a thirty-two year old furniture worker. Due to his heavy workload, he spent most of his time in his workshop, only going outside for a few hours in the late afternoon. Sometimes he came to a majma. Before our formal meeting, I saw him listening to majma several times. Most of the time, I saw that he was very attentive, however I never saw him buying medicine. This made me curious, and I decided to conduct an interview with him.

In our conversation, Ripon confirmed that he never purchased medicine from any majma, although he visited them frequently. Thus, he was not a client, but a non-client audience member.

He stated that he did not buy medicine because he did not have any health issues, but he liked the majmawalas’ talks and their way of delivering a speech.

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‘Majmawla kothay jadu ache’ (‘মজমাওয়ালার কথায় জাদুকরি আকর্ষন আছে’). ‘A majmawala’s speech has a magical attraction’. - Ripon, a non-client audience.

Ripon’s assessment of the majmawalas’ storytelling capacity shows the importance of majma speech among their non-client audience. Ripon described majma speech as having a magical attraction, which is what drew him to join the sessions. According to him, he could learn of interesting topics during his majma time. He enjoyed the majmawalas’ performance as entertainment. He thought it also gave him some release from his heavy workload.

Ripon’s interest shows one explanation for men’s interest in majma street healing. Majmawalas know the language of people, and they have an extraordinary capacity to tell stories, which makes them charismatic speakers. Therefore, people like Ripon come to them though they are busy. My childhood experience, shared in the introduction of the thesis, was very similar to Ripon’s experience of the magical attraction to majma stories.

The Question and Answer technique (Q&A technique) Another important strategy that majmawalas use in their speeches is the question and answer technique. It is an interactive way of involving the audience in majma. In this technique, majmawalas ask questions to the gathered audience and wait for an answer from them. In most cases, the majmawalas themselves answer their questions. They utilise a similar technique to the photo album based storytelling here too; they do not respond to their questions immediately, but rather ask questions, contextualize the issues and then answer the questions (see Figure 4.6).

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Figure 4.6: A majmawala’s Q&A session

Photo source: Fieldwork photograph, 2014-15

All seven majmawalas used the question and answer technique in their majma. Their questions were regarding the historical understanding of nature and religion. They connected their questions to popular cultural beliefs. It was, therefore, stimulating for the audience to participate in the discussion. For example, there is a popular belief in Bangladesh that traditional herbs have no side effects, and that they are useful to the human body. Even the professionals of alternative medicine publish books in Bangla to describe the importance of herbs for the human body. My majmawala respondents produced their questions on the grounds of the cultural knowledge of herbs. Like the other majmawalas, Abbas, one of my respondents, was active in talked about pro-herbal beliefs in a Q&A session:

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It is a shame that we do not know the names and functions of our plants. How can we keep our health if we do not use these plants? Do you know the name of a plant, which can make your semen thick? Do you know the name of the plant, which can help you for a prolonged sexual intercourse? You do not know! However, our grandfathers knew it. That is why they needed less medicine in their life.

- Abbas, A majmawala in Dhaka, Bangladesh

After raising these three questions, Abbas took a pause. With an inquisitive look, the gathered audience were looking at each other. None of them answered the questions. Abbas gave a moment to the audience and started talking again, but he did not state the answer directly. He began with the second part of his argument. He began explaining why the ancestors knew about the plants.

According to Abbas, agrarian production was an opportunity for Abbas’ ancestors’ to learn these things, as they lived in a time when people had to know about plants for their everyday living. He continued that the contemporary urban life was creating isolation from nature. He loudly announced, “The separation from nature is responsible for the contemporary men’s poor understanding about herbs and for their sexual weakness”. Audience members supported Abbas’s position by nodding or murmuring agreement. Still, they were not told the names of the plants.

They had to wait, as Abbas went on to a different topic. It was very uncommon that the audience would ask for the names at this stage. Rather they would wait and listen to the next story. It seems to me that most of the audience had an understanding about majmawalas’ storytelling style. They knew that eventually, they would learn the name.

Not everything from nature was seen as useful for the human body in majma. The majmawalas told stories about natural things that were harmful to the human body too. In one majma, while

Fajol Mia was conducting a Q&A session, he asked about a vegetable which he thought was harmful to men’s sexual health.

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Dear brothers, do you know the name of the vegetable that can damage your sexual potency? That vegetable is fed to male prisoners to reduce their sexual desire and ability. You should not eat this vegetable if you want a real sexual life. Do you know the name? - Fajol Mia, A majmawala in Dhaka, Bangladesh

When Fajol Mia asked about the name, I observed similar responses to that in Abbas’s Q&A session. The faces of the audience portrayed a deep curiosity. Fajol Mia used the same technique as Abbas: he did not provide the answer to the question immediately, but elaborated on the context of his question by talking about male prisoners in Bangladesh. Male prisoners in Bangladesh do not have access to a sex life. It was an important point of reference for the audience to know about the vegetable that reduced prisoners’ sexual desires. The name of vegetable was equally important for the audience to keep their sexual desire. Therefore, utilizing the Q&A technique, Fajol Mia was successful in keeping the audience’s interest in majma.

I was interested in the audience’s Q&A experiences. In my conversations with audience members,

I kept asking about their feelings during the Q&A time. The following conversations show us how

Q&A engages men in majma.

Conversation 1: Conversation with Badal, a client of a Majmawala

Mujibul: The other day when you were listening to the healer, he was asking about fish. Badal: Oh, yes, the majmawala was asking about a fish that was not suitable for a man.

Mujibul: Did you know the name before?

Badal: No, I did not. I eat fish every day. I was wondering whether I was eating that fish. That is why I started listening to him. The healer took the time to tell us its name. He told other stories and then finally said the name. I was waiting until I got the name. Mujibul: Did you leave the majma just after knowing the name?

Badal: No. I was there for the whole session. Gradually, I felt more interest in the majma. I have some health issue too. I went home after taking his medicine.

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Conversation 2: Conversation with Jewel, a client of a majmawala

Mujibul: I saw the healer was talking about plants. What do you think about it? Jewel: Yes, he was talking about plants, which were suitable for a man. Mujibul: Did you know about the plants before? Jewel: I knew that there were some plants, which were good for us. However, I did not know the names. Mujibul: I saw the healer was asking the names. Jewel: Yes, he was asking the names. He did not tell the name very quickly. Mujibul: How did you feel about that? Jewel: It made me curious about the plant. He was taking time and telling other things. Those were also important too, but the name of the plant was always in my mind.

Conversation 3: Conversation with Shahin, a non-client audience member

Mujibul: I saw you were listening to the majma. However, I did not see you taking medicine from the healer. Shahin: Yes, I was listening, but I did not take medicine. Mujibul: Then, why did you listen to majma? Shahin: The majmawala was asking names about some plants, which were good for men’s health. I did not know the names. That is why; I thought it would be useful for me to know the names. Mujibul: Did you learn them? Shahin: Yes, I did. Mujibul: When did you learn? Shahin: Ha ha (laughing), he did not tell us the names in the beginning. He said the names when he started selling his medicine. That is why I had to wait for the whole majma. Mujibul: Did you enjoy the rest of majma? Shahin: Yes, I did. He was discussing another issue of men’s bodies. That was also interesting. Mujibul: Why did you not take medicine then? Shahin: I do not have the problem. Mujibul: Did you get any benefit of listening to majma.

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Shahin: I did not take medicine. However, I got his advice. If I follow his advice, it will keep my good health.

I worked with 33 clients and non-client audience members. At some stage, all of them had Q&A experiences as part of the majma street healing. All of them expressed similar feelings to Badal,

Jewel, and Shahin. The Q&A technique initiated men’s interest in majma street healing and healers gradually expanded that interest to the whole session.

The storytelling approach and the Q&A technique are unique tools for engaging the audience in majma street healing. The audience gets a context for the street medicine from the stories and the

Q&A sessions and then they find a connection with the healing. Therefore, my majmawala respondents were successful in gathering and keeping audience attention on them.

Approaching the audience members to sell medicine Majmawalas do not jump straight into selling their medicine. They establish a context for their medicine first. The storytelling approach and the Q&A technique help them to establish that context, after which they can approach the audience members and ask them to buy the medicine.

Just as for storytelling, there are a number of strategies used for this important stage in the process.

In the following section, I discuss those strategies.

Producing medicine as part of the session Majmawalas make their medicine publicly. They combine and mix ingredients in front of their audience. This process creates an opportunity for majmawalas to hold the attention of the audience. While preparing the medicine, the majmawalas speak to the audience about different aspects of their medication. My majmawala respondents described names, sources, and the function of the ingredients in their majma. They emphasised the herbal value of the ingredients.

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They asked and explained to the audience their understanding of herbal medicine. Mostly, they asked and explained the names and function of the ingredients. I observed three aspects of the production of medicine that influenced people to listen and purchase the medicine from majma.

These were the majmawalas’ descriptions of the sources and preparation of their ingredients, the eye-catching colours and decorations used on their jars and stands, and the mixing of their medicines in front of their audience.

The majmawalas usually described the collection and preservation process of the medicine ingredients to their audiences. It was an opportunity to learn the supply chain of the street medicine production. Like the other audience members, I could learn where to go to collect the herbal ingredients. I learned that the trade centre for the raw ingredients was Babu Bazar, a market of

Dhaka, and that all of my majmawalas respondents depended on that market for their ingredients.

Baktir, one of my majmawala respondents, described how he collected his ingredients.

I do not conduct majma on Saturday. I go to Babu Bazar to purchase my raw material. I go to the market in the morning. I need almost the whole day for purchasing and cleaning the material. It is not an easy task. You need an experienced eye to select the original material from the market. At the same time, you will need to know the cleaning process. The materials you can see here in the jars required a lot of knowledge and labor. I do it every week. Otherwise, I would not be able to give you the medicine.

- Baktir, A majmawala in Dhaka, Bangladesh

Baktir’s description of the collection and cleaning of ingredients showed his deep commitment to the process. After describing the importance of his experience and labor, he looked at the audience and took a pause to see the reaction from them. I found a few audiences nodding their heads to show their appreciation for Baktir’s hard work. It seemed that Baktir expected the audience’s appreciation at this point. He then continued his speech.

Although all seven majmawalas had their own style when preparing the medicine, all of them used herbal and natural components. In the preparation of medicine in public, the arrangements and

108 decorated jars of majma street healing also capture peoples’ attention. The following case of

Nawser Ali shows us how the decoration of majma setup brought his clients.

Nawser worked in a team. He was the main person, and had three assistants. The team required a mini truck to transport their equipment and ingredients from home to the locations of the majma.

They had more than two hundred different jars in which they kept various ingredients which were all nicely decorated. I often noticed that the colourful jars drew a lot of attention from the audience and from passing pedestrians.

Nawser and his team needed at least two hours to organize their pots and jars for majma street healing. They started organising their majma place in the afternoon. They got the decoration ready before Ashor prayer and began the first session after the prayer. When I first saw their majma street healing setup, I was amused by the decoration of jars. It was colourful, and all of the jars had a red top (see Figure 4.7). I wanted to know the importance of the red colour, but Nawser told me that it had had no connection with the medicinecolour. He just wanted the same colour for all of the heads of jars. Red was available, and pedestrians would easily notice the colour. That is why he chose red. Like other majmawalas, Nawser would expect huge gatherings at his majma street healing sessions. I found he was always successful in gathering an audience, and the decorative jars were one of the influential elements in his success.

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Figure 4.7: Colourful jars in Nawser’s majma street healing session in Dhaka

Source: Fieldwork photograph, 2014-2015

In my conversation with one of the audience member, I saw the red jars were drawing peoples’ attention to majma street healing. The first look of the painted jars made pedestrians curious about majma street healing. They started learning more about the jars.

On a Friday afternoon, Kalam, a client of Nawser, shared his experience with me. When I first saw Kalam, I was sitting next to Nawser. Nawser was taking his last moment’s preparation for the session, testing a microphone. I saw Kalam looking at the jars and trying to see the elements in them. When Nawser started the session, I saw that Kalam listened to the whole session very attentively. Afterwards, in my conversation with Kalam, he described his curiosity about the jars.

I was on my way to a friend’s house. Suddenly, I saw those jars. I have seen many majma before but the way this majmawala decorated the jars, it was incredible. I came close to see what there was in the jars. Then he started his talk. I could not leave the place but listened to him. He was telling us about the jars one by one. - Kalam, A client of Nawser Ali

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Kalam was there for the whole session. At the end of the session, he bought medicine from

Nawser. The colourful decoration attracted Kalam’s initial attention, the speech of the healer convinced him, and he purchased medicine from the majmawala.

The production of medicine in public gives an opportunity for the audience to see the ingredients that are used in what proportion. My majmawala respondents described their reason for making medicine publicly. They wanted to be accountable and honest with their audience. They wished to mix real ingredients into the medicine. Didar described his reasons:

In my medicine, I use more than a hundred natural items. Herbs, honey, fruits, seeds are my items. All are natural. Allah gave us as His gifts. We need to know the usefulness of His gifts. You see these bottles. I have all these items here. I will make my medicine now so that you can know what I am mixing. I could make my medicine at home. If I did that, you might think I did not use proper ingredients. Now I will make it in your presence. You will see, and you will realize the quality of my medicine.

- Didar, a majmawala in Dhaka, Bangladesh

Didar also used decorative ingredient jars, but he did not use a single colour like Nawser. Still, his hundred jars with multicoloured tops were attractive. While he was describing the reason behind the public medicine production, he started mixing different ingredients. He was mixing ingredients one after another, and telling the audience what proportion of each was necessary. He would first say the name and then use a spoon to take each ingredient. The audience would watch the movement of the spoon. The spoon moved from the jars to a big bowl, where Didar was mixing the ingredients (see Figure 4.8). The eyes of the audience were following the spoon, from the jars to the bowl, intent on the majmawalas speech and actions.

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Figure 4.8: The moving spoon

Source: Fieldwork photograph, 2014-2015

Fajol Mia’s production of medicine majma was even more interesting and attractive. Fajol Mia had an old motor car. He used the car for transportation, but it had another use, too. He used the car bonnet as a table in his majma street healing sessions (see Figure 4.9). His medicine was also interesting and attractive. He sold genital massage oil that he made from leeches. He carried live leeches and displayed them in three different plastic pots.

Figure 4.9: Live leeches, photo album, and the massage oils on a car hood

Source: Fieldwork photograph, 2014-2015 112

I saw a clear curiosity on pedestrians’ faces about the live leeches on the car hood. Most of them stopped for a moment to see the leeches in the plastic bowls. Fajol Mia picked up on that curiosity and started describing the oil and the leeches.

These are leeches. Most of us are afraid of leeches and think they will suck our blood. They are correct, but you can use leeches for your health. You can make oil from leeches and use the oil for the betterment of your sexual power. I will describe the oil making process. After that, you will be able to make the oil at home. In the preparation of leech oil, you will need a coconut first. Peel off the fiber of the coconut; after that make a hole in it, and through that hole put some leeches inside the coconut. Put some salt in the coconut to kill the leeches. Then mix some olive oil in the coconut. With all of these, you will need to close the hole very securely. Once you firmly closed the hole, you can leave the coconut under mud for at least a month. The leech will produce the oil within this time.

- Fajol Mia, a majmawala in Dhaka, Bangladesh

First the leeches, and then Fajol Mia’s description of leech oil making gathered a large, attentive audience. While Fajol Mia was describing the oil making process, he was also pulling leeches around with a stick. The leeches were moving in the bowl while he continued to tell of the oil’s usefulness. He passionately relayed the story of a bloodsucker worm that he transformed into the raw material for sexual health remedies.

The production of medicine in public allows time for the majmawalas to continue to attract and engage their audience. It also creates a space where the audience can learn about the medicine. My majmawala respondents thought that this public production allowed them to show the authenticity of their medicine. During the preparation, the majmawalas provide the references of the efficacy of their medicine. Mostly, they provide Islamic religious references. In the following section, I describe the religious aspect of the street medicine production and its role in public engagement.

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The use of religion in approaching the audience members to sell medicine The Holy Quran is the most important book for Muslims. They believe the message of the book is from Allah48. They believe every instruction in the Holy Quran is useful for human wellbeing.

Thus, an instruction on health from the Holy Quran will have general acceptance among Muslims.

I found majmawalas were very keen to point out references to their medicine from the Holy Quran.

All of the seven majmawalas referred to the Holy Quran when explaining the importance of their medicine. However, Baktiar made the most use of this strategy.

Baktiar presented ‘honey’ as the best gift from Allah. He recommended that the audience drink honey for the protection of their health. In that session, while he was mixing honey with other ingredients, he described the quality of honey based on his Islamic understanding of healing. He quoted different verses from the Surat An-Nahl49 of the Holy Quran to show the healing power of honey. At some stages, he would recite first in Arabic then give the meaning and interpretation in Bangla. Baktiar continued this for five to ten minutes, repeating the verses and explaining the meaning of the Arabic words. He was emphasizing an instruction from the Quran to use honey for healing: ‘there is healing for people.’ After the interpretation, he paused for a moment, looking at the audience. He then recommenced the discussion and asked for the audience’s opinions regarding his medicine.

My Allah advises us to take honey regularly. Don’t you think my medicine will help you if I make it with this honey? Brother, can I make a medicine for you with this pure honey?

- Baktiar, A majmawala in Dhaka, Bangladesh

48 According to PBS (2016), Archived “For Muslims, God is unique and without equal. They attempt to think and talk about God without either making Him into a thing or a projection of the human self. The Quran avoids this by constantly shifting pronouns to discourage believers from inadvertently reifying God and creating any physical image of Him. God is known in Arabic as Allah”. Please see http://www.pbs.org/empires/islam/faithgod.html (last accessed on 02.10.2016)

49 The Quran has 114 Surah (chapters). Surat An-Nahl is the sixteenth surah of the Quran.

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Audience members were quiet. Most of them were nodding their heads in support of Baktiar’s arguments. For a while, Baktiar paused to observe the affirming response, and then he continued making the medicine. Later I crosschecked the reference with the Holy Quran and I found that he had recited Ayat50 68-69 (Verses 68- 69)51 of Surat An-Nahl (The Bee). The verses were:

Ayat 68: And your Lord inspired to the bee, “Take for yourself among the mountains, houses, and among the trees and [in] that which they construct.

Ayat 69: Then eat from all the fruits and follow the ways of your Lord laid down [for you]." There emerges from their bellies a drink, varying in colors, in which there is healing for people. Indeed in that is a sign for a people who give thought.

While Baktiar was reciting, there was silence among the audience. They stopped moving; some of them closed their eyes to concentrate more on the recitation. Muslims believe that listening to the recitation from the Quran is part of their prayer. They achieve the kindness of Allah in listening to the Quran.

The recitation of the Quran and more specifically the Ayat 68-69 (Verses 68- 69) of Surat An-Nahl was familiar in majma street healing, but It was not the only use of religious connotations. They also often named their medicine in Arabic and showing their devotion to religion.

The majmawalas showed their devotion to religious leaders. It was another aspect of involving religious ideas in engaging people in majma. A pir (spiritual, religious leader) is a famous religious person in Bangladeshi Muslim culture. There is a general confidence among followers that a pir

(পীর) can solve any crisis. Even the dead pirs and their mausoleums can be a way to get help. It is important to note that not only the general public are followers; even in Bangladeshi politics pirs and their shrines have significant influence (Mohsin, 2004). It is common that political leaders

50 A synonym of Ayat would be verses. 51 The English translation of Ayat 68-69 (Verses 68- 69) of Surat An-Nahl (The Bee) has collected from sahih translation. The link is http://quran.com/16/68-69#0 (last accessed on 10.03.2016). 115 would have a connection with a shrine, and even some of the political party chiefs start their election campaign from a shrine. For example, the current Prime Minister of Bangladesh began her 2009 election campaign from a shrine in the north-eastern town of Sylhet52.

Majmawalas show their respect to the pirs, and often describe their charismatic power. One of my majmawala respondents, Kashem Ali, claimed to have a good relation with the shrine of

Chormonai pir. He got the name of his healing centre from the shrine. He described the occasion in a majma.

This is Mujahid dawakhana (Mujahid healing centre). Chormonai Pir shaheb came to my dawakhana, and he gave the name for my dawakhana - Mujahid dawakhana. - Kashem Ali, a majmawala in Dhaka, Bangladesh

The late Maulana Syed Mohammad Fazlul Karim, known as Chormonai pir53 is one of the pirs who is popular among many Muslims in Bangladesh. The naming history of the healing centre established a connection between the followers’ belief and the healing session. The followers of that pir could feel more attachment to a majmawala who was also a follower of a well-known pir.

In an interview with Manik, one of the clients of Kashem Ali, I observed the influence of the pir.

During the conversation Manik said,

My whole family follows Chormonai pir. I have been going to his Mazar (shrine) since my childhood. He is a blessing for us. That majmawala (Kashem Ali) has a good understanding about pir shaheb. He is a follower too. That is why I brought his medicine. I believe it will help me to recover my problem. - Manik, a client of a majmawala in Dhaka, Bangladesh

Manik’s position regarding Kashem Ali was rooted in his trust of Chormonai pir. He was convinced by Kashem’s talk when he came to know the connection of the medicine with the pir. Like the politicians in Bangladesh, Kashem Ali knew the influence and the usefulness of a pir in his healing.

He could convince some of the clients to purchase the medicine only because of his connection

52 Please see details VOA (2009) story http://m.voanews.com/a/a-13-2008-12-11-voa51-66737857/561854.html (last accessed on 21.06.2016 ) 53 Please see details the Daily Star (2006) story http://archive.thedailystar.net/2006/11/26/d61126061975.htm (last accessed on 01.03.2017). 116 with the pir. Therefore he, like other majmawalas, used religion strategically in their business.

During their medicine preparation, they were repeatedly referencing those religious aspects to engage their audience and convince them to buy.

Showing efficacy in approaching to the audience members for selling medicine The public production of medicine is not always enough to convince people of its authenticity.

Often the audience members did not demonstrate an interest in purchasing medicine if they did not see any evidence of outcome of the medicine in the majma street healing session. Majmawalas offered samples after the production. The offering of a sample was to show the immediate effect of the medicine, and to demonstrate its efficacy. By showing that the medicine has a an immediate effect, the majmawalas could gain the trust of the audience and thus sell more medicine. It was a common tactic in all of my majmawala respondents’ majma. Figure 4.10 shows the distributing of free samples to an audience.

Figure 4.10: Distributing a free sample to the audience

Source: Fieldwork photo 2014-2015

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After completing the preparation of the medicine, Nawser would distribute free samples to the audience while continuing to explain the benefits of the medicine. He confirmed for the audience that they would feel an immediate effect from the medicine.

You do not need to wait to see the function of my medicine. You will get the result now. I would not sell a medicine that you would take here and that started working while you were at your home. Grab my medicine now and get the instant result. If you have an erectile problem, I will solve it now. Test the medicine and see the function of my medication.

- Nawser, a majmawala in Dhaka, Bangladesh

Nawser gave a clear offer to the audience to examine the efficacy of the medicine. Similarly, Didar claimed an instant result from his medicine too. Didar described how his medicine worked.

I would request my brothers who have been suffering from the erectile problem to take my medicine. I would ask my brothers who have been suffering from premature ejaculation to grab my medicine. Just after taking my medicine, you will see the changes in your penis. It will regain its power. - Didar, a majmawala in Dhaka, Bangladesh

An instant result was an important aspect of establishing healing authority for majmawala.

After offering the medicine often majmawalas ask their audience to describe their experiences and say whether they notice any change in their body. In one of his sessions, when Abbas was distributing a free sample of his medicine, he asked the audience to bring their right hand only so that he could place the medicine on the palm. He was expecting a level of respect for the medicine from the audience. Taking medicine on the palm of the right-hand showed that respect. After completing of the distribution, he asked the audience to take the medicine in the name of Allah.

Abbas loudly pronounced ‘Bismillah’ (in the name of Allah), and the crowd followed him and started chewing the medicine slowly. Abbas watched the reactions of the crowd.

The audience took less than one minute to take the medicine. When he confirmed that everybody had had their medicine, he asked a volunteer from the audience to share their experience. He openly invited, ‘Brother, can any of you come and share how was it’. The crowd was hesitant to

118 volunteer. He asked again. Then, he found five volunteers raising their hands for sharing their experience. ‘Okay brother, you tell me – how was it’ – Abbas pointed to an audience member. ‘I am getting a hit inside of my body. It seems something is happening’. The audience member answered. Abbas went to the second volunteer and got a similar answer. The third, fourth and fifth volunteer shared the same experience54. Abbas gave a look to the audience and said, ‘See, something is happening inside of their bodies. I am sure all of you have the same feeling.’ This was an implicit reference to sexual desire and erection. Abbas then asked the audience if anyone was interested in purchasing the medicine. I saw more than ten men raise their hand to buy the medicine.

