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The intersection between sex and drugs: a cross-sectional study among the spouses of injection drug users in Chennai, India

It is estimated that there are up to 1.1 million injection drug users (IDUs) in India; the majority are likely married. We characterize HIV, hepatitis B (HBV) and hepatitis C (HCV) prevalence and the risk environment of a sample of spouses of IDUs.

A cohort of 1158 IDUs (99% male) was recruited in Chennai, India from 2005-06. A convenience sample of 400 spouses of the male IDUs in this cohort was recruited in 2009. A risk assessment questionnaire was administered and a blood sample collected. Logistic regression was used to identify factors associated with prevalent HIV.

Median age was 31 years; thirteen percent were widowed and 7% were not currently living with their spouse. Only 4 (1%) reported ever injecting drugs; Twenty-two percent and 25% reported ever using non-injection drugs and alcohol, respectively. The majority had one lifetime sexual partner and 37 (9%) reporting exchanging sex. Only 7% always used condoms with their regular partner. HIV, HBV and HCV prevalence were 2.5%, 3.8% and 0.5%, respectively; among spouses of HIV+ IDUs (n = 78), HIV prevalence was 10.3%. The strongest predictor of HIV was spousal HIV status (OR: 17.9; p < 0.001). Fifty-six percent of women had ever experienced intimate partner violence; Eight-six percent reported sexual violence.

Our finding of a 10-fold higher HIV prevalence among spouses of IDUs compared with general population women indicates their vulnerability; prevalence is likely to increase given the context of low condom use and frequent sexual violence. Prevention efforts directed at IDUs should also include programs for spouses.

Peer Review reports

Injection drug users (IDUs) are at high risk for HIV acquisition and currently drive several of the fastest growing HIV epidemics globally [14]. In India, the HIV epidemic has historically been driven by heterosexual transmission from initial reports among female sex workers (FSWs) to eventual documentation of high HIV prevalence among women who were married and monogamous and reported no risk factors for HIV other than sex with their husbands [5, 6]. However, recent reports have suggested stabilization of the heterosexual epidemic with decreasing prevalence and incidence among FSWs and antenatal clinic attendees [7, 8]. This is likely in part due to interventions (e.g., condom promotion, sexually transmitted infection [STI] testing) targeted over the past decade at heterosexual high-risk populations including FSWs and truck drivers.

Concurrently, HIV epidemics among other risk groups such as IDUs have continued to grow [6]. Though there has been a wide range in the estimated size of the IDU population in India due to use of different estimation techniques, it has been suggested that up to 1.1 million IDUs [1, 4] may reside in India. In the early years of the epidemic, HIV among IDUs in India was concentrated in the Northeastern states (due to proximity to the 'Golden Triangle' - Burma, Laos, Thailand and Vietnam). However, it is now evident that IDUs exist in most major metropolitan cities in India and have high prevalence of HIV and associated blood-borne infections (e.g., hepatitis B virus [HBV] and hepatitis C virus [HCV]) [913]. Beyond transmission within drug using networks, IDUs can also transmit HIV and other blood-borne infections heterosexually because the majority are married and sexually active [1416]. Transmission to wives and other sexual partners is likely facilitated by low rates of condom use with regular sex partners which has been previously reported among IDUs in India [17]. Thus, the wives of IDUs represent another group of married monogamous women who are at risk for HIV and other infections primarily because of their husband's high risk behavior [1820].

Prior studies in India have characterized the prevalence of HIV among spouses of IDUs; a range of prevalence has been observed from 5% in Chennai to 45% of those in Manipur [1416]. However, none of these studies characterized prevalence of other bloodborne infections including HBV and HCV. Further, few have characterized the context of risk for these women; understanding their own level of risk behavior, their economic situation and their relationships with their husbands will provide a broader understanding of their risk environment and will help to design programs for this potentially vulnerable group [21]. Of particular interest is experienced intimate partner violence (IPV). Violence against women is recognized as a global public health problem and can have adverse impacts on physical, mental and reproductive outcomes and can also increase risk for HIV [2224]. A number of studies have demonstrated high levels of IPV in India [2528], but few studies have characterized violence among spouses of IDUs. As violence has been associated with alcohol use [27], it is possible that experienced violence may be even greater in this population and can further influence risk for HIV and other infections.

We previously characterized the prevalence of HIV, HBV and HCV infection in a cohort of 1158 IDUs in Chennai, India to be 25%, 11% and 65%, respectively [29]. Almost two-thirds of the IDUs were married of whom 40% were also sexually active. The objective of this study was to characterize the prevalence of HIV, HBV and HCV infections among a sample of the wives of the IDUs in this cohort as well as to understand their risk environment.

Study Population

Between April 2005-May 2006, 1158 IDUs were recruited into a longitudinal cohort in Chennai, India [29, 30]. The Madras Injection Drug Users and AIDS Cohort Study (MIDACS) operates through the YR Gaitonde Centre for Substance Abuse-Related Research (YRGCSAR) in north Chennai. YRGCSAR was established in November 2004 to provide HIV voluntary counseling and testing (VCT) services to marginalized populations and conduct longitudinal assessments of HIV incidence and drug abuse among IDUs in Chennai. A convenience sample of IDUs was recruited through extensive community outreach as previously described [29]. Briefly, field staff, who were predominantly former IDUs, recruited participants from locales in all zones of Chennai where IDUs were known to congregate (e.g., shooting galleries, drug treatment centers, etc.). Participants were eligible if they (1) provided written informed consent, (2) were at least 18 years of age, and (3) injected at least once in the prior 6 months by self-report. Seven hundred and forty-five (64%) of the 1158 participants were married.

Between June and August 2008, we conducted four focus groups among male IDUs (n = 38) and four focus groups among known spouses of male IDUs (n = 33) to determine the best methods to recruit spouses of IDUs into a research study. While greater than 75% of the male IDUs were interested in their wives participating in a study and receiving HIV testing, most were too afraid to bring them in themselves. IDUs and their spouses revealed that the majority of women married to IDUs were aware that their husbands were injectors but few were aware of their husband's HIV serostatus. Most IDUs wanted assistance in disclosing their HIV status to their wives. This study provided them with an opportunity for disclosure in a setting where couples counseling would be available. Based on this formative work, we adopted two methods of recruitment. IDUs in the ongoing MIDACS were told that they could bring their wives into the clinic for participation in the study. They were assured that disclosure of any personal information to their wives would only be done at their request and consent. In addition, IDUs provided study staff with contact information for their wives and these women were approached directly by YRGCSAR staff. Study staff have worked in the communities of North Chennai since 1999 and have excellent rapport in this region where the majority of MIDACS participants live. As the recruitment of wives took place nearly three years after enrollment of the IDU cohort and a high rate of mortality in this cohort (secondary to drug overdose, HIV and tuberculosis) has been observed [31], 13% of IDUs were dead by the time their wives were contacted. This study was approved by the YRGCARE and Johns Hopkins Bloomberg School of Public Health institutional review boards.

The recruitment for the cross-sectional study took place between April-November 2009. A convenience sample of predetermined size (n = 400 women) was recruited (representing 54% of the wives of all married IDUs in the MIDACS). Women were eligible to participate if they were ≥18 years of age, provided written informed consent and reported having a husband who had a history of injection drug use. To achieve the sample size of 400, 433 women were screened; thirty-three (7.6%) did not consent. As all women were known spouses of IDUs in the ongoing MIDACS, consent was also obtained to link their HIV, HCV and HBV results with those of their husbands who were enrolled in the MIDACS. Even women who were recruited independently provided identification information that permitted linking their laboratory data with their spouses who were enrolled in MIDACS. However, behavioral data from the MIDACS was not linked with the behavioral data from this study as per the mandate of the IRB.

