Health, social and economic problems
The women drug and alcohol users in this study experienced a range of health problems including drug and alcohol dependence/withdrawal, a number of reproductive health complaints, and poor mental health. They also described many social and economic problems that clearly have the potential to impact negatively on their health and well-being, and on their capacity to access services, including financial difficulties, social exclusion, violence, and concerns about the well-being of their children. From the women’s perspective, their health problems were mostly over-shadowed by their social and economic problems.
The main health problems experienced by these women related to symptoms associated with withdrawal from drugs or alcohol, and as these symptoms were alleviated by the use of drugs or alcohol, the use of these substances made them feel ‘well’. This construct contrasts with that of most health care providers who are likely to perceive drugs and alcohol as a source of illness rather than wellness. However, even though the women frequently articulated this bodily experience of drugs and alcohol making them feel ‘better’, there was also a lot of discussion regarding the need for detoxification and rehabilitation services, clearly indicating that drugs and alcohol are also perceived, at least at some level, to be problematic in their lives.
Poor mental health is both a cause and a product of drug and alcohol dependence. Social exclusion and violence, instances of which were vividly described by the women in the FGDs, are also likely to have a negative impact on their mental health, as does rejection by and separation from families. A large study of women and drug use in India identified 75% of female substance users as having a possible underlying psychiatric disorder such as depression or anxiety, and one-third reported at least one suicide attempt during the previous year
Considering the relatively young age of these women, a large proportion were widowed or divorced (almost two-thirds in Manipur and one-third in Nagaland). As in other parts of India, divorcees and widows are socially and economically vulnerable, and if young, sexually vulnerable as well. Young widowhood in Manipur in particular is likely to be associated with the death of a drug-using spouse from drug overdose or HIV. It is possible that for some of these women, divorce has been a consequence of their drug or alcohol use. However, it is also likely that the precarious situation of widows and divorcees is contributing to both drug and alcohol use and engagement in sex work.
Violence against these women was commonplace and not limited only to those who were engaging in sex work. Similarly, in the large Indian study mentioned above, 73% of female substance users had experienced violence, and of these, 91% reported physical violence, 53% sexual violence, and more than 75% had sustained physical injury as a result of the violence
. In South India, violence against sex workers was associated with economic insecurity, more adverse reproductive health outcomes, and greater risk of HIV and STIs
[24, 25]. It is clear that interventions to reduce the level of violence experienced by these women are greatly needed. However, while successful community empowerment of sex workers in South India has been able to reduce the amount of violence perpetrated against them by the police in particular
, effective collectivization of FSWs in Manipur and Nagaland has not been very successful to date
, and interventions targeting only sex workers will not help all of these women.
The situation for the children of women who use drugs and alcohol is concerning. These children can develop emotional, behavioural and learning problems, witness and be subject to violence, and become involved in substance use at a young age
. In Manipur and Nagaland, having children outside of wedlock is socially unacceptable and there are few support structures in place to assist women and children in this situation. Both the mother and the children are likely to suffer poverty and social exclusion as a consequence of single parenthood. Arguably, one of the best ways to support the children of women who are drug and alcohol users is to support their mothers, and one of the best ways to support their mothers is to help with their children. Programs that are trying to attract women drug and alcohol users should also consider the needs of their children, as has happened at the Sonagachi Project in the neighbouring state of West Bengal
, and with the Ambar project in Venezuela
Health and other service needs
According to the participants in this study, the establishment of a comprehensive, integrated women’s health centre is more likely to attract women drug and alcohol users than the current HIV prevention services or existing government health services. Not only would this model provide a ‘one-stop shop’, it would also offer some protection from identification as a member of a high risk group. These centres are more likely to meet the needs of women if they are low-cost, strategically but discretely located, open at times that suited the clients, and staffed by a range of female staff, including female doctors. The range of health services could potentially encompass general health care, family planning, antenatal care, mental health, counseling, HIV testing, STI management, opioid substitution therapy, TB treatment, ART, overdose management, and condom and needle & syringe distribution.
One of the most pressing service needs from the perspective of the women was detoxification and rehabilitation. Services for women requiring detoxification and rehabilitation for alcohol addiction are currently not available, and the options for women drug users who want assistance to reduce their drug use are very limited. To the best of our knowledge, there are no Alcoholics Anonymous or Narcotics Anonymous type programs for women in either state. In the absence of women-friendly detoxification and rehabilitation services it is difficult to imagine how women who are dependent on drugs and alcohol can gain a measure of control over their lives.
