Thursday night and surveys

Time out Thursday night brought me again to western and southern Athens to visit with the transvestites of the city. Amazingly enough, I now know enough of the city's layout to somewhat follow our crazy route through the dark puzzle of streets and roundabouts. As we drove around, I saw one mural I'd seen driving with Dr. Koutras on Tuesday - huge, angry bees parading in a line around the corner of a building. The bees happened to be right near our stop to check in on Bella and Malena that I'd met the previous week. The two were happy to see me, and attempting English small talk as we poured them coffees and told them about the medical clinic happening the next day. The continuity of relationships for even just one week felt satisfying and sweet. And we enjoyed the success of completing several medical surveys with the transvestites while we were out too! The volunteers and staff had been wary of even bringing up the surveys since their relationships with this population are more tenuous than with many of the women. But once we (Emma, really) convinced the staff of the importance of the survey, the whole process became much easier, and many of the transvestites we talked through the questions were grateful for our concern. As happened with the women, we saw it open doors relationally and emotionally that originally we worried might be threatened by the survey's intimate questions.

As for the overall survey, our plan involved an attempted survey of 20-30% of Nea Zoi's contacts in sex work in Athens, approximately 40-50 surveys in total. As this week continued, we pushed past 30, then 37, then 42 and finally an N of 47 as Lindsay and I finished our last outreaches this Thursday. Nea Zoi may continue pursuing the surveying as they need, but with our goal N achieved, we set about analyzing the data and framing future plans based on what we'd learned. The survey design, translation and data analysis were somewhat my project, and Lindsay paralleled that effort with a four-phase plan that we created to move the medical pilot project in a manageable step-wise progression. Our first draft involved an end goal of an on-site medical clinic at Nea Zoi's office, but as we continued the survey, the more valuable effort seemed to be a medical buddy service and mobile clinic to the neighborhoods Nea Zoi visits. Lindsay continued shaping the plan as we worked and learned more through our visits with Dr. Koutras and conversations with the women.

Ultimately, when I completed the data collection with the 47 surveys, we had a fairly complete picture of the health of the women (and several transvestites, although not as complete of a sample for them). We met with Nea Zoi staff on Monday to informally present our findings and discuss what everyone had learned. The meeting was actually quite touching for Lindsay and me, seeing the tangible results of our work (we think they were a bit shocked by our productivity and medical-student work ethic, much to our amusement), and the impact the pilot medical project had on Nea Zoi itself. As you can probably imagine from my discussions in previous posts, the work this group does is not all clear-cut direction and happy endings. Often it's quite the opposite, and we realized over these two weeks that we had joined their team during a dry spell of far more discouragement than encouragement. Madames turning them away bluntly or blustering loudly in shouted curses, new women slipping under the radar, old women wanting to stay in prostitution to make money for themselves, brothels assuming they were reporting information to the police ... the list goes on. We were told over and over that our presence was invigorating and motivating, a breath of fresh air into a stagnant situation. As the surveys became a positive step in their interactions with the women and created enthusiastic, grateful feedback, the Nea Zoi team got the encouragement they needed. And the vision coming out of our work is a very exciting framework for moving their work forward in a way that left our Monday staff meeting fairly impassioned.

The survey showed several widespread needs - emotional and practical support through the process of receiving care through the Greek national health care system, which can be complicated; providing care for the women who don't have legal status in Greece or access to the national medical system; making consistent psychological care available to the women. We also tracked prevalence of specific symptoms and health access, and gave the women an outlet to contribute their ideas for improving their medical situations - some of the possibilities were quite creative!

With that broad picture and the full spread of other details, Lindsay created a basic plan for the continuing medical project as follows:
Phase One - medical survey to assess needs of target population and effective supplemental medical care; detail results to target goals of the proposed project

Phase Two – host 2 pilot clinic sessions on 4/20, 4/27 to determine need for local clinical services; educational socials hosted at Nea Zoi office and 5 minute educational conversations on the street; educate volunteers in medical topics; incorporation of psychotherapy, medical appointments, referrals with network of trusted local physicians who understand the needs of the population, make vaccinations available (Hep B, Hep A, HPV as appropriate).

