Funding and Support Needed for Microbicides

Dawna Cornelissen

As women become more at risk for HIV, microbicides represent a promising technology that would allow women to initiate protection from sexually transmitted infections, as well as prevent pregnancy.

Over the last 20 years, researchers and activists have taken interest in a product that could be the most important innovation in reproductive health since the pill: microbicides. Like the pill, microbicides are being promoted as a woman-controlled or initiated prevention method. But, unlike the pill, microbicides go beyond just preventing pregnancy to preventing sexually transmitted infections (STIs) as well. In fact, at this point the prevention of STIs, with an emphasis on Human Immunodeficiency Virus (HIV) prevention, makes up the majority of microbicide research, development, and advocacy. Although they are not yet available, it is hoped that microbicides will greatly reduce the transmission of HIV worldwide.

Generally, an ideal microbicide would be odorless, colorless, tasteless, non-irritating, fast-acting, long-lasting, inexpensive to manufacture and purchase, and available in contraceptive and non-contraceptive forms. Microbicides come in a variety of forms, including gels, creams, films, suppositories, pre-loaded diaphragms or cervical caps, sponges, vaginal rings, etc. Although most microbicides are designed to be applied topically to the vagina, there are some baseline studies being done on rectal microbicides.

The woman-controlled strategy employed by microbicide advocates is in response to both social and biological factors uniquely affecting women. Social factors like gender inequality and violence against women have led to the feminization of HIV. Biological factors affecting women include women being more likely than men to contract HIV after just one exposure. Worldwide there are now more adult women (15 years or older) than ever before living with HIV. According to UNAIDS, the 17.7 million women living with HIV in 2006 represents an increase of over one million compared with 2004. Clearly, microbicide research and development is greatly needed.

A key factor in getting microbicides available to the public is adequate funding. One way that advocates of microbicides are attempting to increase U.S. government funding is through legislation that would establish and coordinate units specifically designed for microbicide research and development. One piece of legislation that attempts to do this is the Microbicide Development Act (MDA). It is hoped that with this bill, microbicide funding will soon become the priority it should be in the federal government's budget to combat HIV/AIDS. Versions of the MDA have been introduced seven times since 2000, but none have ever passed. It was most recently introduced again in both the House and the Senate on March 8, 2007 (International Women's Day). The Senate version currently has 18 cosponsors and the House version has 54 cosponsors; both versions are in committees.

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Although the U.S. government has appropriated some funding, it has not been adequate to produce an effective microbicide for public use. According to the Global Campaign, barely 3% of the U.S. budget for HIV/AIDS research is spent on microbicide research and development. Passing the MDA would help to secure the funding needed by coordinating microbicide research and development efforts within the three U.S. federal agencies already involved in HIV/AIDS research. It is unclear why exactly the MDA has not received adequate support from Congress in the past. I would hope that curbing and hopefully stopping not only the spread of STIs, but also the HIV/AIDS pandemic is important to the United States. To learn more about what you can do to support the MDA, visit the Global Campaign for Microbicides.

News Abortion

What the ‘Abortion Drone’ Will (And Won’t) Mean for Reproductive Rights (Updated)

Emily Crockett

The Poland "abortion drone" is causing a splash in the media and excited buzz in the reproductive rights community, but it has also become a source of misinformation and anxiety.

UPDATE, June 29, 2:59 p.m.: The first-ever abortion drone flight was a success Saturday, Women on Waves founder Rebecca Gomperts told Rewire. Two women in Poland received and took abortion pills that were delivered to them via drone from Germany. While German police failed to stop the flight, Gomperts said, they threatened criminal charges, and also confiscated the drone controller and some personal iPads belonging to activists. It is “totally unclear on what grounds” criminal charges could be brought, Gomperts said, and official charges could take months. The group’s lawyer is looking into the case.

The first-ever “abortion drone” is scheduled to launch Saturday and deliver abortion pills to women in Poland, getting around that country’s restrictive abortion laws.

The action is causing a splash in the media and excited buzz among reproductive rights advocates, some of whom envision a future in which reactionary state legislatures are no match for nimble robots armed with mifepristone and misoprostol. But the drone has also become a source of misinformation and anxiety, with some media reports garbling the facts and some activists questioning the project’s methods.