Data collection

A blood sample was collected to test participants for HIV, HBV and HCV and a risk assessment questionnaire was administered to all participants (additional file 1). HIV status was ascertained by testing for antibodies to HIV by duplicate ELISA (Murex HIV-1.2.O, Abbott Murex, UK and Vironostika® HIV Uni-form II Ag/Ab, bioMérieux, The Netherlands). Antibodies to HCV (anti-HCV) were identified using the Murex Anti-HCV kit (Abbott Murex, Republic of South Africa), and chronic hepatitis B virus (HBV) infection was diagnosed by the presence of hepatitis B surface antigen (HBsAg) (Hepanostika HBsAg Uniform II, Biomérieux, The Netherlands). All participants were provided with pre-test counseling prior to collection of the blood specimen. Additionally, participants were asked to return to YRGCSAR two weeks later for results, post-test counseling and referrals for HIV care, if needed. The risk assessment questionnaire collected information on demographics, history of substance use (alcohol, non-injection and injection drug use), sexual risk behavior (including main and non-spousal partners, condom use and commercial sexual encounters), intimate partner violence (IPV) and perceived impact of drug use on the family unit. Women were asked about their lifetime experience with verbal, physical and sexual violence; they were also asked to document the number of episodes of each in the prior six months. They were asked about knowledge of their spouses drug use, HIV, HCV and HBV status. Finally, they were asked to disclose all of the ways in which their husband's injection drug use impacted their family (e.g., economic deprivation, negative influence on children, violence) and then to state their primary concern about their husband's drug injection.

Statistical Analysis

Analyses presented are primarily descriptive. Dichotomous/categorical variables are described as n (%) and continuous variables as median (interquartile range [IQR]). Univariate logistic regression was used to identify factors associated with prevalent HIV infection. As only 10 women were infected with HIV, multivariate analysis was not performed. All analyses were performed using Intercooled STATA Version 10.1 (College Station, Texas, USA).

Description of population

The median age was 31 years (IQR: 26-36), the majority were of Tamil ethnicity (97%) and had either no (28%) or only primary-level education (62%). Eighty percent were married and living with their spouse, 7% were living away from their spouse and 13% were widowed (Table 1). The median duration of marriage was 14 years (IQR: 7-19). The majority were employed and earned daily wages. However, reported family income was very low; sixty-seven percent reported an income of less than INR 500 (10 USD) per month. Nearly all (99%) reported that there were children and other family members (in most cases their husbands' parents) living in the household.

Table 1 Description of study population: spouses of injection drug users enrolled in Madras Injection Drug User and AIDS Cohort Study, Chennai India, 2009 (n = 400)*

Risk behavior

Only 4 women (1%) reported a history of injecting drugs. Two of the four had injected in the prior six months. Two reported injecting heroin and the other two reported injecting buprenorphine. All reported injecting with very good friends, but not with their husbands. Twenty-six percent reported some alcohol use but the majority reported drinking < once/week and only 9 women reported daily alcohol use. Among the 102 women who reported any alcohol use, the most commonly consumed beverages were brandy (50%) and a combination of wine and beer (66%). Eighty-eight women (22%) had ever used non-injection drugs. The most common non-injection drug reported was smokeless tobacco (e.g., chewing tobacco products such as mawa, zarda) followed by pharmaceutical drugs.

The majority (85%) reported only one lifetime sexual partner; Fifty-two (13%) reported 2 sexual partners and 7 (3%) reported >2 partners with only 1 reporting more than 4 partners (number of partners = 22) over their lifetime. Thirty-seven (9%) reported having ever exchanged sex for money or drugs. Of the 59 women who reported multiple partners, 37 reported exchange sex and 9 were widowed. Forty-nine (12%) had sex with someone who was known to them to be HIV positive. Condom use with both regular and non-regular partners was infrequent (Table 1). Three-quarters (74%) reported never using condoms with their primary spousal partner and 70% reported never using condoms with their non-regular partners.

Prevalence of HIV, HCV and HBV

Ten (2.5%) women were positive for HIV antibodies, 2 were positive for HCV antibodies (0.5%) and 15 (3.8%) were positive for HBsAg. Of the 10 women who were HIV positive, 8 (80%) had husbands who were also HIV positive. All 10 reported currently living with their spouse. Three reported two lifetime sexual partners and the remaining 7 reported one. One reported a history of exchange sex. Only three reported always using condoms with their primary partner and none reported always using condoms with their non-regular partners. None reported a history of injection drug use while three reported some alcohol use and two reported some non-injection drug use. HIV prevalence was significantly higher among women whose husbands were also HIV positive (10.2% vs. 0.6%, p < 0.001; Figure 1). Of the 14 who were HBsAg positive, only one had a husband who was also HBsAg positive. Of the two who were HCV positive, one had a husband who was also HCV positive and neither reported a history of injection. Five of the 10 HIV positive women were aware of their status; two women reported a prior positive HIV test result but had a negative antibody result in the study. Overall, 40% had been tested for HIV at least once (Table 2). The majority (94%) had never been tested for HBV or HCV.

Figure 1

Prevalence of HIV, hepatitis C virus (HCV) and hepatitis B virus (HBV) among 400 wives of injection drug users by spousal HIV status in Chennai, India (2009).

Table 2 HIV, HBV and HCV testing history among spouses of injection drug users enrolled in the Madras Injection Drug User and AIDS Cohort Study, Chennai, India, 2009 (n = 400)

Factors significantly associated with HIV prevalence (Table 3) included more stable employment (odds ratio [OR] for weekly/monthly wages vs. daily wages: 5.59; 95% confidence interval [CI]: 1.14, 7.27), higher family income (OR for 500-1500 INR per month vs. < 500 INR per month: 5.0; 95% CI: 1.09, 22.9), always using condoms with regular partner (OR: 9.13; 95% CI: 1.93, 43.2), having had sex with someone known to be HIV positive (OR: 11.6; 95% CI: 3.15, 42.8) and having an HIV positive husband (OR: 17.9; 95% CI: 3.73, 86.3).

Table 3 Factors associated with prevalent HIV infection among spouses of injection drug users enrolled in the Madras Injection Drug User and AIDS Cohort Study, Chennai, India, 2009 (n = 400)

Partner risk behavior

Three hundred and eight-six (97%) were not aware of their husband's injection drug use prior to marriage. Of these, the majority (91.9%) learned their husbands were IDUs when they saw them injecting at some point during marriage. Eighty-two percent were aware of their husband's HIV serostatus but only 57.9% were aware of their husband's hepatitis status. Women who reported being aware their husband was HIV positive were no less likely to report sexual intercourse with their husband in the prior six months compared to those who perceived their husband to be negative or did not know their status (86.8% vs. 88.5% and 83.6% respectively, p = 0.53). However, among those who were sexually active with their primary partner, those who thought their husband was HIV positive were significantly more likely to always use condoms than those who did not think their husband was HIV positive or did not know their status (15.2% vs. 0.4% and 3.3%, respectively, p < 0.0001). Among those women who thought their husband was HIV positive, 48% reported never using condoms in the prior six months. Women who thought their husbands were HIV positive reported better knowledge regarding protection conferred by condoms against HIV (66% vs 53%, p < 0.01); however, thirty four percent of women who thought their husband was HIV positive did not know that condoms could protect against HIV. Women who thought their husbands were HIV positive were significantly more likely to have had an HIV test previously vs. those who either thought their husband was negative or did not know (64.2% vs. 24.1% and 28.8%, respectively, p < 0.0001). Thirty-six percent of women who were aware of their husbands HIV positive status had never had an HIV test. Forty two percent of women with an HIV positive husband felt that they could not get HIV from their husband if he was not actively injecting; this did not differ from those women who did not have an HIV positive husband (39%, p = 0.9). Other risk behaviors (e.g., exchange sex, alcohol use, non-injection drug use) did not differ by whether their partner was HIV positive.