Phase Three – provide “outreach medical care” - team will serve as facilitators to medical diagnosis and treatment, providing transportation, paying for laboratory or radiology testing, paying for treatment, providing psychotherapy. Provide social support going to the doctor with the men/women or helping facilitate their care, such as setting up appointments and facilitating follow-up care.

Phase Four – provide mobile clinic to neighborhoods of Omonia, Filis and others as needed; staff with volunteer physicians and nurses within referral network associated with Nea Zoi

The grant proposal is on its way to completion to provide funding for social work staffing and medical supplies, vaccinations, funds to supplement medical care etc. The whole project shows incredible promise to not only address the medical needs of the women and men, but to continue bridging the trust gap and preparing them for the psychological process of moving out of prostitution and addressing trafficking. We'll see what develops with the medical project from the continuing efforts of Nea Zoi, but all in all, we're grateful for a lot of answered prayers and a promising outlook for our time in Athens! It's refreshing to offer a small, targeted solution to part of a broader global problem, and to happily contribute our meager talents to a worthy and tangible fight.

Wednesday in Filis and trafficking

During our outreach this Wednesday, I was again assigned to the Filis team heading to the brothels in this neighborhood just northeast of Omonia. The scene was much like last week (see It's All Greek to Me) but I felt a bit more confident knowing what to expect in advance. This week, my partner was Corinna, a bright young Greek woman with a head of curly blonde hair and plenty of self-confidence and style. She was "leading" for the first time, meaning she did the talking with the madames and prostitutes, and I could tell she was nervous. But each conversation went well, with several of the madames inviting us in to sit and talk. The Filis area has been fairly suspicious of Nea Zoi since their route through this area is new and we attract quite a consistent number of curious neighbors asking us why we're here. In the past few months, the interactions with the women here have been difficult, or prevented all together by the madames. One of the bigger obstacles is actually being able to meet with some of the women face-to-face at all. On the other hand, some of the madames are warming up to the teams coming every week with smiles and coffees. It is incredibly encouraging for the staff and volunteers to watch this shift in perception and see doors opening to better relationships with the women.

Emma and I went into one brothel together where the madames seem to change every week, and we weren't sure what to expect. But as we passed through the darkened rooms back to the kitchen, we were introduced to a young, pale girl with long dark hair. She was a new Romanian girl, the madame told us, and didn't speak any Greek or English at all. Looking at her, fatigued and fragile, with bruises and dirty fingernails, we quickly assumed she had likely been trafficked. Her eyes followed our conversation in Greek back and forth, but we had no way of directly communicating with her. I could see Emma's frustration and sadness at the language barrier, something I've struggled with our whole time here. Sitting in front of someone without being able to effectively communicate anything really, when you desperately want to love them and give them crucial information to improve their situation, is maddening. Suddenly I realized we at least had a medical survey translated into Romanian, and we trailed a finger under the top line "Public Health Survey, Athens, Greece" until she brightened and grabbed the paper and a pen from us. She bent over the survey, reading carefully and checking boxes as she went, her tongue sticking barely out of her mouth in concentration. As I accumulated our survey data later that afternoon, she was our only Romanian survey, and the checked boxes our only communication with her so far.

Before our time here in Athens, the issue of trafficking vaguely appeared on my radar from news articles, but I didn't understand much of the details or the global scale of the problem. We are seeing a small piece of the overall picture in Europe with Nea Zoi, but even interacting with the women nearly daily, I found it hard to really grasp. When we were over at Emma and Yannis' apartment for dinner last weekend, she let us borrow a movie/miniseries "Human Trafficking" with Donald Sutherland and Mira Sorvino. Combined with our experiences here with the women, the movie was painfully educational and eye-opening. I hesitate to recommend it with its graphic scenes and sometimes agonizing reality, but it is certainly a quick and pointed lesson on the issue of trafficking. During our viewing, I found myself watching carefully for portrayals of the women's responses to their situations. Many of the women we meet here already made clear psychological adjustments to avoid continuing emotional trauma and strain, even the portion of the population who weren't trafficked. The concept of just surviving is very prevelant. And as we continue surveying, many of the women are requesting psychological counseling. The untangling of the emotional splits they require to survive can take years. Complicating that process though, it is less threatening and traumatic for the women to simply continue the dual existance. Recognizing the horrors of their daily life, and reconnecting their identities with reality, is a terrifying step. To maintain status quo, many women will refuse to admit being trafficked, much less turn in their traffickers or leave prostitution, along with fear of retribution or shame returning home or many other reasons. Once they have paid off their "debt" to the trafficker - often 50,000 euros or more - the women have fully adjusted to the split life of prostitution and rationalize staying longer to make money for themselves since they've already been damaged.

