The summer months in the chars of western Assam, India where my ethnographic fieldwork was based, are only of respite because of the calm breeze by the river, and conversations over jaggery tea. Because of my positionality, it was easier for me to strike up conversations with the Bengali Muslim women in the chars than men, particularly surrounding sexual health.  I was interested in bringing up conversations of sexual health because chars are known as spaces where the fertility rate among the people is high. The high fertility rate is for a variety of reasons such as low literacy level, early marriage of girls, and high dependence on agriculture requiring more labor.

But for those who are lost about what a char is, chars are river-islands that are unstable and undergo constant formation and destruction and are mostly inhabited by Bengali Muslims of East Bengal descent, who have historically faced stereotyping, violence and harassment in the hands of the majoritarian upper-caste Assamese Hindu society and State alike. They also constantly face suspicion of being ‘illegal immigrants’ and ‘anti-immigrant’ hatred. Most chars in Western Assam, being geographically closer to Bangladesh, allow the Islamophobic and xenophobic caste-Hindu Assamese society and State to propagate such fears fiercely. The high fertility rate of Bengali Muslims has furthered the ‘anti-immigrant’ sentiment and even fears of the Assamese Hindu turning a minority. My conversations surrounding sexual health with mostly women in char areas is embedded in this history and context. However, through my conversations I stumbled upon a rather interesting practice among Bengali Muslim char women.

When I tried asking them about use or knowledge of contraceptives, they were confused by the use of my terminologies. One of the local women who often accompanied me to translate certain things then turned to them and repeated, “Baideo is asking about your use and knowledge of ‘Mala-Bori (pill)’.” The minute she uttered ‘Mala-Bori’ all started nodding their heads and showed evident signs of blush and giggly laughter. Mala-D is a type of oral contraceptive and in my two-year long ethnographic fieldwork, it became evident that Bengali Muslim char women were using these oral contraceptives widely. Interestingly, the use of condoms by their partners is extremely low. Women were candid enough to admit that most men simply refuse to use one, and women, including health workers themselves, find it difficult to even urge men to use condoms. Additionally, it became clear that though usage of oral pills were high, the knowledge surrounding their side-effects were next to none. For women, the pills were handy, saved them from menstrual pain – allowing them to work longer in the house and fields and most importantly, they do not have to face the heat of asking men to wear condoms.

Image 1: Char-land monthly health camps are majorly attended by women and children. Courtesy: Author.

But what is interesting is how the State is enabling this practice where the responsibility of control of Muslim population in the chars rests on Muslim women’s shoulders. Working with local health workers, it became evident that the distribution of condoms is lesser than oral pills citing reasons of low demand. In fact, the health awareness camps that are conducted in the char areas are mostly attended by women. The local health workers called Accredited Social Health Activists (ASHA) are local char women who themselves are hesitant in approaching men with taboo issues like male contraception.

In 2021, the right-wing Hindu state in Assam introduced a “population army” comprising of one thousand local youth in char-chapori areas with the intention to control fertility rate in char areas and improve living conditions thereafter. What is problematic in this initiative is that birth-control measures are specifically targeted with women in mind. Chief Minister Himanta Biswa Sarma in his speech to the State’s Legislative Assembly on July 19 talks about inducting ten thousand additional ASHA workers to provide contraceptives and birth-control measures specifically to women in char-chaporis. The State’s initiatives can be seen in the light of controlling Muslim population by controlling Muslim women’s bodies.

I would also encourage one to think of this initiative of the Assam Government as a nexus of corporatization of the medical sector and the patriarchal state. For in 2019, the Modi Government decided to tweak the law and exempt oral contraceptive pills as Schedule H drugs meaning they could be sold without a doctor’s prescription. HLL Lifecare Limited the firm tasked with selling the contraceptives including Mala-D on behalf of the government had in a letter to Central Drugs Standard Control Organisation (CDSCO) mentioned how their sale was greatly affected due to it. Though not vouching against freedom of choice for women and their bodies, I want to ask, for char women, is the easy availability of oral contraceptives really freedom of choice and greater control over their bodies? When women living in char areas are not even given the choice and access to all kinds of contraceptive methods and knowledge surrounding birth-control, there is no real choice or any control of their bodies. Hence, one needs to ask are marginalized, unaware women’s bodies becoming sites of profiteering for this State?

Image 2: Mobile health clinics on boats cater to mostly maternal health and women’s reproductive health in the chars. Keeping of detailed registers tracking women’s reproductive health is a must. Courtesy: Author.