The innovative and unusual use of technology has the media’s attention, with Gizmodo raving that “Abortion Drone is the Best Drone” and comparisons being made to Amazon and Google’s proposed drone delivery services. Meanwhile, anti-choice groups in Poland have reportedly vowed to shoot the drone down if they can find it.

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The headline-grabbing campaign is the brainchild of Women on Waves, a Dutch group known for keeping ships in international waters to give safe medication abortions to women living in countries that have outlawed abortion care.

Many media reports have been confused and inaccurate about how the drone’s pill distribution will work, Rebecca Gomperts, founder and director of Women on Waves, told Rewire in an interview.

Some reports have said that the pills will go to women’s groups who will then distribute the pills to women in need, or that the drones will drop packages over the Polish town.

“It’s not going to drop boxes full of abortion pills over Poland,” Gomperts said, laughing. “That’s ridiculous. It’s not how we work.”

Another report said Gomperts refused to say who the pills would go to and how.

But Gomperts set the record straight to Rewire in no uncertain terms: The pills will go directly from the drone to the women who are seeking an early abortion, with no intermediaries, she said. That means the local women’s groups openly participating in the action won’t be putting themselves at risk by illegally distributing the medication.

The women seeking abortion care are involved with those local groups, Gomperts explained, but only the women who are taking the pills will handle them. Women on Waves will confirm the women’s identities both in person and with a camera on the drone.

The drone will be small, less than five kilograms, and it won’t travel far—just a quick jump across a river and an international border, from Frankfurt an der Oder in Germany (where abortion is legal) to the town of Słubice, Poland (where it isn’t), staying within eyesight the whole way to comply with drone regulations.

The drone will carry mifepristone and misoprostol, a combination of drugs approved by the World Health Organization for safe termination of a pregnancy of up to nine weeks. Only two or three women are expected to take the pills—as long as they are still ready and willing to take the drugs on the day of the launch.

“We want to give space to them to decide to do it or not to do it,” Gomperts said.

The drone’s mission, Gomperts said, is twofold: providing a few women access to needed services, and raising awareness about the social injustices of illegal abortion.

That awareness serves both to inform women that they have the power to safely terminate their own pregnancies, Gomperts said, and to put pressure on governments to change their draconian anti-choice policies. Poland prohibits abortion except in very limited circumstances, and even then allows doctors to opt out of performing the procedure.

The drone operation is legal, or at least not technically illegal. The scale is small enough that no authorization is needed from either the German or Polish governments. And since Poland only criminalizes doctors who perform illegal abortions, not women who abort their own pregnancies, the women who will take the pills on the other side of the river shouldn’t be in any legal danger.

Gomperts said the local women’s health activists in Poland, who she has been in contact with since an earlier ship campaign in 2003, jumped at the chance to participate in the drone campaign.

“The Polish groups are very excited, and they are very happy to do this,” Gomperts said.

Some reproductive rights activists in other countries, however, are less enthused about the idea of an abortion drone coming to their borders.

The Global Post reported that Gomperts plans to try the drone program in other countries where abortion is illegal or restricted, such as Ireland, Brazil, and Mexico, if Saturday’s delivery is a success.

Sonia Correa, co-chair of the global research forum Sexuality Policy Watch and a longtime reproductive rights activist in Brazil, told Rewire that she and several other activists in her network were “horrified” at the prospect of abortion drones coming to Brazil.

“It’s just going to be an additional problem to cope with,” Correa said. “We need people to understand the conditions in which we are operating, and whatever type of support they provide needs to be in tandem with an understanding of the context and in negotiation with us. It cannot be parachuted.”

Correa said the electoral victories of conservative political segments in Brazil have become so regressive and sexually repressive that the risk of backlash from such a splashy media event would be too great.

Women are already being prosecuted as smugglers for taking misoprostol, which is illegal in Brazil, Correa said. She envisions police staking out a previously advertised abortion drone site to make arrests, or anti-choice groups capitalizing on the event to demonize feminists as using “weapons of mass destruction,” drones, against unborn children.

“For those of us who have been for so many years struggling for abortion rights within a solid human rights frame, a health rights frame—to see the right to abortion be so intimately associated with an instrument that in the popular imagination is correctly seen as an instrument of war … that imagery is very troubling and negative,” Correa said.