All of this to say that the situation here is far more complex than I could have imagined. It's not a simple as just offering the women a way out and them jumping at it with relief, and everything turning out just fine. The process of helping the women leave this situation requires trust and long-term relationships, with provisions for the overlooked medical problems and spiritual and emotional issues in the interim. Before this, I had no idea.

University Hospital Attikon

Tuesday morning Lindsay and I woke up earlier than usual to make our way across Athens to Hospital Attikon, where our acquaintance Dr. Koutras works as an Ob-Gyn professor with the University of Athens medical school. He invited us to visit his Tuesday morning public clinic where he sees women with Greece's national medical insurance (similar to Medicaid). The morning's first task involved actually finding Hospital Attikon. Our touristy maps only show central Athens, and our vague geographical knowledge of the hospital put it in the western part of the city ... maybe. After searching in vain for a while for a decent map online , we decided to just hop in a taxi and say "Hospital Attikon" with confident smiles. Shockingly, it worked, but the cab driver whipped around in his seat to stare at us, and I realized a few seconds later that jumping into a cab and asking loudly for a hospital might deserve that reaction. We drove west on main streets that I slowly recognized from our visits last Thursday night with the transvestites. I snapped a picture of our first stop from that evening as we passed by in broad daylight.

When we arrived at the hospital, Lindsay and I wandered past clusters of smokers and through a blue cloud to enter the smoke-free sanctity of Attikon Hospital. The lobby was modern and airy, full of hustling staff and patients clutching their medical books (the Greek public health system uses books to track use of the system and provide continuity). We soaked in the familiar sights of a university hospital, including the obvious cluster of residents and medical students standing to one side slurping coffees. Dr. Koutras met us in the lobby to escort us back to his clinic and we settled in. Throughout the morning a long line of women came and went, some with general gynecology problems, and others newly-pregnant or just wanting a routine pap smear. Another medical student joined us for a while - a sixth-year medical student learning ob-gyn exams (before you flip out over six years of medical school, let me explain that the Greek system circumvents four years of undergraduate university time by including it in a six-year medical school curriculum, followed by a residency system similar to ours in the US). Lindsay and I were happy to contribute to the clinic, doing paps and gyn exams, and we were curious to notice a few differences in the Greek medical system as we worked.

• First difference - instead of the doctor going from room to room seeing different patients, the physician stays in one place while the patients come in one at a time from a line out in the hall.

• Second difference - hand-washing is less rigorous than in our hospitals

• Third difference - as is privacy ... patients waiting out in the hall regularly popped in to see if the doctor was free yet, even in the middle of oh-so-sensitive exams; despite these interruptions, only a handful of the patients seemed truly bothered by the intrusions!

After we finished clinic at 1:30 (Greek lunch hour-ish) Dr. Koutras drove us back to Syndagma Square close to Omonia. We set a dinner date with him later in the evening, and headed back to the office to get some work done. When he picked Lindsay, Robert and I up later, we were a bit dismayed to be fairly underdressed (aren't we always ..) and quickly realized how much our host wanted to show us the beauty of Athens to counterbalance any one-sided impressions we might absorb from our work in the darker corners of the city. Dr. Koutras brought a date, his cousin and his cousin's wife to join us for dinner in southern Athens on the waterfront. The seven of us had a marvelous time eating incredible Greek food and working our way through often hilarious broken English-Greek conversations about our different persectives on the world. They dropped us off in Omonia well after 1am with full tummies and lingering smiles to stagger back to the apartment and fall happily into bed.