In reality, char areas with their low education level have always been under the strict grip of religious men who are not only widely followed but extremely feared. Local Muslim religious leaders citing religion vehemently argue against the use of any contraceptive methods. The birth of life should be celebrated at any cost, according to them. But the greater availability and use of oral pills over condoms is beyond religion. It is in fact deeply patriarchal. It stems from a sense of sex as an act of display of masculine power and celebration of masculinity. It can be drawn from the narrative where sex is seen as an act where the woman is passive and at the service of providing pleasure to the man. Condoms are seen as road-blocks to that pleasure and the very act of a woman asking a man to wear a condom is seen as questioning his masculine power and masculinity. Hence, when the state forwards an initiative of population control by providing more birth-control measures to the woman, it is actively contributing to that deep-seated patriarchal narrative. Hence, though the state through this initiative can be seen by many short-sighted people as ‘anti-Muslim’, but in reality, this state is ‘pro-patriarchy’ and misogynistic.

Women’s wombs have always remained sites of contention and control by patriarchal states from the Vichy regime in France to anti-abortion laws in Ireland. In the char areas of Assam, when the woman is being provided with more oral contraception pills, the State is instead taking away voices and choices over rights of poor Muslim women’s bodies. In the attempt of the Hindu right-wing state’s motive of lowering of Muslim population, particularly in the chars, who are always seen as ‘illegal’, ‘criminal’ and ‘threatening’, Muslim women have been made into passive objects, which will only tighten the patriarchal grip on them.

I remember in one of the many conversations that I had with char women in health camps, I would ask them why there were more women than men in the camps. One of the replies shocked me – “Women’s bodies are more diseased than men, I guess. We are weaker than men.” The State infrastructure that has kept women’s bodies at the center of sexual health is changing Muslim women’s subjectivities, their sense of self. And in the conflict of changing numbers and dominance of majoritarianism, that is a realization that hurt me the most.

Bhargabi Das: I like to call myself a raging potato, a part-time anthropologist and a poet. Currently a PhD Candidate of Anthropology at National University of Ireland, Maynooth, my doctoral research is based on the riverine ecologies called chars in Assam, India. This ethnographic study looks at char-dwellers’ experiences with the state. I am largely interested in the politics and poetics of water, citizenship, state, bureaucracy, infrastructure and nationalism. My doctoral research is funded by the Irish Research Council, Government of Ireland and Irish Higher Education Authority (HEA).

Editors Note: This is the second in a series of three posts by Bhargabi Das. 

Bhargabi Das

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A Crisis Of (Feminist) Faith Through An Encounter In A Clinical Setting

by Sreeparna Chattopadhyay

Introduction

In the last ten years since I graduated with my doctoral degree, I have conducted research in both clinical and conventional anthropological settings. My doctoral work examined domestic violence in Mumbai, India. My work since then has focused on health and sexual violence, with considerable periods of observation in hospital settings. My experiences tell me that while both types of project have the potential to inflict trauma on the anthropologist, their nature is different. In clinical settings, non-clinicians when witnessing clinical ‘acts’, loosely defined as surgeries and other invasive procedures, may be shocked and even traumatized by these, never having had exposure to such interventions. However, not all clinical acts are equally traumatic. Here, I offer examples of a third-trimester abortion contrasting it with a cesarean section of live twins, both of which I witnessed, to argue that whether procedures are viewed as being traumatic are contingent on the meanings that those acts embody, for us as anthropologists and for the individual undergoing these procedures.

Not all surgical incisions are the same

One winter morning in 2015, in a remote part of northeastern India, close to the border with Bangladesh, my research assistant and I were hanging out in a government hospital. I had just begun a study, the second stint of fieldwork after my Ph.D. on maternal health in the region. We had entered the pre-labor room which was comprised of ten beds, only two of which were occupied that day. We were speaking to one of the women, who was being transfused prior to her induction, about how she managed anemia in a region where 90% of women become pregnant with moderate levels of anemia.

Within what seemed like seconds, but must have been longer, there was a flurry of activities and the doctor was instructing all visitors to clear out the room. A curtain was quickly drawn around the bed of the second woman, whose name we later discovered was Anita [1]. She was accompanied by her mother, her fifteen-month-old daughter and a health worker. As we were wondering if we should leave too, the smell of blood hit my nose. A minute later, I saw the doctor walk across the room holding a bloody sac that left bright red spots on the cement floor. Soon after, Anita was wheeled into the Operation Theatre.