Abu-Bakkar had two different types of medicine SM55 Bonaji Postai Halua and SM Sex Malish. SM

Bonaji Postai Halua was for semen loss and premature ejaculation. SM Sex Malish was massage oil for erectile dysfunction. He made the massage oil at his home and the SM Bonaji Postai Halua during majma street healing sessions. After the preparation of the SM Bonaji Postai Halua, Abu-Bakkar offered free samples to the audience, but he did not provide free samples of the massage oil. It was only for sale. However, he guaranteed a good result for both of the medicines.

My brothers who have been suffering from premature ejaculation, come to me. Whoever is in an embarrassing situation, come to me. Take my medicine and go home. I challenge, today you will be a different man. When you go to your partner, you will not be embarrassed anymore. Your partner will be happy and will ask you the cause of your new performance. If you tell her about my medicine, she will advise you to take it regularly. - Abu-Bakkar, a majmawala in Dhaka, Bangladesh

Abu-Bakkar assured his audience that they would be able to perform better. Abu-Bakkar described the future performance of the prospective clients and mentioned that it would enhance their capacity of the clients to a level that their partner would be surprised with

54 I was curious to know about those volunteers whether they had a previous agreement with majmawalas. During my fieldwork I did not find any such arrangement. They were random audience members.

55 SM refers to Abu-Bakkar’s majma street healing trading name. He used SM as an acronym for the Bangla words Shusto Manus (SM) healthy people. 119

The majamawalas used several strategies to sell their medicine to their audience. They maintained a practice of public production, justified the medicine on religious grounds and showed or gave a guarantee of the efficacy of the medicine. In each of these strategies, they tried to establish their authenticity and the value of their medicine.

I was interested in the responses of clients regarding the efficacy of the medicine. In my interviews with the clients, I asked them about the effects of the medicine. Out of seventeen clients, five had bought the medicine but had not actually taken it prior to the interview. Obviously, they were not sure about the results. Two clients had mixed experiences. They claimed that sometimes the medicine worked, and sometimes it did not. Out of seventeen, ten clients confirmed that they experienced a benefit from the medicine. Among these ten respondents, seven were suffering from premature ejaculation, and three from erectile dysfunction.

The majma street healing – a group consultation method on men’s sexual health Majma street healing engages the audience as a group. It does not require individual information or consultation. The majmawalas discuss the various aspects of men’s sexual health problems with the whole group; they do not target any individual. The nature of the group consultation provides a space for the individual and makes them comfortable hearing the advice on sexual health.

I see the whole majma process as a male-centric group consultation. In my observation of majma street healing, I found that the majmawalas addressed the audience as ‘brothers’ and connected with them as a collective entity - a male group. After gathering men in a group, the majmawalas

120 described various aspects of men’s sexual health issues56. They discuss sensitive sexual issues in general, but never the problem of a particular person. From an audience member’s perspective, it was useful for me to follow the description of issues and I could compare the description with my health issues too. Without disclosing any sensitive information, anyone in the audience group could receive advice for their sexual health - although in some ways, the purchasers of the medicine were revealing their sexual health problems.

Revealing a sexual ‘problem’ can be a source of disgrace. In the introduction of this thesis, I told the story of Hasan, and we saw how difficult it was for Hasan after disclosing his sexual health problem. Therefore, men in Bangladesh prefer not to disclose their sexual health issues to others.

They see any sexual health issue as a weakness in their manhood. Mostly, men in Bangladesh feel shame in explaining their sexual health concerns, and thus, most do not want to go to a professional health provider where they would need to discuss their problem in person. Out of the seventeen clients, I found only two who had visited the professional health providers57 for their sexual health concerns.

The fifteen clients who had never visited a professional health provider expressed their concern about shame in disclosing their sexual health problem. One of those fifteen clients was Sumon.

He described his opinion:

How can you go to a doctor with this issue? They would ask everything. I cannot tell them my problem. It is embarrassing for me.

- Sumon, a client of a majmawala in Dhaka, Bangladesh

56 There is a discussion on the sexual health issues in the following chapter. 57 The professional health providers were the biomedical doctors. 121

Another client who had never visited a professional health provider was Zamil. He shared similar concerns to Sumon.

I feel shy talking about this problem. If I go to the doctor, they will ask a question to me. I do not think I can tell them my problem. That is why; I did not go to the doctor.

- Zamil, a client of a majmawala in Dhaka, Bangladesh

Headaet, another client of majma street healing, told of his discomfort in visiting a doctor.

If I go to a doctor, I will need to tell them my problem. I do not feel comfortable disclosing my sexual problem. If I go, I will need to say the problem to the doctor.

- Headaet, a client of a majmawala in Dhaka, Bangladesh

Like Sumon, Zamil and Headaet, Rakib shared his discomfort at the prospect of visiting a professional health provider. Rakib was one of the two patients who went to a professional health provider once and did not visit him after that. Rakib had erectile dysfunction. He was eagerly looking for a solution. He expressed his experience with me:

I went to a doctor with the problem. He asked me about the problem. I could not tell him my problem. It was so embarrassing to tell my sexual problems. He had his assistant in the room. He was directly asking my problem in front of his assistant. How could I say the sexual problem? I said another problem.

- Rakib, a client of a majmawala in Dhaka, Bangladesh

When I asked him what he said to the doctor, he answered,

I told him that I had a gastric problem, and asked for medicine for that.

- Rakib, a client of a majmawala in Dhaka, Bangladesh

The other client Sabbir had a similar experience to Rakib. He took one of his friends to the doctor’s office to describe his problem on his behalf. He told his experience.

I have a good friend. He knows everything about me. I asked him to come with me to the doctor. He went with me. When the doctor was asking about the problem, I

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could not say anything. I pointed my finger to my friend, and he told my problem to the doctor.

- Sabbir, a client of a majmawala in Dhaka, Bangladesh

We can see the level of discomfort among men in Bangladesh in regards to seeking sexual health care. This discomfort comes from the obligation to describe one’s sexual health problem to the provider. From a biomedical perspective, it is essential to diagnose the problem prior to prescribing treatment. As can be seen in this ethnographic description of majma street healing, personal disclosure is not required by majmawalas.

In a majma street healing, it is a majmawala’s responsibility to describe the nature of sexual health problem; the audience needs to listen and pick out the relevant narrative for their health issue. In addition to that, majma street healing gathers those with sexual health problems. Therefore, the gathering has a homogenous nature. It gives majmawalas an enormous scope to describe sexual health without embarrassing any man in the audience.

The whole majma street healing session has a sequence of narratives and acts which engage men.

It is not majma medicine which is the centre of a majma street healing session, but the majmawalas’ series of performances engage men in the majma. They also involve the audience members in their performance. Therefore, there is another group-based consultation aspect in majma street healing: the healing ritual. For example, when majmawalas distribute free samples of their medicine, they involve the audience members with a number of acts, such as asking for the right-hand palm. First, all the audience members extend their right-hands. After that, they follow the majmawalas and pronounce Bismillah before taking medicine. In this process, the audience members do not only take a medication but also they perform a ritual. This reminds me of Tambiah’s popular definition

(1979) of a ritual.

Patterned and ordered sequences of words and acts often expressed in multiple media, whose content and arrangement are characterized in varying degree by formality

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(conventionality), stereotypy (rigidity), condensation (fusion), and redundancy (repetition). (Tambiah, 1979: 119)

This ritualistic aspect in majma street healing creates a group character among the audience members into a group. They participate, perform and see others in the group who have a similar concern about their health. Therefore, seeking advice for a sensitive issue of sexual health is no more an individual struggle; rather the ritualistic engagements make things easier for them. They overcome the barriers of disclosing the sexual health issue and find a comfortable zone.

REFLECTION AND SUMMARY This chapter described the interactive healing process that occurs on the streets of Dhaka city. The majmawalas utilise a range of interactive techniques to draw the attention of the passers-by and engage them in their sessions. The presence of a large number of men and their attention to majma street healing demonstrate the majmawalas’ capacity to engage. The audience gathers and listens about a very sensitive topic: men’s sexual health.

The question of placebo effects and the possibility of biomedical trials to establish evidence will be touched on later in this thesis. In this chapter, the focus was on the medicine selling process and the majmawalas’ engagement capacity. In addition to that, the aim of this research was not to examine the pharmaceutical efficacy of majma street medicine; rather, I am interested in the sociocultural processes of majma street healing. However, I observed that majmawalas who failed to show a result from their medicine did not experience success in their sessions. Clients of majmawalas expected to see results, and those results were not limited to ‘scientific’ evidence.

Rather, an explanation in accordance with their everyday beliefs was necessary for them to connect majma street medicine to their own life. For example, the evidence from the Holy Quran helped majmawalas to achieve success in selling the medicine. The believers in Islam heard a justification

124 for buying majma street medicine. In this religious aspect, references to religious leaders also acted as evidence of the efficacy of street medicine. Thus, the combination of cultural evidence and physical efficacy contributed to the audience’s positive opinion of majma street medicine.

One description of majma street healing would be as a simple street business that sells product to its clients. That is a narrow idea of majma street healing that sees only the trading aspect. It is also important to consider the Bangladeshi context, where the discussion of sex and sexuality is a challenge, but one that the majmawalas are able to overcome. A broader description of majma street healing, then, acknowledges the success of the majmawalas not only in selling their products, but also in sexual health education. This view allows us to see a different side of Bangladeshi society, where people are ready to listen to sexual health concerns even in front of a mosque and between prayer times.

The techniques used in majma street healing can inform discussion on ways to reduce the challenge of discussing sex and sexual health. The following chapter describes what the majmawalas offer for sexual health problems during their majma street healing sessions.

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Chapter 5: The Majma Boyan - A Guiding Framework Underpinning the Majmawalas’ Approaches to Sexual Health

INTRODUCTION The majmawalas discuss their understanding of sexual health in the majma boyan (speech). They articulate a framework of meanings which draw together ideas about the body and male sexuality within the Bangladeshi socio-cultural context. The meanings they articulate both map onto existing ideas among Bangladeshi men as well as advance ways to think about changes in the social landscape, including the influence of the west and, in particular, biomedicine. Drawing on

Kleinman’s (1980) notion of an explanatory model58, this chapter analyses the majma boyan as a means to describe the framework majmawalas use in their conceptualisation of sexual health. A set of questions guide the outline for the explanatory model59. Based on Kleinman’s suggested questions, this chapter shows the majma explanatory model of sexual health in Bangladesh.

What are the sexual health problems discussed in majma street healing?

How are the causes of those sexual health problems explained?

How are the symptoms and sufferings of these sexual health problems described?

58 Please see details in Chapter 2. “[T]he notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process” Kleinman 1980: 105 59 Kleinman (1980) suggest the following questions for eliciting the details of patient explanatory models: 1. What do you call your problem? What name does it have? 2. What do you think has caused your problem? 3. Why do you think it started when it did? 4. What does your sickness do to you? How does it work? 5. How severe is it? Will it have a short or long course? 6. What do you fear most about your sickness? 7. What are the chief problems your sickness has caused for you? 8. What kind of treatment do you think you should receive? What are the most important results you hope to receive from the treatment? (Kleinman, 1980: 106) 126

What is offered in the majma to treat these problems?

In the following sections, I address each of these questions in order.

SEXUAL HEALTH PROBLEMS DISCUSSED IN THE MAJMA The majmawalas discuss a number of sexual health problems, both those that are part of biomedical discourse such as gonorrhoea, and syphilis as well as a number of sexual ‘performance’ matters such as premature ejaculation, erectile dysfunction, semen loss, penis size and shape. Their emphasis is always on performance centred sexual health matters and their consequences for broader aspects of health and wellbeing. It is important then to start this discussion with an analysis of meanings related to sexual performance, since it is these meanings which drive broader overarching ideas about sexual health for men in Bangladesh and provide a key sociocultural backdrop to how any sexually transmitted infections are understood. In the following sections, I discuss how the majmawalas define different sexual health problems.

Premature ejaculation In their discussion, the majmawalas argue that men require a minimum duration before their ejaculation in order to satisfy their female sex partners. According to my majmawala respondents the duration should be 20 to 30 minutes. They claim any duration less than 20 minutes is a premature ejaculation, and any duration less than 10 minutes is terrible premature ejaculation. They strongly promote the idea of prolonged sexual intercourse as a symbol of a healthy man.

The word birjopat, (বীর্যপাত) meaning ejaculation, is commonly used in the majma. The majmawalas use the word duroto birjopat, (দ্রুত বীর্যপাত) meaning quick ejaculation for the concept of premature ejaculation. They also use an analogy from everyday life for the concept of duroto birjopat, such as tarahura (তাড়াহুড়া), which means being in a hurry to describe a situation. The majmawalas see an

127 attitude of quick desire and little preparation as associated with the idea of premature ejaculation.

They believe any work without enough preparation can cause a premature result. In the context of sex, they show the tendency to hustle is synonymous to premature ejaculation.

Men are very active in the case of sexual things. They get sexual desire very quickly. They just need to see something sexy. But females’ desire is not like that, it sleeps. They need some sensational touches. There are some men who cannot handle it properly. When they try to touch their partner, they get wet on the top of their penis. They cannot even start it. - Fajol Mia, A majmawala in Dhaka, Bangladesh

The majmawalas explain the situation with the idea of not having enough power to stay fit for long-term work. They say ‘bashikhon thakte na para’ (বেশিক্ষণ থাকতে না পারা), cannot stay for long, which is ‘cannot have sex for a long time’, is a description for premature ejaculation. In their majma, all seven majmawalas discussed premature ejaculation as a prime concern among men in

Bangladesh.

A specific timeframe is often used to describe the nature of premature ejaculation. Baktiar, one of my majmawala respondents, described premature ejaculation as the most common concern among men in Bangladesh. He described the concern with a Bangla phrase ‘bashikhon thakte na para’. In a majma, he told his audience,

You start the work (sex), but cannot stay for long (bashikhon thakte paren na). 3 minutes, 4 minutes or highest 5 minutes, you have the capacity. Then you surrender. It is not only you. I observe many of us have the problem. You know we need at least a 20- minute capacity to satisfy our wives. But we can continue only 3, 4 or 5 minutes. We do our part only, but often do not think about our partners. - Baktiar, a majmawala in Dhaka, Bangladesh

Abu Bakkar, another majmawala respondent, described premature ejaculation as an embarrassment for men.

You asked your partner for sex. She was busy with her work. As you asked, she stopped working and came to you. You started and finished. She even did not feel

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anything. You felt shame. This is not only for a day. It is happening every time. You cannot escape from the embarrassment. - Abu Bakkar, a majmawala in Dhaka, Bangladesh

My majmawala respondents spent a lot of time explaining the nature of premature ejaculation.

They gave meaning to premature ejaculation as a matter of great embarrassment and of letting down their female partners. Women’s sexual satisfaction formed a significant part of the narrative even though this was driven by a ‘male centred’ construction of it.

Erectile dysfunction The majmawalas describe erectile dysfunction as a ‘desire in the mind that cannot be executed due to a particular inability’. They see that inability as a major concern for men in Bangladesh. Like premature ejaculation, my majmawala respondents used analogies in describing erectile dysfunction. I found four different analogies for erectile dysfunction in the majma. These are: jinish kharay na, (জিনিস খা女ড়ায় না), the thing does not get up, jontro kaj kore na (যন্ত্র কাজ করে না), the machine does not work, penis paralysis ( পেনিস প্যারালাইসিস), tempar haray fela, (টেম্পার হারায় ফেলা), losing one’s temper.

All seven majmawalas gave importance to erectile dysfunction in their majma. Abbas, one of my majmawala respondents, described erectile dysfunction with the analogy ‘the thing does not get up’. In a majma, he explained:

You feel sexual desire in mind, but your thing does not get up, jinish kharay na, (জিনিস খা女ড়ায় না). If you have this problem, you will need treatment. - Abbas, a majmawala in Dhaka, Bangladesh

Nawser, another majmawala respondent, described erectile dysfunction with the idea of penis paralysis:

You see a man with a paralysed hand or leg. He cannot move his hand or leg. Just like that a man cannot have sex with his paralysed penis. If you do not seek treatment for that, it will never erect. - Nawser, a majmawala in Dhaka, Bangladesh

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Didar brought the idea of losing one’s temper in describing erectile dysfunction:

You had a strong penis. Now, you notice your penis which was like a daikon radish is soft as cotton. It lost its temper, and the machine does not work. - Didar, a majmawala in Dhaka, Bangladesh

Temper is a commonly used English word among Bangla-speaking people in Bangladesh. It is used here as it would be with tempered steel, as a process to toughen or strengthen. There is, also another common usage of the word among Bangla-speaking people in Bangladesh, which carries the meaning of original quality. In this context, losing temper refers to losing the real functionality of the penis.

Semen loss concern The majmawalas see involuntarily semen discharge as a concern for men’s sexual health. They describe semen as an essential part of the body. It should not be wasted; hence any unnecessary loss of semen is a problem. Abu Bakkar described semen and semen loss then in the following terms:

We have 206 bones in our body. Bone has white semi liquid things in it. You can see it when a slaughterer processes bones of cows or goats. These semiliquid things are calcium. Our semen is produced from this calcium. If you lose your semen, you will lose your calcium. When you lose semen in your urine, it decreases a huge quantity of your calcium. That is why you lose your sexual power. - Abu Bakkar, a majmawala in Dhaka, Bangladesh

Abu Bakkar brought everyday examples into his discussion of human physiology. He described calcium as contributing to a healthy body. Therefore, he saw the loss of calcium through semen loss from the male body as a critical issue for male sexual health. Like Abu Bakkar, Nawser described the erosion of body calcium as a problem for men’s sexual power:

A male can have two kinds of calcium loss – through defecation and urination. We call calcium erosion through defecation amm (আম), and the other one as meho (মেহ). The calcium loss will decrease sex power. It will also reduce the eye’s power and brain power. It makes bones’ dry. - Nawser, a majmawala in Dhaka, Bangladesh

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Fajol Mia expressed his concern about semen loss. He saw nocturnal emission as one of the main sexual health concerns for men. He argued that nocturnal emission causes calcium deficiency and decreased sexual potency:

Be careful anyone who has nocturnal emissions; one nocturnal emission is equivalent to more than seven times of sex with your wife. You can lose excessive calcium due to nocturnal emissionss. It will reduce your sexual power. - Fajol Mia, A majmawala in Dhaka, Bangladesh

Fajol Mia warned his audience that nocturnal emissions would ultimately result in sexual incompetence.

Size and shape of penis The majmawalas talk about the length of the penis to demonstrate men’s masculine sexual power.

They take time to describe standard penis size. Like the ejaculation time, the majmawalas see a particular length as the essential length to prove male’s sexual capacity. My majmawala respondents described a minimum six to eight inches erect penis as standard penis size for a male. However, I observed a disagreement from Kashem Ali. He did not support the idea of eight inches as a standard penis size or the claimed capacity to increase penis size. He argued that it would depend on each male’s overall physical structure:

There are a few healers who claim that they can increase the penis size. I do not agree one can increase the penis. This is natural like overall height. You do not need to think about the size of your penis. Size does not matter. - Kashem Ali, a majmawala in Dhaka, Bangladesh

I observed the disagreement only in the case of penis size. Other than that, all seven majmawalas hold similar thoughts in the discussion of male sexual health problems.

Sexually transmitted infections and AIDS Sexually transmitted infections and AIDS are discussed in the majma street healing. The majmawalas describe STIs based on their understanding of germ. They describe a microscopic

131 germ as being responsible for those sexual infections. All of my majmawalas respondents told their audience that a microscopic germ was responsible for gonorrhoea, and syphilis.

Brother, you might hear about gonorrhoea, and syphilis. These diseases can transfer from one human body to another human body. A kind of very small germ lives in the body of gonorrhoea and syphilis. This germ is so tiny that you cannot see that germ with your eyes. If you have sex with a gonorrhoea or syphilis patient, there is a high chance that you will be affected with that germ. - Abbas, a majmawala in Dhaka, Bangladesh

When Abbas was describing his germ theory, he was trying his best to show an example of that tiny germ. He would search for something so that he could show the example to the audience. He took a small grain from one of his pots and told the audience that the germ would be thousand times smaller than that tiny grain. He also said that the medical doctors could see those germs with their high-power machines. It was interesting to see how a traditional healer group, majmawalas, combined their way of explanation with the biomedical explanation of STIs. However, one of my majmawala respondents, Didar, had a more accurate biomedical explanation of gonorrhoea, and syphilis. He described gonorrhoea and syphilis as caused by bacteria.

The patients with gonorrhoea or syphilis have bacteria in their body. These bacteria can come into your body if you have sex with them. - Didar, A majmawala in Dhaka, Bangladesh

Didar used the English word bacteria to describe the infections, and he also made a connection between those two infections. According to him, gonorrhoea was the primary stage of the infection and syphilis was the severe stage of infection.

All seven majmawalas mentioned the English words syphilis and gonorrhoea in their majma narratives. They described sexually transmitted infections as penis diseases and an outcome of an unsafe sex. According to them an example of an unsafe sex would be having sex with sex workers without using condoms.

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If you have sex with a sex worker without using a condom, there is a high chance that you will be affected. A few days after the sex, there is a possibility that you will notice some kind of pus in your penis. That is gonorrhoea or syphilis. You need quick treatment for those penis diseases. - Kashem Ali, a majmawala in Dhaka, Bangladesh

The majma narrative also discusses AIDS. I found that all seven majmawalas referred to ‘AIDS’ at some point in their majma, but there were no detailed descriptions of AIDS in the majma, and

I did not hear them discuss the concept of HIV. The majmawalas described AIDS as being like other STIs, but a very serious one, and warned their audience that they could become victims of

AIDS if they did not follow safe sex practices.

CAUSAL EXPLANATIONS OF MEN’S SEXUAL HEALTH PROBLEMS The majmawalas discuss the causes of men’s sexual health problems in majma. My majmawala respondents explained three different types of causes for men’s poor sexual health. These were poor food and smoking, everyday stress, and ‘inappropriate’ sexual practices. In the following sections, I discuss these three causes.

Food contamination and poor food habits The majmawalas blame food contamination and poor food habits as one of the causes for men’s poor sexual health. In contemporary Bangladesh, food gets a lot of public attention. In particular, the excessive use of formalin in different food items is a common problem. Formalin60 is a chemical which can be used as a solution in water to keep fruit, fish fresh and attractive. During

60 “Formalin is a colourless strong-smelling chemical substance usually used in industry of textiles, plastics, papers, paint, construction, and well known to preserve human corpses. It is derived from formaldehyde gas dissolved in water”. Please see details BIMC (2016) report http://bimcbali.com/medical-news/formalin-in-food.html (last accessed on 08.12.2016) 133 my fieldwork in 2014 and 2015, I noticed regular police action against the excessive uses of this chemical on fruit. In July and August in 2014, Dhaka metropolitan police found that most of the mangos from different parts of Bangladesh had excessive chemicals.

At the same time, stories about excessive uses of chemicals in food were common in newspapers.

The newspapers were also covering regular news of police action against that contamination. At the same time, in no way did I or probably most Bangladeshis believe that these actions were ever going to be effective in stopping the chemical contamination of the food supply.

The excessive use of chemical fertilisers and pesticides is a major concern to many Bangladeshi people. Anxieties about this have been raised in terms of everyday food items of vegetables, fruit, milk, fish and meat. Often, I observe anxieties among my family members, relatives and colleagues about the illegal overuse of chemicals in food growing and distribution. With this background, it was an interesting finding for me to find that food contamination also figured in the majma in association with men’s sexual health. All seven majmawalas were equally concerned about excessive chemical use in food production. In their narratives, they illustrated the consequences of this for sexual health. They argued that the chemical fertilizers, pesticides and preservatives were all damaging to human health. They described the contemporary food chain in Bangladesh as unhealthy, and that it was gradually decreasing men’s sexual ability.

