Prepared by Castillo, T., Department of Health and Behavior Studies, Teachers College, Columbia University, USA for International Conference on Public Health and Well-being 2019, 4-5 April, Negombo, Sri Lanka

1. THERESA P. CASTILLO, EDD MA CHES
R E S E A R C H G R O U P O N D I S PA R I T I E S I N H E A LT H
D E PA R T M E N T O F H E A LT H A N D B E H AV I O R S T U D I E S
T E A C H E R S C O L L E G E , C O L U M B I A U N I V E R S I T Y
❖
INTERNATIONAL CONFERENCE ON PUBLIC HEALTH & WELL BEING
SRI LANKA, APRIL 2019
Exploring Health Inequities among Indigenous Women
in post−conflict Nepal & Bangladesh:
Community Perspectives on Gender Based Violence & Reproductive Rights

2. UN Working Definition of Indigenous Peoples
Indigenous communities, peoples and nations are those which
having a historical continuity with pre-invasion and pre-colonial
societies that developed on their territories, consider themselves
distinct from other sectors of the societies now prevailing on those
territories, or parts of them. They form at present non-dominant
sectors of society and are determined to preserve, develop and
transmit to future generations their ancestral territories, and their
ethnic identity, as the basis of their continued existence as
peoples, in accordance with their own cultural patterns, social
institutions and legal system.
Source: Martínez Cobo, UN ECOSOC, Human Rights Commission, Special Rapporteur 1982 Report

3. Current Status of Indigenous Women’s Health
Vulnerability of indigenous women.
➢ Experience similar health issues at higher rates compared to non-indigenous peoples,
i.e malnutrition and TB.
Negative health effects of land displacement, urbanization, conflict & gender inequities.
➢ Exposure to health issues such as reproductive complications, nutritional deficiencies,
and sexual violence in conflict-affected settings.
Gaps in current indigenous women’s health research in Asia.
➢ Lack of statistics and systematically collected data by tribal and national government.
Source: PAHO/GHU, 2004; UNDESA, 2009; Stephens et al., 2006 ; Black et al, 2014; Tebtebba Foundation, 2013; Levesque et al., 2008;
UNDESA, 2009.

4. Source: http://pixgood.com/southern-asia-map-with-capitals.html

5. Case Study
Profiles:
Nepal &
Bangladesh
Both are among the top 6
Asian countries with the
highest indigenous
populations.
Nepal has the highest
population percentage
within Asia.
Source: Levesque et al., 2008; IWGIA, 2014; Witter et al., 2011; Amnesty International, 2014;
Bhadari & Dangal, 2014; Samandari et al., 2012; Guttmacher Institute, 2012, September;
icddr-b, 2014
Country Nepal Bangladesh
Indigenous
Population
9.5 million
~63 tribes/groups
3.0 million
~54 tribes/groups
% of National
Population
35.8% 2.1%
Recognizing
Indigenous Peoples’
Sovereignty
Formal recognition by the
interim government
constitution, 2010
UNDRIP signatory
Limited recognition by
government; amended
constitution, 2011
Abstained UNDRIP
Sexual &
Reproductive Health
(SRH)
Rights
Free maternal care; Legal
abortion care services;
Free utr. prolapse surgery
Low-cost maternal care;
Menstrual regulation
services

6. Purpose Objectives
For Asian indigenous women in
Nepal & Bangladesh:
 To address knowledge gaps in defining
priority health issues
 To improve the knowledge-base about
women’s access to quality health care
 To increase regional knowledge about
factors impacting health rights
Through in-depth interviews with
community-based leaders, the study aims
to:
1. Determine current health challenges
for indigenous women
2. Identify promising practices for
meeting indigenous women’s health
needs
3. Elicit recommendations for improving
indigenous women’s health, including
ensuring the right to health
Study Purpose & Objectives

7. Study Design
 Exploratory study using purposive, criterion sampling
 Primary data: Semi-structured, open-ended interviews with
community-based leaders
 Secondary data: Field notes and documents collected in field
 Coordinating human rights organizations: Kapaeeng Foundation
(Bangladesh) & Justice for All (Nepal)
 Theoretical framework: Social Learning Theory, Social-Ecological
Framework, Social Determinants of Health, Grounded Theory, Right to
Health

8. Methodology
 Primary data collected over 60 days in NYC, Dhaka & Kathmandu
 Snowball sampling; Voluntary participation; Informed consent obtained
 Community-based leaders (N=23) , 16 in-person interviews; 7 Skype/phone interviews
 Interview duration: 42-86 minutes (M=59.6)
 74% (n=17) of interviews were digitally audio-recorded, transcribed verbatim for coding,
and double-checked against audio files
Data Analysis
 Confidentiality: Alphanumerical codes
 Data analysis software: ATLAS.ti7
 Iterative process: 226 initial codes, 2 cycles of coding, using member checks after initial
coding
 Triangulation using field notes and collected documents

9. Study Findings
There were 12 main
findings that emerged
from the study.
Domain I :
Current Challenges
(7)
Domain II:
Promising
Practices
(2)
Domain III:
Recommendations
(3)