When women were queried about the potential harmful impact of their husband's injection drug use, the primary fear was that he would get HIV/AIDS (36.7%), followed by the impact on income for the family (33.2%) and being a bad influence on their children (22.4%).

Intimate partner violence

Two hundred and twenty-two (55.5%) women reported that they had ever experienced intimate partner violence (IPV). Of these, 127 (56.7%) reported that violence always occurred while their husband was under the influence of alcohol and 90 (40.2%) reported that it sometimes occurred while their husband was under the influence of alcohol. Sixty-nine (30.8%) reported that violence always occurred when their husband was under the influence of drugs and 139 (62.1%) that it sometimes occurred when their husband was under the influence of drugs. Of the women who experienced violence, 98.2% reported verbal violence, 96.4% reported physical violence (beaten/kicked/pushed/slapped by their spouse), 85.5% experienced sexual violence (forced to have sex against their will) and 8.2% had been burned with a cigarette. The overall proportion experiencing different types of violence and the frequency in the prior six months is illustrated in Figure 2. In the prior six months, women experienced verbal violence a median of 348 times (IQR: 262 - 424), physical violence a median of 186 times (IQR: 142-214) and sexual violence a median of 76 times (IQR: 54-96).

Figure 2

Prevalence of self-reported experienced intimate partner violence among 400 wives of injection drug users in Chennai, India (2009). Bars represent percent ever experienced and lines represent median episodes (interquartile range [IQR]) of experienced violence in the prior 6 months.

HIV prevalence among the spouses of IDUs in this sample in Chennai is about ten times higher than the prevalence of HIV among antenatal clinic attendees in Tamil Nadu (0.25%) [6]. Prevalence of chronic HBV was also high but HCV prevalence was comparable to the expected general population prevalence. The low HCV prevalence despite high prevalence of HIV and HBV confirm that these women have little to no injection-related risk of their own. It appears that the majority of these women are married and monogamous with low risk outside of unprotected sexual intercourse with their husbands. This risk is compounded by the context in which these women appear to be living; women were subject to poverty and high levels of IPV including forced sex particularly when their husbands were under the influence of drugs and/or alcohol. These data further substantiate the importance of including these women in prevention and treatment efforts to reduce bloodborne infection transmission and IPV.

We observed a lower HIV prevalence among the women in this study compared with what has been previously observed, particularly in the Northeast, but our estimate was comparable to prior data from Chennai. Chakrabarti and colleagues reported in 2000 that 45% of the wives of 233 HIV-infected injectors in Manipur were HIV positive [14]; Panda et al reported a prevalence of 5% among spouses of 226 married IDUs from Chennai - 16% of the spouses of HIV-positive IDUs tested positive for HIV antibodies [15]. The higher HIV prevalence among the wives of IDUs in Manipur may reflect an older HIV epidemic in the Northeast as well as a higher prevalence of injection drug use among women in this region compared with others [32]. In both studies, the primary factor associated with HIV aside from HIV/STI status of the partner was duration of HIV infection in the husband [16]. HIV prevalence among these women in Chennai will likely continue to increase particularly given the setting of ongoing sexual violence and low condom use even among women who were aware of their husband's positive HIV status. These data further highlight the need for female-controlled prevention measures.

Our study extends these other studies by including data on HBV and HCV as well as more detailed characterization of risk environment of these women. We observed relatively low HCV prevalence (0.5%) which is consistent with data that suggests that heterosexual transmission of HCV is infrequent [33]. Further, injection was negligible among these women. By contrast, the prevalence of chronic HBV infection was higher. Interestingly, there was little concordance with the HBsAg status of the spouse; however we did not have information on all markers of HBV infection so it is possible that some of their spouses were also infected but had previously cleared (HBsAg negative but anti-HBs positive).

The strongest correlate of HIV was husband's HIV serostatus. Our data are fairly consistent with prior reports from India suggesting that these women have relatively little risk of their own. Less than 1% had ever injected, 85% were monogamous and a very small proportion had more than 2 sexual partners. Though 37 women reported a history of exchanging sex for money or drugs, only one woman reported more than four partners. Not surprisingly condom use was extremely low in this population reflecting general trends among married couples in India [1820]. The positive association between condom use and HIV infection likely reflects higher levels of condom use among those who were aware of their HIV status as has been previously observed in India and other settings [20, 34]. Yet, it is important to note that even among the women who were aware that their husbands were HIV positive, consistent condom use was not universal and rates of HIV testing were low.

Prior studies from India and South Asia have also suggested low rates of condom use among similar groups of women [16, 17, 35] and low testing rates [15, 17]; however few of these studies had information to link behavior with women's knowledge of their husband's serostatus. Therefore, it is particularly concerning that such behaviors were low even among those women who believed their husband was infected. Future studies should explore in more depth, possibly qualitatively, the reasons for these low rates. Our data suggest that knowledge plays a role given that 33% of women with an HIV positive spouse did not know that condoms could protect against HIV and 42% did not know they were at risk for HIV if their husband was not actively injecting. Beyond knowledge, the reasons for low condom use are likely multifactorial and include fear [36], the idea that unprotected sex in long-term partnerships is a sign of intimacy and a request for condom use a sign of distrust [17] and that the power and control in sexual relationships in this region is unequally distributed by gender [37]. It is not uncommon for women in south India (especially from low income groups) to be subject to verbal/physical violence for suggesting condom use during sexual intercourse with a primary partner [38]. As has been done in other settings, interventions targeting IDUs need to focus on issues beyond risks associated with needle sharing and need to target their sexual partners. Drop-in centers and voluntary counseling and testing (VCT) centers targeting IDUs should include services for sexual partners (VCT, condom distribution, targeted information, education and communication (IEC) sessions), as has been recommended by the World Health Organization, United Nations Office of Drugs and Crime (UNODC) and UNAIDS as a component of the comprehensive package of services for IDUs [39].

Second to HIV/AIDS, the most pressing concern for these women was the impact their husband's drug use had on income of the family. The median income reported by the married IDUs enrolled in MIDACS was ~1500 INR per month compared to a median 500 INR reported by the spouses suggesting that IDUs might have been using a large proportion of their income for drugs/alcohol. The positive association between stable employment and HIV may be further reflective of the strain placed on these families. Husbands who are riskier (e.g., inject more frequently) may consequently bring less income home forcing their wives to seek stable employment. Further, it is also possible that women seek stable employment after their husbands become ill with complications of HIV or die as has been seen before in India [20]. Indeed 70% of HIV positive women worked for weekly or monthly wages vs. 37% of HIV negative women. Further, 13% of the spouses of the women enrolled in this study died within three years of enrolling in the MIDACS. It is possible then that at least some of these women were forced to work to support their families.

The economic adversity is further exacerbated by a climate of violence and potentially fear. We observed high levels of intimate partner violence, both physical and sexual in this population. Sexual and physical violence have been previously reported to be common in India [38]. While direct comparisons of prevalence are difficult due to differences in definitions of physical and sexual violence, the lifetime prevalence of sexual violence of 50% appears to be higher than other studies, even those conducted in Chennai with other high risk groups (e.g., men in wine shops) [25, 26, 28]. This likely reflects the added effects of substance abuse in a population where baseline levels of sexual violence are already higher than normal. Even more alarming than the lifetime prevalence of violence were the frequency of recent episodes of both sexual and physical violence suggesting that on average, violence occurs daily. Sexual violence was not associated with higher HIV prevalence but we were not able to perform multivariate analysis to rule out negative confounding. Further, the lack of association may simply reflect the overall high prevalence of sexual violence.