Baktiar told his audience that Bangladeshi men in the past were stronger than contemporary men in Bangladesh. He thought that the poor food quality was gradually reducing their energy level:

What we eat today are full of medicines and chemicals. The hilsa fishes which we used to eat in our past were more tasty and nutritious. You will not get the same taste of the present hilsa. These are full of chemicals. The similar condition is in fruit. You will not see any flies in the fruit markets. Fruits sellers use formalin. That is why you do not see flies in the fruit market. How would you get energy from these contaminated foods? How would you work and do sex? - Baktiar, a majmawala in Dhaka, Bangladesh

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Baktiar’s statement shows the contemporary condition of chemical use in food and his concern about the food. He talked about the traditional fish, hilsa of Bangladesh. This is the most popular fish in the country. Most Bengalis would prefer to have a special meal with this fish. Like Baktiar other majmawalas discussed the golden past of Bangladeshi foods in their narratives. Often, they compared the sexual ability of males from the past and males from the present. They observed that men from the past were more capable than men today. They blamed contaminated foods for this weakening of men’s sexual ability. They argued that in the past, men could eat healthy food, and that is why they enjoyed a better sex life. In this context Fajol Mia told his audience:

The crisis of men’s sexual power was not so severe in our past. The generation of our grandfathers was lucky. They could eat good food. There were not taking in any chemicals in their food. But now all food is full of chemicals. We are eating poison. How could we have a sex life like our grandfather’s generation? - Fajol Mia, a majmawala in Dhaka, Bangladesh

The discussion of the sexual ability of the older generation and the young generation was a popular topic in majma narratives. I observed the tendency of this comparison in the daily life of

Bangladeshi people. In most contexts, I found people had greater confidence in the older generations. They thought that the older generation was more physically fit, as they had had fresh food, air and water. They blamed contemporary pollution for all kinds of deteriorations in health.

The majmawalas described the consequence of contaminated food in the human body, in order to provide a better understanding to their audience. Abu Bakkar discussed how physical damage was occurring from contaminated food:

When you eat contaminated food, it will damage your nerves. It will also create a problem in your digestion. In my healing understanding, if you have a problem in your digestion, it will be a problem for everything. You will not have good health. You will not have enough sexual power. - Abu Bakkar, a majmawala in Dhaka, Bangladesh

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The majmawalas saw good digestion as a basic requirement for good health. I found that all seven majmawalas gave particular attention to the digestive system, blaming contaminated foods for damaging the system.

In conversation with one of my majmawala respondents, Nawser, he gave me an explanation of food contamination. He blamed ‘immoral’ business practices for the overall damage to health. He claimed that greediness and the lack of moral practices in business made this situation worse. He argued that this process was reducing men’s health status and sexual ability. He saw this process as a silent killer. He was keen to create awareness against the silent killer but he also suggested that government should intervene immediately.

Everyday stress/tension The Bengali language has a tradition of using words from different languages. Some English words are common in everyday conversations. ‘Tension’ is one such word. Bengali speakers use tension as a synonym of another English word, ‘stress’.

The majmawalas blamed everyday life stress as one of the factors explaining male sexual incompetence. They explained how the demands of everyday modern life were inducing stress, and related this stress to men’s sexual health. They believed stress prevents men enjoying their sex life properly. They described everyday stress as reducing men’s’ self-confidence and sexual ability.

During my fieldwork, lower income groups of Dhaka city suffered earnings loss due to political instability. Frequent strikes and other political violence forced many factories to cease production61. This, of course, then led to a major shortfall in income for many people. The majma

61 See details Ahmed & Hume (2015). 136 narratives referred to these sorts of crises and their consequences for ‘tension’. Kashem Ali thus used political and economic crises to explain problems in men’s sexual health:

I know, due to different tensions, most of you are not able to do that work [sex] properly. This tension can come from a different condition. See the current condition of our country. Your expenditure is higher than your income. You are not sure about your job. You have tension in your workplace. The same tension is in your home. Your tension for house rent, tension for a tuition fee for your kids is at your home. How would you get money if you cannot work in this strike? How would you solve the demand of family if you do not get money? So, you will have tension all the time. Your brain would not work properly. How can you do that work [sex] properly with all these tensions? - Kashem Ali, a majmawala in Dhaka, Bangladesh

Kashem Ali discussed the impact of political unrest in everyday life. That political unrest was challenging many Bangladeshis’ capacity to earn their regular income. In his narrative, we see the link between economic affordability and a ‘proper’ sex life. According to him, economic hardship and its associated stress could spoil men’s sex life and sexual ability. Didar used the opposite context of the rich world to explain the importance of a stress-free life in men’s sexual health:

Sex is totally dependent on your mind. If you have sex without the tension, you can really enjoy it. Both you and your partner will need a tension free mind. If you can ensure that tension free condition, you will have good sex. It is not only for sex, you know you will need a tension free mind to do any kind of good work. Men from the rich countries do not need to think about kids’ tuition, house rent or food cost while having sex. So, they can enjoy it without having any tension. They get the real charm of sex. - Didar, a majmawala in Dhaka, Bangladesh

The majmawalas often discussed the importance of a stress-free sex life. In their narratives, poverty and poverty-induced stress are challenges for men’s sexual health. They explain the economic hardship produced stress in everyday life for many men in Bangladesh, which brought uncertainty to their lives. The majmawalas connected uncertainty with men’s sexual incompetence, where they saw men’s mental stress as a possible risk for men’s sexual health.

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‘Inappropriate sexual practice’ Men’s sexual practice is a popular discussion topic in majma street healing. The majmawalas judge sexual practice based on popular Bangladeshi understandings of sexuality. They advocate for

‘moral’ and ‘appropriate’ sexual practices, and see a range of ‘inappropriate’ sexual practices for men. My majmawala respondents pointed to four inappropriate sexual practices as causes for men’s sexual health problems. They thought these inappropriate sexual practices were weakening men, and were affecting men’s sexual health. According to my majmawalas respondents,

‘inappropriate’ sexual practices were masturbation, sex with sex workers, men having sex with men, and sex during menstruation. In the following section, I discuss majmawalas’ thoughts on

‘inappropriate’ sexual practices.

Masturbation All of my majmawala respondents described masturbation as a harmful act for men’s sexual health that causes men to lose their sexual ability. For example, one of my majmawala respondents, Fajol

Mia, explained the possible damage which could be done to the penis due to masturbation. He claimed that masturbation could damage different nerves of the penis and that it could hamper the

‘normal’ function of urinating, which could result in a poor male sexual organ:

If you discharged semen with your hands, you did a terrible mistake. You have misused your youth in your own hands. You have tortured your own penis. That is why your penis has got a poor shape and size. It does not work properly. - Fajol Mia, a majmawala in Dhaka, Bangladesh

The majmawalas described another harmful result of masturbation too. They saw masturbation as a voluntary and ‘abnormal’ semen discharge. They describe this ‘abnormal’ semen discharge as damaging men’s sexual strength. They often related the ‘abnormal’ semen discharge with their discussion of semen loss described earlier. They found masturbation as an abuse of bodily energy.

In a majma, Abbas described the issue of masturbation:

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Most of my clients have this problem of masturbation. They lost their energy and penis due to masturbating. I asked them, you know it causes many problems for you. Then why do you do that? Most of them have not any control on it. They lost their control, and they do it regularly. - Abbas, a majmawala in Dhaka, Bangladesh

The majmawalas showed even more concern about children masturbating. They suggested that masturbating from an early age could destroy fitness as well as their strength of maintaining sexual ability for future life. Nawser was particularly worried about young people:

Nowadays, kids in our country know how to masturbate. They cannot keep their body fit for their future. How would they become doctors and engineers? How would they control their female partner after doing masturbation in their all early life? They are destroying their own futures. - Nawser, a majmawala in Dhaka, Bangladesh

In the Bangladeshi context, doctors and engineers enjoy the best lifestyle for their better income, and so are often used as examples of success. In his narratives, Nawser used that example to explain the uncertainty of the futures for boys who masturbate.

The concern for semen loss in the south Asian context (Alter, 1992) explains why the majmawalas in Bangladesh worry about masturbation. Because semen is seen as the source of men’s strength, energy, knowledge and skill, the majmawalas consider masturbation an unnecessary loss of semen, and thus a problematic sexual practice.

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Sex with sex workers My majmawala respondents saw sex with a sex worker as another inappropriate sexual practice that is harmful for men’s sexual health. They saw sex with a sex worker not just as a possible cause of sexually transmitted infections, but also a cause of decreased sexual ability. For example, Didar explained that sex with sex workers could cause impotence and transmit diseases:

My brothers, who are having sex with sex workers, be alert. You will lose your sexual power and it will give you severe diseases. You will be affected with syphilis and gonorrhoea type diseases. Please control your sexual urge. - Didar, a majmawala in Dhaka, Bangladesh

Like Didar, all other majmawalas were vocal against sex with sex workers. Blaming female sex workers for STIs is obviously a continuation of the hegemonic masculine sexual understanding of sexual practices, which the majmawala respondents echoed.

Men who have sex with men The majmawalas convey a heteronormative socio-sexual structure in their understanding of sexuality. Therefore, sexual practices which do not fit with their understanding of heteronormativity, can be seen as dangerous to men’s sexual health. In this regard, the majmawalas identified men who have sex with men (MSM) as another inappropriate sexual practice which could cause sexual health problems. They characterized MSM as a moral aberration, and suggested it was a mistake of youth. They claimed that this mistake at a young age could be a source of suffering for men later in life. That is why a man who had sex with another man in his youth would later suffer from sexual incompetence. The majmawalas saw MSM as a much worse problem than masturbation.

In his speech, Kashem Ali declared MSM as adultery. He used a widely used word for adultery - jena (জেনা) to address this sexual practice. I observed that the word, jena, got extra attention in his

140 speech. Bangladeshi Muslims see jena as an unpardonable sin, and therefore, Kashem Ali emphasised the word.

Thoses who could not control themselves in their young age and had sex with other boys, they did jena. If you did that, you have lost both your current life and life after death. Due to this unpardonable sin you did, your penis will be impotent. You would not be able to have sex with it. Additionally, you will have a serious punishment after your death for the jena. - Kashem Ali, a majmawala in Dhaka, Bangladesh

The majmawalas mentioned MSM as a serious immoral act. They also gave a similar opinion in their session where they told about the possible risk of males’ impotency and punishment after death. All of them advised their audience not to become involved with such acts. The majma narrative on MSM is a reflection of Bangladeshi societies’ heteronormative understanding of sexuality. They see only heterosexual sexuality and do not acknowledge the existence of other sexual practices.

Sex during menstruation The majmawalas discussed sex during women’s menstruation as an inapproprite act in their speeches. They described menstrual blood as dangerous and hot, and able to burn the skin.

Therefore, they saw two possible risks in this context: i) it could be painful for the female and ii) it could damage the penis. They advised avoiding sex during menstruation. As Abu Bakkar suggested:

You should not have sex with your wife during her menstruation. It is a sin. It will be a torture for your wife. It will also damage your penis. It will burn your penis. Your penis will be darker. Your penis will be useless. - Abu Bakkar, a majmawala in Dhaka, Bangladesh

According to the majmawalas, the above ‘inappropriate’ sexual practices can contribute to men’s sexual health problems in Bangladesh. They saw men’s sexual practices through two different lenses: appropriate and inappropriate, and their classification was derived from the moral social codes of Bangladeshi societies. In this context, it is important to note that the majmawalas work

141 in the dominant heteronormative and marriage normative socio-sexual structures of Bangladeshi society.

SYMPTOMS AND SUFFERINGS DESCRIBED IN MAJMA In this section, I analyse the majmawalas’ speech on men’s suffering from sexual health problems in Bangladesh. They describe three different types of sufferings from sexual health problems for men. They describe the sufferings as physical, social and spiritual sufferings (see Figure 5.1). They place less emphasis on physical pain or suffering. Rather, they see men’s sufferings from sexual health problems as more associated with social and spiritual suffering.

Figure 5.1: The levels of suffering due to poor sexual health

Source: Drawing from reflection on the relevant data of the chapter

In the following sections I describe the majmawalas’ thoughts on men’s sufferings due to sexual health problems.

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Physical suffering Physical suffering such as bodily pain was not at the centre of the majma street healers’ narratives.

The majmawalas referred to physical suffering like penis damage when they discussed sexually transmitted infections such as gonorrhoea, and syphilis, saying that these infections could damage the penis and thus the men would experience bodily pain.

If you have gonorrhoea or syphilis, you will notice some kind of pus in your penis. You will also feel pain and irritation. If you do not take proper treatment you may have a severe problem in your penis. Gradually, the poison will go to the whole body and you will suffer a lot. - Abbas, a majmawala in Dhaka, Bangladesh

The majmawalas also discussed the suffering of having AIDS. They described AIDS as a deadly and non-treatable disease but did not characterise the types of suffering. As Didar described, “You might listen about AIDS. It is a deadly disease. Yet, there is no treatment for the disease.”

It is important to note that the majmawalas mostly explained this physical suffering as a possible outcome of sexual infections. However, as I have discussed earlier, they also see a connection of physical suffering with the habit of masturbation and sex during menstruation.

Social suffering In the context of social suffering, the majmawalas suggested that performance related sexual health problems could cause suffering in their social life. In this type of suffering, the majmawalas mostly discussed sufferings in conjugal life.

‘Male is six volts and Female is nine volts’ is one of the most popular narratives in majma in

Bangladesh. The majmawala use this statement to describe the ratio of sexual strength between men and women. Thus, they think a man would not be able to satisfy his wife unless he has enough sexual ability. They think failure to achieve a wife’s sexual satisfaction can initiate suffering in

143 conjugal life. According to my majmawala respondents, suffering in conjugal life would lead to the wife engaging in an extramarital affair.

The majmawalas see the possibility of a wife’s extramarital affair as the topmost risk in conjugal life. Often, they remind their audience about the role of a husband. One of my majmawala respondents, Baktiar, gave this advice:

Marriage is nothing but a sexual contract. A father or a brother wants to be sure about the sexual satisfaction of their daughter or sister. Therefore, they gave their girls to you. If you do not give her the satisfaction, you will break the contract. Your wife would not stay with you faithfully. - Baktiar, a majmawala in Dhaka, Bangladesh

In this part of his narrative, Baktiar started with the English sentence ‘marriage is nothing but a sexual contract’. He said the sentence three times before starting a further explanation. He explained that marriage gave a legal understanding of the sexual interaction between men and women. He claimed it was the man’s responsibility to satisfy his wife’s sexual needs. He thought weakness in men’s sexual ability would lead to their not being able to fulfill their responsibilities.

He saw this as a risk for unfaithfulness. Didar discussed it more directly:

Females have more power. They carry more urges as well, but they control themselves. If your wife does not get the satisfaction, she would not tell you anything. But if you have an impudent wife, she would directly tell you and would start having sex with other men. - Didar, a majmawala in Dhaka, Bangladesh

Didar gave an explanation of the sexual power of women, saying that a wife would usually keep the secret and would not talk about her husband’s weakness. However, he saw two other possible threats for a sexually weak husband – verbal abuse from the wife and the wife’s involvement in an illicit relationship. Like Baktiar and Didar, Newser narrated similar kinds of threats to men:

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If you fail to satisfy your wife, she will start having sex with other men. She would not listen to you. Rather, she would say to you, ‘you cannot make me happy; therefore, I go to other men. You would not able to do anything because you are weak’. - Newser, a majmawala in Dhaka, Bangladesh

Newser speaks of the helpless condition of a husband. He claimed that a man would not have a say about his unfaithful wife due to his sexual incompetence. Abbas also reminded his audience that a real man should have enough capability to satisfy his wife’s sexual urges. Otherwise, a husband would lose the faithfulness of his wife.

No matter what kind of valiant male you are, if you fail to satisfy your wife, she would not be faithful you. - Abbas, a majmawala in Dhaka, Bangladesh

All seven majmawalas discussed the possibility of extramarital affairs of a sexually unsatisfied wife.

They showed different news items of extramarital affairs from the newspaper as evidence to establish their arguments. Often the news was about a female who left her husband and joined another man.

The majmawalas describe the idea of conjugal happiness based on sexual satisfaction. They see a connection between conflict in conjugal life and social status. They say that men should have a respectful position in their family life. If they do not get proper respect from their wives it would impact on their social status, and they would lose their respectful position in society.

The majmawalas say that a man should have enough sexual strength to satisfy his wife. The popular discourse in Bangladesh says that a wife would not follow the instruction of a weak husband. She would not show proper respect to him. Such disrespect ultimately damages the social status of the man. All seven majmawalas showed their concern about men’s social life. Abu Bakkar explained the crisis in social life of a sexually weak male:

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You go to the wife for sex but cannot keep your semen for a minute. Your wife would think in her mind, ‘my husband, you can set the fire but should not then extinguish it’. What does a wife want from his husband? She may think about money, jewellery, but mostly she wants an erect penis. If you cannot erect your penis how can I call you a real man? Your property and wealth will not work here. Nobody will respect you if your wife starts misbehaving with you. We are men because we can erect our penis. - Abu Bakkar, a majmawala in Dhaka, Bangladesh

The majmawalas see a threat of conjugal conflict and unfaithfulness due to men’s poor sexual performance. They see this issue as being as much about social suffering as it is about bodily dysfunction, as it can bring dishonour for men. The majmawalas perceive dishonour as a central part of social sufferings for men, and so claim their own position as being indispensable to them in this situation.

Spiritual Sufferings All seven majmawalas were Muslims and thus, they discussed religious duty based on their Islamic ideas. The majority of Bangladeshi people are also Muslim and so the majority of majma audiences were Muslims, too. In the context of spiritual sufferings, the majmawalas referred to religious sufferings relevant for Muslims. All of my majmawala respondents discussed men’s sexual practices in the context of their religious obligations. They pointed out men’s sexual responsibilities toward their wives as part of their religious duty. They described how failure to ensure a wife’s sexual pleasure would be a spiritual suffering for a man.

Abu Bakkar described women’s sexual pleasure as a religious obligation for men. According to him, if men fail to fulfil their wives sexually, that means they do not complete their religious duty properly. Therefore, they will suffer after their death:

You would be a sinner if you failed to satisfy your sexual need. You will have to face punishment for that on the day of last judgment. There will be a sign on your forehead and everybody will understand - you did not satisfy your wife sexually. - Abu Bakkar, a majmawala in Dhaka, Bangladesh

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Like Abu Bakkar, other majmawalas discussed women’s sexual pleasure in the context of spiritual sufferings. Fajol Mia suggested that his audience must take proper care of their penis and their sexual ability. Abbas described sex with women and their full satisfaction as a mandatory religious duty. Didar went further. He described women’s sexual satisfaction as more virtuous than any other religious duty. All of them confirmed to their audience that an impotent man would not have success in his worship.

The most valuable organ of a male is his penis. You should take proper care of it. Allah has told about this in the holy Quran. Sex is a mandatory duty. So, take proper care of your penis. If your penis does not work properly, you will not benefit from your prayers. - Fajol Mia, a majmawala in Dhaka, Bangladesh

Allah has said a number of mandatory duties in the holy Quran. Sex between husband and wife is one of those mandatory duties. If you fail to obey the duty, you will be a sinner. - Abbas, a majmawala in Dhaka, Bangladesh

The most important worship in this world is having sex with your wife. If you are unable to perform it properly, you are unfit for any kind of worship. If you stay in a Mosque for the whole day, it will be useless. Who has no strength in his penis, has no respect for his God. If you satisfied your wife properly, it would be the best worship. - Didar, a majmawala in Dhaka, Bangladesh

The majmawalas saw sex with one’s wife as a mandatory religious obligation, and they referred to the holy Quran. They even claimed that sexually weak men would get no benefit from their religious activities if they did not perform well sexually.

Please tell me a truth - how could I come to this earth unless my father and mother had sex. This is not only my case. It is true for everybody. Allah has declared it in the holy Quran that a male should make his wife sexually satisfied. - Kashem Ali, a majmawala in Dhaka, Bangladesh

The majmawalas’ interpretation of the Quran was not always accurate. They tried to convince their audience from their own theological understanding. For example, like other majmawalas, Fajol

Mia also quoted from the Surah An-Nisa, one of the 114 Surah of the Holy Quran, and espoused a similar opinion to Kashem Ali, above. He also added that a religious leader with impotence

147 should not be able to continue his religious leadership, and suggested to his audience that they should not follow a religious leader who had impotence. The Surah An-Nisa discusses the unity of the human race and the mutual obligations of men and women towards one another; however,

I did not find this instruction in it. It is also important to mention that Islam, as a religion, has detailed instructions about conjugal relationships, and a full explanation of the Islamic understanding of women’s sexual rights is beyond the scope of this research.

In the context of spiritual suffering, an important part of the majma narrative is that the majmawalas raise the issue of sexual health and a husband’s obligation to his wife. They promote men’s responsibilities towards women and connect men’s sexual health to their conjugal life. The majmawalas show us that suffering from health problems are not only a bodily suffering, but also has connections with the overall understanding of the community.

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SEXUAL HEALTH SUPPORT IN MAJMA In the management of sexual health problems, I observed two different methods. One method was the majmawalas’ giving advice for different sexual health concerns, and the second was the majmawalas’ medicines. I describe these two aspects in the following sections.

The majmawalas’ advice for different sexual health concerns

Eat healthy food All the majmawala respondents suggested to their audience to have healthy food and drinks. They emphasised milk, fruit and honey, which they described as sources of energy for the human body.

For example, all of the majmawalas suggested to their clients that they drink a glass of milk every night, and to consume such healthy foods and drinks while they were taking medicine for their sexual health problems.

Avoid junk food and smoking The majmawalas expressed their concern about junk food and smoking, as they consider both habits injurious to overall health. I observed five out of the seven majmawalas advising their audiences to avoid smoking (the other two were smokers themselves and did not talk at all about smoking in their sessions). In place of smoking, the five majmawalas recommended the consumption of fresh food to their audience. They also argued that not smoking would save money, which could be used to purchase healthy food. They also argued that contaminated food, bad food habits and smoking were responsible for a poor digestive system. One majmawalas,

Abbas, advised his audience not to smoke and maintain a good food habit.

I know most of you are spending money on smoking and oily food (junk food). Brothers take my advice. Do not eat oily food all the time. Eat fresh fruit, vegetables and do not smoke. You will get a healthy life. - Abbas, a majmawala in Dhaka, Bangladesh

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Enjoy sex without tension The majmawalas saw stress, which is known as tension in the majma, as an obstacle for enhancing sexual performance. Thus, they suggested not worrying about everyday problems during sex, and claimed tension free sex would increase men’s self-control and allow them to perform better. One of my majmawala respondents, Didar, described the importance of stress free sexual practice, praising the openness and the stress-free sex life of Western society. He thought openness and a stress-free life ensured a better sex life in the West, and that Bangladeshi men keep a suppressed desire of sex all the time, and so they were unable to enjoy sex due to their stress. He provided an imaginary example to explain his argument:

Both you and your partner would enjoy if you could have a better understanding about sex. In the rich countries, they do not need to think too much about sex all the time. For example, if someone feels horny in the middle of something they would prefer to have sex with the partner at that time. They would come back to work with a cool head. They can work properly. But we cannot do that. We keep thinking about sex while working and we think about everyday needs while having sex. - Didar, a majmawala in Dhaka, Bangladesh

The majmawalas told their audience to enjoy the moment. They were well informed about the everyday pressures of their audience and suggested a coping strategy. According to Didar, that strategy could be openness and less worrying about everyday needs. He also thought that society needed to accept sex as a normal act. During his interview, he expressed his thoughts on openness.

A mature male and a mature female should have access to regular sex. They should not wait for their marriage. If I say this, this society will hate me. All kind of medical sciences will say it. I think a medical doctor will advise the same because sex is necessary for mature males and females. It helps to keep the normal mobility of blood cells and the brain. - Didar, a majmawala in Dhaka, Bangladesh

Didar’s comments on premarital sex are not likely to be welcomed in most Bangladeshi societies.

He knew that, and therefore, he never suggested it in his majma, but only in our conversation did he give his opinion

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Don’t jump into it, allow some time The majmawalas suggested a few pre-intercourse activities, or foreplay. They told their audience not to jump into intercourse immediately. They suggested touching, hugging and kissing before intercourse, and described how such pre-intercourse activities would enhance men’s sexual performance. The majmawalas also saw pre-intercourse activities as useful for stimulating female partners, saying that female sexuality needed stimulation for a proper response. They advised the audience to slow down in their actions. Fajol Mia told his audience members about foreplay.

Dear Brothers, do no jump into it. Allow some time. Touch your wife, hug her, and kiss her. She will enjoy it, and she will be ready for the final things. Do not be hurry, and you will be getting more times. - Fajol Mia, a majmawala in Dhaka, Bangladesh

Other majmawalas advised similar actions to their audience. They described foreplay as an essential part of a proper sexual relationship. Baktiar, another majmawala respondent, provided similar suggestions to Fajol Mia, and suggested to his audience to spend time with their wives before intercourse. He described that an understanding between sex partners is essential for a better sex.