In the afternoon when we returned to the recovery room, Anita laid on the bed clutching her knees to her chest, her green skirt bloodied, face twisted with pain. I asked her mother whether she had a boy or a girl. I was wrong – it was a medical termination of pregnancy (MTP) at 7 months. My shock soon gave way to sadness and anger. A medical termination of pregnancy at 7 months is illegal in India. Besides, we now have the technology that ensures that a fetus is viable outside the womb at 7 months.

I discovered that Anita was an indigenous woman who lived forty kilometers from this facility. She had not known that she was pregnant until she was in her fifth month, because she was still breastfeeding her older daughter. It took her another two months to gather the resources to make this trip using three different modes of transport. She did not have enough money to bring up two children and had decided to end this pregnancy. The doctor and the health worker had counselled her on the possible harms, but she insisted on the MTP. She returned home that same evening with antibiotics and analgesics.

About four years later, in the early summer of 2019, in Karnataka in Southern India, I had front row seats to a pair of twins being delivered through an emergency Cesarean section. In a busy state facility, a very competent Ob/Gyn allowed me to accompany her into the OT as she performed the complex procedure. I saw the scalpel draw blood. She used scissors to widen the cut just above the woman’s pubic bone, standing on a stool to reach deep into the woman’s uterus as one of the twins was stuck below her rib cage with a cord tied around his neck. He was extracted first, while his sister was taken out a few minutes later, crying lustily as she tasted her first breath of air.

This was the first C-section or any operative procedure that I had seen. This was a far bloodier encounter than the MTP I had partially borne witness to. Yet the meanings that these acts embodied could not be more different. It was not the blood and gore of the clinical procedure itself that left its long shadow on me, but what it meant for me as a feminist and a woman who cannot bear her own children.

A crisis of (feminist) faith

When I remember that day in the winter of 2015, I remember pacing anxiously in my small cold room at the missionary boarding house, my home for the duration of the fieldwork. I remember having a fitful night, in fact several unsettled nights where sleep was punctuated with nightmares of children shrieking and worms splitting my skin to emerge like alien births.

As a feminist who is committed to pro-choice, but simultaneously unable to bear children and has yearned for motherhood for years, this encounter was emotionally traumatic, intellectually disruptive, and morally unsettling for me. While my immediate response was affective – grief, guilt, anger and fear – in subsequent processing of this encounter, I experienced an intellectual crisis which itself was deeply traumatic.

I knew that Anita had all the “risk” factors, for landing in this medically dangerous situation – she was poor, indigenous, lived in a remote, hilly part in a disadvantaged Indian state. Yet I oscillated between feeling that she “chose” what was right for herself and grieving the loss of a potential life. Anita went against medical advice and the advice of two family members in choosing to have a late-term abortion

I felt embittered and puzzled.  Why hadn’t she considered giving birth and then giving up the baby for adoption? I would have willingly adopted this baby and, as a recent adoptive parent, I know that the queue for legal adoption is long in India.

The feminist in me chided myself for thinking of Anita as a mere reproductive vessel. I knew intellectually that only she had autonomy over her body. Yes, the termination was medically risky, but so are many other medical procedures. Yet patients choose them, weighing the benefits and risks of such procedures. What was different here? Perhaps when it comes to late-term abortions, I was flexible with my feminist ethics? Perhaps my inability to bear children was clouding the intellectual apparatus required for feminist praxis? Worst of all, perhaps I was not a feminist at all?

The Return of the Prodigal Feminist

These doubts continued to plague me for a while. A year later, I chose to write a case study on ethics about Anita and the attendant ethical, moral and intellectual conundrums it presented. I also discussed my experience and responses with my friends, family and colleagues. As I unburdened myself through speech and text, the shame chipped away, and the edges of my guilt felt a little less jagged. The existential angst I had experienced, unsure of my identity as a feminist, had settled a bit by then.

With time, I choose to see things differently. My feminist self and the mother in me didn’t have to be like Sophie’s Choice – I could be both, and still grieve this death. Strathern famously said that anthropology and feminism make for strange bedfellows, an “awkward relationship.” But feminism gifted me a lens and a language which was not burdened by ideas of cultural relativism or individual versus collective rights.

Porter, in moving away from a rights-based discourse on abortion in a very divisive Ireland, draws out similarities between pro-life and pro-choice activists and argues that both sides “…advocate responsible sex, good parenting, and caring communities.” Thus, abortion moves away from being a strictly medical procedure or a rights-based claims to a social and moral issue, where nurturance is the bedrock on which women take these decisions, and never lightly.