Gomperts clarified to Rewire that Women on Waves doesn’t have plans right now to go to Brazil or the other countries mentioned by the Global Post, and that the organization always consults closely with local groups before taking action. She mentioned those places as potential candidates for future actions, she said, but she recognizes that a country like Brazil with more restrictive policies would require a different approach.

“I really want to focus on what’s going to happen here [in Poland],” Gomperts said. “We don’t know what’s going to happen, so we have to really learn from this moment and then make decisions on where and how and what we can do in the future.”

She added that drones are also increasingly used for humanitarian and commercial purposes, and she urged activists not to restrict their strategies based on fears of backlash.

“The anti-abortion groups will say whatever they want. They will use anything,” Gompert said. “I think it’s more important to stay positive and creative and try to find indeterminate legal spaces where you can actually move ahead and create change … than to be afraid of backlashes.”

Other reproductive rights advocates are cheering the campaign as an innovative action that could help expand access to safe abortion.

“I think it’s a really excellent way of calling attention to the fact that women want access to safe abortion, and they are willing to do whatever it takes to get it,” Alice Mark, senior clinical advisor to the international reproductive rights group Ipas, told Rewire. “This is one possible way of getting the safest medications into their hands.”

Writing for Dame Magazine, reproductive rights journalist Robin Marty fantasizes about a “drone-led abortion revolution” that wouldn’t just work within the increasingly restrictive anti-choice regime in the United States, but instead “break it wide open.”

Gomperts said the United States is unlikely to see a Women on Waves drone, even though she decries the “desperate” and “unbelievable” situation where women in states like Texas are running out of options for safe abortion access. Her organization prefers to focus on countries in which abortion is illegal and women have even fewer options, she said.

Still, she hopes abortion rights groups in the United States might follow her lead someday. She’s excited about the possibilities for the technology, and she hopes it might give a boost of positive energy to activists who are burned out by relentless attacks on women’s human rights.

“It also has something fun about it,” Gomperts said. “Of course you’re not allowed to say ‘fun’ when you’re talking about abortion, but it’s not just negativity and heaviness and suffering. I mean, abortion is also a positive experience for a lot of people.”

Q & A Human Rights

A Conversation With Four ‘Youth Champions’ of Reproductive and Sexual Rights

Imani Gandy & Zoe Greenberg

From a 21-year-old who first saw the need for sex ed when he was the only out gay man at his Catholic school in Louisiana, to the 27-year-old web editor of one of the most popular love and relationship sites in India, these young activists are leading local sexual and reproductive health and rights movements around the world.

On a brisk morning last week, 19 young reproductive rights activists gathered in a second-floor conference room in Palo Alto as part of the Youth Champions Initiative. They had come to California from Ethiopia, India, Pakistan, Mississippi, and Louisiana for an intensive week of sexual and reproductive health training.

Clustered in geography-specific groups for a media training session, the YCI participants discussed the stigma that surrounds sex ed, how to report on rape, and what to do with Twitter trolls, all before noon.

The Youth Champions Initiative was inaugurated this year in honor of the David and Lucile Packard Foundation’s 50th anniversary, with the goal of bringing international young leaders to a Silicon Valley-like incubator focused on sexual and reproductive health and rights (SRHR). The goal is for young leaders to meet peers in other countries and learn new strategies to “shake up” the field, according to the program’s executive director, Denise Dunning.

During the incubator, YCI participants heard from SRHR experts (including Rewire’s Jodi Jacobson), visited the offices of Ideo and Mozilla Firefox, and brainstormed projects that would further the work they had begun at home. Innovation is the watchword at the new program.

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“We often say, ‘Why aren’t young people using condoms?’ And then the solution is, ‘Let’s make the condoms bubble-gum flavored,’ as opposed to, ‘Young people aren’t using condoms. What radically different thing needs to happen in our space to change this?'” Dunning told Rewire.

The program is designed to help young leaders think in challenging, fresh ways about their work, while making connections and meeting colleagues. After the incubator, participants can apply for YCI grants to fund their newly designed projects.

Rewire sat down with four of the program’s participants to learn more about their work and what they hope to do in the future.