India is a strong patriarchal society and specific gender roles are embedded deep within the culture. A key role of men is to provide financially for their families. When men are injecting drugs, this impacts their ability to function in this role causing tremendous strain on their wives and families. Women are somewhat powerless in this situation as the majority of these women marry without knowing about their husband's drug use. When they ultimately find out, it is too late for them to change their situation as divorce is not commonplace in Indian society, particularly in lower socioeconomic communities. This situation appears to produce a volatile environment, one in which resources are strained and stability is thereby affected, leading to high levels of violence and disease transmission.

We were limited in this analysis by self-reported data, which may be subject to social desirability, particularly in this population where high-risk behavior is not normative. However, all participants were reassured regarding confidentiality and all interviewers were women to ensure the highest degree of comfort possible. Also, the women were reassured that none of the information shared with the interviewers would be relayed to their husbands. Due to the cross-sectional nature of the study, we were not able to establish temporal associations between exposures and HIV and other outcomes. Indeed, some of the associations observed (e.g., HIV and condom use) may reflect reverse causation. Further, the small number of HIV infections (n = 10) prevented us from conducting multivariate analysis. It is possible that some of the associations we observed or did not observe would have changed after accounting for confounding.

These data reinforce that HIV epidemics do not end with the persons engaging in high-risk behaviors. Spouses of IDUs represent another group of mostly monogamous women in India who are placed at risk for HIV by the behavior of their partners. Their risk context is further strained by compromised economic resources and high levels of intimate partner violence. Our data coupled with other investigations support that HIV prevention and treatment programs targeted at IDUs should also include components directed at their families. Strategies to empower these women are clearly needed; of particular interest may be interventions that provide economic opportunities for these women. Trials of pre-exposure prophylaxis (PrEP) and female-controlled prevention tools such as vaginal microbicides should attempt to recruit this population at high-risk for HIV acquisition. In the meantime, while such novel tools await efficacy demonstration, all programs providing services to IDUs need to include services targeting wives/sexual partners of IDUs (VCT, condom distribution, couples counseling, etc.) as recommended by the WHO, UNAIDS and UNODC.

Confidence interval

female sex worker

hepatitis B virus

hepatitis C virus

human immunodeficiency virus

indian rupee

injection drug use

interquartile range

intimate partner violence

Madras Injection Drug User and AIDS Cohort Study

men who have sex with men

odds ratio

sexually transmitted infection

United States dollar

voluntary counselling and testing

YR Gaitonde Centre for AIDS Research and Education

YR Gaitonde Centre for Substance Abuse Research

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This study was supported in part by the National Institutes of Health, USA (Grant# R01-DA-12568) and the Indian Council of Medical Research (ICMR), India as part of the US-India Bilateral Collaborative Research on the Prevention of HIV/AIDS, and the Fogarty International Center/USNIH: (Grant# 2D-43-TW000010-20-AITRP). We would like to thank the study and field staff at YRGCARE and YRGCSAR who helped with the implementation of the study. Finally, we would like to thank the participants of the study without whom this would not have been possible.

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Correspondence to Shruti H Mehta.

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The authors declare that they have no competing interests.

Authors' contributions

SSS conceived the study, participated in its design, conducted the analysis and helped to draft the manuscript. AKS participated in the design and supervised data collection. DDC participated in the design. SCJ participated in qualitative and quantitative data collection. KGM carried out laboratory testing. SA participated in data management and analysis. MSK participated in the design and critical review of manuscript. SS participated in the design and critical review. SHM conceived the study, participated in design and drafting of manuscript. All authors read and approved the final version of the manuscript.

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Additional file 1: Risk assessment questionnaire. This is the behavioral survey that was administered to the 400 women in this study (DOC 238 KB)

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Solomon, S.S., Srikrishnan, A.K., Celentano, D.D. et al. The intersection between sex and drugs: a cross-sectional study among the spouses of injection drug users in Chennai, India. BMC Public Health 11, 39 (2011).

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  • Intimate Partner Violence
  • Sexual Violence
  • Injection Drug User
  • Primary Partner
  • Lifetime Sexual Partner

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text:
From a Sealed Room by Rachel Kadish

BOMB 55 Spring 1996
Issue 55 055  Spring 1996

Every few days Fanya made some motion to leave; she began to gather the cosmetics she had spread over the dresser-top in Tami’s and Nachum’s bedroom, or she asked for the telephone number of a taxi company for the Jerusalem/Tel Aviv route.

“Stay as long as you like, and leave when you like,” Tami said as if she did not care. Tami longed for her mother to stay, to stay a long while, although she did not know why. The longer Fanya stayed the more alone she felt.

Nachum made no mention of Fanya’s presence, and he did not seem to mind sleeping on the mattress in their son Dov’s room. His silence unsettled Tami and after a time she asked him whether now that the war was over he thought it was time for Fanya to go back to Tel Aviv. The SCUD attacks had ended weeks ago, after all. Ariela no longer appeared at the door at the first wail of sirens, clutching her dolls to her chest; the radio announcer’s voice no longer sounded alerts and all-clears in language after language through the night. Still Tami and Nachum slept in the airless bedroom, its windows sealed shut although there was no more danger of chemical attack. Jerusalem was emptying of its Gulf-War refugees, did Nachum perhaps think Fanya should be leaving soon.

Nachum smiled his broad weathered smile and said only, “She’ll leave when she feels steady enough. Dov is in army training, what does he care if we use his bedroom a few weeks longer? Right now Fanya is out seeing Jerusalem and it makes her happy, nu, so what’s the harm?”

She had never understood Nachum’s patience, his slow easy manner that won him confidences and friends in places where he did not even look for them. She was grateful, now, that he did not say anything about Fanya’s staying on. Still it made Tami want to rage sometimes, how easily he passed through life. Long ago this way of his had charmed Tami, but now it made her feel alien to Nachum and alien to herself, untrustworthy because she wound herself in knots while Nachum continued at his same easy pace, never hurrying, while the world slowed down to accommodate him. He was late for everything and apologized with the easiest of smiles; he never turned away a question or a request on the street, and when he lagged because of it people shook their heads and laughed. That’s Nachum, they said. Nachum can get away with anything. Friends at the post office let him ahead of hour-long lines; the last bus of the night slowed to let him on as it pulled away from the station. Next to Nachum Tami felt methodical and ineffectual.

“Once,” Nachum would begin a favorite story when urged by friends, “Once, when I was 18, and I had just gotten my first apartment. Here in Jerusalem so I could be closer to where I was stationed for the army. I had moved all my things into the place, but the telephone company said I had to wait for a line. Wait and wait and wait again. Every day that I was free from the army, it was me going to the secretary at the telephone company and telling her I had no telephone, and she chewing gum and saying well that’s a shame, because the only person who can get me a line is her superior, and he’s on vacation and she can’t contact him until he returns.”

Telling the story, Nachum would lean forward as if inviting his audience to join him in a secret. “I said to her, ‘But the telephone company is government-owned. The telephone company is the government, nu, what do you mean you don’t have a superior in the country?’ She said to me, ‘Complain to the government then, I’m supposed to be on my lunch break already anyway.’”