Although, for Anita, this abortion was not a choice in a real sense.  She had it to give her young daughter a better life. In a country where female fetuses are routinely aborted due to a cultural preference for sons, perhaps Anita should, in fact, be be lauded for her actions?

The affective dissonance that this incident elicited in me, though unsettling, was ultimately productive. Hemmings (2012: 151) writes, “Challenging the status of the expert, considering the shared epistemic claims from below, thinking outside one’s own initial investment in the desire for clearer and more accountable knowledge; these are all the features of an affectively attentive epistemology that allows for the transformation of all participants in the research field as well as knowledge itself.” I may never do what Anita did or had to, but Hemmings argues that empathy is not a prerequisite for building affective solidarity since it requires a departure from an identity-based politics. Ethical concerns demand that we do not judge choices based on similarities between us and the doer.

I don’t know how Anita will process her experience later. For me, while nothing is settled, this experience forced a reckoning of my feminist self. The questions continue.

Like a circle in a spiral

Like a wheel within a wheel

Never ending or beginning on an ever spinning reel

As the images unwind, like the circles that you find

In the windmills of your mind!

Windmills of your mind.

Songwriters: Marilyn Bergman, Michel Legrand, Alan Bergman

For Further Reading

1. Nordstrom, Carolyn, and Antonius CGM Robben .1995. Fieldwork under Fire: Contemporary Studies of Violence and Survival. Univ of California Press.
2. Leibing, Annette, and Athena McLean. 2007. “Learn to Value Your Shadow!” An Introduction to the Margins of Fieldwork. The Shadow Side of Fieldwork: Exploring the Blurred Borders between Ethnography and Life: 1–28.
3. Hemmings, Clare. “Affective solidarity: Feminist reflexivity and political transformation.” Feminist Theory13, no. 2 (2012): 147-161.
4. Porter, Elisabeth. “Culture, community and responsibilities: abortion in Ireland.” Sociology30, no. 2 (1996): 279-298.
5. Strathern, Marilyn. “An awkward relationship: The case of feminism and anthropology.” Signs: Journal of Women in Culture and Society12, no. 2 (1987): 276-292.

[1] All names have been changed to protect identities and the precise location of the hospital has not been shared since what we witnessed was not only dangerous but also an illegal act.

Trauma and Resilience

This is a blog series curated by Beatriz Reyes-Foster and Rebecca Lester in collaboration with the Anthropology of Mental Health Interest Group.

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“Homework”: The highs and lows of anthropology at home

by Chelsey Carter

John and Janice’s Devotion

In fall of 2018, I went to visit John and Janice (1) at their home in East St. Louis. When I walked in, I was immediately greeted by Janice, a tall, Black, stately, and curvy woman with big warm brown eyes. I had no idea that this first ethnographic encounter would not only change the entire trajectory of my 16 months of homework (2) (i.e. “fieldwork” aka “research” aka data collection), but also change my life.

I first met John and Janice at an ALS clinic for veterans while conducting my dissertation research. I will never forget Janice’s first words to me about her husband’s condition: “We know it doesn’t get any better, but we just want him to live the best life he can… while he’s here.”

ALS is a devastating disease that affects different patients in very different ways. It’s a constant assault of unknowns as the disease progresses towards permanent disability, paralysis, and death, usually within 2 to 5 years. For some patients the early symptoms are a foot drop or a loss of speech, but for John it was the loss of his ability to use his legs.  As his body continues to decline, he won’t be able to say a word or move his body to communicate all that’s going on in his head. When I arrived at his home, the physical decline of his disease had advanced since I had last seen him at clinic.

Janice left John and me alone and I leaned over, and asked John quietly, “What’s been the hardest thing for you?” He explained that he was falling more frequently and proceeded to show me pictures of his black eye and busted lip after he attempted to climb the stairs prior to getting his power wheelchair.

“I’m gonna tell you the truth… I had a feeling something was gonna happen to me… And I said, I don’t want Janice to have to depend on nobody.”

He told me that once he found out there was no cure for ALS, he didn’t want Janice running from place to place after he passed. Without Janice knowing, he had researched properties and found their current home for well over his budget. After months of prayer and conversation he was able to talk the owner down to a price that he could afford. He told me the house is now half paid for and that he hopes to have it paid off before he dies. With tears running down his face he said “Chelsey, she’ll always have some place to stay… I know that Janice can live here.” I was moved. This house was a way for John to show his empathy, care, and unconditional love for Janice, even when he was facing an impossible future.