From a 21-year-old who first saw the need for sex ed when he was the only out gay man at his Catholic school in Louisiana, to the 27-year-old web editor of one of the most popular love and relationship sites in India, these young activists are leading local SRHR movements around the world.

Gayatri Parameswaran is the web editor for, the first website in Hindi to focus on “blush-free information and news on sex, love, and relationships.” Originally from Mumbai, Parameswaran is an Erasmus Mundus Scholar in journalism, with a specialty in War and Conflict Reporting.

RH Reality Check: How did you first become involved in work around sexual and reproductive health?

Gayatri Parameswaran: When I was about 17, I stood very close to a friend who was going through an abortion. It was probably one of the most traumatic times in my life, although I didn’t have to go through it myself. We had to keep it secret, and the stigma around it was really depressing.

Rewire: Was your friend open in talking to you about it?

GP: She was open telling me about it, but no one else knew. We couldn’t tell her parents. We couldn’t tell anyone else.  We found a gynecologist who didn’t require any personal information and agreed to do the abortion. After that, my friend said two things that stuck with me. One was that she wished she had known better. And the other was that she wished there wasn’t so much shame around what she had done.

In India, we really don’t talk about sex; it’s just a taboo subject. Not having information, as clearly illustrated by this case, doesn’t help. There’s no need to have this shame and guilt around everything related to sex.

When I was about 20, I was studying in Amsterdam and interning at Radio Netherlands Worldwide. In 2011, they were piloting a project called Love Matters, targeted to young Indians. I started as a blogger and contributor, and then my role kept growing. Now I’m the editor for the India site.

Rewire: What do you publish?

GP: The most important thing about the website is that we emphasize pleasure. We really believe that sex is about pleasure. That is one of the most important things that people leave out when talking about sexual and reproductive rights. We all know that the reason people have sex is that it’s fun, and it makes you feel good. If we don’t talk about that component of sex, we’re missing out on talking to a lot of people. By implying that sex is about pleasure, and by talking openly about sex being something we do to feel good, we imply that sex is not about violence. It’s not about abuse.

In most states in India, we don’t have comprehensive sex education. We have a “resources” section of our site where people can look up information and find answers to their questions. We want to develop an alternative comprehensive sexuality education guide.

Another important element of our website is “Auntyji,” our sexual, reproductive and relationship expert. She answers a lot of sensitive questions: “Is masturbation a bad habit?” or “Is menstrual blood harmful?” or “I feel like beating my wife. What should I do?” She is very, very popular. We get hundreds of questions every day.

Rewire: What do you do on a daily base?

GP: I coordinate writers, work on partnerships, and think about content strategy. This week, for example, is marriage and wedding week, where all of our content is focused on that topic.

We’re also thinking about new technologies and new ways in which we can reach out to people. The website is currently targeted at urban young people with Internet. So how do we reach people who don’t have Internet? This incubator has made me think about services we can offer—like SMS services—to reach young rural youth.

Rewire: What are your personal goals for your own work?

GP: I wish I could have a conversation openly with my extended family about these things. There is still so much taboo and silence around topics related to sex and sexuality and gender and reproductive health. If I sat in a room for dinner with my cousins and aunts and uncles, and could speak openly about what I do, that would be a great day.

Rewire: What has been your family’s reaction to your work?

GP: My parents, and my brother—my close family—is very supportive. They understand very well the importance of what I do. That’s not the case with my extended family. I’m not comfortable talking about what I do with them. So I kind of skirt the issue, and say, “Uh, I run a website, it’s journalism.”

Rewire: Has there been anything particularly surprising about your work so far?

GP: None of us at LoveMatters expected it to be doing so well. We have more than half a million people on our social media sites. We are having a global impact in what we’re doing. It started in one room in the Netherlands with three people sitting down and saying, “Let’s talk about sex.” Now it’s become this phenomenal success.

Rahul Kumar Dwivedi is a campaign coordinator and special correspondent for Citizens News Service, a rights-oriented media organization based in Lucknow, India. He currently coordinates Vote for Health, a campaign focused on youth participation and activism around health issues.

Rewire: How did you first become involved in reproductive and sexual health work?