Monday night in Omonia

Omonia is our Athens neighborhood, with Omonia Square only a few blocks from our apartment and the Nea Zoi office only a few blocks further. Omonia is pronounced like ammonia, but more of an O sound starting the word with a slight pause - "O-monia". Many Athenians react negatively to references to Omonia, often because of its reputation for drug trafficking and use. As I've mentioned before though, we've been able to walk around together at night and still feel fairly safe despite crazy things going on around us. Passing through the main square or the plaza outside the Nea Zoi office (or in front of our apartment for that matter) we often see drug users who are clearly high, and the exchange of drugs back and forth. A few times, the main square has been actually crowded late at night with clusters of hundreds of users mingling together! The more popular drug in Omonia is heroin, and the high users often show slowed motor movements and responses, creating a scene of dark figures swaying and staggering in slow motion.

I describe all of this to provide a context for our outreach this past Monday night, when I had the chance to walk the streets of my own neighborhood to talk with Nigerian, Greek and Albanian women. It sounds funny, but the landmarks near our apartment are already familiar and wandering through recognizable territory added a different layer of surrealism to the evening. During our time of preparation at the office beforehand, I presented a brief seminar on heroin abuse and the symptoms of use and withdrawal. We hoped to better prepare the Nea Zoi folks to interact safely and effectively with heroin-using prostitutes. Compared to populations of sex workers in the UK or US, the women and men here usually are not using drugs, particularly the trafficked women. Only a small group also get involved with drugs, but many of those women can be found in Omonia's streets.

As we headed out from the office, we walked down the "back way" to the apartment through side streets instead of going through Omonia Square. At night, we usually avoid the back way, and I saw why as we passed through these narrow, dark streets with our team. On a corner not far from our apartment, we encountered four or five Nigerian women working. Apparently Nea Zoi knew these girls from encounters over a year ago, and the women hadn't been seen again until tonight. Several of the girls told stories of working in Italy for several months, and we suspect a trafficking ring is involved between Italy and Greece. As with the Nigerian girls at the hotels, these five women were friendly and English-speaking, allowing me more freedom in discussion and verbal compassion. And I love to be able to connect and communicate easily! One girl with the street name "Special" told me about her desire to work in medicine and get training as a midwife or a doctor. When I mentioned the Friday clinic and asked her if she wanted to be there to help, she absolutely glowed! All of the women were willing to complete medical surveys, and amazingly the discussion over medical topics often opened doors to more honest conversation. More about that later ...

Our route through Omonia took us by several bars that host prostitutes, and we met many Albanian and Greek women sitting at tables in front of the bars or waving at us from inside. With this group, my role changed to handing out cards advertising the clinics and smiling with the occasional "neh" and "yassis" (a new word for me, means literally 'your health' often used as a greeting or goodbye, or in toasts ... it's incredibly useful for my non-Greek speaking-ness). One woman talked my ear off in Greek as I kept saying 'English, English?' over and over. When I offered her a nail polish for completing the survey, she put her hands up as if refusing it, then ran off into the bar. I stood there for a minute completely confused. I mean, the nail polish is pretty cool and I hadn't gotten any flat-out refusals yet. But after a minute or so she re-appeared carrying a bag of chips that she thrust in my hands. And she gladly chose a bright pink nail polish from my bag as I examined her gift. A lot of these interactions pose similar language confusions and subsequent surprises for me, usually in the eager response of the women to the teams' attention and concern for them. This woman, her eyes laced with thick mascara and framed with bleach-blonde hair, drew close and grabbed my hands with an awkward English "tenk uuu" as my mind raced to memorize her face. Originally I hoped to complete a series of portraits of the women and men we're meeting. But I haven't been able to photograph the darker side of our time in Athens because it seems like a violation of trust and confidentiality. And at moments like this one, I wish a futuristic neuro-camera existed that could freeze frame her smile and bright eyes and save it permanently in my mind.

Out and About

Our Sunday started with a Metro ride over to the neighborhoods underneath the Acropolis for church. Both Emma and Jennifer are part of this particular church, which is appealing since we tend to trust their general tastes, but it is also English-friendly to boot! Now, this friendliness does involve wearing a set of big Mickey-Mouse-ears black headphones transmitting a kindly British voice from the congregation's interpreter. It feels a wee bit goofy, but certainly gets the job done. And we do sing in English while everyone sings in beautiful Greek whaa waa waaaaas, but the services have been fulfilling and peaceful to attend.