Mom’s Hospitalization

A few days after I spoke to John, I got a phone call from my mom that she wasn’t feeling well. She described feeling lightheaded, cold, and shaky. By the end of the day she called me from a local hospital where she had been admitted. She was septic and had a bacterial infection, cellulitis.

My mom was in the hospital for a week and I vividly remember one day when she was in so much pain. The doctors had already given her Naproxen and Morphine, but nothing relieved the pain.

I stepped out to call my partner Aiden and begged them to come to the hospital but all I received was coldness, distance, and blame for how much I was asking for. They wouldn’t come. I hung up. I had no idea this coldness was the beginning of Aiden’s infidelity just when I needed them most.

When I came back to my mother’s room, I found her on the verge of tears as a flustered White nurse attempted to draw blood for the 9th time. Her entire body was bruised from multiple failed attempts over the hospital stay. Because she was morbidly obese coupled with the fact that she has rolling veins, finding a good vein every 3 hours to monitor her for sepsis was a monumental endeavor.

At this point my mom had asked for the head floor nurse or IV specialist but the White nurse ignored these requests. This was just one of many times my mother or I had made a request that went unheard by the hospital staff over the four days we had been there at this point.

Words weren’t working but action was necessary… my mother was suffering more than she should. I explained to the nurse that I was a phlebotomist and asked to draw my mother’s blood. She asked where I had gone to school, and I explained I had a degree in public health and was a PhD Candidate studying people with ALS.  She stared blankly and said I couldn’t and that I had to wait for the IV specialist. “When did you call them?”  I asked. She rudely replied, “Before you got here.” “Ma’am I work with people with ALS. I draw blood on people with atrophied muscles, paralysis and who sometimes weigh less 100lbs. I go to a top 10 university and went to John Burroughs, I can draw my mom’s blood… since you can’t.” “You went to Burroughs?” she inquired with surprise.  I never responded. Her surprise at my attendance to the number one high school in St. Louis suddenly granted me legitimacy into this space and the authority to complete the draw. I quickly grabbed the blood draw supplies, tied two tourniquets to the top and middle of my mom’s forearm, felt for a vein, and one stick later filled the 4 vials required for the blood test.

White Supremacy in Action

This entire encounter at the hospital with my mom reminded me of an experience with a White participant a few months back. He was enrolling in a genetics study that the ALS lab was recruiting patients for. I walked in the room and was mesmerized by the patient’s sleeve of colorful tattoos. Aiden had recently gotten a similar sleeve and I was in a habit of fawning over the color and details of each tattoo.

The room was cold, and he and his wife were tense. So, as I felt the gentlemen’s veins, I complemented his tattoos trying to engage him in a lighthearted conversation before drawing 13 tubes of blood. The room instantly got even colder. I looked up and he said to me “I’m not proud of all them. Some were some mistakes I made when I was younger.” As he finished his sentence, I found a bouncy vein in the middle of his right arm. I stepped back to grab the alcohol wipe and then realized the reason for their coldness. The vein I was about to puncture was right at the center of a swastika. I hesitated and silently continued drawing his blood, never saying another word. I felt like I was in the episode of “Greys Anatomy” with Dr. Miranda Bailey operating on the racist with the swastika.

The Painful Nature of Homework

As a queer Black feminist anthropologist studying my home, I find my personal experiences intertwined with my ethnographic fieldwork in ways that cannot be untangled. John’s love for Janice showed me the unconditional realities of love. John, a husband, father, deacon, and veteran, has every reason to be entitled, to be selfish, to be cared for as he enters the last years of his life. Yet, his gaze wasn’t inward but on Janice. Once I saw this unconditional love, and realized I had nothing to prove to be loved, I knew I had to end my relationship with my abusive partner.

In the last year, I’ve lost myself and found myself and realized that suffering, pain, and heartache have the ability to generate a reawakening both in my personal life and as a native ethnographer. The story that I thought was a love story for John and Janice, also turned out to be a much-needed lesson for me to learn my own self-worth and self-love both in my relationships but also in my relationship to this discipline and how I deploy and engage with my homework.