Rahul Kumar Dwivedi: I was born and brought up in a disconnected part of India, and there were several instances in my life when I wanted sexual health counseling, but there was no one I could talk to. I had a feeling that my sexual and reproductive health and rights were being denied.

For example, when I had my first sexual experience at the age of 15, neither of us knew anything about safe sex practices. There wasn’t any time for preparation. When I realized that she might be pregnant—though she was not—the lack of information fueled my anxiety and depression. I thought about the possibility that things could have gone in an unintended way. The guilt slipped towards shame, and I even thought about committing suicide.

When I moved to Lucknow in 2002, I got involved in a youth network called Indian Society Against Smoking, and later joined the Citizens News Service in 2008. Then my own understanding of sexual and reproductive health grew. I started leading Vote for Health, a policy, advocacy, and communication campaign that addresses structural drivers that negatively impact health and development outcomes. We work in schools and colleges. Eventually the Indian Society Against Smoking merged into Vote for Health.

Rewire: Have you faced any challenges when trying to bring this information into schools?

RKD: We find it very difficult to convince school administrations to prioritize sexual and reproductive health issues. They often say that there is no need for such discussions with the young. Rather, they want to talk about less controversial things, like anti-smoking. There is a culture of silence around sex and sexuality. There is an unavailability of safe places, which makes it even more difficult for youth to come forward and demand their rights.

Rewire: How has your work expanded since 2008?

RKD: I’ve gotten more involved with the issues. I organized Rights and Responsibilities Summer Training Camps to identify young leaders in Lucknow and educate them about sexual and reproductive rights. Since 2008, I have conducted at least seven or eight training sessions. That means I have trained more than 100 young people on what policies empower them and how they can seek information.

Rewire: What makes the Citizen News Service unique?

RKD: At the Citizen News Service, we do a lot of policy and advocacy initiatives, and we focus on involving the key populations that are affected. We engage with people living with HIV, people living with Hepatitis C or tuberculosis, people living with diabetes, with women, young people, transgender people, men who have sex with men. We document their voices and disseminate them on social media platforms.

Rewire: What are some of your personal goals for your future work?

RKD: I want to enhance the visibility of young voices. Young voices should be recognized, and young peoples’ participation in these issues should be meaningful, not just tokenistic. Somehow we need to break this culture of silence around sex and sexuality. Until and unless we break the silence, I don’t think there will be any sustainable impact on sexual and reproductive health and rights.

When I grew up, there was limited information available around sexual and reproductive issues. Nowadays there is increased access to information. That is of course good, but there are also caveats. There are now unreliable sources of information, such as pornography. That means it’s even more critical to work on these issues. That is why I am advocating and educating on this issue, and trying to build youth competence. Young people are not only part of the problem, but they are also part of the solution.

Michael Byer is a research and communications assistant at Louisiana Progress, a statewide advocacy organization. He has also helped organize the Louisiana Queer Conference, and was a past intern at GLSEN.

Rewire: What is your involvement in this program?

Michael Byer: I’m a research and communications assistant at Louisiana Progress. Louisiana Progress is a progressive statewide advocacy organization trying to do movement building in order to change Louisiana into a more progressive state. [Laughs] It may be a shock to people that we’re not.

We’re trying to do it on lots of broad levels. A lot of what we do is statewide policy advocacy as well as education by hosting forums. There’s a huge barrier as far as progressive media goes to talking about what is happening. It used to be that there were media who had to come to the legislature and who could put a check on a lot of these things, but there are only maybe two or three reporters now. And so we do a lot of broad-ranging things.

Rewire: When you say you’re an advocacy group, is it specific to sexual and reproductive health?

MB: No, it’s way broader than that. For example, during the next legislative session we’re going to do things on racial profiling, we’re running a version of ENDA (the Employment Nondiscrimination Act) in Louisiana, we’re doing things on foster care and child care, and we may do something on juvenile justice. We are trying to figure out what we’re going to do about sexual and reproductive health during this legislative session too. We’re working closely with the people at Planned Parenthood to talk about what to do there.

Rewire: What inspired you to do this kind of work?

MB: A lot of it was my own personal experience. I went to a Catholic school in New Orleans and was the only out gay kid in my grade. It was an all-male Catholic school. That informed me about how the system I was in—the Catholic school system—was not set up for someone like me to succeed. I had to search for support.