“And I said to myself, ‘You don’t have a superior in the country? We’ll see about that.’ So that afternoon I was at the tank base and I went to a pay telephone.” Nachum made a swift motion as if picking up a receiver. “I called the operator and told her quick, put me directly through to the office of the Prime Minister of Israel. The secretary in the Prime Minister’s office sounded suspicious, she wanted to know if it was important, and I said ‘Oh yes, it’s very important.’ And the secretary hesitated and then she said, ‘Because the Prime Minister isn’t in, but if it’s urgent I can get him on the field telephone. He’s on a tour of the Jordanian border with the Commander-in-Chief, the Ramatkal, you understand.’ So I said of course I understood, of course it was important, would Nachum Shachar call if it wasn’t important?” Nachum waited for his listeners’ laughter. “And she didn’t know what to say to that. So she connected me to the Ramatkal’s field telephone and over the static, I had to shout so he could hear me, I said to the Prime Minister of Israel, ‘Hello, this is Nachum Shachar, I just called to say good-day, and do you know by the way why it is that I’m calling from a pay telephone?’ And there was only silence, so of course I had to explain the whole situation to him, how as our elected leader he might be interested to know that the national telephone company hadn’t seen fit yet to give me a telephone line. And when I’d finished saying that, he didn’t say anything for a while. We both listened to the telephone crackling and whining, he didn’t say anything for a while. This was Nachum’s favorite part of the story and those who had already heard it nodded encouragement. “‘Shahar,’” Nachum said in the raspy voice of the Prime Minister, “‘Shahar, you are a thorn in my rear end.’” Nachum smiled and cracked a sunflower seed between his teeth, sucking out the inside and picking the shell halves delicately off his tongue with quick fingers. “And within an hour my apartment had a dial tone. Of course I immediately called our Prime Minister to thank him, nu, don’t let anyone say I don’t have manners, but apparently he’d left a very clear message with his secretary that he was not to be disturbed again. Even for Nachum Shachar.” While his audience laughed Nachum winked and reached for the bowl of seeds again.

She had known Nachum, of course, when he had made that telephone call; she had known him growing up, in Tel Aviv. Nachum had been in her scout troop, and had gone to the high school in the next neighborhood. Whatever the group’s activity had been he had always been one of the leaders, arranging hikes or carpools, or meeting points in parking lots by the beach for midnight bonfires. Tami had known him only vaguely; they had never spoken. She had participated from time to time in one of these activities that seemed near-constant, but most often she ignored the invitations that Nachum and his friends passed out after school.

When they had met at the laundry counter of the Negev tank base to which they had both been assigned, he had not recognized her. But he was quick with an invitation to a gathering that evening at the shed where sodas and coffee were sold until midnight, where the soda vendor left his radio propped up on the stony ground so they could sit on the plastic benches and listen to American rock and Israeli news. Tami had brought Gila with her to the shed that first night, and again the second night, but she had come alone the third.

She had not had many boyfriends before; three counting Aryeh, who used to walk her home from school with an arm across her shoulders. Fanya had not thought any of the boys at school good enough for her, and Tami had not resisted her mother’s judgments.

She was quiet with Nachum, and she thought he would lose interest in her quickly. The girls she had seen him with before had been loud and free with their opinions, long-haired and tall, the first to rush to the front of the hiking column to lead the group through the dry, bone-colored chutes of a wadi. While Tami herself trailed behind, running her fingertips over the slippery, water-smoothed stone that arched over and around the hikers and made their voices echo out into the blue sky beyond.

She was surprised when Nachum told her that he liked her quietness. “I’ve never met anyone like you,” he said, and she felt a flush of unfamiliar pride. When they had first slept together they had already been dating for more than six weeks; Nachum seemed to take pride in being courtly with her, as if she were another breed from the sharp-tongued daughters of Tel Aviv he had known before her.

They had been given the day off from their training; Nachum convinced Uri at the garage to let them take a jeep off the base, and they drove for an hour until they were deep in the desert, first on the highway and then off the road on the rocky plain. They had eaten their sandwiches in the jeep; now they turned off the engine, and Nachum spread a tarpaulin on the hard ground. They had planned to build a fire, make coffee, scout the area before settling in for the night—Nachum’s ideas—but instead they sat.

They took off their boots, stuffing their socks inside, and, moving on hands and knees to keep the tarpaulin from blowing away with the cooling breeze, they anchored each corner of the crackling cloth before settling back again. He kissed her and she smiled at him and looked away. Around them the hills were dark against the paling sky. There was no sound of motors, of voices or animals or anything save the breeze casting pebbles against the side of the jeep. The silence engulfed them easily along with the rock-strewn hills.

“Are you comfortable?” he asked, and she nodded, too full of them and the desert and the wind to answer. They watched the sunset spread and sink over the hills to the west. As the air dimmed a cluster of lights emerged in the distance between two hills, marking the kibbutz at the border with Jordan. Nachum had his eyes half closed, and the last of the light cast a faint shadow at the base of his throat.

She thought that he looked like they were supposed to look, like she had always wanted to look: dark-haired and strong-featured, suntanned and unafraid, blending into the darkness of the sand. She imagined them free, wandering the hills as easily as the night-animals, as unquestioning as aged, ancient men and women who knew that this was their home. This was it, what her European-born mother would never understand: the Israel that had always eluded Tami herself, yet that at this very moment seemed closer to her reach than ever before.

She told Nachum about her re-assignment to the office of the base’s communications station and about Gila’s new boyfriend, and he seemed to listen. He took her hand, caressed it between his warm dry hands, and pushed it and her gently down onto the tarpaulin. He began to undress her and without a word she mirrored his actions. They lay on the unyielding ground, soundless themselves in the cool and silent desert air, under a sky so black and thickly clustered that she could reach out her hand past his back as he moved into her and fit her fingers between the stars.

Jerusalem bloomed that spring in muted colors. The rainfall had not been enough, the Galilee was low, and the lilacs in Liberty Bell park gave only a hint of scent. Tami, walking home from work along the edge of the Valley of the Cross, watched two soldiers flag down a car on Herzog Street and ask the driver for a lift to the central bus station. In the valley outside the monastery one of the monks stood in his black robe, conversing with an elderly tourist in a long flowered skirt. They were good neighbors, the monks, Tami thought, with their quiet smiles and their odd Greek Orthodox hats. She passed through the cement tunnel and out onto the tree-shaded path.

Dov would be at home; he had arrived in Jerusalem the previous afternoon on a bus from the north, toting his soldier’s bag and his gun. His face was weathered and slower to change expression, marked from too much sun and coffee, too many cigarettes, too little sleep. He was thin and hoarse, and he favored his right leg when he walked. When he spoke it was in monosyllables, his vocabulary taken over by acronyms and slang that Tami did not understand, and even Nachum had to ask him what he meant by some of the phrases he slung about as casually as he dropped the M-16 onto his bed. Tami concentrated on his laundry: uniforms matted with dust and sweat and dried mud.

They were laughing in the kitchen, Nachum and Dov, and Rafi, who nodded with mock formality at Tami’s entrance. Rafi had lost weight as well, the last time Tami had seen him was at the high school graduation just before both boys had left for the army. Now Rafi’s eyes were bloodshot from lack of sleep, his freckled face was gaunt, but his grin was wider than ever. The three of them were splitting seeds between their teeth and piling the shells on the table next to something they were looking at together.

“I’ll just be a minute,” Tami told them. She was changing her clothing at the other end of the apartment when she heard a vague call from Nachum, something about taking the boys down to the shop. The door slammed and there was silence. Buttoning her shirt, Tami came into the kitchen. She stared at the pile of photographs left carelessly where the three of them had sat. Gingerly she sat in the seat her husband had occupied.