As we work to decolonize our sensibilities around the discipline and fieldwork, and as funding structures, political climates, and institutional shifts occur, making “traditional” international (read: colonial) fieldwork less accessible, more anthropologists are turning their lenses inward toward fieldwork at “home.” Although I am an advocate for the validity and legitimacy  of anthropological inquiry done by “native” anthropologists in the tradition of Zora Neale Hurston and other Black feminist anthropologists; it is also important to recognize that the labors of this homework in the United States can be filled with trauma and pain. Anthropologist Kwame Otu said during a keynote presentation a year ago “I find home to be an inherently violent place.” Often, I experience the very racist encounters, stereotypes, and microaggressions that I study while getting to know people with a fatal diagnosis and living in St. Louis. And the objective and subjective lenses of trauma are both critical here.

Subjectivity as a methodological approach potentially provides an opportunity for greater accuracy in the ways we make meaning of culture. My positionality and life history as a “native” or ethnic ethnographer–within and outside of St. Louis, within and outside of the hospitals where I work, within and outside the role of caregiver for an ill person–creates shifting “double-visions” that inform my ability to approach the project from a number of different lenses and conceptions that are fruitful but also violent and traumatic. I believe the  strategies below support resiliency for marginalized scholars conducting homework “at home.”

Strategies for Resiliency

1. Affirm yourself daily. Remind yourself of your potential and strength. I got this tattoo recently.

1. I recognize the privileges that exist on whether or not you can or cannot access professional counseling. However, even with the small stipend support we receive, I strongly encourage the investment during homework and even writing it into your grant proposals.
2. Build community outside of your department. You are not alone. Find like-minded people that exist outside of your physical and virtual academic spaces. There are brilliant people that do not exist solely in elite academic spaces.
3. Love yourself. I don’t mean this in the cliché self-love way that is currently the buzz word for healthy self-discovery; but really love on yourself. Eat food that makes you feel good. Do activities that make you feel good. Talk to people that make you feel good. Actively practice treating yourself the way you would treat your best friend.
4. Take care of yourself first. Remember the greater purpose. The discipline needs y(our) work. Your interlocutors need to be heard. But, it’s never worth your health and well-being. A friend and colleague once told me “The work can wait, your health and well-being can’t.”

Àṣẹ.

Notes:

1. All names used in this post are pseudonyms.
2. In addition to Kamala Visweswaran’s book Fictions of Feminist Ethnography, Brackette F. William’s article “The Public I/Eye: Conducting Fieldwork to Do Homework on Homelessness and Begging in Two U.S. Cities” is useful for thinking through the concept of homework and fieldwork.

Trauma and Resilience

This is a blog series curated by Beatriz Reyes-Foster and Rebecca Lester in collaboration with the Anthropology of Mental Health Interest Group.

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Fistula Politics. Birthing Injuries and the Quest for Continence in Niger  by Alison Heller  is an ethnographic account of the experiences of women left incontinent by injuries they sustained through giving birth  in the West African country of Niger,  and of the clinics and humanitarian organizations which make claims to save them. The book, based on extended fieldwork and life history interviews,  strives to show how ordinary women’s lives are changed by obstetric fistula while   confronting the stereotypes of abject social exclusion commonly circulated in the emotive marketing of Western development agencies.

The book’s main strength is showing  how different  women are affected by the  injuries  they sustain  through prolonged labor  which often  results in the death of the child.  Its most revealing insight, essential for those seeking to improve maternal health in low income settings, is the contribution of role strong local support networks in  determining  how far the  effects of  injuries acquired during  delivery  lead to social withdrawal  and marginalization.  Heller’s  detailed  ethnography explores how pre-existing vulnerabilities,  of which the most significant was the loss of a  woman’s own mother,  predispose some unfortunate women to extreme social isolation. Whether they had previously borne surviving children,  or were first or second wives,  were also likely to affect women’s abilities to sustain their social selves as they strive to manage their incontinence.

Shame, seclusion and reduced social interactions did, however, characterize the lives of most women affected by obstetric fistula, provoking an ongoing, frequently unsuccessful, quest for treatment.  Occasional fistula repair clinics, the majority supported by  foreign, mainly US funded, humanitarian  organizations, operate within an inadequate and overstretched health system slanted towards the priorities of  better off urban residents. Niger’s health system cannot meet the  needs  of  women living in remote rural locations whose birthing injuries are caused,  in large part,  by delays in the referral hierarchy.  Rural women’s first point of contact  with  maternity services  are understaffed health centers far from  the  sites  of obstetric capability where complex births could be more safely managed.