Avoid pornography Pornography is widely known as ‘blue film’ in Bangladesh. The majmawalas suggested avoiding pornography. They think most men in Bangladesh rely on porno-centric sex ideas due to insufficient knowledge about sex, and that porno-centric sex ideas increase anxiety and misconceptions about sexual strength. I observed a high level of anxiety about pornography in the majma. The majmawalas showed their concern about the consequence on excessive dependency on pornographic elements and the new technological expansion of it. They blamed the expansion of mobile phones and the Internet for the excessive dependency on pornography, and claimed that pornography provoked inappropriate sexual practices, such as masturbation. Therefore, they suggested avoiding pornography. Abbas expressed his concern about pornography.

The Internet and mobile phones contribute to men’s inappropriate sexual acts. They watch dirty movies and get an addiction. - Abbas, a majmawala in Dhaka, Bangladesh

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Another majmawala, Abu Bakkar, thought that young boys were more addicted to pornography.

The addition to pornography influenced them to inappropriate sexual acts like masturbation.

A few minutes ago, a young boy came to my majma. He was talking about intercourse. I asked him, ‘where did you learn about this?’ ‘I watch this on my phone’- he answered. They watch blue films on their mobile phone. After watching blue films, they go to the bathroom for masturbation. They torture their penis. His penis will not have any energy left. What would this boy do with his female partner in his mature time? - Abu Bakkar, a majmawala in Dhaka, Bangladesh

The majmawalas were aware of the making of pornography, and told their audience that pornography was not from real life. They also suggested learning the difference between reality and pornography. Baktiar described the difference between film and reality.

I know what you feel after watching all of the blue films. You want sex hour after hour just like them. But listen to me, they are not real. That is in the film. You should know the difference between film and reality. - Baktiar, a majmawala in Dhaka, Bangladesh

Use of condoms The majmawalas advised their audience not to have sex with sex workers but they provided safe sex instruction as well. I found that all the majmawala respondents advised their audience to use condoms in the event of sex with sex workers. Abu Bakkar explained the importance of safe sex.

I know many of you will not listen to me and will go to sex workers. I give you an advice: whenever you will go to them, use a condom. It will protect your penis from diseases. - Abu Bakkar, a majmawala in Dhaka, Bangladesh

It is important to note that majmawala respondents had an understanding about safe sex and kept promoting the idea of using condoms. However, their understandings about safe sex showed their gender bias. They saw only female sex workers as a possible threat for STIs.

In majma street healing, any audience member can hear the advice. As I discussed in the previous chapter, the open nature of the majma street healing provides the opportunity for anyone to listen the majmawalas’ advice for different sexual health concerns free of cost. The majmawalas do not ask for a consultation fee, and therefore, even the non-client audience hear the advice.

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Medication for managing sexual health problems in majma The majmawalas provide medication for managing sexual health problems. I observed two types of medication in the majma, halua (হালুয়া), a mixture of different herbal ingredients, and malish

(মালিশ), massage oil. They offered halua for premature ejaculation, and erectile dysfunction, and also claimed that it helped to replace the energy lost through semen loss. The majmawalas offered malish for premature ejaculation, erectile dysfunction and for the problem of penis size and shape.

In Table 5.1 below I show my majmawala respondents’ medicines and their prices.

Table 5.1: Majmawalas’ medication and price62 Majmawala Medication Price Price Medication Price (BDT) Price (BDT) (AUD) (AUD) Didar Halua 50-100 0.76 -1.5 Malish 50 0.76 Abbas Halua 40-80 0.61-1.2 ------Fajol Mia ------Malish 50-100 0.76 -1.5 Baktiar Halua 100 1.5 ------Kashem Ali Halua 100 1.5 ------Abu Bakkar Halua 60-100 0.92-1.5 Malish 30 0.46 Nawser Halua 60 0.92 Malish 40 0.61 Source: Fieldwork 2014-2015

Among the seven majmawalas, three sold both halua and malish. Three of them sold only halua and one of them sold only malish. Didar sold both halua and malish. Depending on the container sizes, the value of halua varied from 50 to 100 Bangladeshi Taka, which was equivalent to less than 1

Australian dollar for a small container and less than 2 Australian dollars for a large container. A small container was suitable for two weeks per client and the large container for five weeks per client. He also provided malish, which was 50 BDT (less than 1 Australian dollar). Abbas sold only halua. He had two different types of containers. A small container was 40 Bangladeshi Taka and a large container was 80 Bangladeshi taka. Though the price was less than Didar’s halua price, the amount of halua was almost the same. He suggested a small container for two weeks per client and a large container for five weeks per client. Fajol Mia sold only malish in two different sized containers. The price of a small container was 50 BDT and a large one, 100 BDT. Both Baktiar

62 During my fieldwork, 1 AUD= 65 Bangladeshi Taka (BDT) 153 and Kashem Ali sold only halua, and they had only one size container. The price was also same: both of them asked for 100 BDT. Neither sold malish. Abu Bakkar sold both halua and malish. He had two different size halua, small one 60 BDT and large one 100. He also sold malish for 30 BDT.

Nawser sold both halua and malish. Both of his medications had one size, halua was for 60 BDT and malish was for 40 BDT.

The price of the medication was the only cost for a client in the majma street healing. Clients got a further one to one discussion if they wanted to. The majmawalas did not charge for that. Most majmawalas provided their mobile phone number, and they were available for any further discussion over the phone. All of my majmawala respondents confirmed that they were getting phone calls from their clients from time to time. Those phone calls were mostly about clients’ particular sexual health concerns, and the enquiries about the medication.

The low cost of a majma medicine is one of the reasons for the popularity of majma street healing in Bangladesh. Money is a challenge for many men in Bangladesh, and expensive treatments for sexual health concerns are beyond the means of many.

REFLECTION AND SUMMARY This chapter shows how detailed the majma street healing can be when discussing sexual health issues in Bangladesh. It also shows that the majmawalas follow a clear guiding framework in describing sexual health concerns. The narratives define sexual health problems, describe their understanding and the types of men’s suffering due to these problems, finally, give a range of advice and medications to manage them.

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In the majma description, we see the majmawalas emphasise men’s performance related sexual health concerns, describing them as having a combination of socio-economic and physical issues.

They see socio-economic issues like the availability of good food and a stress-free life as part of good sexual health, showing their broad understanding of sexual health. Although the majmawalas use a biomedical perspective to describe sexually transmitted disease, they do not see sexual health as an exclusive physical phenomenon but as an issue that is also explained by socio-economic, cultural and religious factors.

The majmawalas see the level of suffering from a holistic perspective too. They do not see suffering in men’s bodily experiences only; rather, their descriptions show men’s relation to social and spiritual worlds. The majmawalas see the level of suffering from a holistic perspective. They do not see suffering in men’s bodily experiences only; rather, their descriptions show men’s relationship to social and spiritual worlds. They connect men’s sexual health with men’s everyday social and religious life. The social expectations for a ‘real man’ include for example both earning a good income as well as being a sexually capable man. Gilmore (1990) has described this as a manhood making process and Arefeen (1986), Islam (2005) or White (1992) describe this as a feature of a strongly patriarchal system in Bangladesh. Majmawalas also reference the social and spiritual sufferings of men in Bangladesh. Important here is the wholeness of the majma narratives.

A biomedical perspective would not consider these non-bodily experiences in examining men’s sufferings, but majmawalas make this central. It gives us a better understanding of Hasan’s case and his level of suffering. Bangladeshi sexual health programmes fail to bring this discussion in their health promotion. Therefore, the majmawalas have a high possibility of utilising emic perspectives in describing men’s sexual health. In the context of sexual health management, the majmawalas suggest a healthy life style first, and then offer an affordable medication.

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Majma narratives also bring the importance of a better understanding of sex and sexuality. The majmawalas describe a gap between technological advances such as the internet and mobile phones, and their proper use, in particular in the context of pornography. At the same time, they advocate openness in sex and sexuality, and promote the importance of education to enhance knowledge about sex and sexuality.

At the centre of the majma narratives, men’s sexual insecurity is widely discussed. Arens and Van

Beurden (1977) describe masculine sexual ideas in Bangladesh, where sexual pleasure is perceived as exclusively a men’s issue. Their ethnography shows women’s sexuality is not an issue for consideration. Women are seen as only for men’s sexual pleasure. Therefore, when the majmawalas compare the sexual strength between women and men and when they describe women as sexually stronger than men, it may give scope to see women’s sexual agency. It may show an emic understanding where we see men’s vulnerability, and women’s sexual capability. But it is also important to acknowledge that the majmawala are active in the construction of male sexual health to justify the importance of their medicine. Therefore, when the majmawalas place emphasis on women’s sexual satisfaction, it provides an opportunity to see how men in Bangladesh perceive women’s sexual desire as well as providing a strategic marketing device within the majmawalas’ narratives of manhood. Thus, the illusive concept of women’s satisfaction, coupled with ideals of performance provided by the majmawalas are designed to deepen male insecurity and reliance on the products that they are selling.

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Chapter 6: The Meanings of Sexual Health among Bangladeshi Men

INTRODUCTION As in the previous chapter, I shall use a modified version of Kleinman’s (1980) explanatory models in order to set out a framework for understanding the majmawalas clients’ sexual health. This chapter asks the following questions to examine the dominant meanings in regard to sexual health among the majmawalas’ clients.

• What were the sexual health concerns identified by clients of the majmawalas?

• What were the causes the majmawalas’ clients described for their sexual health concerns?

• How did the clients suffer from those sexual health problems and what were the impacts and

implications?

• What type of health care did they seek and why?

I found strong congruence between the concerns of the clients and concerns of the majmawalas is perhaps not very surprising due to the majmawalas’ active role in the construction of male sexual health problems. However, I have drawn attention to this for the purpose of showing the value of working with community. It is the congruence which is the key to the opportunity to construct sexual health promotion in ways that actually work.

SEXUAL HEALTH ANXIETIES In this section, I discuss the first question, ‘What were the sexual health concerns identified by clients of the majmawalas?’ I found strong congruence between the concerns of the clients and the concerns of the majmawalas. The Bangladeshi men I spoke with who had frequented the majma street healing were more anxious about their sexual performance than sexually transmitted

157 infections. None of them spoke with me about concerns regarding HIV/AIDS or any other STIs.

Their anxieties centred around four issues: premature ejaculation, erectile dysfunction, semen loss and penis size. Premature ejaculation was the most common concern with nine out of the seventeen clients telling me this was their primary reason for seeing the majmawalas. Premature ejaculation was also the issue the majmawalas had told me was the most common problem

Bangladeshi men sought help for. Hence the men I spoke with appear to be reasonably typical in regards to their sexual concerns. I do not claim that Table 6.1 below is representative of all men in Bangladesh, but the pattern and focus of concern in regard to matters of sexual performance is at least representative of the majmawalas experience. It is also worth observing that the dominance of men in their 30s and early 40s also reflects my broad observations about which men are most likely to attend the majma street healing sessions.

Table 6.1: Sexual health concerns among the majmawalas’ clients Name Age (Years) Problem Murad Hasan 35 Premature ejaculation Badal 45 Erectile dysfunction Jewel 37 Semen loss concern Kalam 38 Penis size Manik 28 Premature ejaculation Sumon 33 Erectile dysfunction Zamil 28 Premature ejaculation Headaet 35 Erectile dysfunction Rakib 31 Erectile dysfunction Sabbir 28 Semen loss concern Sohel Rana 31 Premature ejaculation Rasul 29 Premature ejaculation Shahidullah 32 Premature ejaculation Easha Khan 42 Premature ejaculation Mitun 36 Premature ejaculation Eklas 38 Premature ejaculation Bony 42 Erectile dysfunction Source: Fieldwork 2014-2015

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Premature ejaculation Perhaps not surprisingly, the men I spoke with who were concerned with premature ejaculation understood a very similar framework for understanding this problem to the one explained by the majmawalas. Like the majmawalas, the men held a strong view about ‘a standard time’ for intercourse. Their anxieties always emerged when they realised they were not achieving the desired duration of intercourse. They complained to me about ‘not having enough time.’ They often used the three-word Bangla expression, somoy pai na (সময় পাই না), meaning ‘not getting time’. They also showed how they had learnt well from the majmawalas by using the same language. One of the clients, Zamil, described premature ejaculation with the same words that majmawalas used - duroto birjopat, (দ্রুত বীর্যপাত) meaning quick ejaculation. The usages of duroto birjopat were not common outside of majma street healing. Mostly, the clients shared a concern of premature ejaculation with the idea of time. As Eklas explained:

If you do not get enough time in doing sex, that is a problem.

- Eklas, a 38 year Bangladeshi man and a client of a majmawala

I have recorded the views of clients in regard to their perception of an acceptable duration for sexual intercourse in Table 6.2. It is interesting to observe how the idea of ‘premature’ is so different to that found in western biomedical discussions, where somewhere between 30 seconds and one minute is more likely to be found as the indicator of this problem (Waldinger et al., 1998).

Table 6.2: The majmawalas’ clients’ perception regarding the standard time for intercourse Name Age (Years) Standard time for intercourse (minutes) Murad Hasan 35 30-40 Manik 28 30-40 Zamil 28 40 Sohel Rana 31 20-30 Rasul 29 20-30 Shahidullah 32 30-40

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Easha Khan 42 20-30 Mitun 36 30 Eklas 38 20 Source: Fieldwork 2014-2015 Most of the men thought that at least 30 minutes were required for standard intercourse. None of them could prolong their intercourse for that duration. Four could not prolong their intercourse for more than five minutes and the rest could not continue beyond ten minutes. The strict metrics being applied by the men to their assessment of their sexual performance provided a clear-cut way of determining the existence of their problem.

Erectile dysfunction The second most cited sexual health anxiety was erectile dysfunction. As noted in the previous chapter, the majmawalas used the idea of jinish kharay na, (জিনিস খা女ড়ায় না), the thing does not get up, jontro kaj kore na (যন্ত্র কাজ করে না), the machine does not work, penis paralysis (পেনিস

প্যারালাইসিস), tempar haray fela, (টেম্পার হারায় ফেলা) losing one’s temper to describe erectile dysfunction. The clients used similar concepts in the explanation of their anxieties. For example,

Headaet used a Bangla concept sara dey na (সাড়া দেয় না), which means non-responsive, in the explanation of his erectile dysfunction. Headaet, a thirty-five-year-old who had a small business in

Dhaka, had been married for twelve years, but his wife and their children lived in their village in a

Norther District. He could not afford the expenditure involved in having his entire family live in

Dhaka. Thus, he lived alone in Dhaka for his business, and his wife took care of their family in the village. He could go home only once a month. Headaet regularly visited sex workers. In this regard his behaviour was at odds with the advice of the majmawalas who not only advised against sex with sex workers, but also described the behaviour as likely to lead to sexual health problems including erectile dysfunction. Headaet recently felt shame due to his erectile dysfunction:

I do not have enough control of myself. Whenever I get sexual desire, I cannot concentrate to anything but to release myself. From a young age, either I go to a hotel [sex worker] or masturbate. However, for the last six months, I have been observing a problem. I go to a hotel with a huge sexual desire, but my penis does not respond

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(sara disse na) (সাড়া দিচ্ছে না) to that. I am giving money to the hotel girls [sex workers] without doing anything. Often, they make fun of my situation. Some of them asked me to treat my problem before visiting them again. It is embarrassing for me. - Headaet, a 35 year old Bangladeshi man and a client of a majmawala

Headaet was not concerned that having sex with sex workers was the cause of his problems as the majmawalas described. Headaet was content to ignore the ‘moral’ advice of the majmawalas, but still valued their treatment advice. For him, it was ‘natural’ that in the absence of his wife, he would use sex workers.

Semen loss Whilst sexual performance is still at the heart of the anxiety here, semen loss has a very particular meaning in South Asia. Citing from Yogacharya Bhagwandev, Alter (1992) explained the concern some South Asia men experience due to semen loss:

Celibacy improves the condition of your semen. However, much semen you are able to retain, you will receive in that proportion greater wisdom, improved action, higher spirituality and increased knowledge. Moreover, you will acquire the power to get whatever you want (Alter, 1992: 63).

The clients of majmawalas in Bangladesh were like many South Asian men concerned about their semen loss. I observed two types of semen loss concerns among my participants. The first came from anxiety about masturbation and the second one was related to nocturnal emissions. The men considered semen loss a source of losing energy from the body. Weakness in the male body is often conceptualized in relation to semen loss. Among the seventeen clients, two clients expressed their concerns about semen loss. Those two clients Jewel and Sabbir believed that they did not have enough strength for their everyday activities due to semen loss.

Penis size Penis size was an important issue in the performance anxiety felt by some participants. Whilst only one man was concerned about his penis size, several men referred to it and, like premature ejaculation, they referred to a very specific benchmark for penis measurement. According to them,

161 the standard erect penis size of a male was subject to his overall physical structure, and the erect penis should not be less than the length of that person’s eight fingers. In this measurement, one would need to measure the length with the eight fingers vertically, without the thumbs. Based on this, I drew Figure 6.1 below.

Figure 6.1: The eight fingers measurement

Source: Drawing from field notes

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The popular idea of measuring the penis might not have a scientific basis, but it had a strong influence among many men in Bangladesh. During my fieldwork, I observed concerns regarding penis size in the discussion of majmawalas and their audience. The size of the penis was seen as related to the males’ capacity to satisfy their female partners. Therefore, less than the eight fingers penis size was an issue. For example, one of the clients, Kalam, was anxious about his penis size as he believed his penis was less than the width of his eight fingers in length. Therefore, he believed that he could not satisfy his wife sexually.

CAUSAL EXPLANATIONS This section addresses the question: What were the causes the majmawalas’ clients described in regard to their sexual health problems? Out of the seventeen clients, only two were not sure of the particular cause for their sexual health condition. The rest of the clients held firm views about the cause of their problems. Their descriptions were again very similar to the majmawalas’ descriptions of the causes for poor sexual health. It is interesting to observe the very different kinds of causative factors put forward, ranging from individual factors such as ‘too much masturbation’ through to the impact of unemployment. Table 6.3 summarises the clients’ views of the cause of their problem.

Table 6.3: The majmawalas’ clients’ views on the causes for their poor sexual health Name Problem Causes Murad Hasan Premature ejaculation Sex with sex worker Badal Erectile dysfunction Road accident Jewel Semen loss concern Excessive masturbation Kalam Penis size Not sure Manik Premature ejaculation Poverty, poor food Sumon Erectile dysfunction Poverty, poor food and everyday workload Zamil Premature ejaculation Unemployment, poverty Headaet Erectile dysfunction Excessive masturbation, sex with sex worker Rakib Erectile dysfunction Work pressure and economic challenges

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Sabbir Semen loss concern Nocturnal emissions due to watching pornography Sohel Rana Premature ejaculation Not sure Rasul Premature ejaculation Poverty, poor food Shahidullah Premature ejaculation Poor food Easha Khan Premature ejaculation Stressful family life Mitun Premature ejaculation Unemployment Eklas Premature ejaculation Masturbation, sex with sex worker Bony Erectile dysfunction Poverty, poor food and heavy workload Source: Fieldwork 2014-2015

Poverty and poor food Out of the seventeen clients, three thought that they suffered sexual health problems due to the quality of their diet, blaming poor nutrition for their problem. They believed that consuming foods containing chemicals (due to the excessive use of fertilisers) was the key problem for their sexual health.

Manik was very unhappy with his everyday food. He thought he was unable to have proper sexual ability due to the poor nutritional value of his food. Rasul thought the pollution and poor food made him sexually weak causing him to experience premature ejaculation. Shahidullah believed that due to poor nutrition; he was unable to prolong sex. He believed the poor food made him weaker. Thus, he was unable to have a proper sex and satisfy his wife.

There was another group of clients, who thought that along with the poor food quality their heavy workload made them suffer from poor sexual health. I found two clients – Sumon and Bony in this group. Sumon worked as an assistant mechanic in a motor mechanic shop, and claimed that his poor food intake and the heavy work pressure in the motor mechanic shop caused his sexual health problems. A similar explanation came from another client, Bony, a forty-two-year old who had been married for ten years. Recently, he had experienced erectile dysfunction. He had a desire to engage in sex but did not get an erection, making him frustrated and depressed. It was

164 embarrassing for him. Bony, a garments worker, thought his heavy workload was responsible for the problem. He had had to work hard since joining the industry, and he got little rest and very poor food. He blamed his profession and his poverty for his poor health condition.

You know the load in the garment industry. I work more than 12 hours every day. Most of the time I work in a standing position, I do not get to sit. I operate a machine. It requires heavy physical labour. I do not have any other option but to continue this work. I am the only earning person in my family. My wife and son stay with me. I need to send money to my parents back home. They need my money badly. My earning is not bad, but I have to maintain two different families. It gives me very little time to think about my health. I even cannot take rest properly. Even the food I eat is not sufficient for this work. I cannot spend money for good food for me. - Bony, a 42 year old Bangladeshi man and a client of a majmawala

There was a regular heavy physical workload in Bony’s profession, and he had no other choice but to continue doing this job. Like most Bangladeshi men, his elderly parents depended on him financially. Bony’s poverty did not allow him to look after his health, leading him to blame his socio-economic condition for his erectile dysfunction.

Everyday stress Out of seventeen men, three thought their everyday stress affected their sexual health. One of them was Zamil, and he blamed his unemployment on his sexual health issues. He had been unemployed for a long time, making him feel insecure about his future. This uncertainty haunted him all the time. Lately, he had experienced premature ejaculation, making him more depressed.

He did not feel comfortable meeting his friends or actively looking for a job. He spent his time mostly outside of his home to avoid questions from his family and relatives. He thought he was experiencing premature ejaculation due to his experience of unemployment. Another client, Rakib, also blamed the everyday stress of work pressure and economic challenges for his poor sexual health.

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Easha Khan thought his premature ejaculation started from his stressful family life. Easha Khan had been married twice and was experiencing family stress after his second marriage. He believed his premature ejaculation started from family conflict.

Sexual practices There was a group of clients who thought their particular sexual practices were responsible for their poor sexual health. There were five clients in this group. The most prominent example from this group was Murad Hasan, who I described in the introduction of this thesis. There were four more clients who believed their particular sexual practices were affecting them.

Jewel, a 37 year old rickshaw puller, did not feel strong enough. He was married, but his wife lived in his village, while he lived alone in Dhaka so that he could send a good amount of money to his family. He did not have the economic ability to bring his wife and three children to join him in

Dhaka. He had been visiting his wife only once every two months. He had had a habit of masturbating from an early age and felt he could not control his habit. He thought the separation from his wife made him even more dependent on masturbation, and so he now saw masturbation as a cause of his semen loss.

Similar to Jewel, Sabbir thought his physical condition was gradually weakening due to nocturnal emissions. Sabbir, a 28 year old fruit seller, had regular nocturnal emissions. He thought his excessive consumption of pornography was responsible. He also believed that his semen was not thick enough, and that this was another reason for the nocturnal emissions.

My semen is not thick enough. It is very light. Therefore, I have nocturnal emissions easily. If I dream about a girl, I would have a nocturnal emission. - Sabbir, a 28 year old fruit businessman

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Headaet had a habit of frequent masturbation from his childhood, and, as noted earlier, he was a regular visitor to sex workers. He believed his childhood habit was responsible for his current erectile dysfunction.

Eklas had been suffering from premature ejaculation. He thought his early life was responsible for that. He had been watching pornography for a long time, engaging in masturbation and visiting sex workers. Blaming his past sexual practices, he was convinced that this semen loss was at the heart of his premature ejaculation in the present.

Accident Badal believed he was suffering from erectile dysfunction due to a road accident. He had been a motor car driver for a business person’s family for the last ten years. Badal first experienced erectile dysfunction in his 30s, after a road accident. He received treatment from a medical centre for the injury but not for the erectile dysfunction. He did not bring the issue to the attention of his doctor as he did not feel comfortable describing the problem and initially, he thought the problem would resolve itself gradually. He had now waited years but had not experienced any improvement.