The first few photographs were of Dov and some other boys in uniform, looking serious as they leaned against each other and against their guns jammed into the ground. The next pictures showed lithe uniformed figures bent over a pile of gear on the hard-packed dirt. Then a picture of an airplane overhead, and then three pictures of parachutes in the air, figures dangling from them, and something dizzying about the angle of the shot that Tami could not place. She tried to find Dov in the photographs but all the jumpers looked the same, stick-figures dangling by strings from white bags of tautly rippling air. A picture of a parachute billowing close overhead and filling the field of the camera startled Tami, and when she came to the pictures of Dov’s face grimacing at close range, his features pushed up from the force of the air and his eyes slitted in laughter against the wind and his arms extended to hold the camera in front of him, she realized: he had taken his camera on the jump, he had sneaked his camera onto the plane, and she sat and stared at her son’s cleverness that ran ahead out of her reach like water.

It had been hamsin when Dov’s hate for her had become irrevocable, a day when the air felt thick and heavy with demands. The sky was white and merged with the light-colored buildings on the hills beyond the Valley of the Cross. It hurt to look across the valley; it hurt to look at anything beyond arm’s reach.

Nachum had returned from reserve duty the previous evening. Tami had stayed up half the night before his return, cooking in the relentless heat, making grape leaves, tomato-eggplant salad, kubeh, and lemon and strawberry mousse pies for dessert. It was nothing compared to what some of the other women in the building did for a simple Friday night or to what Gila did for Yoram when he returned from reserve, but Tami had never liked to fuss in the kitchen, or join in the other women’s conversations about how many and which dishes they were making for a homecoming dinner. Still this time she had cooked with the grim determination that Nachum’s return would chase away a loneliness she had not been able to contain lately, so that sometimes at the customs office she stared at familiar forms as if she had never seen them before.

They had eaten her meal in silence. Nachum was exhausted and close-mouthed about exercises in the heat and dust storm. He ate some of everything and took extra helpings of both pies and while Tami was washing dishes he fell asleep at the table with Ariela in his lap. “Nachum,” Tami had said, and Nachum had opened his eyes, set Ariela on the floor and walked to the bedroom without a word. When she came in moments later he was asleep.

When Tami awoke in the morning, her head throbbing with the heat, Nachum had already left for the shop. In her t-shirt and underwear she shuffled into the kitchen and, eyes half closed, took a glass out of the cabinet over the stove. The sponge with which she had washed dishes the previous night was so dry she could have snapped it in half, and her eyes filled with tears as she opened the tap and let cool water splash into the glass.

She dressed carefully before going to the greengrocer’s. She wore her blue tank top and brown shorts, and her sandals with the leather straps that cut into her ankles when she walked. At the last minute before she left the apartment, she reached into the back of a dresser drawer and pulled out a scratched bottle of perfume, one Fanya had left behind on a visit years before and Tami had never bothered to return. She dabbed some perfume on her wrists.

The greengrocer’s smelled of sour milk and overripe fruit. A girl painted her nails behind the register and in the doorway stood a boy, talking to the girl and leaning on a push-broom that he did not seem intent on pushing anywhere. Tami circled the store, filling her basket with carrots and peach juice for Ariela, mango for Nachum. She picked up a box of Osem soup-almonds, pitas in a damp blue plastic bag, a package of cheese and four heavy boxes of milk, and still she did not see him.

When she took her basket to the counter the girl was gone; he stood in her place, smiling at her with those black eyes that she had wondered about so many times.

His name was Nissim. For years he had rung up her groceries, helped her find misshelved cans of soup, and told her what she owed with a smile in which she saw a knowledge that made her blush. He was dark-skinned, Sephardic, at least ten years younger than she. He kept accounts without writing them down, shaking his head quietly on those occasions when she apologized for not having enough money with her. “You’re a good customer, you always pay your account, so who needs to write it down?” he said. “When a woman like you says she’ll pay, she’ll pay.” He would offer to carry her groceries to the apartment for her. She had always refused.

“Will that be all?” he asked her now.

“Yes, thank you.” She met his eyes and looked away quickly, fidgeting with her purse. “And could you bring the packages to my apartment for me? The groceries are heavy and I’m not feeling so well today.”

“Of course,” he said quickly, as if he did not know what she meant.

She sat in the apartment waiting for him; she thought to herself that this was crazy. She was a mother of two children. Her stomach was flabby and pale, she had not worn her bikini to the beach in more summers than she could remember. Here she was, waiting for her Nissim from the greengrocer’s to climb the stairs to her apartment. It was ridiculous; she would not answer the door when he came.

The doorbell rang, and she jumped, froze for a moment, then, cursing herself, unlocked the door. He was out of breath from the stairs, and he walked past her and set the box of groceries on the kitchen table with a thump.

“Thank you, Nissim,” she said slowly, fingering the money she had counted out in advance. She could hear her heartbeat.

He waited. She turned abruptly and, taking a pitcher from the refrigerator, poured a glass of cold water. She thrust it into his hands. “Here,” she said.

They stood on opposite sides of the narrow kitchen table, and she watched his Adam’s apple rise and fall as he swallowed.

When he had finished he placed the glass on the table. “Thank you,” he said, and waited.

In one hand she clutched the money she owed him. Before she could hesitate she lifted her other hand in a quick motion and brushed her palm against his tight dark curls, and at the same moment as she registered the look of shock on his face and realized she had made a terrible mistake, the door banged open and Dov was staring at the two of them from across the kitchen.

She dropped her hand and Nissim turned and fled the apartment, clattering down the stairs in his sandals without the money she still clutched in her hand. “Dov,” she said, but her son turned and left the apartment without a word. The door closed so gently behind him that she held her breath to hear it, and the heat that filled the apartment in the silence that followed told her everything.

The week Fanya returned to Tel Aviv they moved back into their bedroom, but Nachum’s graphs and magazines stayed in the sealed room, and some nights Nachum fell asleep over his work. When Tami woke him and he had stumbled back to their bedroom then sometimes she sat on her son’s bed for a while before returning to their bedroom. If she fell asleep on Dov’s bed she was woken by the sound of Nachum mixing his mango juice in the doorway of the kitchen in the morning.

Still they reached for each other at night, less often than during the war but still with that same detached intensity, as if they were two young people who had not yet realized that time was not something that could be snatched and prevented from passing. She wondered if Nachum saw someone on the overnight trips he sometimes took to Tel Aviv for business, but she did not ask, and she knew after all that he did not; he would never be as weak as she, to try something like that. It was only she who had somehow fallen into a crack in this great collective society; only she who had somehow, for all her reaching, never grasped what everyone else seemed to hold so easily.

Hamsin again, and the dripping laundry that Tami strung from the porch before waking Ariela was stiff and gritty with dust by the time the girl left for school. Tami filled the tub with cool water and stripped off t-shirt and underwear to sit in it before leaving the apartment for the office. She left a note on the refrigerator door for Ariela with instructions not to go out to play until she had had three full glasses of water, no cheating. Writing the note gave her satisfaction; at least Ariela still listened.

Nachum was tight-lipped when he dropped the evening paper on the kitchen table. He sat on one of the green vinyl chairs and, resting his elbows on the table, pushed his face into his hands as if he were trying to seal his eyes shut by force. “Did you hear?” he asked.

“Hear what?”

“Three soldiers died in a training accident in the Negev. Dehydrated.”

Dov was in the desert for more training this week; Tami had been trying not to think about him in this heat, going along with whatever craziness his commander ordered as if the lives of his unit depended on it.

“Didn’t the officers know to—”

“One of them was Rafi,” Nachum interrupted her.

Nachum did not answer or remove his hands from his face.

She snatched the newspaper from the tabletop. On the front page were the faces of three boys. She recognized the photograph of Rafi from Dov’s high school yearbook. Rafi was grinning from the depthless paper.

“Oh,” Tami said softly. She lowered herself into a chair next to Nachum.

“Does Dov know?”