I remember being in our health class, and they were saying, “You can’t have sex until you’re married.” And I remember initially thinking, “Well, I can’t get married. They’re not talking about me. They’re not talking about ways that I can be healthy.” The only time they brought anything up about gay people was when they talked about how gay people were impacted by HIV or how gay people have higher rates of HIV. But there was no connection about what to do about it. No one ever told me how I was supposed to care for myself. No one had ever taught me that. And the only thing they said about sex is if you’re not married, don’t do it.

And so I would have people who would come up to me and ask questions. For example, a close friend came up to me and she said, “My boyfriend and I had sex.” I said, “OK.” And then she says, “I have to ask you a question.” I said, “OK.” Now, she went to an all girls’ Catholic school—Catholic schools are very prominent in New Orleans—and she said, “So if you ‘pull out’ you can’t get pregnant, right?” And I said, “No!” And she slammed her hand on the table and said, “No one ever told me!” So I’m passionate about this because we have been denied crucial information that would give us control over our lives.

Here’s another example: In college, at Louisiana State University, I went to the doctor because I had gotten a call from someone I had slept with saying that he had contracted chlamydia, and that I was the last person he had slept with. So I was freaking out and thought, “What can I do? What are the steps I can take to do something about this?” So I thought I’d go to the health center.

So I’m at the health center and telling the provider about this. She said, “We can get you tested.” I said, “OK, great.” So she said, “You’ll find out the results tomorrow.” Later she calls me and she says, “It’s negative. You don’t have chlamydia.” I said, “OK, great. This is awesome.” And she said, “Yeah, I know. I was surprised too.” And I said, “What?” And she says, “Well, considering you sleep with men.”

Rewire: Well that has nothing to do with anything!

MB: Right. Providers weren’t given ideas about what compassionate care looks like. And so I’m really turned off by going to the people who are supposed to be treating me. Schools weren’t set up to help me. The health-care system and doctors weren’t set up to even react to the things that were happening to me because of this lack of information. And that’s why I’m passionate about this. I got so frustrated and worn down and exhausted by stuff happening on a day-to-day basis. Not just to me, but to friends around me. I have friends who tried to get birth control, and providers would make them take all sorts of tests and would say all sorts of insulting things about the people who were trying to get care.

Rewire: So you’re really focused on providing accurate, reality-based information to people about sexuality education, and at the same time making sure that the people providing that information and care are doing it in a compassionate manner?

MB: Well, we are focused on the legislative level and trying to improve it there. If we can change the conversation at that level, and get people at that level to change and have conversations in their communities, that will lead to broader change.

Louisiana Progress is doing very broad things. We’re doing movement-building at the ground level and then also trying to do it in the legislature because people have written the legislature off. They say, “Well you can’t do anything there. There’s nothing productive that can ever happen there right now because of the makeup of the legislature and because the forces are too strong.” So we’re trying to get small wins because we can only have small wins at this time.

Rewire: Where do you see yourself in five years?

MB: Hopefully I’ll be getting out of law school. But I don’t want to practice; I want to do policy. I like law a lot. Even tweaking very small things has a huge impact on people’s lives. Trying to find little ways that we can have a huge impact. So, for example, at Louisiana Progress last year, one of the finalists for the Youth Champions Initiative was able to pass a bill that made it easier for homeless families to access childcare in Louisiana. It only affected 100 families. That was the target. But it was altering the way we were using a federal grant at the state level. Small stuff like that related to broadening access is something that I hope to be able to do in Louisiana.

What’s frustrating is that the people who could change the state leave. There’s a shortage of people who are committed to broadening access in a lot of the areas we are working in. The people with a lot of resources end up leaving. The people who stay are the ones who are really committed to the area or have family and never left. I want to leave and see how other places work, and then come back.

A big problem is that people don’t know what other people have in other places. If people only knew the amount of public resources that are available in other areas of the country, people would be protesting in the street every night! People would be so angry.

Rewire: What kind of things would you like to see change in Louisiana?

