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

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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 i Dedicated to My Parents & My Wife ii 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. iii 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 iv 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. v 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. vi 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 vii 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 viii 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 ix 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
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