“Who knows? Who knows where he is? It must be on the radio by now.”

They sat without moving and without touching until the kitchen was dark.

They came unsummoned to the apartment that night, dozens of Dov’s classmates in uniform who had been allowed to leave their bases to come to Jerusalem. Guns cluttered the sealed room, covered the bed and spilled onto the floor. They left their weapons in Dov’s room and locked the door behind them, and the girls held Ariela on their laps in the living room so that she wouldn’t go near the guns. They sat in the living room in silence, the hamsin hanging in the air between them, and they held onto each other as if to gather strength before going together to the apartment on Radak Street, to Rafi’s parents and sister. No one spoke. Tami put out a pitcher of water and cups and her son’s friends thanked her in soft voices, those same friends who for years had breezed past her on the telephone as if she were a road sign on the way to Dov. She moved through the room, touching one girl’s hair, brushing a hand over a boy’s dusty uniformed shoulder, wanting to touch them all, as if her touch could heal, or at least hold them in place so that they would not disappear, ever. No one moved.

It was after one o’clock in the morning when Dov arrived. When he pushed open the apartment door they stared at him, as if now that he had come there would be an answer. Pulling the key from the door, he turned in the hallway and instead of entering the living room where they waited for him he walked to his room, took the single key from its hook on the wall and opened the door. When he saw the guns piled on his bed something in him seemed to sag; he rested his own gun against the wall inside the room and, stepping out, closed the door softly behind him and locked it. When he walked back into the living room one of the girls, the one Tami now recognized from the open yearbook on Dov’s floor, walked over to him and, tears running down her cheeks, hugged him hard. As if automatically, Dov’s arms went around her waist, but Tami could see that he was not reacting to her, only staring at the far wall past the girl’s back.

The telephone rang.

Shalom Tami, I heard.” It was Fanya. “Is Dov with you?”

“Yes he is.” Tami felt suddenly feverish at the sound of her mother’s voice. Her mouth was dry and she held onto the wall for support. “His commander drove him down. He has three days leave.”

“I don’t believe it, I don’t believe they could allow something so stupid to happen. A bullet I understand, but the sun? They should have known what can happen out there, they should never have had them train during a hamsin as bad as this one. Even if they force them to drink it’s still not enough in heat like this.

“You’re right.”

“I hear there’s going to be a military investigation to get to the bottom of this. Three boys, dead like that, just like that, it’s not a thing to be believed. But they’ll investigate, they’ll get to why and how and when and what happened. Does Dov know yet that there’s going to be an investigation?”

“Does he know yet?”

Tami’s head felt so heavy she could barely hold it up. “I don’t think this is the time,” she said.

“Let me talk to him,” Fanya said.

Tami opened her mouth to protest but a strange bitterness stilled her. Who was she to judge, who was she to protect her son?

Tami watched Dov hold the receiver to his ear. “Yes, I know,” he answered Fanya once, and, once, quietly, “Just a few minutes ago.” There was a long silence, at the end of which Dov opened his mouth as if to say something, but instead only nodded and hung up the receiver. He walked out of the kitchen without looking at Tami.

From the balcony Tami watched them walking away down the street, a huddle of arms and heads pressed together and only her son walking to one side, walking straight ahead and ignoring anyone who approached him. Nachum had gone to put Ariela to bed. “But why did they let Rafi go out in hamsin without drinking enough?” Tami heard Ariela ask for the third time that night, but she did not hear Nachum’s answer. The sealed room was strangely empty, its door swinging ajar. Dov had remembered to lock his gun in the cabinet in the living room, and there was nothing on the floor of the room but some of Nachum’s papers and the yearbook still open under the bed. Tami moved Nachum’s papers into the living room. She closed the yearbook and put it on the shelf over Dov’s desk.

It was close to 4:00 in the morning when Dov returned from Radak Street. Nachum was asleep; Tami listened to Dov run water in the bathroom, and heard him click off the light switch. She waited. There was no sound from Dov’s room. After a while she got up and, passing his locked door, walked into the kitchen. She sat in one of the chairs, picking at the seat’s chipping green vinyl with a fingernail.

The following day and the day after, Dov sat in his room and refused to eat or answer the telephone. Nachum tried to talk to him but Dov only turned his back, and when he came out of the boy’s room there was such a look of bewildered hurt in Nachum’s eyes that Tami felt sorry for him and vindicated at the same time. Once Nachum came to Dov’s door with a soccer ball. “Come on outside,” he said. “We’ll play, just you and me. As slow as you want.”

The glance that Dov passed over Nachum was condemning in its indifference. “No, Abba,” he said. And when Dov saw Tami peering into the room from the hallway after Nachum had gone, he rose, glaring, and shut the door. Tami followed Nachum out onto the porch. She watched him brace himself against the railing with both hands and look down through the glare of sun and dust onto the street. For the first time since she had known him he seemed to her so lonely, and she was ashamed of the suddenly overwhelming tenderness she felt. Hesitating a moment, she reached out and rubbed his shoulders. He patted her hand absently before moving back into the apartment.

The third night was relentless; the forecaster said the heat had spent itself, but the hamsin did not break. Nachum had taken Ariela out for ice cream and a movie. He had said Ariela needed extra attention and Tami had agreed without a word.

She sat on the porch in the sagging plastic chair. She had showered again, turning her face up into the cool trickling water. Already sweat prickled at the back of her neck through her wet hair. She watched the moths circle the light-bulb that dangled above her from the stone overhang. Framed in a window across the alley, a woman, seated in a chair, combed the hair of the girl who sat between her knees on the floor. In the blackness of the Valley of the Cross a light burned in an upper room of the monastery, and a few pieces of the monks’ clothing caught the light, white underclothes and long dark shadows huddled together on a line. They bobbed slightly, noiselessly; the rest of the clothesline trailed off into darkness. On the hill the yellow-white lights of the Knesset building lit a small area of surrounding garden, and a single car honked from outside the gates to the circular drive.

From inside the apartment there was a muffled sound that was repeated twice and then, after a pause, again. Rising slowly, Tami wrapped her robe more tightly around her. She pushed aside the curtain and stepped inside.

In the sealed room Dov stood with his head down nearly to his chest. His hair was matted and his uniform hung on his body. Blood laced over the knuckles of his right fist in spidery-thin lines and dripped onto the floor.

“Oh god.” Tami stepped forward to touch his hand. He snatched it away.

In the wall over the desk beneath the taped and unshuttered window there was a ragged hole, bits of plaster chipping from its edges. Looking, Tami expected somehow to find the air of a cool night pouring into the room at last, bringing with it stars, the smell of eucalyptus. But Dov’s fist had only knocked away the plaster, only cracked the sheetrock and exposed the stone behind.

“Leave me alone,” Dov said, and when Tami did not speak or move he looked up at her, his eyes filled with hate. “Leave me alone,” he shouted.

She stood barefoot, staring at the spots of blood on the cool tile floor, and a sudden rage blew through her. What right had he to look at her that way. As if she had chosen that the world be the way it was, as if she had ordered the wars and the terrorism, the dust wind and the desert with its patches of black sand that heated up to 60 degrees and killed boys without warning. The rage that gripped her now, making her hands tremble and her jaw ache, was a comfortable rage; it was a collective, inevitable, irrefutable rage, so complete it absolved her of whatever she alone had done. What right had he. As if she had chosen this path for them, as if she had chosen that they live clinging to each other’s bodies and the soil and the here and now, lest someone catch them without their roots deep in each other and all would be lost, with no second chances.

Looking at the boy before her, she saw that his hand was scarred and ugly and the sight tightened her throat until it burned.