THE CHARACTERISTICS OF SUFFERING This section is about the third question of the chapter: How did the clients suffer as a result of their sexual health problems and what were the impacts and implications of this? It is important to acknowledge that the word suffering is used here to acknowledge the various ways that people may suffer. Suffering may include a ‘medical’ suffering but can also include anything that causes distress in whatever form the person experiences that distress. In this case the client group expressed to me accounts of suffering which broadly fit three categories: individual level (physical and mental) suffering, family level suffering and spiritual suffering. In this section, I outline the

167 three types of suffering expressed to me by the men, while acknowledging the potential for some overlap.

Individual level (physical and mental) suffering Due to poor sexual health, the men spoke of physical (body) and mental stress. Most of the clients saw physical weakness as an outcome of their poor sexual health. For example, Jewel blamed his physical weakness on semen loss. Jewel used the phrase shorire bol pai na (শরীরে বল পাই না), meaning

‘do not get energy in my body’ for describing his situation. During my interview with Jewel, I found him to be exhausted. He told me that in the last couple of months he was feeling sick very often. His sickness severely hampered his capacity to work as a rickshaw puller, which significantly reduced his earnings. He blamed his habit of masturbation for this difficulty. He believed that, due to excessive masturbation, he was losing semen, which was ultimately decreasing his physical energy. He believed the masturbation made him sick, and unable to make good money. He was looking for a solution that would help him to regain his physical energy.

Jewel blamed his semen loss not only for his physical suffering, but for his poor income. Poor income can impact on his family, and it can have implications in his everyday life. Thus, Jewel identified a cascade of suffering from an individual level through to a family level. Sabbir, who was also suffering from semen loss anxiety, was similarly concerned. He told me that he felt drowsy all day long. He believed his regular nocturnal emissions of semen made him weak. Sabbir also saw a relationship between his physical suffering and his income level. His chronic drowsiness was impacting on his capacity to run his fruit business. He could not set-up his fruit business everyday, and this resulted in a major loss of income.

Though Jewel and Sabbir were suffering from sexual health problems; they were still living a family life, and they were active in their profession. However, my experience with Badal was more painful.

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Badal first experienced erectile dysfunction in his 30s, after a road accident, and during my fieldwork, he turned 45 years old. Over the previous fifteen years, he had suffered from erectile dysfunction and he did not know what to do about the problem or where to go. Badal was unmarried and lived alone in a small room, where we had our conversation. Badal was emotional during his interview. It was the first time he had shared his story, and he was happy that at least someone listened to him. Before sharing his story, he told me, “I do not have a friend who would listen to my story. I cannot tell my family about my condition.” The shame and stigma associated with a problem like erectile dysfunction pushed Badal away from speaking with family, friends or health professionals.

Badal believed that he had nobody who could listen and give him advice. He chose not to marry and continued a single life. He kept avoiding his family, because they had been asking him to get married. He could not tell them his problem, as he believed that his erectile dysfunction was something very shameful. He was missing his family, especially his mother, and he had not seen her for a long time. Badal’s mother lived in a rural village in a Southern District in Bangladesh.

Shewanted to see her son married – it was her only wish in the last days of her life. She kept telling

Badal it was time for him to marry. Badal did not visit her for the last two years to avoid the

‘embarrassing’ discussion of marriage.

Badal described his life as meaningless, and he thought of himself as having no importance in society. Therefore, when a stranger like me was interested in his life story, he was surprised and touched. In our first meeting, he could not say anything about his problem but he asked me to meet him another day at his house. During the interview, he repeatedly told me that he got relief by sharing his story. Badal’s decision to not get married because of his sexual health problem weighed heavily on his capacity to see himself as having social worth.

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Family suffering In the opening chapter of this thesis, I described Hasan’s premature ejaculation and its effect on his life. Although Hasan’s case was perhaps an extreme example, it was not uncommon for individual sexual problems to become problems for a whole family. Indeed, most of the men I spoke with were worried about their family suffering.

For the men, I spoke with, it was not just that sexual performance was itself a problem which could result in family ridicule, it was the additional consequences which could ensue. Shoel Rana and Rasul believed that they were unable to be a father due to their problems with premature ejaculation. They believed that a minimum intercourse period was essential to conceive and that their inability to prolong intercourse was affecting their ability to have a child.

Sohel Rana had been married for six years. He and his wife had been planning for a baby for the last three years without luck. Sohel Rana thought that their infertility was due to his premature ejaculation. He thought it was important to have sex at least for 20 to 30 minutes at a time to conceive. But, he could only have sex for less than ten minutes. Therefore, his wife did not conceive. He wanted to have longer intercourse so that he could be a father.

Like Sohel Rana, Rasul had been concerned with his sexual health problem. Rasul had been married for two years. He had paid for a visa to enable him to work in Malaysia and planned to go in a couple of months. He wanted to be a father before his departure to Malaysia. In his absence, he thought a baby would play an important role in their conjugal life. They had been trying to have a baby for two years.

Rasul had been worried about his visa and his premature ejaculation. He had already spent a good amount of money on his visa application, and did not know how long it would take for it to be

170 processed. At the same time, he was worried about his conjugal life. He knew once he got the visa, he would need to go to Malaysia for at least three to four years. His visa status and the cost of travel would not allow him to visit his wife and he would not be able to bring his wife to Malaysia.

He saw having a baby as an important addition to his family during his absence. He blamed his poor sexual performance for not fulfilling his plan.

Both Sohel Rana and Rasul wanted to be fathers; and they strongly believed that their premature ejaculation was the real ‘problem’. In the Bangladeshi context, children are a very important aspect of married life; children bring social status for their parents. A childless couple will face questions every day. Even in my own married life, I had to face this situation. ‘When are you planning for a baby?’ was the most common question for us before my wife’s pregnancy. We had to face the question for at least five years. Friends, family members and relatives kept asking about our plan.

Thus, I can see the importance of babies in Sohel Rana’s and Rasul’s family life. In our case, we could clearly tell people that we did not want a baby at that time. In the case of Sohel Rana and

Rasul, they were struggling with a different reality. They wanted a baby, but they failed. Therefore, they had to face more critical questions from their friends and families. Rasul shared his humiliation with me.

My well-wishers ask me about our children. I cannot answer them properly. I do not know the answer, what can I say to them. - Rasul, a 29 year old Bangladeshi man and client of a majmawala

Sohel Rana had to face the possibility of a more critical condition. I know people started to call me atkura. Even in my absence, my friends call me atkura. - Sohel Rana, a 31 year old Bangladeshi man and client of a majmawala

Atkura (আ女টকুড়া) is a Bangladeshi term, used for a man who does not have the capacity to be a father. This is a matter of serious humiliation for a man. A man with the atkura identity will not have social respect in Bangladeshi society. He will not be able to give his opinion on any social 171 issue. He will be seen as an incomplete person. Thus, when Sohel Rana said that people started calling him atkura, he was sharing a sentiment of extreme social humiliation. Sohel Rana experiences humiliation in his social life, and Rasul feels insecurity in his family life. They blame premature ejaculation not only for their poor sex life, but also see it as intricately connected with their uncertain futures.

Bony was married and had a son but still faced humiliation because of his erectile dysfunction.

I take initiative when I feel the desire for sex. But my penis does not work. This is embarrassing. My wife does not say anything, but sometimes she laughs at my condition. I feel humiliation with this situation. My wife is a good person, and she will never complain about my incapability. However, I am not happy with this condition. - Bony, a 42 year old Bangladeshi man and client of a majmawala

Shahidullah commented that proper sex was essential for peace in family life. Shahidullah was suffering from premature ejaculation. His wife did not blame him either, yet he felt insecure. He thought his wife was not happy with their sexual relations. Shahidullah was concerned about his wife’s lack of sexual satisfaction.

I do not get enough time before my ejaculation. My wife does not say anything about this. But I can understand. She is not getting any satisfaction because of my premature ejaculation. - Shahidullah, a 32 year old Bangladeshi man and client of a majmawala

A wife’s sexual satisfaction was not of concern for all participants. Two clients Easha Khan and

Mithun, rather complained about their wives. Easha was married twice. He thought his first wife had been content with his sexual ability, but he was worried about his second wife. His second wife was young, and he thought she would not accept his poor performance. He was afraid that his second wife could start a fight any day as she did not obey him that much. The premature ejaculation he experienced could become more of an issue. Here the patriarchal nature of Easha’s marriage was being undermined by his lack of sexual performance. Like Easha Khan, Mithun saw

172 a similar threat to his family life. He believed that his wife did not listen to him properly, and she spent most of her time in his in-laws’ house. Mithun believed this was due to his premature ejaculation.

Spiritual suffering In this study, spiritual suffering refers to the crisis in religious life. The majmawalas discuss the religious obligation for the wife’s sexual satisfaction. They see it is a husband’s duty to satisfy their wife sexually, and say that failure to satisfy one’s wife sexually will cause religious suffering for men. I observed a similar understanding among the clients. For example, Manik believed that his religious life was not appropriate due to premature ejaculation. He wanted to maintain a proper religious life. He believed his wife’s sexual satisfaction was one of his major responsibilities as a husband. Thus, he was unable to reach the level of a proper follower of Islam without ensuring his wife’s sexual satisfaction. His sexual health problem made him insecure in his religious life, and he thought his religious devotion would be meaningless unless he could find a solution.

SEEKING SUPPORT FOR SEXUAL HEALTH PROBLEMS This section discusses the last question of the modified explanatory model: What type of health care did the clients seek and why? Out of seventeen clients, fifteen found that majmawalas were the most appropriate person for dealing with sexual health problems. Those fifteen clients sought support only from majmawalas. I observed three important factors for the high level of dependency on the majmawalas: 1) There was a general belief among the clients that the majmawalas were the appropriate persons for dealing with sexual health problems; 2) Clients were concerned about their financial situation; therefore, most of them appreciated the low cost of majmawalas; and 3) Clients were concerned about their privacy, and they did not want to disclose their sexual health problems to health professionals. One of the clients, Sohel Rana, sought

173 support only from a majmawala. Like the other fourteen clients, he believed this kind of problem could be solved only by majmawalas, and that biomedical doctors were not useful for his problem.

He also believed that the majmawalas were the best at describing sexual health problems.

The majmawalas know how to explain the problem. They know what to suggest for the problem. I do not think I could explain my problem to a doctor. - Sohel Rana, a 31 year old Bangladeshi man and client of a majmawala

Privacy concerns were important when seeking sexual health support. The majma consultation helped clients maintain their privacy and avoided the ‘embarrassment’ of seeking help in a medical clinic. For example, Rasul did not feel comfortable going to a doctor and disclosing his ‘problem’ there. He wanted to keep his sexual health problem a secret. Somewhat ironically, he felt anonymous in the public space of the majmawala. The fact that many men stopped to listen made the act of being a ‘client’ somewhat ambiguous. He may be there just to be entertained or just out of interest. Certainly, he believed he would not be able to keep the secret if he went to a doctor.

Therefore, he found a majmawala a good solution. They would keep his secret, and he would not be humiliated by anybody.

Out of the seventeen clients, only Rakib and Sabbir went to biomedical doctors. Due to his uneasiness with the doctor and his concern about his privacy, Rakib never did explain his sexual health problem to a doctor, but rather sought help for a gastric problem instead. With the help of a friend, Sabbir did consult a biomedical doctor regarding his semen loss concern. At the same time, he felt no contradiction in also seeking help from a majmawala. So, he collected medicine from both a biomedical doctor and Baktiar’s majma.

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In addition to trusting the majmawalas, cost was another aspect in seeking support for sexual health problems from them. For example, Bony sought support only from majmawalas, as he found the majma treatment affordable. According to Bony, his wife suggested that he go to a biomedical specialist, but he did not want to because he knew it would be costly. As a result, he chose to visit Kashem Ali, a majmawala, instead.

Although the seventeen clients got different outcomes from taking majma medicine, most were very positive about the efficacy of majma treatments. Table 6.4 shows the clients’ responses regarding the efficacy of majma medicine.

Table 6.4: The majmawalas’ clients’ comments on the efficacy of majma medicine Comments regarding the efficacy of Name Problem majma medicine Murad Hasan Premature ejaculation Not sure Badal Erectile dysfunction Mixed Jewel Semen loss concern Mixed Kalam Penis size Not sure Manik Premature ejaculation Not sure Sumon Erectile dysfunction Benefited from the majma medicine Zamil Premature ejaculation Benefited from the majma medicine Headaet Erectile dysfunction Not sure Rakib Erectile dysfunction Benefited from the majma medicine Sabbir Semen loss concern Not sure Sohel Rana Premature ejaculation Benefited from the majma medicine Rasul Premature ejaculation Benefited from the majma medicine Shahidullah Premature ejaculation Benefited from the majma medicine Easha Khan Premature ejaculation Benefited from the majma medicine Mitun Premature ejaculation Benefited from the majma medicine Eklas Premature ejaculation Benefited from the majma medicine Bony Erectile dysfunction Benefited from the majma medicine Source: Fieldwork 2014-2015

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The clients who were not sure about the efficacy of majma medicine had only just started taking medicine during my interview period. Therefore, they were not yet sure about the results.

The two clients, Badal and Jewel, had mixed experiences. Both of them told me that the majma medicine sometimes worked and sometimes did not work for them. They did not have an explanation for that mixed outcome of the medicine.

I do not know why this is happening with me. When I take the medicine, sometimes I have a feeling I am strong, but sometimes I do not feel energetic to anything. - Jewel, a 37 year old rickshaw puller

The clients who thought they had benefitted from the majma medicine described their bodily changes to explain the efficacy of the medicine.

I could not hold my semen for a minute, but now I am better. I think that due to the majma medicine I can continue for longer with my wife. I hope we will be able to have a baby soon. - Rasul, a 29 year old Bangladeshi man

The majma medicine is a blessing for me. Now, I get an erection. Kashem Ali’s medicine is really working for me. I am very grateful to him. - Bony, a 42 year old Bangladeshi man

The clients have their own explanation to describe the efficacy of the medicine. They mostly see a bodily change as an outcome of the majma medicine. In chapter four, I explain that, during the majma street healing sessions, majmawalas try to produce some immediate result, so that they can show the efficacy of their medicine. They see the results of their medicine as essential to convince the clients to purchase the medicine. However, it is impornt to note that the efficacy of majma medicine can not be defined only with the medicine, rather we need to see the whole process of majma. The majmawalas discussion about sexual health, their narratives and their advice make the majma street healing a comfortable zone to discuss sexual health concerns. This particular characteristic of the majma street healing shows theefficacy of the process.

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REFLECTION AND SUMMARY During my fieldwork, I observed men’s interest in majmawalas. In most cases, I found the audience of the majma was very attentive to the majmawalas. In my interviews with the men, they spoke of the significance of their anxieties and their suffering. For many of them, majmawalas were the only source of support for their sexual health concerns. They provided an accessible, culturally appropriate, safe space to discuss their anxieties and generally provided affordable and efficacious responses to their problems. I do not claim that the responses of the majmawalas were

‘biomedically sound’, however, men sought out the majmawalas in preference to biomedical professionals; hence this situation deserves our attention.

Structural and social injustice, what Rashid (2007) called ‘a brutal political economy’, is a reality for the poor in Bangladesh. The men in poor economic conditions need to struggle for their livelihood and any social comfort. More often, they are the victims of social injustice. Their struggles in the system create insecurity in their life. For example, my participants who work in the garment industry complain about not getting their salaries. Often the garment workers in Bangladesh need to demonstrate on the street about their wages. The exploitation and difficult working conditions in that industry make garment workers’ lives insecure.

Those participants who pull rickshaws have a similar experience of exploitation. Often, they must pay part of their wages to an illegal syndicate that controls the rickshaw pulling network. They are not only subject to economic exploitation; there is also a high vulnerability to health problems in rickshaw pulling. Begum and Sen (2005) described the poor condition of rickshaw pullers in the city of Dhaka.

The unsustainability of the livelihood is related to the extreme physical demands of the activity, which are unrealistic in the context of poverty and malnutrition, and which result in high vulnerability to health shocks. (Begum and Sen, 2005:11)

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Even small businessmen who go for medicines to regain sexual power have to face difficulties in continuing their business. The police and local influential politicians ask for money from them, and they are forced to give them money to continue their business. None of the clients are free from structural and social injustice.

I see a strong relation between structural and social injustices and men’s performance anxieties.

Social injustice makes them insecure and that brings insecurity to family life. Thus, when a participant pays money for his work visa but does not know his visa status – it brings insecurity and uncertainty in his life. He finds the consequence of that insecurity in his family life and blames his sexual capacity for not fulfilling the family needs. Similarly, due to economic unaffordability, some participants live alone in Dhaka city. They are unable to bring their families to Dhaka. This separation from families also creates insecurities among them.

During the conversations with clients, I observed how poverty pushes them to helplessness. From the very beginning of their life, most of them had to earn money for their families. The struggle against poverty was the biggest challenge for most of the clients. The poor economic conditions pushed many of the clients to an insecure condition where they were not confident about themselves. Therefore, there is a strong impact of broader social, political, and material inequalities on men’s sexual health.

In addition to poor economic conditions, an image of masculine sexuality is at the centre of the majmawalas’ clients’ sexual performance related anxieties. In my conversations with the clients, I explored the sources of information regarding their sexual practices. None of the clients had received any formal sexual health education, and the idea of sex education was a new concept for them. They were not familiar with it at all. I found that pornographic elements had a significant impact in spreading concerns about sexual performance; all of the clients confirmed that they

178 watched pornography. Along with pornography, the street leaflets, posters, and sometimes television advertisements endorse a culture of masculine sexuality where prolonged sexual intercourse was presented as a symbol of a ‘real’ masculine man. In the context of a patriarchal society, that idea of a ‘real’ masculine man can produce more inequality and exploitation.

Bangladesh has a strong patriarchy. It reproduces a set of beliefs and practices among Bangladeshi men and makes them consider their role as ‘real men’. Culturally, the idea of a ‘real man’ defines men’s responsibilities to their families, their control of family members and social life. More importantly, the idea of a ‘real man’ reproduces ideas about the control of women and female bodies. In this context of sexuality, men in Bangladesh see the female body as a subject of sexual penetration and the establishment of their real manhood (Arens and Van Beurden, 1977). Their insecurity in everyday life brings challenges for the men to establish their experience of themselves as ‘real’ men. Thus, these sexual health problems challenged their manhood. They see poor performance in their sex life as the ultimate embodiment of their inability to establish their supremacy; and they search for a solution to regain their patriarchal authority.

The consumption of pornography in the context of a strong patriarchal society produces a hypersexualised, unrealistic masculine icon to follow. On the other hand, sexual health promotion in Bangladesh fails to address the social dynamics of pornography, sexual performance and its impacts on men’s health. Disease-based health promotion approaches fail to give attention to males’ actual concerns about their sexual health.

This chapter described sexual health anxieties among men in Bangladesh. It showed the urgent need for effective sexual health promotion programmes that can be of benefit to Bangladeshi men.

The Bangladeshi public health authority is concerned about that urgency. However, their dependency on external resources and an etic approach are not helping my participants. Public

179 health professionals also see the challenges of their current health promotion programmes. In the next chapter, I describe their thoughts.

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Chapter 7: The Challenges and Opportunities in Sexual Health Promotion in Bangladesh

INTRODUCTION At the beginning of this thesis, I outlined some of the challenges involved in sexual health promotion in Bangladesh. In this chapter, I address this topic again but now with specific reference to the potential opportunity to engage the majma street healers within a community based approach to sexual health promotion in Bangladesh. This chapter is based on interviews I conducted with ten public health professionals concerned with sexual health in Bangladesh. I do not consider this small sample of health professionals to represent an exhaustive inquiry into the attitudes of public health professionals in Bangladesh; however, it does provide an initial starting point for considering the path ahead. There are many challenges for public health professionals in Bangladesh, not least the minimal resources they have at their disposal in proportion to the magnitude of need within Bangladesh. Having said that, there are also cultures of practice which evolve over time, and which can compound problems of resource scarcity. In this case, I am interested in the ways that public health professionals have imagined their task. In particular, I am interested in their views regarding the potential for the majmawalas to be part of a co-ordinated sexual health promotion strategy. As I have shown in previous chapters, the majmawalas are already part of the Bangladeshi health system, just not part of the formal system sanctioned by the state. Thus, although there are diverse government and non-government agencies (including foreign aid agencies), there is a divide between those deemed legitimate parts of the official public health system and those like the majmawalas, who are essentially small street vendors operating to their own cultural, economic and political accountabilities.

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In this chapter, first of all, I give background information about the public health professionals and their work. Following on from this, I describe their views regarding the challenges in sexual health promotion in Bangladesh and opportunities for the majmawalas within the Bangladeshi public health system. In the final section of this chapter, I provide a summary and reflection.

THE PUBLIC HEALTH PROFESSIONALS I worked with ten public health professionals. Among those ten professionals, only one worked for the government; the other nine worked for non-government organisations. This situation reflects the broad pattern of non-government versus government in providing sexual health promotion in Bangladesh (see Table 7.1). NGOs are the main players in sexual health promotion programmes in Bangladesh.

Table 7.1: The public health professionals and the background information Total Type of working Professionals’ organisatio Recent involvement experience name63 n s (Years) Siddukur Rahman NGO HIV/AIDS programme 20 Rahim Mia NGO Family planning and reproductive health 30 Tushar Paul NGO HIV/AIDS programme 15 Akbar Ahmed NGO HIV/AIDS programme 10 Farukh Hossen NGO HIV/AIDS programme 15 Shovon Mia NGO Health system management 30 Malik Hasan GO Alternative health care 10 Bashir Hossain NGO HIV/AIDS programme 10 Mostofa Kamal NGO Sexual and reproductive health and rights 30 Sultan Abedh NGO Sexual and reproductive health and rights 15 Source: Fieldwork 2014-2015

63 These are pseudonyms. 182

One broad pattern to observe in table 7.1 is that five of these professionals were involved in

HIV/AIDS programmes. It is also important to recognise that the group I spoke with are all very experienced, with a minimum of 10 years’ experience and a maximum of 30 years’ experience.

According to the public health professionals, sexual health promotion in Bangladesh was mainly international aid dependent, and decisions about how best to go about sexual health promotion were thus made by external parties without reference to the local context. It is impossible not to observe that the central problem of the Bangladeshi health system in general is one of limited resources64. In a country where basic health care resourcing is very limited, sexual health promotion is a long way down the list of health priorities. Furthermore, given the social, cultural and religious sensitivities surrounding this area of health, it is also seen as challenging terrain even with resources. It is perhaps not surprising then why much of the work of sexual health promotion is left to external donors. It is partly about prioritising scarce resources, but also about the challenges in working in the moral terrain of sexual health. Thus, it seems that the Bangladesh government prefers sexual health promotion to be a job for the external donors.

The support of international development partners is essential for sexual health promotion in

Bangladesh, given there is a very limited funding from local sources. However, the international development partners have their preference and strategies to implement their programmes that can often miss the local needs. For example, HIV/AIDS is a major concern globally, and it is appropriate that is an important part of sexual health promotion in Bangladesh too, however it should also be noted that Bangladesh remains a low HIV prevalence country, with less than 0.1%

64 Naheed and Hort (2015) claimed that the major funding source for health sector in Bangladesh is international development partners. The Bangladesh government budget for 2016-17 fiscal year shows that the budget has only 5.13 per cent of the total outlay for the health and family welfare sector.

183 overall prevalence in general population (Azim et al., 2009). Table 7.2 shows 2015 status of

HIV/AIDS in Bangladesh.

Table 7.2: HIV and AIDS status in 2015 Indicators Status

Number of people living with HIV 9600 [8400 - 11 000]

Number of adults aged 15 to 49 prevalence <0.1% [<0.1% - <0.1%] rate Number of adults aged 15 and over living with 9300 [8100 - 11 000] HIV Number of women aged 15 and over living 3200 [2800 - 3600] with HIV Number of children aged 0 to 14 living with <500 [<500 - <500] HIV Number of deaths due to AIDS <1000 [<1000 - <1000]

Number of orphans due to AIDS aged 0 to 17 5100 [4100 - 6200] Source: Modified from UNAIDS’ HIV and AIDS estimates (2015)65

HIV/AIDS represents the major area of interest for international aid agencies, whether or not this is the view of locals. I became aware of another aspect of external donor dependency and its limitations when I saw the working experiences of the public health professionals. Except for

Malik Hasan, who was a government employee, nine of the public health professionals worked in different programmes across different organisations. None of them worked with only a single issue. They moved from one programme to another on a regular basis. Under these circumstances, it was very difficult for them to develop their approach in ways which reflected their locales of operation. With time pressure always lurking, they needed to respond to what was in front of them in ways which would be most supported within their agency. Three public health professionals confirmed that in their job they had had to discontinue one project in order to take

65 Please see details http://www.unaids.org/en/regionscountries/countries/bangladesh (last accessed on 18.09.2016) 184 up a new project due to funding changes, though they thought the previous project was working well.