Interventions that aim to promote the mental health and well-being of these women are potentially available, affordable, and effective
, and may reduce risk-taking behaviours, and increase participation in HIV testing and adherence to treatments. Such interventions also have the potential to assist these women with anger management, and thereby reduce their own acts of violence
Health care workers located at services that are likely to be patronized by female drug and alcohol users need to be sensitized to the health services needs of these women, and equipped to provide non-discriminatory treatment and care. This is especially the case for specialist obstetrician and gynaecologists, primary health care centres, mental health services, and hospital staff.
Awareness raising and sensitization of church leaders and groups are also important in the context of Manipur and Nagaland. The Church has a powerful influence over societal attitudes to these vulnerable women
, as well as huge potential to promote social inclusion and provide them with much needed supports. A similar program among women’s and youth groups and police could also be beneficial.
The suggestion that FSWs be provided with a safe place where they can both live and work is a tantalizing one. However, there are obvious challenges to the establishment of such a venue in a very conservative setting where organised anti-sex worker campaigns are a reality and the legal status of sex workers is precarious. Nevertheless, it must be acknowledged that this type of arrangement has the potential to reduce the risks of HIV and STI infection and exposure to violence, as well as making it easier to target FSWs with health and other services. Many of these women are homeless, so it would also provide them with shelter.
Limited overlap between the felt needs of the women and the services provided by HIV prevention programs
As women who use drugs and alcohol are reluctant to attend mainstream health services because they anticipate and often encounter discriminatory attitudes on the part of the health care workers, and they are unable to afford the service and the associated costs of tests and medicines, another point of entry into the health care system for these women is through the HIV prevention and care services provided by NGOs (funded mostly by government and large donor agencies), which were viewed as more sympathetic to their situation. Health care for HIV positive women, and HIV prevention services for women who inject drugs, FSWs and female sexual partners of IDUs are predominantly provided by NGOs in Manipur and Nagaland. The content of these services is determined by policy makers and program planners with an HIV prevention and care agenda firmly in mind e.g. ART treatment, HIV testing, STI treatment, IEC, needle/syringe and condom distribution. However, these services as currently structured are unlikely to meet the needs of the women participating in this study. This lack of congruence between the services the women say they want and the services actually provided probably, at least in part, accounts for the relatively poor uptake of these services by vulnerable women.
Women drug and alcohol users’ most pressing needs were often not directly related to health, and certainly HIV and STIs were not high on the list of issues that concerned them most. Financial insecurity, inability to adequately feed and shelter themselves and their children, family and social rejection, violence, and related to all of these, poor mental health, were the main concerns of the study participants. These findings resonate with those from the larger Indian study on women and substance use that ranked the top ten services that female substance users had not accessed but would like to as: mental health services, vocational training, housing/shelter, legal/advocacy services, nutritional programs for children, microfinance, female condoms, OST, de-addiction services for women, and STI services
. Additionally, these women perceived NGOs as the place to which they were most likely to turn for support
. Consequently, if NGOs who currently implement HIV prevention programs are able to expand their services so that they more effectively respond to the stated needs of these women, more women may attend. However, a major challenge for any NGO wanting to offer a more integrated service is the struggle to mobilise and coordinate sufficient funds from multiple agencies and government sectors in order to do so.
This study has a number of limitations that should be considered when interpreting the findings. There could be some selection bias because the FGD participants were recruited through the NGO networks, but this is somewhat offset by the fact that we deliberately recruited both NGO service-users and non-users. Given the sensitive nature of the questions about socially taboo behaviours of women, some participants may have been inclined to provide more socially acceptable responses, at the expense of valid responses, resulting in bias. We were unable to identify those participants engaged in sex work from the majority who were not, and it is probable that the health service and other needs of women engaging in sex work are somewhat different from those who do not. It is a qualitative investigation so findings cannot be generalized, although there is no compelling reason to assume that the situation is very different for other groups of female drug and alcohol users in Manipur and Nagaland. A follow-up survey with a representatively sampled group of women would strengthen the findings.