MB: The oil companies in Louisiana have bought the legislature. They’ve bought every statewide elected official. And so people were shocked when a Democrat from Louisiana—Mary Landrieu—was basically acting as the personal spokeswoman for the oil and gas industry, doing the Keystone XL pipeline. Oil and gas companies have been able to get away with so much for a long time, and have been able to buy politics, and have bought a lot of the politicians.

Even in a local school board election in Baton Rouge, Aramark—a private prison company—is contributing to make sure that someone who is pro-charter schools wins the election. We know that charter schools disproportionately punish students of color. We know they punish LGBT students more than non-LGBT students. They will put more people in prison, so Aramark donates to them.

Our politics have been bought. It’s pay-to-play. People don’t realize what is happening: that our state has been bought and sold to the highest bidder, and the highest bidder is the oil and gas companies and other corporations. So anything that happens that’s good is good for them, and it’s not good for everyone at the ground level. So people don’t even realize what’s happening, because everything seems great: We still have our food, we still go to church on Sunday, everything about our lives is the same, even though it’s not. Things have changed dramatically.

Rewire: What do you think needs to change in the sexual and reproductive health field?

MB: In sexual and reproductive health, I think the important thing is that we haven’t trusted people about where they are. If someone says, “I’m LGBT,” we don’t trust them. If a woman says she needs to have an abortion, we don’t trust her.

One of the problems is that there are faith leaders who have taken over the conversation and have said, “This is what God says, and if you don’t do this, or if you talk about it, you’re going against God’s will.” So we need to take back that conversation. There are tons of faith leaders who have been shut up by a lot of what’s happening and have been told that their view is not actually the Christian or mainstream view. They’ve been shut out of the conversation. If we can get them to to show up at places like the legislature or talk about it in their communities, that will have a dramatic impact on a lot of what’s happening in the state.

Neha Mankani is the monitoring and evaluation manager at Aahang, a Karachi, Pakistan-based sexual and reproductive health and rights organization.

Rewire: What does Aahang do?

Neha Mankani: There are two components: We work with teachers to build capacity and provide life skills education in schools and with community workers who talk to the community about marriage, family planning, and nutrition. And the other component involves working with health-care professionals to train their faculty members on the provision of a client-centered approach, and on STIs, and things like that.

Rewire: What got you interested in this line of work? What was your inspiration?

NM: When I got out of undergrad, I just wanted to be in the development sector because it was all I knew, but then I became interested in Aahang because it’s one of the few organizations in Pakistan focusing on sexual and reproductive health, and I was really intrigued about how one works on sexual and reproductive health in Pakistan—I just wanted to know. Then I started working there, and the kinds of things I would see in the field were just so interesting, like being able to train female welfare workers on a better client-centered approach and how to talk to their clients. They would tell us all these crazy stories, like this woman who came for an abortion six times in eight years because her husband kept “renting” her out to his friends. Just in that year-and-a-half that I was initially there, I heard powerful stories. So public health, reproductive health—this is what I want to work on.

Rewire: You mentioned training female welfare workers: Welfare means a different thing to many people in the United States, so can you explain what you mean by that?

NM: A female welfare worker is a community health worker who provides basic primary health-care services and contraception and basic reproductive health services.

Rewire: When you talk about a client-centered approach, what do you mean by that? Is there an approach that is the opposite of that?

NM: Yes, physician-centered is the opposite of client-centered. Client-centered is about talking to people with respect and dignity—asking questions and ensuring that there’s going to be follow-up to treatment protocols and making patients feel comfortable. It shouldn’t be a scary situation for clients; clients should keep using health services.

Rewire: In the United States, abortion is a very taboo issue and I imagine it’s probably the same in Pakistan. Can you tell me some of the challenges you face in trying to do the work that you do?

NM: There’s a lot of challenges working on these topics. In life skills education—that’s what we provide in schools—it’s actually a very neutral curriculum. We don’t really talk about sex. We talk about puberty, communication, negotiation, and decision-making. But even getting that curriculum into rural areas is really challenging, because if people misconstrue what we’re trying to do, we can get shut down.

We’ve had instances where we’ve worked with organizations, and someone in the community thought we were providing sex education, and the programs shut down for a little while.