THE CHALLENGES IN SEXUAL HEALTH PROMOTION Meaningful communication is essential for sexual health promotion. Though Bangladesh public health professionals have been working with HIV/AIDS and other STIs for a long time, they struggle to create meaningful ways to communicate their health promotion messages to the general population. Standard approaches to mass communication contained an abundance of restrictions on what could be said and how it could be said. They explained that often they had to develop their approaches knowing that they had to accommodate many and varied concerns about using

‘appropriate’ language. They found this so difficult at times that they ultimately failed to develop any useful material at all.

Mostofa Kamal’s organisation was involved in incorporating HIV/AIDS information in school text books. He shared the difficulties that his organisation experienced in developing those textbooks. He found the task impossible because government officials regularly vetoed the inclusion of critical information.

The government officials were the government representatives. They were determining the language of those textbooks. The government officials were concerned that the language was not appropriate for school children, and that the explicit information could lead to inappropriate sexual practices.

- Mostofa Kamal, a public health professional in Bangladesh

Therefore, the team at Mostofa Kamal’s office had to develop the books according to the instructions of those officials. Mostofa Kamal thought they could not incorporate the necessary text due to the moral rigidity of state authority. I found a similar claim on Program for Research and Intervention for Development, Education, Training and IT, Bangladesh (PIACT

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Bangladesh)’s Website66, an organisation working on the ‘Integration of HIV/AIDS Information into School Curriculum and Textbooks in Mainstream Education in Bangladesh:’ There was serious opposition from selected individuals at the national level who even tried to mobilize and build opinions in several ways against inclusion of HIV/AIDS information in school education. All these were protected by timely interventions of some high level policy makers, national level opinion leaders from the civil society as well as high level politicians. Finally, there were serious objections from the Islamic Foundation which formed a national level review committee including representatives from the Islamic Foundation. The review committee went through curriculum and texts very carefully, made necessary modifications and finalized the curriculum and texts from grades VI to XII. - PIACT Bangladesh, An NGO in Bangladesh

One of the participants, Faruk Hossain, shared his concern regarding the absence of meaningful communication in sexual health promotion programmes. Faruk Hossain had been working on

HIV/AIDS for more than fifteen years. He observed that most of their promotional messages were indirect, vague, or clinical, and would be unlikely to be understood by most Bangladeshi people. He thought that often sexual health promotion failed to achieve its desired goals because of this discomfort with direct, explicit information. He felt the message was constantly

‘compromised’ as a result.

The critical point here is that although HIV/AIDS awareness programmes are now more than 25 years old in Bangladesh, the moral dilemmas over how to communicate meaningfully within this space are largely yet to be resolved. The policy directives in this area continue to be driven by international agendas, not local ones, and yet the data appears to indicate low prevalence of

HIV/AIDS despite these failings.

The lack of a skilled workforce is another key factor in sexual health promotion in Bangladesh especially, in a context where developing meaningful communication is challenging. The sexual

66 Please see details: http://www.piactbangladesh.org/programs/education/school-education-of-hiv-aids/76- behru.html (last accessed on 27.03.2017) 186 health workforce in Bangladesh clearly requires great skill in negotiating the manner of their work in a way which is sensitive to their context of work but committed to meaningful health promotion.

In this regard, the public health professionals I spoke with all raised the shortage of skilled workers to undertake sexual health promotion programmes. For example, Bashir Hossain described a concern in their work with injecting drug users. He often saw his team struggling to communicate with injecting drug users and observed a large gap between the tough life of injecting drug users and the lives of health promoters working in this field.

The shortage of a skilled workforce was also critical in the teaching of HIV/AIDS information in school education. Teaching HIV/AIDS information in school education was a new experience for most school teachers in Bangladesh. The public health professionals reported that the topic was not easy for teachers to teach. For example, Sultan Abedh spoke about his job experience in monitoring a school programme on HIV/AIDS. He found that many teachers who were responsible for teaching HIV/AIDS did not actually introduce content on HIV/AIDS in their class. Rather they suggested their students ‘read those chapters at home’.

During my school visits, I see many school teachers not teaching HIV/AIDS chapters. Some of them suggest their students read those chapters at home. The teachers are not confident in teaching those chapters. They do not feel comfortable. That is why they tell their students to read those chapters at home. - Sultan Abedh, a public health professional in Bangladesh

Like Sultan Abedh, Siddukur Rahman, whose organisation was involved in teaching HIV/AIDS in school education, described similar challenges in school education. He argued that although they were doing their best in their school teachers’ training programmes, it was not enough, and that teachers were simply not equipped to discuss sexual health with their students. He thought it would take some time for school teachers to develop this competency. It is worth noting that this comment is backed up empirically in Sarma and Oliveras (2013) study which showed that ‘lack of

187 skills among teachers for imparting sensitive information to students can lead to programme failure in terms of achieving goals (Sarma and Oliveras, 2013: 20).’

In the context of school based HIV/AIDS education, I do not think skill only is a constraint. I think in that, in addition to the lack of skills, school teachers’ social position can be an issue for many of school teachers’ poor performance in implementing HIV/AIDS education. Sexual health promotion is a sensitive task. The dilemma of school teachers in Bangladesh is understandable.

Despite being a teacher in a tertiary level academic institution and working in the field of sexual health, I am still hesitant to discuss sexual topics with my students in Bangladesh. We will need to consider the social position of a teacher in Bangladesh. We cannot only push them to a classroom with training on a topic of sexuality, as it could be a traumatic experience for many.

Some of the public health professionals thought it would take time to accept sex education such as HIV/AIDS information in schools. They thought that, due to social stigma, they were unable to introduce effective HIV/AIDS information in school education. For example, Shovon Mia expressed a concern regarding social stigma and sex education.

I think Bangladesh is not ready yet for sex education, therefore it will difficult for the school to implement the sex education. Even the adults do not feel comfort in learning of sexual health issue. - Shovon Mia, a public health professional in Bangladesh

Shovon Mia also believed that in the era of internet technology, people could easily learn about sexual health issues. He blamed the overall society for not utilising that resource in a proper way.

He found Bangladeshi society highly stigmatised in the context of sex education. It was not only the public health professionals who blamed ‘society’ in their individual interviews; even their organisations’ websites blamed the stigmatised social context for not achieving their goals. PIACT

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Bangladesh wrote about their community level experiences of HIV/AIDS information in school education programmes on their website67.

In general, the stakeholders at the community and education institution levels were not in favour of teaching HIV/AIDS in the classroom. - PIACT Bangladesh, an NGO in Bangladesh

Social stigma is a common constraint for sexual health promotion everywhere in the world. In

Bangladesh, the public health professionals I spoke with all indicated that social stigma was their main challenge. Akbar Ahmed believed that sex-related social stigma sometimes caused people to police even who could speak on the topic, not just what they might say. He was involved in a project where his office was conducting awareness sessions on HIV/AIDS and Sexually

Transmitted Infections among youth. This position was his first job after completion of his university studies. As he and his target youth groups were almost the same age, the educational authorities did not give permission for him to conduct these sessions for their students. According to Mr. Ahmed, the authorities did not allow him to undertake this role because he was not seen as being old enough to speak on these matters. The topic was already confronting to this group, but the idea of (almost) peer to peer based learning was also a problem in this case.

Social stigma was not only affecting public health professionals’ attempts to undertake sexual health promotion work; some also experienced a very personal level of stigma because of the field they were working in. One of the public health professionals, Farukh Hossen, expressed his experience of being put down by friends and family for spending time with ‘homosexual’ and

‘transsexual’ persons. He spent this time with these communities in order to do his job well. His friends and family did not appreciate his contact with these groups. He thought even some of his

67 Please see details http://www.piactbangladesh.org/programs/education/school-education-of-hiv-aids/76- behru.html (last accessed on 27.03.2017). 189 colleagues in his organisation could not appreciate this. He believed the high level of social stigma was the reason behind their attitudes.

Rahim Mia also shared the influence of social stigma in his personal life. However, his context was different from Farukh Hossen’s experiences. Rahim Mia was in a dilemma regarding sharing sex- related information with his children. In his job, Rahim Mia had to conduct frequent training on sexual and reproductive health. However, he could not discuss those issues with his children. He explained to me the dilemma he experienced in that, in Bangladeshi culture, it was not an appropriate job of the parents to teach or share sexual and reproductive health related information with their children. According to him, parents in Bangladesh are not allowed to discuss or share sexuality-related information with their children. In his interview with me, Rahim Mia described this as being a similar dilemma for school teachers in Bangladesh. According to Bangladeshi society, students should be treated like the teachers’ own children. Therefore, he saw that many teachers in Bangladesh could not teach the HIV/AIDS information in their class. Rahim Mia was sympathetic with the teachers who failed to share HIV/AIDS information with their students:

How can I expect a teacher to teach sex and sexuality-related information to their students, if, with all of my experience, I fail to teach my children? - Rahim Mia, a public health professional in Bangladesh

Rahim Mia described a critical problem of sex education in Bangladesh. Though he saw that social stigma was responsible for problems in implementing sex education with the family and at the school level, he was also respectful of the tradition in Bangladeshi society that parents or teachers should not discuss such matters with their children or students.

Two of my respondents discussed their strategies for promoting sexual health in a context involving high levels of ‘stigma’. Sultan Abedh discussed one of his previous programmes where they promoted sexual and reproductive health related information for youth. During that

190 programme, Sultan Abedh’s team used a club as a meeting place for youth. Sultan Abedh and his team told the local parents that they would teach computers in their club, thus parents agreed to send their children. However, the main goal of the club was sharing sexual and reproductive health related information among the youth. Sultan Abedh argued that parents would not send their children if they knew the main goal of the youth club. That is why he did not see a problem with hiding the information from the parents. Clearly, this approach lacks ethical accountability, but it does show the pressing need to develop programs which negotiate ways of working which are culturally sensitive but still effective.

Siddukur Rahman shared a very similar strategy to Sultan Abedh. In his last job, he was responsible for a training programme with the field level workers who were sharing HIV/AIDS related information among adolescent girls. They had a group meeting with young women in the communities. Siddukur Rahman told me that often his field staff complained about their uneasiness in approaching girls in the communities. According to him, most of his field staff could not successfully organise a group meeting if they told parents the session was about HIV/AIDS, as most of the parents would not allow their daughters to attend. Siddukur suggested some ‘tricks’ to his field staff.

When they were telling me about the problem in gathering the girls, I suggested they not tell the real agenda of the meetings. I told them, ‘say to the parents that you will organise a meeting about their future careers. - Siddukur Rahman, a public health professional

Siddukur Rahman’s strategy worked; his field staff could organise the meeting. However, there were other problems during the meeting time as some mothers joined the girls unexpectedly.

Siddukur Rahman’s had another ‘strategy’ for that situation as well. He suggested to his team to discuss the girls’ careers in the presence of their mothers. He thought once the mothers would see that their daughters were getting feedback on careers, they would trust them and leave the meeting

191 place. Again, Siddukur Rahman’s strategy worked, and his team could successfully conduct the session on HIV/AIDS.

This is the space that sexual health promotion occupies in Bangladesh. It is a troublesome space for authorities and workers on the ground alike. It is either entirely avoided or it produces unethical deceptions like those recounted above. In addition to that, the dependency on international development partners in the area of sexual health is itself a phenomenon worthy of further investigation. Although this pattern relieves the state of thorny questions regarding how to go about sexual health promotion within a space of considerable moral guardianship, it also means that localised ways of doing sexual health promotion are not developed. Instead the arena is left vulnerable to the agendas of external parties, who often have good intentions, but are not well positioned to connect to the local context, even where locals are employed by these agencies. In this context, it is important to see how public health professionals respond to the idea of engaging the majmawalas to be part of a localised sexual health promotion strategy.

THE POTENTIAL FOR ENGAGING MAJMAWALAS IN SEXUAL HEALTH PROMOTION IN BANGLADESH

This section is about the public health professionals’ thoughts on engaging the majmawalas in sexual health promotion programmes in Bangladesh. I report here the diversity of views of these professionals, ranging from strong support through to antagonism for the idea. I describe these viewpoints and juxtapose them with what appear to be the possibilities for engaging the majmawalas in sexual health promotion. In this section, first I discuss the thoughts of professionals supportive of the engagement of majmawalas in sexual health promotion programmes, and then I

192 discuss the arguments against the use of majmawalas. The last part of this section discusses the perspectives of those with mixed views about this engagement.

The supportive view Out of the ten professionals, four were in favour of including the majmawalas in sexual health promotion activities. This group was optimistic about the potential of the majmawalas. All of them had different experiences with the majmawalas. Two of them had experience working with majmawalas in their project work, one worked on a project where they adopted a majma street healing style for health promotion; while another adopted the majmawalas’ language for training purposes. All of these engagements were temporary and personal initiatives. They recognised the skills of the majmawalas, but more with a view to informing the practice of others rather than directly engaging the majmawalas as agents of health promotion. However, in my conversation with those four professionals, they strongly acknowledged the contribution of the majmawalas and the majma street healing practice as very useful for informing their work. Based on their previous experiences, they saw a high relevance of the majmawalas in sexual health promotion in

Bangladesh. In the following four case studies, I write about those four professionals’ experiences and their thoughts on majmawalas.

Case Study 1: Rahim Mia and his family planning activities Rahim Mia had been working in the area of family planning68 and reproductive health for more than 30 years. He recounted to me an initiative he had taken many years before involving the majmawalas in creating awareness of family planning.

68 The total population of Bangladesh is about 152.51 million. In terms of the number of inhabitants, Bangladesh is fifth in Asia and eighth in the world (Population and housing census, 2011). Population control is a big challenge for the policy makers of Bangladesh. All the family planning activities have stressed the importance of a small family, but it is challenging indeed.

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In the 1980s and the 1990s, Rahim Mia was coordinating the rural family planning activities of two districts. He faced a lack of skilled workers who could communicate family planning information and demonstrate the use of birth control devices to rural people. Moreover, because of religion, birth control was treated as a sin. Rahim Mia described the challenge as follows:

During that time, all of the family planning workers were women. They used to go door to door; could talk to the women of the families about the importance of birth control and distributed birth control materials to them. Mostly, they could not talk to the men of those families. As a result, most of the men were unaware of the birth control issues. Though the women knew it; they were less motivated to use birth control materials as the men were not aware of it. To some extent, men had a negative concept of it. As a result, we were not getting the expected success. - Rahim Mia, a public health professional in Bangladesh

Thus, Rahim Mia searched for a solution which could help them to share the information on the importance of birth control among the men in rural areas. Under this circumstance, he came up with the idea of including the majmawalas in his programme in 1983. According to him, he knew the motivational capacity of the majmawalas. He thought to utilise them in family planning activities so that men would be engaged with the information too and then be more likely to be supportive of their wives. In particular, he wanted to utilise the ‘performance’ capacity of majmawalas for spreading the family planning message to the men in rural areas. In his language, the justification of hiring the majmawalas was as follows:

I know majma very well. During my travels in different parts of Bangladesh, I can see them gathering people, giving lectures to the audiences fluently. They are very popular in the marketplaces. They can gather people in a moment. It made me think about them. I thought if I engaged them in our work, they would be easily passing the importance of birth control and family planning messages to the men. - Rahim Mia, a public health professional in Bangladesh

Rahim Mia executed his plan of hiring the majmawalas for the birth control promotion programme. After the initial verbal agreement with the majmawalas, the first step of his work was to arrange a workshop with the majmawalas. The goal of the workshop was to introduce the birth control programme to the majmawalas:

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During the workshop, we trained up the participants by providing general knowledge on family planning. We also informed them about the importance of birth control as well as how to use family planning materials. We made a work plan in the workshop. We decided that the majmawalas would describe the family planning issues and sell contraceptives along with their normal work. We agreed that my office would provide the contraceptives to the majmawalas free of cost, and the majmawalas would charge very minimum fees. - Rahim Mia, a public health professional in Bangladesh

After the workshop, Rahim Mia’s office provided the contraceptives (mostly condoms and birth control pills) without any cost. According to the agreement, majmawalas started discussing birth control and family planning issues in their majma street healing. They were also selling birth control materials with a minimum price in their majma while discussing family planning issues and their importance to their audience. During the arrangement with the majmawalas, Rahim Mia visited different majma street healing sessions:

I was regularly visiting the majmawalas. Sometimes, I would be part of the gathering; sometimes I would observe them from a distance. I could see people were attentively listening to them. We gave them basic information about family planning, and most of them showed a proper judgement to the information in delivering their lectures. With their usual hilarious speaking capacity, they would make fun for not having family planning. Audience would enjoy it, laugh, but they would listen to the majmawala. - Rahim Mia, a public health professional in Bangladesh

Rahim Mia found the majma street healing process to be very effective in engaging men in a topic that was very difficult for others. Not only were the majma successful at ‘breaking the ice’, they provided an acceptable space to convey explicit information about the use of condoms, a topic of instruction which was very difficult for family planning instructors in Bangladesh.

Our female family planning workers were mostly promoting contraceptive pills for women. It was not possible for them to show a condom to men. But it was not an obstacle for the majmawalas. They were able to show the condom and were able to describe how it should be used. - Rahim Mia, a public health professional in Bangladesh

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As the female family planning workers could reach only the women, the majmawalas’ work was filling the gap by also reaching men. Men learned how to use a condom or other birth control materials from the majma street healers, which was impossible for female family planning workers.

In their ethnographic study, Schuler et al. (1995) argued that, due to existing gender norms, village- based female workers were often unable to provide adequate information and support to contraceptive users. They also showed the limitations of women-centric family planning. They said, “….the family planning program in its current form does little to promote men’s involvement in family planning and that this is a problem for women (Schuler et al. 1995: 134).”

The photograph below (Figure 7.1) shows a condom promotion scenario in rural Bangladesh in

1995. It shows a community health worker showing a condom. This photograph shows only women listening to the community worker.

Figure 7.1: A community health worker promoting condom use in a village in 1995

Source: Eco Images69 and Najma Rizvi70

69 Please see Eco images (undated) http://www.gettyimages.com.au/detail/photo/mobarakdi-village- matlab-district-hashina-high-res-stock-photography/98449109 (last accessed on 16.09.2016).

70 Please see Rizvi (2014) http://www.dandc.eu/en/article/successful-family-planning-bangladesh- holistic-approach-leads-lower-fertility-rates-rates (last accessed on 16.09.2016). 196

The arrangement between Rahim Mia’ s office and the majmawalas could resolve the challenges in approaching men about family planning awareness issues in that locality. The majmawalas had established social acceptance and they could draw on it to bring family planning to men. It was the first initiative of Rahim Mia’s office of reaching men in family planning issues.

Though it was Rahim Mia’s personal initiative, later on, his office implemented the same idea in the village markets of 20 sub-districts under 20 districts of Bangladesh. These activities continued during the period between 1984 and 2005. However, in 2005, the government and donors changed their strategy and the program was discontinued. According to Rahim Mia, family planning activities started getting less funding, and therefore they had to discontinue the project with the majmawalas. Rahim Mia strongly believed that his office utilised the majmawalas’ skill very efficiently to implement their project successfully and was very disappointed to see the program finished. It was not a new experience for him. He said that their organisation had had to change their focus several times. According to him, those changes were not instigated by the organisation itself, but rather they had to change the focus for securing the external funding.

Rahim Mia and his family planning programme shows the importance of the skill of the majmawalas. Unfortunately, like most of the NGOs in Bangladesh, Rahim Mia’s office was also dependent on external donors. As a result, when donors changed their preferences, they had to change their programme to ensure continued funding for future projects, even though the project with the majmawalas was effective. Moreover, it is a matter of regret that when I followed up

Rahim Mia’s story by reviewing the related documentation of this program I did not find any documented acknowledgement from Rahim Mia’s office for the contribution of the majmawalas in their project. Moreover, I was unable to find any other publication with a description of the

197 majmawalas’ contribution to the family planning programme in Bangladesh. Thus, the majmawalas are an invisible part of the history of this program. Neither their skills nor knowledge, let alone their success, in a challenging area of public health were documented.

Case Study 2: Tushar Paul and his HIV/AIDS awareness programme Tushar Paul was responsible for awareness raising activities in the HIV/AIDS programme in his office. Building awareness among bus and truck drivers was one of the major activities in his programme. Initially, Mr. Paul and his colleagues started working at Gabtoli, a large and busy bus terminal in Dhaka city71. Tushar Paul and his workers found it difficult to engage with the bus and truck drivers. Tushar Paul searched for an alternative strategy and finally came up with a similar solution to Rahim Mia. Like Rahim Mia, Tushar Paul observed the majmawala at Gabtoli who managed to draw a crowd of bus and truck drivers, despite their busy routines.

During that time, we spent a good amount of time in the terminal. I found a majmawala efficient in gathering people. We met with him and discussed our plan. From the first meeting, I could see we would be able to work with drivers and finally we did it. - Tushar Paul, a public health professional in Bangladesh

Tushar Paul described how, following the first meeting, they had several other meetings with that majmawala72. During these meetings, they discussed different aspects of the HIV/AIDS awareness programme and finalised the relevant awareness topics for the majma street healing discussions.

After the arrangement, the majmawala talked about HIV/AIDS in his majma street healing twice a week for a year.

The majmawala was also a good singer. He used to sing before the majma. Thus, he could easily gather the drivers and their colleagues. He had not any problem in seeking the attention of the drivers, which was a big challenge for our team. He was also successful organising his majma and part of his majma he discussed HIV/AIDS issues. - Tushar Paul, a public health professional in Bangladesh

71 Rashid et al. (2012) described the everyday scenario of Gabtoli terminal. They wrote, “According to Dhaka City Corporation, approximately 1,400 buses run every day from the Gabtoli terminal, and it has the capacity to accommodate up to 1,800 buses and 70,000 passengers each day. Five to eight thousand drivers and transport workers work in and out of the terminal (Rashid et al., 2012: 95).” 72 Unfortunately, Tushar Paul could not recall the name of the majmawala. 198

It is important to have an attractive strategy in gathering bus and truck drivers to listen to information about HIV/AIDS. Tushar Paul told me that the project with the drivers achieved good success with the support of that majmawala. However, the funding of this project was finished after only one year, and Tushar Paul was shifted to other work. Therefore, again the work with the majmawala was discontinued. Tushar Paul told me that he had since lost contact with the majmawala and also, as was the case for Rahim Mia, there was no documented information regarding the majmawala’s contribution.

It is well known in sexual health promotion literature that bus and truck drivers are an important risk group for HIV/AIDS (Huda et al. 2016). Tushar Paul’s experience shows that the majmawalas can be a very effective ally in reaching this group.

We can see from the above cases that majmawalas can play an important role in public health.

There were two other public health professionals who did not directly hire majmawalas, but instead utilised the communication methods and working strategies of the majma street healers. I share their experiences in the following two case studies.

Case Study 3: Akbor Ahmed and their adoption of majma street healing A German development agency was the donor for a project called the Join-In Circuit on AIDS, Love, and Sexuality programme73. The term ‘Join-In Circuit’ referred to a platform where a huge number of young people were gathered to participate in the programme. The aim of the project was to increase awareness among youth about HIV/AIDS, human rights, and sexually transmitted

73 Please see details Roos-Bugiel (2011). 199 infections. This programme utilised awareness raising tools in HIV/AIDS prevention from different countries.

The local partner NGOs in Bangladesh were responsible for implementing the programme in

Bangladesh. Akbor Ahmed, one of my participants, worked in one of those partner NGOs. Based on his working experience in that programme, he stated that they adopt the majmawalas’ style to make the awareness tool effective in the Bangladeshi context. According to Akbor Ahmed, the target group of that project was high school and university students. Akbor Ahmed described the

‘Join-In Circuit’ activities.

We used a big room to implement the activities. First, we made five portable booths in that room. Seventy-five youths used to attend in a one-day session. Usually, we divided them into five groups and sent each group to each booth for a fifteen minute session. In those sessions, the students had a chance to participate in games, discussion sessions, and question and answer sessions. We used pictorial stuff for better communication. The score of each group was recorded, and students got prizes according to their scores. In this way, the students were taught about different topics by the project people. - Akbor Ahmed, a public health professional in Bangladesh According to Akbor Ahmed, the original plan for the ‘Join-In Circuit’ activities was not suitable for the Bangladeshi context. They experienced challenges in gathering students, facilitating sessions and engaging students with the prescribed content. Moreover, they had limited time. For that reason, Akbor Ahmed’s office adopted the majma street healing style in their sessions. Akbor

Ahmed and his colleagues followed the performance style of the majmawalas and tried to engage the participants by showing different pictures like the majma street healing sessions. In each booth, there were two facilitators who followed the majmawalas’ style in their talk and activities.