After the service today, we enjoyed lunch and an afternoon with Jennifer. To say a bit about her, she has honestly been our most comfortable, familiar bit of happiness here in Athens. Always amazingly accomodating and understanding, hilarious and friendly, she is also kind, wise, godly and generally fun to be around. We're big fans. Initially, she started Nea Zoi with Emma six or seven years ago, and only this year is transitioning to a different role of international policy work on behalf of the women. With her visionary personality, this is a perfect position for her, and for Nea Zoi's next stage moving from a local scale with plenty of international issues involved, to the global scale in hopes of affecting the local situations in more countries at once.

We enjoyed homemade Asian food at Jennifer's cute, tiny apartment followed by a hearty hike across Athens to Lykavittos Hill and a climb up to the small white chapel of St. George perched on top. Lykavittos is one of the random dark green hills popping up in the midst of the city's sea of white buildings, with a theater tucked into the woods on its north face. The hike felt like a never-ending stairmaster, but stayed pleasant with the dry air and cool breeze. We were pleased to see the familiar agave plant with its broad dusty green leaves and tall flowering stalks, and as we reached the higher, rockier slopes our pictures became very Big Bend-ish, just with a huge city in the background. Check out the Athens picture album for a photographic spread of the fun! The view from the chapel was wonderful, with all of the detail and color of Athens spread out in every direction. And tomorrow we're planning a hike to one of Athen's highest ridges with the goal of reaching an isolated monastery for a lunch picnic before heading to work through the Monday evening outreach late late tomorrow.

Pilot medical clinic numero uno

This afternoon, we hosted our first two-hour clinic at the Nea Zoi offices. Lindsay and I set up one of the rooms with our medical equipment, a rudimentary exam table (picture a desk with a mattress laid over the top and draped with sheets ...) and chairs for the physician and patient. In all of our preparations, we weren't sure what to expect - we might have ten patients, or none at all! Along with a Greek nurse, Lindsay and myself, we were staffed by Dr. Terazakis, an internist, between 2 and 3pm, and our sweet Dr. Lydia Ogur, a general practioner, followed from 3-4pm.

Right at 2pm, we greeted our first patient, a blonde Albanian woman with a face aged well beyond her 31 years. She came with questions about abnormal blood tests she'd received recently - anemia, as it turned out - and the conversation turned almost immediately to her job and unique medical questions concerning prostitution. But as we continued, it became quickly obvious that she is dealing with stresses even beyond prostitution's usual difficulties. Her ex-pimp is currently in prison in Albania, and trying to locate her to "reclaim" her. Despite being behind bars, he has been utilizing the extensive network of the Russian mafia to find her and her 9 year old son here in Athens. Last week, prostitutes in her area reported being asked about her by a man who mentioned being paid 2000 Euros to track her down. The police were called and chased him away, but this woman now lives under the constant threat of kidnapping or even death. She told us about recurring colds and pains, headaches and nausea, that are intesifying as this fearful story continues. Any solutions available for this type of situation will likely not provide much protection for her, including the Albanian witness protection program she enrolled in before the pimp's arrest. The visit felt incredibly frustrating. Even with fairly simple medical solutions - an iron supplement and counseling about anemia - we had no immediate solution for the much larger social issues threatening her life far more than her anemia. We prayed with her and talked through the possibilities of returning to the relative safety of her family in Albania, and she left the office with our phone number knowing the office could be a safe haven if the situation worsens.

One of the other patients was also Albanian, and a smart 23-year-old proficient in Albanian, English and Greek, with some Italian and Spanish to boot. She and I sat talking together for quite a while after she saw Dr. Terazakis, a refreshing change for me to be able to communicate quickly and clearly with one of the women! After she filled out the health survey, she offered some editing tips for the Albanian survey as well, and talked frankly with us about how to make the survey more approachable for the other women. As the afternoon went on, a local psychiatrist showed up and we engaged in an intense discussion of the women's psychiatric needs in broken English. Her input proved invaluable as we checked through surveys from Wednesday, last night and today, and saw the high prevalence of depression. One of the Nigerian women seen on the outreach last night had mentioned feeling suicidal on occasion, and we talked through the options for immediate medical care in similar situations encountered out on the streets. All in all, the clinic saw three patients, and we started planning further steps in our phase plans with the help of this psychiatrist and Dr. Ogur.