“What’s wrong with you?” she shouted into the quiet apartment. “What’s wrong with you?” She stared at him. “Did you think you’d punch through? Did you think you could? Did you?”

She stood still, her bare feet trembling from the stone tiles. He was sobbing quietly with his head bent to his chest. His hands hung unclenched at his sides.

It was the simplest of steps that carried her forward, as easy and unwilled as a heartbeat, and she held him; held his lean battered body and she felt herself becoming something huge and primal and ancient.

He cried into her shoulder, he held her tightly, he did not let her go.

Rachel Kadish lived in Jerusalem, where she worked for the Israel Women’s Network. She has received grants from the Whiting Foundation and the Rona Jaffe Foundation, and is currently a literary editor for the Public Media Foundation’s The Radio Play. This excerpt is from her novel, From a Sealed Room.

Poets of the Levant by Lee Smith
Eyal Weizman’s The Least of All Possible Evils by Legacy Russell
Weizman 1

It was Eyal Weizman’s collaboration with fellow architects and geopolitical theorists Sandi Hilal and Alessandro Petti that first caught my attention years ago and incited my enduring admiration.

Operators of Art and War: Salar Abdoh Interviewed by Michael Archer
Out Of Mesopotamia3

On writing about the Middle East from the inside.

Two Sunsets by Adam Golfer
Golfer Two Sunsets 002

A film investigating memory and history, premiering exclusively on BOMB, with a brief interview by Alex Zafiris.

Originally published in

BOMB 55, Spring 1996

Featuring interviews with Frances McDormand, A.M. Homes, Padgett Powell, Tina Girouard, William Pope. L, Butch Morris, Malcolm Morley, Jafar Panahi, and John Elderfield.

Read the issue
Issue 55 055  Spring 1996


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Black cat analysis essay

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Since the black cat, associated with evil, bit the narrator, he now has evil inside of him. After this attack, the narrator first shows signs of mental illness. After the attack, the narrator took out his pocketknife and stabbed the cat in the eye, an irrational decision showing the increasing severity of his illness. The Black Cat: Deranged Narrator Throughout the opening paragraph of "The Black Cat," the reader is introduced to a narrator who, because of his grotesque actions, has become mentally deranged and very untrustworthy, ".
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The Black Cat Essay

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The Black Cat Analysis - Words | Internet Public Library

As described by many critics and literary writers, Edgar Allan Poe is, without a doubt, one of the most influential writers, critics, poets and editors in America history and well-known in the world of literature. After he lost both of his parents at a very young age, he and his sister were raised by John Allan in Virginia. When he was 6, he went to school in England for five years and learned Latin and French as well as math and history there. In he went to the University of Virginia but because of his bad addictions like alcohol and gambling he became in debt and had to quit school. In , he moved to Boston and enlisted to Army. His first collection of poems, Tamerlane, and Other Poems, was published that year.
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Overwhelming Obsession in "The Tell-tale Heart" and "The Black Cat"

A brief summary of this short story; the narrator of this story is an insane man who knows he's about to die. The story talks about a cat that he used to have, named Pluto. He was very close to the cat until he starts to abuse his wife and other animals.
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Overwhelming obsession and guilt often lead to deadly consequences. The narrators differ in their dispositions but fall victim to the same circumstances. Even though the murders are very different—one premeditated, one spurred on by a temporary rage—both narrators are haunted by their dark deeds.
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Essay Jazz Latin

Despite its inauspicious debut, the tune has become one of the most frequently recorded modern jazz standards, played in an impressive variety of settings ranging from piano trios, to Latin jazz combos, to ska-jazz ensembles, to a full orchestra featuring players from the US Air Force.For some musicians, “Nardis” becomes an object of fascination—an earworm that can be expelled only by playing it.

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For months, while his bandmates got thunderous ovations after solos, Evans got the silent treatment, which reinforced his self-doubt.

In his eagerness to be regarded as an equal, he accepted a first fix of heroin from Philly Joe, whom Evans respected more than any drummer on earth.

vans once told a friend that a musician should be able to maintain focus on a single tone in his mind for at least five minutes—and in playing like this, he achieved a nearly mystical immersion in the music: a state of pure, undistracted concentration.

Even before writers like Jack Kerouac and Gary Snyder made Buddhism a subject of popular fascination in America, Evans saw parallels between meditative practice and the keen, alert state that jazz improvisation demands, when years of work on perfecting tone and technique suddenly drop away and a direct channel opens up between the musician’s brain and his or her fingers.

He listened to other pianists closely, but rather than imitate a player like Bud Powell, he would try to extract the essence of Powell’s approach and apply it to different types of material.

“It’s more the mind ‘that thinks jazz’ than the instrument ‘that plays jazz’ which interests me,” Evans told an interviewer.By maintaining a singularly intense focus on “Nardis” over the course of his career, Evans managed to turn the melody that had frustrated “Blue” Mitchell that night in 1958 into a vehicle for dependably accessing “the mind that thinks jazz,” like a homegrown form of meditation that could be performed on a piano bench before rapt audiences in clubs night after night.By bringing the story of Evans’s quest for a kind of jazz samadhi to light, I hope to understand the enduring hold that “Nardis” has on the ever-widening circle of musicians who play it, while reckoning with my own personal fixation.He had been recommended for the job by George Russell, an avant-garde composer whose book of music theory, The Lydian Chromatic Concept of Tonal Organization, was a decisive influence on Miles’s modal conceptions of jazz in the late 1950s. After being invited to sit in with Miles’s sextet at a bar called the Colony Club in Bedford-Stuyvesant, Brooklyn, Evans got the gig, though he was in for several more rounds of hazing before being allowed to play alongside Cannonball Adderley, John Coltrane, Paul Chambers, Philly Joe Jones, and Miles himself, all at the peak of their powers. Miles would counter Evans’s musical suggestions by saying, “Man, cool it.When Russell first mentioned Evans’s name, Miles asked, “Is he white? At one point, Miles, in his inimitably raspy voice, told the wan young pianist that to prove his devotion to the music, he would have to “fuck” his bandmates, “because we all brothers and shit.” Evans wandered off for fifteen minutes to entertain the possibility, before telling Miles that while he wanted to make everyone happy, he just couldn’t do it. We don’t want no white opinions.” At the same time, the trumpeter became the young pianist’s staunchest advocate, saying that he “played the piano the way it should be played,” and comparing his supremely expressive touch on the keys to “sparkling water cascading down from some clear waterfall.” He would sometimes call Evans and ask him to just set the handset down and leave the line open while Evans played piano at home.Though superb versions of “Nardis” have been recorded by everyone from tenor sax titan Joe Henderson to bluegrass guitar virtuoso Tony Rice, no one embodied its melodic potential more than Bill Evans.For him, Miles’s serpentine melody was a terrain he never tired of exploring.He also began dating a chic young black woman, Peri Cousins, for whom he wrote one of his sprightly early originals, “Peri’s Scope.” Cousins observed how quickly the drug filled a crucial role in Evans’s existence, providing a buffer between his acute sensitivity and the realities of life on the road.“When he came down, when he kicked it, which he did on numerous occasions, the world was—I don’t know how to say it—too beautiful,” she said. It’s almost as if he had to blur the world for himself by being strung out.” On Kind of Blue, widely regarded as the greatest jazz recording ever made, Evans became a conduit of that unbearable beauty, mapping a middle path between Russell’s Lydian concepts, Miles’s unerring sense of swing, and the luminous romanticism of Ravel and Debussy.For more than twenty years, Evans played it nearly every night with his trios, often as the show-stopping climax of the second set.Indeed, he became so closely associated with the tune that some of his fans dispute that Miles actually wrote it, insisting that Evans deserves the credit.

Comments Essay Jazz Latin

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