As a facilitator, Akbor Ahmed had to act like a majmawala. He found that mimicking majmawalas made the sessions work; although without the experience of the majmawalas it was a very tough job for him and his colleagues. They could only mimic, as they did not have the genuine skills of the majmawalas. He confirmed that he was not able to attract audiences like the majmawalas.

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Further, despite their best efforts, he and his colleagues still found it difficult to talk about sexuality in front of so many people. He perceived that the audiences were uneasy during his speech, which made his job more difficult.

I had no previous experience to talk about sex in public. Therefore, I was not confident enough. Most of the audiences were also hesitant. As a result, we found less response from them. I was also not spontaneous enough. - Akbor Ahmed, a public health professional in Bangladesh During his work on the ‘Join-In Circuit’ project, he often visited different majma street healing sessions to observe the performance of the majmawalas. He tried to adopt the presentation skills of those healers. However, he did not have the time and opportunities to undertake the long-term training he felt he needed. In addition to the time constraint, he was aware that his project was going to finish one day and then he might not be able to use that skill again. As a result, he was not able to nurture the majmawalas’ skill. Like the other two case studies, Akbor Ahmed’s office could not continue their ongoing work as the project duration was completed and the donor closed the funding. After that project, Akbor Ahmed did not have any further opportunities to apply the majma street healing strategies in his public health work.

Case Study 4: Farukh Hossen Farukh Hossen was another public health professional who supported the idea of incorporating the majma street healing in sexual health promotion in Bangladesh. Farukh Hossain had been working on HIV/AIDS for more than fifteen years. He appreciated the majmawalas’ skills in performance, especially their engaging language. He believed that the majmawalas were successful in quickly and effectively establishing a relationship with their audience.

Majmawalas express many sensitive terms regarding sexual health which is commonly used in the community. As a result, they can establish a relationship with the general people. - Farukh Hossen, a public health professional in Bangladesh

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The effectiveness of the everyday language influenced him to think about the majma street healing language in sexual health promotion. He brought the issue to a training workshop, where he was a trainer. He shared his ideas of the majma language with his colleagues and asked them to think about the usefulness of majma languages in their work. He also provided some examples in favour of his position. He used a few terms of the majma street healers in that workshop so that the participants could understand the skill of a majmawala. One of his examples regarding the terms was kit kit kore kamrano (কীট কীট করে কামড়ানো) which is an expression of physical discomfort and pain. This expression is common in everyday language, but it is not in formal Bangla language.

According to Farukh Hossen, those words were easily understood by local people, and the majmawalas could spread their messages to the local people. On the other hand, there were no such words in the official Bangla language which could express the same meanings. He believed, as a result, that formal projects like their HIV/AIDS programmes often failed to communicate effectively with their target group.

Faruk Hossain wanted to utilise majma language for better communication in a HIV/AIDS awareness programme. However, they did not hire or engage any majmawala in their programme, and during my interview with Faruk Hossain, he expressed his frustration for not doing so. He thought that the programme would have a better result if it involved the majmawalas:

We can benefit from the majmawalas. Our project would have better success. We do not have the scope to engage majmawalas in our project. Our current project design does not have that provision. - Faruk Hossain, a public health professional in Bangladesh

The above four cases show the potential benefits of the inclusion of the majmawalas in sexual health promotional activities. These case studies also show that some public health professionals seek support from the majmawalas or use their communication strategies to achieve success in their health promotion programmes. Nevertheless, the public health professional or their

202 organisations had no long-term plan to nurture and engage the majmawalas’ skill. In all cases, public health professionals utilised the majmawalas’ skill from their personal initiative and for a short period. Though they could not continue their working relationship with the majmawlas, all of them expressed their interest in working with them. In the last two cases, the majmawalas were not directly employed; instead their knowledge and skills were observed and appropriated by public health professionals. Yet, the majmawalas have been made invisible in the success of these projects, and in this case, they did not receive any financial benefit or acknowledgement for the contribution their knowledge had made.

The non-supportive view Not all of the public health professionals were supportive of the proposal of integrating the majma street healing in sexual health promotion activities in Bangladesh. Out of ten, two professionals strongly rejected the proposal. The two public health professionals who expressed very negative attitudes towards the inclusion of the majmawalas did not have any direct working relationship with the majmawalas. They claimed that the majmawalas did not have any ‘modern’ education.

Moreover, they thought that the majmawalas had been promoting superstition and so were actually counterproductive to sexual health promotion. Furthermore, they believed that the majmawalas were a problem for the health service system of Bangladesh, and they should be permanently excluded from the system. In the following case studies, I describe the clusters of meanings associated with these attitudes.

Case Study 5: Shovon Mia Shovon Mia was trained as a biomedical doctor in Bangladesh. He had been working in a health service programme in one of the important public health institutes in Bangladesh for a long time.

He thought that the majmawalas were spreading superstition because of their lack of ‘modern’

203 education. For Shovon Mia, the majmawalas represented everything he did not want in a health system. He was trying to ‘modernise’ the system and he questioned the rationale for my study during the course of the interview in his office. I quote a part of our conversation:

Shovon Mia: What is the benefit of doing a PhD on traditional healers?

Mujibul: You know the traditional healing system is important to our health service system. The understanding of traditional healing would be better after this research. Moreover, this research can hopefully comment on the better utilisation of the traditional healing system in public health.

Shovon Mia: I want to ban this superstition and ill-education under the name of traditional healing. Their popularity is decreasing day by day. Very soon they will quit finally. You should not do a PhD on this topic. Rather, you could research how to eliminate them quickly.

Mujibul: Why do you think so?

Shovon Mia: You would not find any developed country which relies on their traditional healing system. However, when they get any student from a developing or underdeveloped country like us, they assign those students to research on the traditional healing system. They do not care about their own traditional healing systems, but they show interest in the traditional systems of others.

Shovon Mia believed that doing a study on the majma street healing was a misuse of time and resources, as it should never be included in the mainstream health system. He stressed the need for expansion of biomedical health services and wanted to focus only on this area. He did not see any other solution regarding male sexual health without the help of biomedical health professionals. Moreover, he was in favour of banning the traditional healing system as fast as possible, as a step toward better public health. Shovon Mia was very much concerned about the limitations of the health service situation of Bangladesh. He knew about the lack of human resources in this sector. He was also concerned about the crisis in male sexual health services in

Bangladesh. Still, he believed that the majmawalas had no value in solving this problem and he considered the majma street healing as a burden.

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Cast Study 6: Malik Hasan I also found a similar unsupportive view from a health professional who interestingly had graduated in Unani and Ayurveda medicine. After graduating from the only institution for postgraduate degrees in alternative medicine, Bangladesh Ayurveda and Unani Medical College,

Malik Hasan, had joined the college as a staff member of the health ministry of Bangladesh. In the following case study, I discuss his opinion regarding the majma street healing, which, given Malik

Hasan’s association with alternative medicine, shows that the perceptions about the majmawalas are more complex than simply a tension between biomedicine and ‘the rest’.

Like Shovon Mia, Malik Hasan believed that the majma street healing should not be recognised in any way. He too suggested that I should not be working with them. He thought that working with

‘uneducated traditional healers’ would help the group to achieve better recognition. He was concerned that in that case; there would be no differences between a formally educated professional like him and ‘an uneducated majmawala.’ He believed that that would bring disrespect for professionals like him. In this regard, Shovan Mia saw himself as leading the way with ‘proper’ alternative medicine. Thus, while there are clearly strong tensions surrounding the authority of biomedicine and ‘alternative’ medicine, there are further tensions in authority and status among various traditions of ‘alternative’ healing practice. For Shovan Mia, majmawalas sit at the bottom of this group.

He argued that the majmawalas were not institutionally educated, and therefore they cheated common people. He was in favour of banning all forms of informal traditional healing systems including the majma street healing. He shared his story of professional disrespect.

After getting admission at Bangladesh Ayurveda and Unani Medical College, one day I went to a majma at Farmgate (one of the important city centres of Dhaka). The healer claimed his medicine was like Ayurveda and Unani medicine in front of his audiences. I felt very bad about that. On the one hand, I was studying those medicine systems, on the other hand the healer, who did not study, was selling whatever medicine with the name of Ayurveda and Unani. If we now formally recognise them,

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they would be more encouraged and empowered to sell their medicine. They do not have any formal education. Rather they should be abolished for the improvement of the official traditional medicine system. - Malik Hasan, a public health professional in Bangladesh

Malik Hasan was very open about his position. He expressed his strong objection to the majmawalas. He also informed me that he often took initiatives against all kind of informal traditional healers. He had a good relationship with the police department as he was working with the ministry of health. Therefore, often he utilised that connection and requested that police take steps against informal traditional healers. In the case of the majma street healing, he thought that majmawalas should not occupy the road with their majma and that police should strictly control them. He also suggested that legal steps should be taken to stop the majma street healing.

Malik Hasan saw majmawalas as disrespectful to his profession. Some of his friends made fun of him by calling him a majmawala. He thought his friends could do that because majmawalas had falsely taken the name of Ayurveda. Therefore, he saw ‘non-institutional’ traditional healers as a problem for the dignity of the ‘proper’ traditional healing system. He believed only the full elimination of those informal traditional healing systems could strengthen the dignity of institutionalised traditional healing systems in Bangladesh.

Though Shovon Mia and Malik Hasan had two very different schoolings in medical education, both of them had a similar view of majmawalas. Both were very strict about their position and expressed their anger about the majma street healing. They were very disappointed that I was studying ‘uneducated’ people and their ‘superstitions.’

The mixed views The other four public health professionals in my sample had a mixed opinion about majmawalas.

In this section, I discuss their thoughts on the majma street healing. The mixed views group

206 acknowledged the potential abilities of the majmawalas in sexual health promotion, but at the same time, they were keen to also acknowledge the limitations of the majmawalas.

The strengths of the majma street healing The mixed views group saw three important strengths of the majmawalas. These were the majmawalas’ public speaking capability, their confidence, and the image of the majma street healing as associated with ‘forbidden’ topics.

The mixed views group admired the majmawalas’ public speaking capability. They found the majmawalas were very effective in their speech, and admired the use of local communicative terms.

They believed the majmawalas’ speaking style would be useful in sexual health promotion. Sultan

Abedh described the majmawalas’ speaking strength.

The way majmawalas speak about the sensitive topic of sex in public is really powerful. The content of their sex talks comes from local languages. They use phrases like the locals in describing sexual health problems. Therefore, they can easily communicate with their audience. - Sultan Abedh, a public health professional in Bangladesh

The mixed views group marked another potential strength of the majmawalas. It was the majmawalas’ confidence in their work and speech. They believed that self-confidence flourished in the majmawalas’ work and expressions. Therefore, during the majma, the audience would become interested in their speech. According to this group, the audience had faith in a self- confident speaker.

Siddikur Rahman, one of the public health professionals in this mixed views group, described the nature of the majmawalas’ self-confidence. Siddikur Rahman had been working for an international organisation on sexual health issues for a long time. One of his responsibilities was to create awareness about sexually transmitted diseases.

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You will see the main strength of a majmawala is his self-confidence. He knows what his work is, and how to do the work. This self-confidence is essential for any work; specifically, when you need to face thousands of unknown people in an open discussion. Because of the self-confidence, healers never feel nerves in front of the gathering. They do not know most of the audience during their lecture times. Mostly, they do not have any prior information regarding the gathered audience. Even so, they do not feel any problems. Their self-confidence helps them in this regard.

- Siddikur Rahman, a public health professional in Bangladesh

According to Siddikur Rahman, the majmawalas’ self-confidence was necessary for their work.

They could face challenges at any time. In the methodology and research setting chapter, I mentioned my encounter with a reporter, who came to Didar’s Majma. I said that I did not see any nervousness on Didar’s face while the reporter was filming the session. Though the reporter was filming without any prior discussion with Didar, he continued his speech confidently. As stated by Siddikur Rahman, self-confidence made the majmawalas’ speech convincing to the audience.

The mixed views group of public health professionals found the content of street healing important for attracting an audience. They thought that in addition to their good speaking capability, the content of the majmawalas’ speech was also influential in attracting attention. There is perhaps a ‘forbidden attraction’ due to the content of the discussion. Bashir Hossain gave an explanation of his notion of ‘forbidden attraction.’ Bashir Hossain had been working on

HIV/AIDS for ten years. There was a regular majma near to his office. He could observe the majma on his way to the office or home. He thought that the ‘forbidden content’ of the majma street healing attracted men to the majma.

Due to the restrictions in the discussion of sex, there is a forbidden attraction at work here. In this case, a majma is a place where men can hear about sex, and most of the men in Bangladesh have an understanding about the majma talks. Therefore, they have a forbidden attraction to the majma. A majmawala conducts a majma street healing near to our office. On my way home, I observe him sometimes. I see a huge gathering in his majma all the time. I think the forbidden attraction brings the audience. - Bashir Hossain, a public health professional in Bangladesh

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As discussed in previous chapters, there is limited scope for public discourse about sex in

Bangladesh. Bashir Hossain’s comment on the majma street healing refers to the unique place that majmawalas have in Bangladeshi society to be able to speak publicly about sex. For many

Bangladeshi men, the majma is the only source of sex information. The majma street healing has been successful in establishing itself as a safe space for sex talk among men in Bangladesh. Bashir

Hossain could see that but, like the others in this group, had some concerns too.

The weakness of the majma street healing The mixed views group spoke of three limitations for working with the majmawalas in health promotion: the tendency to capitalise on men’s weakness, misinformation, and using too many inappropriate words.

This group believed that the majmawalas made too much of men’s weaknesses, which was obviously good for their business. They thought that, due to lack of sexual health knowledge, men in Bangladesh were often anxious about their sexual performance. As Mostofa Kamal articulates below, this pushes the engagement down a very particular pathway:

Due to no sex education, most of the men in Bangladesh suffer from performance anxiety. The majmawalas target that anxiety. When they talk about men’s poor sexual health performance it works. - Mostofa Kamal, a public health professional in Bangladesh

A similar perception came from Bashir Hossain.

In their discussion, the majmawalas mostly stress male sexual performance. They discuss it repeatedly. Men who have a concern about sexual performance feel sexually weak, and buy medicine from them. - Bashir Hossain, a public health professional in Bangladesh

According to the mixed views group, the second weakness was the majmawalas’ information. This group of public health professionals were concerned about the lack of ‘scientific’ education

209 involved in the work of majmawalas. They also thought that the majmawalas provided misleading information to their audiences. For example, Siddikur Rahman said,

There is no science behind what the majmawalas say about penis size and masturbation. They do not discuss these issues based on scientific evidence; rather they depend on their own understanding. - Siddikur Rahman, a public health professional in Bangladesh

The mixed views group also found a problem in the majmawalas’ language. They thought that sometimes majmawalas used too many ‘dirty’ words in their discussion. They thought using ‘dirty’ words in majma created a negative image of the majmawalas.

Some of the majmawalas often speak dirty words in majma. The words they use in majma are not suitable for civil societies. In this context, if we utilise them for sexual health promotion, that could create a debate. People might think we are spreading dirty language. - Sultan Abedh, a public health professional in Bangladesh

The mixed views group examined both the strengths and weaknesses of the majma street healing.

Though they were critical about the weaknesses of the majmawalas, they did see some benefit in using the majmawalas in sexual health promotion. This group suggested a project with sufficient funding for engaging the majmawalas in sexual health promotion. They suggested the project should include training and a salary component for the majmawalas, and proposed a programme for training the majmawalas first, in order to improve the majmawalas’ understanding about sexual health. After the successful completion of the training programme, and with an arrangement for regular payment, the majmawalas would effectively contribute to sexual health promotion in

Bangladesh.

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SUMMARY AND REFLECTION The findings of this chapter show how the majma street healing can potentially contribute in that essential part of sexual health promotion. It is important to consider the opinion of the public health professionals about the usefulness of the majmawalas. If the relevant professionals are convinced of the potential importance of the majmawalas for responding to the challenges of sexual health promotion in Bangladesh, they can formulate a plan to bring the majmawalas into the formal public health system. Therefore, their opinions and perceptions about the street healing are important to establish the role of majma as a community resource in sexual health promotion in Bangladesh.

The public health professionals who had actual working experience with the majmawalas were strongly supportive of the idea of inclusion. Their judgements of the majma street healing were important to understand the capacity of the majmawalas in the proposed sexual health promotion.

This suggests that there is a starting point needed for training of public health professionals in community and strength based approaches to health promotion which might assist them to identify and enhance existing resources within the community, rather than using top-down approaches. All of the health professionals agreed about the presentation and speaking skill of the majmawalas. Even the non-supportive group, who wanted to eliminate the majma street healing, affirmed that the majmawalas were very skilled speakers, and they knew how to establish their point with their audience. In their view, the main constraint of accepting the majmawalas was their lack of modern education.

The findings of this chapter show that the majority of the professionals see the potential of the majmawalas in sexual health promotion in Bangladesh. The majmawalas’ skills, such as their speaking and public engagement capacity, are appreciated by most of the professionals. Some of them already had successful experiences working with the majmawalas. Therefore, there is a

211 supportive attitude among most of the professionals toward the idea of inclusion of the majmawalas in sexual health promotion.

From the beginning of this thesis, I have illustrated both the constraints in the existing sexual health promotion in Bangladesh and the potential role of the majma street healing in overcoming those constraints. I have argued that the majma street healers can contribute to an emic approach and resourceful localised sexual health promotion. In the following, final chapter, I will once again bring together my arguments to establish the importance of the majmawalas in sexual health promotion in Bangladesh.

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Chapter 8: Conclusion: The Importance of the Majma Street Healing in Sexual Health Promotion in Bangladesh

During my own fieldwork on ritual healing (Sax 2008), I encountered numerous examples of the “modernist” critique of ritual healing. The first time I ever spoke about the topic was at the Institute for the Study of Human Behavior [American spelling] and Allied Sciences in Delhi, where I had been invited to give a talk to a group of medical professionals. I told my learned audience of doctors and psychologists about the system of oracles and healers, showed them a brief video clip, and proposed that ritual healing sometimes “works” by addressing the social causes of stress-related disorders. After my talk I expected an enthusiastic round of applause and a stimulating discussion. What I got instead was outrage. “How dare you conduct research on such a topic?” they asked. “This is nothing more than primitive, superstitious nonsense! You should be spending your time stamping it out, not conducting research on it! (Sax, 2010: 10)

INTRODUCTION Sexual health promotion in Bangladesh can be characterised as resource-constrained and morally hesitant. These two aspects of the health system have been limiting the scope of sexual health promotion in Bangladesh. These issues are interconnected and both are responsible for inadequate sexual health promotion in Bangladesh. But a close-to-community resource, i.e. the majmawalas, could help supplement the current, inadequate sexual health promotion in Bangladesh. As it stands now, a potential community resource, the majmawala, is not being utilised, despite a strong need for a culturally sensitive sexual health promotion. This final chapter focuses on this paradox and argues for the possible contribution of the majmawalas in sexual health promotion in Bangladesh.

After this introduction, I assert the majmawalas’ potential contribution to sexual health promotion and then discuss the devaluing the majmawalas in this particular context. In the third section, I revisit the research objectives of the thesis. In the fourth and final section of this chapter, I

213 articulate my final reflections in regards to the utilisation of the majmawalas in sexual health promotion.

THE MAJMAWALAS’ POTENTIAL CONTRIBUTION TO SEXUAL HEALTH PROMOTION In this research, I set out to consider whether the majmawalas may be able to assist in the challenging task of sexual health promotion among men in Bangladesh. I took up this challenge based on the simple premise that the majmawalas were already providing sexual health information and support to men in Bangladesh, and that their capacity to do this reflected both their skills and their sociocultural positioning, which together enabled them to talk with men about sexual health in a relatively straightforward, non-stigmatising manner, in street spaces which men could access very easily both geographically and economically. In this section, I summarise the findings of the thesis and discuss the implications in terms of the potential role of the majmawalas in the

Bangladeshi public health system. In this context, I see three major potential roles for the majmawalas in sexual health promotion. In this section, I discuss those three roles and how they contribute to improving men’s health in Bangladesh.

Valuing the insider perspective The need for an insiders’ perspective is crucial in sexual health promotion in Bangladesh. As we can see disease centred sexual health promotion starts with a biomedical category rather than with the people. But men in Bangladesh discuss their sexual health in very different terms to the ways in which it is constructed within western biomedicine and western health promotion. Whilst these latter two perspectives may seem quite different in their approach within the west, from my perspective they both share a colonial edge which continues to ignore, marginalise and subvert knowledge systems outside of the west in ways which not only disrespect these non-western

214 knowledges, but also do not work. Westernised approaches to sexual health promotion largely fail in Bangladesh because in broad terms they do not connect with people’s social, economic, religious and political circumstances. In a more narrow sense, the specifics of what constitutes sexual health are also in question here.

Men in Bangladesh are indeed anxious about their sexual health, not only in terms of sexually transmitted infections, but also sexual performance. This area of sexual health is not what western sexual health promotion designers have in mind when they contend with the challenge of

HIV/AIDS. Men in Bangladesh are concerned about premature ejaculation, erectile dysfunction, semen loss and penis size. Bangladeshi men experience these as weaknesses in their daily lives.

They suffer physically and mentally as a result of the associated stresses in relation to such issues.

Further, these individual stresses create trouble in their social existence, including breakdowns in family relationships. For many men, there is a strong spiritual meaning at work here too. Their lack of satisfactory sexual performance can also mean spiritual failure. Within the siloed thinking of western knowledge systems these sorts of sexual problems are seen as unrelated to the goals of

HIV/AIDS prevention. This thesis challenges this reductionist thinking. This is precisely the space in which Bangladeshi men speak about sexual health and therefore it is the space in which

HIV/AIDS can be most readily incorporated.

The thesis started with Hasan’s story. Hasan had become divorced from his wife, and separated from his family. He was displaced from his home village and was attempting a new life in the city.

He saw hope in majma, because that was the place where he could share his experiences and ask for a treatment. The other clients of the majmawalas had different life experiences but there was a similarity among them; they all were concerned about their sexual performance and went to the majma street healing as that was their hope of cure.

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The majma acts as a culturally appropriate space for responding to men’s sexual health, and helps us understand the types of psychosocial sexual health concerns among men in Bangladesh. This research has shown a range of similar conceptualisations of cause and treatment among the majmawalas and their client and non-client audience: they utilise similar names and syndromes for those sexual health concerns. Both groups – the majmawalas and their audience (clients and non- clients) expressed their concern more about psychosocial issues than about sexual health diseases, where they bring a holistic understanding to describe those psychosocial concerns. More precisely, they share similar explanatory models.

The majmawalas use local terms and explanations to describe psychosocial concerns and provide suggestions and remedies to their audience, and it is well known among men in Bangladesh that they can learn about these aspects of sexual health from the majma, and that the majma discussions maintain the anonymity of the audience. In addition to the psychosocial concerns, majmawalas potentially provide an opportunity for men to speak to men about safe sex. In the majma narratives, the majmawalas often bring up the issue of safe sex, and the importance of safe sex practices, such as the use of condoms, is a common discussion topic. Therefore, majma street healing provides an equal opportunity to address the psychosocial concerns of sexual health and safe sex from an insider’s perspective.

Current sexual health promotion approaches in Bangladesh fail to consider these psychosocial concerns in their promotional programmes. A number of studies, such as Khan et al. (2008),

Hawkes and Collumbien (2007), Nahar et al. (2013) and Schensul et al. (2006), emphasise psychosocial concerns in sexual health promotion. They suggest incorporating psychosocial concerns in sexual health promotion but again they rely on the existing etic approach. None of them provide insight regarding existing community level resources (such as majmawalas) to address those psychosocial concerns. In the context of psychosocial sexual health promotion, the

216 majma provides an opportunity to learn about Bangladeshi men’s psychosocial concerns and promote sexual health in a more culturally appropriate way.