Selection for fistula  repair  surgery  is a lottery based on the likelihood that intervention will be successful  and the availability of  skilled medical personnel whose flying visits are financed through international philanthropy.  Those not selected wait, sometimes for years at a time, in the hope that they can access future treatment.  Because the system favors those whose fistulas appear amenable to simple surgical procedures,  women requiring more extensive operations are either left untreated or receive ineffective  treatment. Many such women, desperate to regain continence, subject themselves to repeat, often unsuccessful, operations.

This sensitive and compassionate book shows how the prevalence of fistula  in low income countries in Sub Saharan Africa today cannot be understood as an unfortunate consequence of female reproductive processes.  The high incidence of fistula in Niger is socially and politically produced through  ineffective maternity services  and the transnational philanthropic initiatives which prioritize surgical repair for a small number of women over the repair of the fractured health system.

Fifty years of neo-liberal polices and a thoughtful reflection on  the persistent colonial  rationalities  which  inform the  representation of the problem and its technical surgical fixes promoted  through philanthro-capitalist humanitarianism  are  invoked explain the current state of the health system in Niger and the orientation of  interventions directed at  helping women with fistula across  sub Saharan Africa. These  points are important. But  these institutional  factors are accentuated by, and co-produce, a culture of acceptance of poor reproductive care, high incidence of still birth and staggering rates of  maternal mortality  which is enacted through the health seeking behavior of mothers and the practices of  clinic staff.  The book’s concluding chapter rightly argues that  changing these expectations and the politics which creates them must be the starting point for more effective health interventions.

Why women’s reproductive health is so little valued within a socio-political milieu  where reproduction is paramount is left largely unexplored in a book which is at pains to distance itself from  the  explanatory tropes of cultural practice and failures of  local knowledge conventionally  invoked by Western aid agencies.  Nevertheless, the reference point of Western humanitarianism and its strategies of representation provides an entry point for wider debates about humanitarian philanthropy,  health systems and human rights.  A recommended read for scholars and practitioners in global public health, international development and medical anthropology.

Maia

Maia Green works on the anthropology of international development and issues of social transformation in East Africa. She has written on diverse topics ranging from anti-witchcraft practices to the proliferation of NGOs. Maia Green teaches at the University of Manchester.

manchester.academia.edu/MaiaGreen

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One night in early 2018, a doula-friend of mine, Josie who is white, sent me a photo of a Black woman sitting in a wheelchair. A doula is a person who provides support during pregnancy and post-partum care. The woman’s name was Michelle. Michelle was both Josie’s friend and her client. The photo was taken as she had arrived at the hospital because she was in labor. Michelle looked beautiful sitting in the wheelchair.

She was smiling.

Josie sent me the picture about five hours after it was originally taken, because she was so distraught about the way Michelle, who was on Medicaid, had been treated during her labor and delivery. What Josie described was obstetric racism, which is when a woman is belittled and medical staff use fear tactics to control and force her to comply with professionals’ mandates within the context of race. In Michelle’s case, it took the form of a forced vaginal exam and grabbing the baby as it was crowning. “Sometimes medical professionals are deliberately hurting people,” Josie said.

She was so beautiful.

Josie told me that Michelle was probably about 8 centimeters dilated when she arrived at the hospital. But upon admission, Michelle was told she was less, which justified administering Pitocin, the synthetic version of Oxytocin, a hormone that is naturally produced by the body, that induces contractions.

Because she was on Medicaid, Josie believes the labor and delivery staff told Michelle she was only allowed to have one person in the room with her; they made her choose between her mother and her doula. “She chose me,” Josie said. Josie was baffled because she had been at the same hospital a week earlier with a white private pay client who had “had six people in her room.”

Josie continued by saying that in the labor and delivery room, the doctor put Michelle’s legs up in the stirrups, and scolded Michelle saying, “I did not know you were having a doula. Why didn’t you tell me?” When Michelle pushed, the doctor, who was Black and the nurses instructed her to stop. They told her there was a cord prolapse, which is when the head is really high and the umbilical cord comes down. But according to Josie, Michelle’s water had not broken yet, so there could not have been a cord prolapse. Eventually, Michelle gave birth. And, although she did not have a lot of bleeding, the doctor said, she had clots and aggressively went in to remove the clots. Aggressive entry after a birth can cause infection.

Josie said Michelle screamed, “Stop! Stop!”