10. Study Findings: Domain I Current Challenges
 Finding 1- Sexual reproductive health
issues represented approximately two-
thirds (67%) of the identified challenging
health issues by study participants.
 Finding 2- An overwhelming majority
of participants (91%, n=21) referenced
indigenous women’s exposure to
different forms of violence as a barrier
to health.
 Finding 3- Approximately 74% (n=17) of
the participants discussed nutrition and
food security as a major concern for
indigenous women’s health.
 Finding 4- More than three-quarters of the
participants (78%, n=18) indicated language as a
communication barrier for indigenous women seeking
and receiving healthcare.
 Finding 5- Most of the study sample (91%, n=21)
highlighted the impact of geography and land rights
on indigenous women’s access to healthcare.
 Finding 6- The overwhelming majority of participants
in both countries, approximately 96% (n=22), indicated
insufficient resources as a challenge to indigenous
women’s health rights.
 Finding 7- More than three-quarters (82% n=20) of
the sample referenced mainstream politics and/or
traditional systems as a challenge to indigenous
women’s health rights.

11. “But when woman becomes
victims, then you know, it’s
like… humiliation, like
disrespect, like they touch
woman or they sometimes
abduct woman, rape or…
somehow this message is…
because you are still there, then
your girls are not safe”
“Sometime they die within that
countries, but sometime they
come [back]. They are sent with
pregnancy, with the children and
sometime, mentally tortured,
you know… So many indigenous
women are facing the mental
problem after going [away]…”
General Perspectives on Violence/ Bangladesh
Bangladesh Nepal

12. Domain I,
Finding 2
An overwhelming
majority of
participants (91%,
n=21) referenced
indigenous women’s
exposure to different
forms of violence as
a barrier to health.
Summary of Domain I, Finding 2: Violence
Sub-themes Bangladesh Nepal Total
War & post-conflict 4 (36%) 2 (17%) 6 (26%)
Abduction 3 (27%) 0 (0%) 3 (13%)
Witch hunting 1 (9%) 4 (33%) 5 (22%)
Domestic violence 5 (45%) 2 (17%) 7 (30%)
Sexual violence 8 (73%) 4 (33%) 12 (52%)
Human trafficking 4 (36%) 8 (67%) 12 (52%)
Forced/bonded labor 1 (9%) 3 (25%) 4 (17%)
Child marriage 4 (36%) 7 (58%) 11 (48%)

13. • The terrorization of women post-insurgency is because
the region “still remains fully militarized and the
politically motivated violence against women still
continues.”
• “Rape and abduction and killing after rape has been
used to occupy the land, to uproot the indigenous
people from their ancestral land.” - Bangladesh
• Most participants agreed peace remained fragile and
tailored programming was unavailable or non-existent.
War &
Post-Conflict
Settings
Roughly 26% (n=6) of
the entire sample
referenced violence-
related issues in a
post-conflict setting.

14. Abduction
Only 13% (n=3)
of the sample
discussed the
abduction of
women related to
political violence.
• Abduction solely discussed in Bangladesh by three
informants.
• Politically motivated: “many cases of abduction as
a result of the inter-group rivalry of these parties”
was intended to derail “the process of post-conflict
reconciliation.”
• One respondent believed the limited
implementation of the CHT Peace Accord
encouraged, “such type[s] of communal attack,
rape, killing, abduction of women.”

15. • Only 9% (n=1) of the Bangladesh sample referenced “witchcraft”
compared to 33% (n=4) of the Nepal sample.
• Defined as practice of a dainy (local priest) naming a woman as the
cause for an illness arbitrarily which incites community violence:
“they [community] will attack and they kill [women] sometimes…
And always, the priest is a man.”
• Means for discriminating against elderly women, especially widows
in the community.
• One community worker shared her perspective, “Yeah, [women
are] burnt, killed by beating and feces, stool feeding and social
rejecting and avoid, isolation and even… abandoned from the
society.”
• One participant underscored that “we [Nepal] are actually
developing one [legislative] Act against this witchcraft.”
Witch Hunting
Witch hunting was
emphasized by
almost 22% (n=5) of
the participants.

16. Domestic
Violence
Among the total
sample, 30% (n=7) of
the respondents
mentioned domestic
violence.
• Violence was found more commonly in the form of
physical abuse in the home in Bangladesh:
• “Actually indigenous women’s husband used to beat
their wife… it’s impacting on their health. Maybe that’s
all … only maximum is the beating.”
• “Attitudes of men are frustrating… Women come [from]
a history of hitting each other- family violence and
outside [the home].”
• Need for DV education and counseling services in Nepal.
• Fistulae was referenced a condition possibly caused by
“family violence,” based on one clinician’s observations.