Developing essential and culturally appropriate sexual health promotion content Sexual health promotion content needs to be “comprehensive, clear and focused, up-to-date, inclusive, developmentally appropriate, sensitive to community values” (Thomas and Aggleton,

2016: 23), but sexual health promotion programmes in Bangladesh often fail to establish meaningful communication with their target groups. One of the reasons is the compromised communication content. Stereotypic and superficial imaginations of Bangladeshi culture draw on the monolithic understandings of Muslim religion and South Asian sexual norms and values. In this development space, western NGOs and other western government funded programmes reside in dominant political spaces where essential content is compromised due to concerns about

‘appropriate public language’.

The incorporation of HIV/AIDS information in a recent school text book project is an example of this compromise. This project could have developed comprehensive sexual health content for school students but struggled even with basic content on HIV/AIDS. During the content development, the challenge was to balance between the moral code of Bangladeshi society and the discussion topics of sex and HIV/AIDS related information. Therefore, the tendency during the content development was to highlight the risk Bangladesh faced with the HIV/AIDS epidemic only. Because of the Muslim majority in Bangladesh, there is a strong understanding among policy makers that any content which disagrees even slightly with Islamic ideas may create a controversy and initiate political instability. In recent times, various Islamic groups have been very vocal about the content of school text books, arguing for the elimination of so called non-Islamic content.

Some of their demands have already been met, and significant content has been removed from

217 many books74. In this context, it is very unlikely to be possible to include “comprehensive, clear and focused, up-to-date, inclusive” sexual health content in school text books. As Karim (2012) says,

The rise of religious fundamentalists and their increasing influence on state

governance and its policies has directly impacted on lives and made the already

conservative approach towards sexuality and SRHR by the states even more limited.

(Karim, 2012: 218)

This example of compromising text book content is important for understanding the overall failure to provide meaningful and communicative content on sexual health promotion in Bangladesh.

Like the school text book programmes, sexual health promotion follows a strict moral code and often compromise explicit information too. In the introduction of this thesis, I included an image of an HIV/AIDS poster (figure 1.1) in Bangladesh as an example of a hesitant mass marketing campaign. This kind of campaign is not enough to communicate with people and convey meaningful information. These examples show how often sexual health promotion programmes need to compromise the required content to accommodate moral dilemmas.

It is important to decide whether we want to compromise the content in sexual health promotion and continue to use a western approach to sexual health promotion, or instead consider using the community resources that are already in place. In the context of meaningful and communicative content, the majmawalas are unquestionably important. They operate in a zone of cultural acceptability, and have the cultural licence to speak about sex and sexual health in public places.

They understand and work within the complexities of Bangladeshi society. Thus, while there are

74 See Barry & Manik (2017).

218 indeed rules about appropriate public discourse and the extent to which it can contain information about sexual health, the accepted norms about the majmawalas include sexual health information.

The majmawalas can attract and keep the attention of their audience. In their majma narratives, they explicitly discuss sexual health issues, and provide examples which are meaningful to their audiences. They do not compromise the content out of fear of any ‘controversial’ debate. Rather, they enjoy the freedom to use all kinds of explicit sexual terms in their majma, and use language which the audience can easily understand and connect with. In most cases, majmawalas use photo albums with images that help illustrate different sexual health concerns, which help them present their argument clearly and persuasively. The presentation in the majma provides both entertainment and critical information. The holistic explanations of different sexual health issues combined with everyday examples deliver a meaningful message to the audience in the majma.

Unlike most sexual health promotion material, the audience do not need negotiate coded conversation that is so camouflaged that the real meaning is lost.

The willingness of Bangladeshi men to join majma street healing gatherings shows that they do not have any moral issues about learning about sex and sexual health from the majma street healing. This social acceptance also shows that the majmawalas have the ability to overcome the moral issues involved in any sexual health programme.

Establishing a culturally appropriate sexual health promotion strategy It is not only clear and comprehensive content that is lacking in sexual health programmes in

Bangladesh. In most cases, the public health authority adopts a temporary strategy to achieve their programme goals. For example, the school based HIV/AIDS information programme has been pushing school teachers to be more engaged with the dissemination of HIV/AIDS information.

This programme does not consider the social position of Bangladeshi school teachers and ignores the fact that school teachers in Bangladeshi culture play a similar role as the students’ parents. In

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Bangladeshi culture, neither parents nor teachers should discuss sex with their children. Teachers who do discuss such topics may find it has a negative impact on their social position. Therefore, when school teachers are required to disseminate HIV/AIDS information, they are likely to be reluctant, and try to avoid it. This is a clear example of ignoring the local perspective and promoting sexual health information against the social norms. Therefore, I do not anticipate that this programme will be particularly successful, because as Nichter said, “Lack of sensitivity to the health concerns of lay persons, and the introduction of educational messages that fail to take their health culture into consideration result in misinterpretation, the compartmentalization of information, and desensitization to priority issues” (Nichter, 1996: 393).

We need to consider the local perspective in order to formulate culturally appropriate sexual health promotion. Who can communicate health information is as important as the content of their communication. It is not true that people in Bangladesh do not want to learn about sexual health or that they always create obstacles to learning about it. It is also not true that sex talk is always taboo. People do want to listen and learn about sexual health, and they do discuss sex. The source of the information is critical to social acceptability. It is our responsibility to understand this and to work within rather than against such cultural considerations. As shown in the last chapter, some public health professionals have used majmawalas to achieve their goals in various programmes, although none developed any long-term collaboration. The engagement of the majmawalas was successful, but the majmawalas did not receive any acknowledgment for their contribution.

Men’s voluntary involvement in majma gatherings that discuss sexual health (detailed discussed in chapter 4 and 5) and family planning (detailed discussed in chapter 7) shows that they are willing to hear about these sensitive topics from the majmawalas. Chapter Four mentioned the time and location of the majma. In most cases, majmawalas conduct their majma near a Mosque and design their schedule around prayer times. The time and place of the majma play a significant role in

220 drawing people to join the majma. This shows that by working within the local culture it is possible to talk openly about sexual issues, even in front a Mosque, after prayer time, and with the men leaving the Mosque. It also shows the level of acceptance that the majmawalas have in the community. They do not face the same difficulties as others in explicit discussion on sexual topics.

An important fact that supports the need for an emic solution for sexual health promotion is related to the nature of overall sexual health service approach. In biomedical sexual health services, it is important to document clients’ sexual and medical history, which includes recording their identity. Revealing both their sexual history and their identity causes discomfort for many men in

Bangladesh, as they feel embarrassed to disclose their sexual health concerns in front of practitioners. The social acceptance of the majma, and the group consultation method used removes these barriers. The majmawalas do not require the clients’ identity, nor do they document their problems. This encourages many men in Bangladesh to join the majma street healing gatherings, and thus seek help for their sexual health problems.

The majmawalas can be found everywhere in Bangladesh. They are present at the community level in market places, stations, religious centres and on the street. They are equally present in urban and rural areas. They speak the local languages, so their expertise on local dialects is also useful for different regions. They have strong communication skills and experiences, and adapt their styles to both urban and rural areas. These factors combine to create a valuable ability to effectively promote sexual health through this nation-wide sustainable network.

I want to emphasise, that sex talk is not always taboo in Bangladesh, but it is important to understand who the appropriate speakers are in the cultural context. External approaches, such as school based sex education and billboard based health promotion, often fail to understand and accommodate the local values and context which are essential to promote a meaningful sexual

221 health message. When such an external approach fails to achieve its goals, the local ‘social stigmas’ are blamed, without examination of why men are willing to listen to sex talks from the majmawalas, but not from these sexual health programmes. Therefore, we need to review the existing external strategy of sexual health promotion and work on understanding the local cultural context and the community resources for better sexual health promotion.

THE PARADOX OF NOT VALUING THE MAJMAWALAS IN SEXUAL HEALTH PROMOTION The devaluing of the majmawalas in sexual health promotion is connected with the overall status of informal traditional healing systems in Bangladesh. These traditional healing systems provide the major proportion of health care services in Bangladesh (BHWR, 2008, 2012), but their contribution is not well acknowledged, and they are often described as ‘non-qualified’ or an

‘obstacle to the health system’. The majmawalas, as part of these informal traditional healing systems, are described in similar ways. Although they contribute significantly to men’s sexual health, and can be more useful in sexual health promotion, there are only limited initiatives to incorporate or acknowledge them within mainstream sexual health promotion. This potential community resource is not just under-utilised but actively oppressed. This paradox has its roots in three major factors: the institutional/colonial legacy of this region, the influence of scientific evidence based practice, and aid dependency in sexual health promotion in Bangladesh. These three influential aspects are inseparably, interconnected and together result in the lack of perceived value of the majmawalas in mainstream sexual health promotion.

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The institutional/colonial legacy A central idea in the establishment of colonial medical institutions was to neglect the traditional healing system and displace local knowledge in favour of western knowledge (Arnold 1993). The hegemony of the institutionalised biomedical system still dominates postcolonial societies, and this hegemony of institutionalised education does not often consider traditional knowledge and resources. On the contrary, these resources are often considered harmful, superstitious and unscientific. The institutional/colonial legacy thus focuses on modern and institutionalised education and often fails to see the usefulness of alternative community resources. Therefore, the proposition of engaging the majmawalas in sexual health promotion can earn critiques. Even the institutionalised traditional healing system raises questions about the majmawalas. Because of the institutionalisation of the traditional healing system, it is not only the biomedical professionals who may see the lack of education in majma street healing as a problem, but also the traditional healing professionals who are trained in institutions may use similar biomedical lenses when viewing non- institutional traditional healing systems.

This perceived need for institutionalised education often means that the informal traditional health systems, such as the majma street healing, are seen as a constraint on the overall development of health care, as many mainstream practitioners see only an institutionalised system solution to any kind of health issue. Therefore, they may be able to support a traditional healing system which has institutional accreditation, but often this process of accreditation undermines the contribution of the traditional healing systems and imposes biomedical pedagogy that transforms the traditional healing system into an institutionalised healing system. Langford (2002) shows such a situation in the context of the modernisation of Ayurveda in India. She describes how the traditional

Ayurvedic knowledge was transformed through institutions and technologies such as anatomy labs, clinical trials, sonograms and hospitals. None of these phenomena existed in traditional

Ayurveda. She argues that the intervention of these types of technologies has transformed the

223 tradition of Ayurveda. Though my research was not to examine the impact of institutionalisation of traditional healing system, I also observed a strong effect. As he had graduated from an institutionalised Ayurveda college, one of my respondents, Malik Hasan, used the title ‘doctor’. In the Bangladeshi context, ‘doctor’ is a professional title for biomedical graduates; traditionally,

Boidho (বৈদ্য) in Ayurveda, and Hakim (হাকিম) in Unani are used for healers. However, institutionally trained, non-biomedical health practitioners often feel more association with the biomedical system than with the traditional system, and therefore, not only the biomedically trained health professionals, but also the institutionally trained alternative medicine practitioners may see the majma street healing as an uneducated system.

In my view, this pro-institutional perspective (Bhuiyan, 2014; Nahar et al., 2013, van Reeuwijk et al., 2013) places the informal traditional system in opposition to this ‘formal’ system. The advocates of ‘institutions’ describe institutional intervention, such as school curriculum or mainstream public health interventions as the only solutions to address sexual health issues. There is a desire to solve all the problems with a ‘scientific’ or ‘institutional’ method by excluding informal traditional methods. By stressing the ‘institutional’ ideas, often the mainstream health system ignores the existing informal community knowledge and resources. Therefore, the existing social acceptance of the informal system is often ignored.

The influence of reductionist accounts of evidence in health promotion The influence of reductionist accounts of evidence shows how biomedical institutions operate in health promotion and establish informal traditional healing systems as a ‘problem’. The ‘evidence’ in evidence-based medicine is found through standard scientific process. From the beginning of evidence based medicine there was strong influence of reductionist account. For example, in the early years of evidence based medicine, Sackett et al.(1996) saw the meaning of this practice along

224 with ‘integrating individual clinical expertise with the best available external evidence from systematic research. By individual clinical expertise, we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice’ (Sackett et al.,

1996:71). This understanding of evidence is still the same in evidence based medicine even there are initiatives to identify the crisis of evidence based medicine movement in recent time. For example, Greenhalgh and colleagues (2014) a range of crisis in evidence based medicine but endorses the reductionist accounts of biomedical clinical expertise to overcome the crisis.

Therefore, it is obvious that this perspective would not find any scientific evidence to acknowledge the effectiveness of majma street healing, and would therefore describe it problematic due to lack of scientific evidence.

The popularity of evidence-based medicine has increased the search for ‘evidence’ of the efficacy of alternative medical systems, with more studies now examining effectiveness using randomized clinical trials (RCTs) (Barry, 2006: 2647). Without considering the context of the alternative system, this RCT approach could fail to take into account traditions and their relation to people’s lives.

Barry (2006) uses ethnographic evidence to show the efficacy of alternative medicine, is critical about the randomized controlled trial evidence of evidence-based medicine, and discusses anthropological notions of evidence. She narrates the different context of evidence from an anthropological perspective, where she finds transcendent, transformational experiences, and changing lived-body experience as evidence. These may not be evidence in biomedical science, but they are rooted in culture and tradition. Barry compares this contrast between biomedical and the anthropological approaches in the understanding of what is ‘evidence’.

Like Barry (2006), Ecks (2008) is critical of the idea of ‘evidence’. Ecks (2008) asks anthropologists to work on ‘evidence’ from a medical anthropological perspective. He believes ethnographic work on evidence will show the multiple understanding of evidence in communities. My understanding

225 is very similar to Barry and Ecks’s understanding that anthropological evidence is as valid as

‘scientific’ evidence of efficacy. I want to discuss the ‘evidence’ of efficacy in the context of the majma street healing.

The evidence of efficacy in the biomedical context is reductionist as it focuses on whether or not the “symptom” or “health issue” has improved or has been fixed; in the context of majma, efficacy is much broader. It focuses on the whole person and their sociocultural environment. The efficacy of majma is connected with the individual’s engagement, empowerment, feeling listened and acknowledged, speaking a common language. The efficacy that one can gain in a majma is a complete package of the whole environment of the healing process. The majmawalas’ talks, engagement procedures and the clients’ engagement with the process, all suggest the efficacy of the majma street healing. The medicine in a majma is only one of the contributing factors. Thus, when I search for the evidence of efficacy in majma, I see the clients’ engagement in the system. I see the efficacy in majma in the whole environment of the session. Evidence of the efficacy comes when a client gets the space to discuss his sexual anxiety, because that is the only space in which many Bangladeshi men can break their silence and share their sexual health problems.

The effect that one can gain in a majma is essentially different from the efficacy of the reductionist approach of biomedicine. The reductionist accounts of evidence may not see the effect of the majmawalas as evidence of the efficacy of that healing system. Because of the reductionist approach of the clinical trial, biomedical evidence based approach may only find the evidence of efficacy through integrating individual clinical expertise, and majma healing may not pass the biomedical requirements to prove its efficacy. Therefore, the biomedical point of view may describe majma as based on non- or even anti-scientific theories and practices, and would not be able to see the majmawalas as a potential resource in sexual health promotion.

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Aid dependency and sexual health promotion in Bangladesh My critique of aid dependency is not the denial of an unequal ‘World-System’ and its resulting discriminative health care system. My position is against aid dependency, not against aid. I do agree that aid is necessary and that it can be effective in many ways (Quibria, 2010), and we can make use aid in the context of social needs. However, an aid dependency with an all-time recipient attitude can destroy the community potential and the dependency can contribute to a discriminatory World System. Aid can be an instrument that prolongs inequality in the global capitalist system. In the context of Bangladesh, Gardner (2012) describes how aid networks produce a discordant development. She shows that during their operations, a vast multinational mining company destroyed the local livelihood and ecology of a region in Bangladesh; and aid was an instrument to justify their destruction of that area. The external expertise or top down development approach is not always the solution. Without considering the local context, an external perspective is unlikely to bring good to the people. Moreover, inappropriate external initiatives can result in long term damage of a local community. In this context, it is important to respond with local peoples’ self-development initiatives (Rahman, 1993) and their street science.

As Corburn (2005) says,

Lay people often are in a better position than professionals to make judgements over

the democratic character of science because they experience how science impacts their

everyday lives. (Corburn, 2005: 40)

In the context of sexual health promotion, the external perspective does not look at the responses to sexuality and sexual health in the local context. The biomedical understating often promotes an individualistic model of sexual health promotion which fails to understand the cultural meaning of sexual health. Parker and Aggleton (2003) show the limitations of individualistic models of sexual health promotion, and state that these models fail to alleviate the stigma of HIV/AIDS, and

227 propose instead rights-based community mobilisation for stigma alleviation in sexual health promotion, and particularly for HIV/AIDS.

Sexual health promotion in Bangladesh is mainly dependent on international aid. This aid dependency also contributes to the lack of perceived value of the majmawalas in sexual health promotion. The initiatives dependent on external aid are grounded in the modern institutional education system, and therefore the choices of focus and strategies for health promotion funded by this aid come from science, and in particular, public health research.

In general, public health research has a strong belief that communities lack knowledge and that it is the duty of health promotion professionals to provide the appropriate knowledge to the community. This approach is limited to either providing baseline data on what a population does not know, enabling the measurement of knowledge and practice change following an intervention, or identifying cultural barriers to health programmes (Nichter, 2008). Nichter thinks this general approach of public health ignores the broader reasons for people’s behaviour, pays no attention to context, and largely ignores the reasons for actions taken and not taken. He argues that focusing on what people do not know diverts attention away from what they do know and how they learn.

Furthermore, it privileges biomedical knowledge and pays little attention to local practical knowledge and the role this might play in health promotion as well as disease prevention and management. Nichter suggests it may also overemphasize cultural barriers which are used as covers for poor programme planning and implementation, cultural insensitivity, an inconsistent supply of resources, poor access to information, and poverty.

Like the global context, the major sexual health research and intervention programmes in

Bangladesh either look for information gaps or see local cultural barriers as their challenges. This approach does not see peoples’ knowledge, such as majma street healing, or strengths in health

228 promotion, but rather promotes a biomedical understating of an individualistic model in health promotion.

RESEARCH AIM REVISITED The central aim of the study was to explore the scope of majmawalas’ possible engagement in men’s sexual health promotion within the public health system in Bangladesh. With that central aim, the study also wanted to contribute an understanding of an insider’s perspective of sexual health. The research achieved the aims by using ethnographic tools and techniques during the fieldwork and contextualising the scholarly works. The ethnography of majma street healing provided an insider’s perspective on sexual health and the existing gaps in sexual health promotion.

In this ethnography, I described the engagement capacity of majma street healing in Bangladesh.

The gaps in current sexual health promotion and the majmawalas’ capacities to address those gaps showed the potential contribution of majma street healing in sexual health promotion in

Bangladesh.

I worked with three different questions to achieve the aim of the study. The first question was

“What guiding frameworks underpin the majma street healing approaches to sexual health promotion in Bangladesh?” Sexual health promotion in Bangladesh needs a communicative and intensive promotion strategy which can deal with the moral grounds involved in sexual health promotion. Along with a culturally sensitive approach, I found two influential elements in majma that help overcome the moral issues involved in sexual health promotion, which were the process that engages the audiences in the majma, and the content of majma narratives. The engagement process is useful to implement a fruitful sexual health promotion strategy. The theatrical performances in majma street healing draw the attention of random men and engage them in the process healing. The success of engaging men in majma shows that mainstreem public health may think about the majmawalas for a engaged sexual health promotion. The majma narratives help

229 develop content in sexual health promotion. The uses of local languages, local terms, and the style of presentation in majma show how the majmawalas make the best uses of local culture and languages in approaching their healing system. The majmawalas prove that a meaningful communication is important to get a success in convincing the audience where communicative language is the key of success. In the context of sexual health promotion, the majma narratives can be an effective way of delivering sexual health message.

The second research question was related to the audience and clients of the majma street healing.

The question was: “How do the audiences of majma street healing describe their understanding of sexual health problems?” I described the narratives of a group of Bangladeshi men who suffered from different sexual health anxieties. I discussed how both the majmawalas and their clients shared a very similar understanding of men’s sexual health. The answers to this question demonstrated the potential contribution of majma street healing in sexual health promotion efforts in Bangladesh.

The final question was: “How do public health professionals in Bangladesh perceive the majma street healing? Do they see any opportunity for collaboration with majmawalas?” Public health professionals experience both logistical and strategic challenges in the promotion of sexual health.

Those logistical and strategic challenges once again showed how majma street healing could be used effectively in sexual health promotion. Most of the public health professionals agreed that majma street healing as a potential resource for sexual health promotion. Most of them supported the idea of including the majmawalas in sexual health promotion. Some of the professionals see a need for training the majmawalas for effective delivery of sexual health promotion programmes. I think training is essential for any professional development. However, some suggested a regulatory framework for the engagement process, and a few did not want to engage with the majmawalas at all.

230

Communities can benefit from a combination of the traditional and modern systems and so it is important to encourage these systems to work together, rather than oppose each other. Therefore, the opportunities provided by majma street healing should be acknowledged and utilised to improve health outcomes. The majmawalas are open to incorporating new ideas in their sessions.

They are happy to negotiate their roles. Their undocumented contributions to some public health programmes show that they can accommodate different requirements. This flexibility could provide an opportunity for bridge-building between the formal public health system and the majmawalas.

The significance of this study is to advocate for incorporating an insiders’ perspective of sexual health promotion in Bangladesh, which reminds us of the importance of cultural understanding in health promotion. This insiders’ perspective is the main strength of the study. This study also contributes to the understanding of the informal system that operates outside of the formal health system, and that that informal system has a high level of social acceptance. Engaging the majmawalas in sexual health promotion could address the critical shortage of skilled sexual health promoters in the field. More importantly, this study is advocating the use of this community resource in a sustainable health promotion programme, and recommends the following guidelines to engage the majmawalas in sexual health promotion:

1. The majmawalas should be recognised as a resource. They and their work should be

documented.

2. The majmawalas should get an authority of their work. They should get the opportunity

to learn about any proposed sexual health promotion agenda and they should have a voice

to decide how to deal with that agenda.

3. The majma is a holistic approach to deal with sexual health concerns. It is therefore

important to ensure that holistic aspect when engaging the majmawalas in sexual health

promotion. No one should only partially adopt the majma approach.

231

4. It is important to consider the living of the majmawalas. The majmawalas should get

proper remuneration for their work.

5. The engagement of the majmawalas should be sustainable for a long time. It should not

be a temporary arrangement.

6. The majmawalas should remain able to choose their working area and working times.

This PhD project has some limitations. First of all, because of the nature of majma street healing,

I worked only with men in Bangladesh. The audience members and the majmawalas were only men. I acknowledge the need for equivalent attention to be given to the sexual health promotion needs for women especially in regard to similar close-to-community resources for women health.

The second limitation is related to the achievement of the study. Although this study has highlighted the importance of engaging the majmawalas in sexual health promotion in Bangladesh, it did not include any piloting of such an engagement process. It only explores the context of bridge building and suggests a few recommendations to engage the majmawalas, but does not implement a proper framework for that engagement. However, I think the study plays an important role in starting a dialogue on this topic, and further study can recommend a proper framework for implementation.

FINAL REFLECTION: THE PLANT IN THE COURTYARD CAN BE A MEDICINE There is a South Asian proverb – ‘the plant in the courtyard is not a medicine’. Nichter and Nichter

(1996) interpret the meaning of the proverb in the South Indian context, which equally reflects the meaning of the proverb in Bangladeshi context, ‘what is familiar and close is often overlooked as a valuable resource’ (Nichter and Nichter, 1996: 401). The majma street healing in Bangladesh is the plant in the courtyard. This community resource is so familiar and close that the Bangladeshi

232 public health authority fails to see it as a valuable resource. They have been focusing on external resources and strategies for a long time; most of the previous and current sexual health promotion efforts use an external resource-based strategy for creating awareness among communities. These etic promotion strategies pay very little attention to the communities’ thoughts or the usefulness of community resources to address sexual health promotion.

In any health promotion, it is important to ensure a setting where the target group will have enough reason to engage in the promotional activities. In the case of sexual health promotion, it is even harder to ensure a proper setting for target groups’ engagement. In the Bangladeshi context, sexual health promotion is highly sensitive, and it is easy to see the difficulties in the communication of sex-related messages in public health programmes. Majmawalas show us a different approach at the community level. They have the social support for the discussion of sexuality and sexual health and can effectively engage people in their discussion. Their strength of public engagement is rooted in their expertise in the local cultures, and they use these cultural understandings to effectively explain sexuality and sexual health. Therefore, with all of its potential, majma street healing is sitting in the courtyard, and it’s time to consider this long- overlooked resource for sustainable and appropriate sexual health promotion in Bangladesh.

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