On April 11th, the New York Times Magazine published an article, Why Black Mothers and Babies Are in a Life-or-Death Crisis by Linda Villarosa. The article focuses on societal racism and racial bias in the health care system and the role that doulas play in helping Black women give birth. Just eleven days later, on April 22nd, Governor Cuomo announced that New York State was going to reimburse for doula coverage. Was this a win? Yes and no. Although I recently completed training to be doula I do not think offering Medicaid reimbursement is the primary answer to the problem of Black women’s adverse birth outcomes.

I have heard other stories like Michelle’s because I have just completed research examining pregnancy, prematurity, and race in the afterlife of slavery. Black women have the highest rates of premature birth in the US, according to the March of Dimes and I argue that their adverse outcomes are plagued by vestiges of the past. Some of their medical experiences reflect what Saidiya Hartman calls the afterlife of slavery which are skewed life chances, limited access to health and education, premature death, incarceration, and impoverishment (Hartman 2007:7). Michelle’s treatment by medical personnel, who were disrespectful and abusive, exemplifies the afterlife of slavery, because Black women experience similar treatment contemporarily.

Interviewing forty-seven people—including college-educated, mothers, fathers, doulas, midwives, birth justice advocates, doctors, nurses, social workers, and March of Dimes personnel, between 2011 and 2018—revealed how Black women view the medical system during their pregnancies, labor and deliveries. But, while many blame Black women’s adverse birth outcomes on factors such as poverty and lack of resources, rarely is the focus on medical professionals’ practices. Some births are marred by racism ranging from dismissing women’s intuition that something is wrong to performing procedures women do not want or are not made fully aware of. These are the circumstances which reflect variations of medical racism in the form of diagnostic lapses and obstetric racism. What women are subjected to is similar to the “violence of care” that Mulla uses to describe the complex ways that rape victims are revictimized in the care process (Mulla 2014).

The racism that women describe is clearly connected to ideological and political mechanisms in which reproductive stratification, that is the differential ways in which particular people are encouraged to reproduce and others’ reproduction, is replicated (Colen 1995). In other words, Black women’s reproduction—due to historically constituted racism including forced reproduction to sustain the slave economy, reproductive exploitation such as sterilization and use of black bodies as “clinical material” (Washington 2006)—is compromised or discouraged.

Meanwhile, Black women’s adverse birth outcomes continue to rise and simultaneously results in profit because the Medical Technological Complex (MTC) is infused with technological innovation that commands and takes in capital, but does not seek practices that may reduce racial disparate outcomes. Instead, the MTC develops increasingly sophisticated technology that drives its utilization. In other words, the technology becomes its own justification.

While some applaud the Governor’s announcement to support doulas in the state of New York to reduce Black maternal mortality, let us not be lulled into forgetting that some birth outcomes result from racism in practice.  Without insisting on structural changes in the MTC, such as offering better reimbursements for fewer interventions, and without supporting preventive strategies, racism will not be interrupted. Michelle’s doula, Josie, was present and provided support, but Josie could not prevent the doctor and nurses from treating Michelle inhumanely. Although as a doula, Josie could and should be in the delivery room, medical racism has no place there.

Dána-Ain Davis, MPH, PhD is the Director, Center for the Study of Women and Society and is on the faculty of the PhD Program in Anthropology at the Graduate Center, CUNY. Davis’ research interests include gender, race and political economy and feminist ethnography. Her manuscript Pregnancy, Prematurity and Race in the Afterlife of Slavery, is scheduled for publication in early 2019.

REFERENCES

Colen, Shelle. 1995. “‘Like a Mother to Them’: Stratified Reproduction and West Indian

Childcare Workers and Employers in New York.” In Conceiving the New World Order: The Global Politics of Reproduction, edited by Faye D. Ginsburg and Rayna Rapp. Berkeley, CA: University of California Press.

Ferré-Sadurní, Luis.  2018. “New York to Expand Use of Doulas to Reduce Childbirth Deaths.”

New York Times. April 22.

Hartman, Saidiya. 2008. Lose Your Mother: A Journey Along the Atlantic Slave Route. New

York: Farrar, Strauss, Giroux.

Mulla, Sameena. 2014. The Violence of Care: Rape Victims, Forensic Nurses, and Sexual

            Assault Intervention. New York: New York University Press.

Washington, Harriet. 2006. Medical Apartheid: The Dark History of Medical Experimentation

            on Black Americans from Colonial Times to the Present. New York: Anchor Books.

Villarosa, Linda. 2018. “Why America’s Black Mothers and Babies are in a Life-or-Death

Crisis.” New York Times. April 11.

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