Robert and I are going out to dinner in Monistirakis tonight at our favorite restaurant, before meeting a third-year Ob-Gyn resident from the University of Athens. Dr. Koutras, a friend of Dr. Hurd from UTHSCSA's faculty, met with Lindsay and me Tuesday evening and treated us to coffee at a lovely restaurant beneath the Acropolis. He wanted us to see the beauty of Athens, including the warm glow of the Acropolis lit up at night. Our conversations with him - Emma translating and explaining Nea Zoi's purposes - continued our education of the Greek medical system and the possibilities open to the clinic for connections with the local clinics and hospitals. Lindsay and I are pretty sure that Dr. Koutras, who emphasized wanting to be a hospitable host for us, recruited this resident to show us the town ... for now that will just be a coffee date near Monistirakis after our late bedtime last night. We're a bit wiped out, but caffeine is always welcome!

Another unusual Thursday night

Another Nea Zoi outreach started at 11pm last night with a meeting of the volunteers and staff in the office, gathering for prayer and preparation before heading out to different areas of the city. One team headed towards the hotels where the Nigerian women gather, equipped with health surveys and brightly-colored nail polishes to reward the women for their time. Lindsay and I picked out the colors earlier in the day ... the sparkly or super-bright ones were the most popular. Along with the usual Greek volunteers, several American women showed up to help who are teaching English in a Greek city south of Athens. The two teachers, Carrie and Diana, ended up on my team with Martha - a kind-faced Greek mama - and Yiannis, Emma's husband. The five of us went out to the streets of west Athens in Martha's car ... and wow, she could DRIVE, weaving in and out through a mess of taxis and mopeds. As we wound through dark avenues and side streets of Kavalas, she and Yiannis knew exactly where to look for our hopeful contacts for the night, the tranvestites of Athens.

The experience was vastly different from last Thursday's interactions with the Nigerian women on the streets or the Wednesday morning Eastern Bloc women of the legal brothels. The tranvestites tend to park their cars along major roads (usually near car dealerships, for whatever reason) with emergency blinkers on and the constant glow of a lit cigarette, dressed immaculately in wigs and make-up. Each contact was isolated, sitting alone in their car, and more demure in interactions with us than the clusters of Nigerian women with their shouts and hugs. At the same time, I was surprised to see how warmly the men responded, particularly to me, the "little girl doctor from America". Yannis and Martha translated for me as necessary, but my verbal interaction stayed fairly limited. Several of the men talked my head off - in Greek, of course - telling stories or asking about medical problems, others gave hugs, and even pats on the head. I haven't been patted on the head in years, and it was such a tender gesture that I wasn't sure how to respond in Greek except to say "nay" (yes) over and over.

We weren't able to complete any medical surveys with the transvestites, simply because it didn't seem appropriate in the context of the relationships Nea Zoi had with the particular men we saw last night. One big challenge we've noticed with the survey is knowing when and whom to ask, to get the information we need without damaging the trust these people have in Nea Zoi. For some of the men and women, sensitive medical information is difficult to share, and yet others are willing to openly answer any and every question. Our goal of 20-30% sampling of the populations of women seems very possible, but the tranvestites will likely be under-represented. Lindsay and I started researching the different spread of risks and medical needs shared by most transvestites, discussing how to integrate their needs into our data. Many of the women seem to be experiencing fairly expected medical issues - depression, pain in various areas of the body, extreme stress responses, anxiety - but the men's specific needs remain somewhat of a mystery.

One moment from last night stuck in my mind as I finally fell asleep back in the apartment at 4am. At one of our stops, Bella, a tall, lanky tranvestite with a black maroon-streaked wig of curly hair, accepted a hot cup of coffee from me tenatively, almost shyly. As we talked with the two other men with him on the corner, I noticed several timid looks my way. Went I met his glances with a smile in return, he seemed stunned and uncertain how to respond for a few seconds. But as I kept smiling, a small smile played on his lips and got bigger and bigger until his eyes crinkled in a huge grin. We passed Greek and English back and forth with no comprehension on either end, but the smiles said a lot on their own. I'm quickly learning the language of smiles and eyebrow raises and hand motions, connecting as best as I can to the men and women, and I feel immensely grateful for any attempts made in return.