As for abortion: We have a couple of projects dealing with abortion. And that is really difficult. We always frame it in the context of post-abortion care. We don’t ever really say “abortion services,” because there’s so much stigma associated with talking about abortion and talking about sex. So there are a lot of constraints. I know that we’ve trained providers on provision of post-abortion care services; they’re trained, and they want to do it, but there are such strict policies in place that they’re actually really nervous about it.

Rewire: What kind of policies?

NM: Policies against the provision of abortion.

Rewire: So abortion is legal in Pakistan?

NM: Yes. Abortion is legal in Pakistan, but only under certain circumstances. You can do it for rape, incest, and health of the mother.

Our projects are mostly not about promoting abortion, but about working with physicians to ensure that all the women who are dying of post-abortion complications because of things like coat-hanger abortions—to make sure that doesn’t happen.

Rewire: So you’re not involved in the actual provision side—you’re involved in training people on how to care for women who have already had abortions.

NM: Yes. Like using misoprostol to deal with post-abortion complications. We also do a lot of value clarification with providers because they can’t even do post-abortion care until their values on abortion are clarified.

Rewire: What does “value clarification” mean?

NM: We do these exercises with providers: We make them look at their own values and figure out why they think that way about abortion.

Rewire: So you’re trying to reduce providers’ personal stigma so they’re not transferring their attitudes about abortion to their patients?

NM: Yes. It’s been really effective because afterwards they turn around and say, “There have been a lot of times I’ve turned women away because of something that I thought.” What we do is train them to be able to separate what they think themselves. It’s the difference between being a provider and your personal attitudes.

Rewire: So basically you’re trying to change the way these people think about abortion so they’re not furthering the stigma for women, either by turning them away or treating them poorly while providing care for them?

NM: Yes.

Rewire: Tell me a bit more about why this work is important in Pakistan.

NM: Right now adolescent sexual and reproductive health is a really big issue for Pakistan, for a number of reasons. The biggest reason is that the population under the age of 25 is so large, and we really need to take advantage of the demographic dividend before it turns into a disaster.

Also, the schools we work in, where we’re providing comprehensive sex education, are lower- to middle-income schools, and our evaluations have shown us that the work we do is really impacting girls’ lives there. Girls have come back and told us, “After this program, I negotiated with my parents about staying in school for one more year,” or “I convinced my aunt not to get my cousin married at age 16.” We’ve had parents say, “I trust my daughter more, so I let her go out to the market by herself, because she seems more confident and she seems like she knows what she’s doing.” So really interesting things are coming out of this program.

The other part is that we have learning forums to get teachers to share what their experiences have been. Teachers are equipped much better to deal with cases of sexual violence in schools, and they tell us stories about how girls have become more confident and are telling them what’s been happening with them. There are a lot of stories about violence in the home. People will say, “My neighbor came in and abused me,” or “This person would touch me, and I never had the confidence to talk to anyone about it before, but now I’m telling you.” The teacher can intervene and make sure the girl gets what she needs.

Rewire: So it’s beyond just health care. It’s more of a holistic approach.

NM: It’s a package.

Rewire: It’s also a feminist approach, in terms of teaching girls about their own liberation and teaching them to be confident.

NM: Right. It teaches them to say, “This is what I need, and this is why I think I need it. We do a lot of work on early marriage prevention, and the strategy we’re taking is to go to schools and empower these girls, and give them the skills they need to talk about these things with their families. Even just bringing it up with their families, that’s a critical step—to say, “You know what? I don’t want to get married at 15.” Sexual violence, sexual abuse, and sexual harassment are other things that these girls have become better equipped to deal with.

Rewire: Did you find in your own life that there was a struggle to get advanced education? Was there any push-back from your family?

NM: No, there wasn’t any push-back really. That’s also been interesting for me—to think that these things have been really easy for me, but it’s not easy for a lot of people.

It’s really interesting that in Pakistan there aren’t that many in the development sector and there aren’t that many people who have a solid enough background to be able to work on it properly. That’s why I feel like it’s really important to keep working on it.

Rewire: What do you want to be doing in five years?

NM: I am really interested in maternal health. So I’m going to be in training to become a midwife. I’m going to start that in a few months. And then I want to combine my maternal health technical knowledge with my public health knowledge and develop programs with the proper technical skills.

The above interviews have been lightly edited for length and clarity.