17. Sexual Violence
About half of the
sample (n=12)
discussed sexual
violence in terms of
sexual assault, incest,
and rape.
• Absence of statistics, limited access and information to care
and legal justice in both countries.
• Gang rape by the military cited by more than 1/3 of the
Bangladesh sample, with some citing homicide after rape.
• No indigenous word for rape – “non-existent in indigenous life
prior to conflict.”
• Unwanted pregnancy from rape is common and distressing:
“so many rape cases are happening… And without the
husband, they are pregnant and so many children is
increasing day by day.”
• Increased incidents of incest due to seasonal migration: “Incest
and rape, you know, where father-in-laws, brother-in-laws,
whoever is remaining in the house, because their husbands
have gone for long periods, [begin] raping daughters.”

18. Human
Trafficking
Slightly more than
half (n=12) of the
total sample
discussed trafficking,
with approximately
one-third of the
Bangladesh sample,
compared to two-
thirds in Nepal.
• Dire economic situations propel indigenous girls to seek
opportunities: “outside of their territory... and they are
being subject to sexual exploitation, particularly in [the]
Garments sector and beauty parlors.”
• A few Nepal respondents described the traumatic
aftermath of trafficking: return abused, raped, or pregnant
with mental health issues/ need for reintegration services
• Intensified border trafficking in Bangladesh: “maybe more
than 60 percent are the girls among the violence,
[mainly] sexual violence.” The respondent elaborated on
the growing concern about HIV as a negative health
impact of trafficking.

19. Forced &
Bonded Labor
Approximately 17%
(n= 4) of respondents
mentioned the specific
issue of forced and
bonded labor.
• Bonded labor has left young girls vulnerable to ongoing
physical and sexual abuse
• One Bangladesh informant gave the example of a
domestic worker, “The girl… after torturing her, the
family left her in the street. Such type [of] violence [is]
happening in our society.”
• In Nepal, the traditional practice of kamlari (bonded
labor) was used for family income through child
servitude: “So, they [families] will go and beg loan from
the rich person, you know… Even if you are a pregnant
woman, they will buy your kids even before born.”

20. • Linked early child marriage to issues such as malnutrition,
pregnancy complications, and reproductive health
concerns. “women are getting married early and so they
should have some maternal health problems… their
physical structure and physical stamina is going down.”
• Early marriage as a result of the insecurity in post-conflict
Nepal: “Child marriage is not necessarily cultural practice
anymore, but for security reasons, for various reasons,
you know.”
• Others discussed “patriarchy’s impact” on young brides:
“where [pregnant] women are expected to gather their
own fodder and carry heavy loads.”
Early Child
Marriage
Approximately half
of the entire sample
indicated the
sociocultural
tradition of early
marriage was a
challenge for
indigenous women’s
health.

21. Discussion:
Analysis
using the
Right to Health
Framework
Source: WHO & OHCHR, 2008;
WHO & OHCHR, 2007
The Right to Health Framework consists of
four elements (AAAQ):
 Availability
 Accessibility
 Acceptability
 Quality
… of public health facilities, goods, and services.
States’ obligation to respect, protect, and fulfill
the right to health

22. Discussion
 Drivers of violence were multifaceted: sociocultural, economic, and political.
 States were inadequate in addressing survivors’ needs and their right to health. Limited
availability, quality, and accessibility of services compromised indigenous women’s health
rights.
 Violence was compounded by other health issues such as HIV, unwanted pregnancy, fistula, and
uterine prolapse.
 Cultural practices can be both beneficial and harmful to women and girls health.
 Forced labor, child marriage & early pregnancy are prominent GBV issues that negatively impact
health outcomes
Source: Solotaroff & Pande, 2014; UN OSAGI, 2010; FIMI, 2006; Giri, 2009; Plan International, 2013; ICRW 2006; WHO, 2014; Black et al, 2014; WHO, 2013; Cottingham et al, 2008

23. “Yes, there is a lot of uterus
cancer, nowadays. One is
because of this health access
tradition… bad practice and
another is food and habit.
Another is this pest-
pesticides…” (Participant N10).
“Many people come with
[uterine] prolapse. It is
common here, but don’t know
the numbers. Women say
‘something is coming down
vagina’” (Participant B9).
GBV & Reproductive Health: Uterine Prolapse
Bangladesh Nepal

24. Conclusions & Recommendations
 Ensuring the right to health for indigenous women is complex, and
cannot be realized by any one factor.
 Data disaggregation, collaborative partnerships, and cultural and
linguistic tailored programming are essential for improving health.
 Studies comparing indigenous women’s health status to the dominant,
mainstream population.
 Studies on indigenous women’s exposure to violence and its effect on
reproductive health outcomes.
 Expanded research on the mental health of indigenous women and
adolescent girls.

25. Acknowledgements
Asian Indigenous Women’s
Network; Asia Indigenous
Peoples Pact Foundation;
International Indigenous
Women's Forum (FIMI); Justice
for All; Kapaeeng Foundation
Bipasha Chakma; Regina
Cortina, PhD; Robert Fullilove,
EdD; Cicely Marston, PhD;
Evelyn Quinones; Vicky Tauli-
Corpuz; Sarmila Shrestha; Elsa
Stamatapoulou; Monica
Stanton-Koko, EdD; Barbara C.
Wallace, PhD; Michelle
Yeboah, DrPH