Sunday, November 27, 2011

Involuntary Sterilization, Cowboy Doctors, and the West in Africa

J from Tales from the Hood sure knows how to cheer a girl up.  By sending her a story about someone bragging about participating in a non-consensual sterilization in Tanzania!

Now, this is not some big well known person, and there are lots of stupid people on the internet, posting about doing lots of terrible things.  So why does this warrant a post?  Well, maybe, because J felt the need to "share the love" with me, and now I want to share it with you, so we can stare open-mouthed together.  But also, because even though this is just one guy posting about doing stupid things in developing countries, I think his mindset is reflective of a far more common, and deeply damaging, mindset in aid workers: "We're here to help.  Therefore, we're helping."  And also: "We know better than the poor people (after all, they are poor, and we are not)."  Neither of those are true, as J and others have meticulously documented.  So, into the meat of our story.

The blog's author, Erik, is a doctor working in a village in Tanzania.  A Tanzanian doctor comes to his house at 9 pm, asking for help:
"Hello Dakatari, come on in." We never used each others name. Only Daktari. It's how it is done. The challenge was to use it in every single sentence.
"Daktari, I wonder if I could beg a little help from you this evening. We have a little bit of a problem, Daktari."
"Happy to help, Daktari. What's up?"
"Daktari, a woman has come in to the clinic tonight. She is pregnant and has been in labor for two full days. She has been with the village Traditional Healer for the whole day."

The Traditional Healer. Say no more. Straight away I knew this was not going to go well. Each village had a Traditional Healer/Witch Doctor who practiced ancient arts of medicine. These techniques included ritual skin cutting, herbs and randomly placed sticks through punctures. I'm sure that many of their methods worked, but the only ones we ever saw were the ones that didn't. In those cases the patients would be dragged to our hospital as a last resort. They were usually in septic shock, nearly dead or horribly late for treatment like our Sunday night patient.
The woman needs a C-section, and the Tanzanian doctor has an injured hand, so can't perform the surgery himself.  Eric is hesitant since OBGyn isn't his specialty, and he hasn't performed a C-section in 20 years, but he ultimately agrees.  The patient's health takes a turn for the worse during the operation:
"How's it going up there, doc?" I asked. Everyone who wasn't a Daktari, I called doc. It was simpler.
"Hmmmmmm..........." I thought he didn't understand my English. I spoke slower.
"How is she doing, doc?"
"Hmmmmmmm...................Well, Daktari, maybe she is not breathing. I cannot be sure," he said without an ounce of panic. I thought: that's a little nonchalant for what he's talking about.  
They begin CPR:
"Daktari, the epidural injection must have gone too high and paralyzed all her nerve function," I said as I started doing chest compression over her sternum.. I heard a rib crack with a loud POP under my hand and I winced.
"Yes Daktari. I believe that is correct," said Dr. M. She is a young woman and this is her fifth baby. She has a good heart."
Fifth baby, I thought. Holy shit. All I could think of was five orphans.
"C'mon, cmon," I said to no one in particular, "this cannot go down like this."
And here's where it happens:
As I pumped on her chest I saw Dr. M working inside her belly with his one good hand. With her body heaving back and forth from the chest compressions it must have been like trying to do a tattoo in a car on a bumpy road.
"How's she doing down there, Daktari?" I asked.
"Fine. I am tying her tubes. I think she does not need another baby after this." Dr. M was a cool character. I was wondering if she was going to survive the next five minutes and he was already doing family planning.
"Cmon, cmonnnnnnnnnnn.............."
 Ultimately, the woman's heart starts beating, and she lives.
The patient didn't remember anything that had happened. It was like she went away and then came back. We told her she had a baby boy. She asked why her chest was hurting. Dr. M told her not to worry about it. She was wheeled into the recovery room. Dr. M. told me to go home. He would handle it from here.
The post ends with Erik celebrating that five kids still have a mother, and the role his own heroism played in saving the woman's life.  I have no doubt that his medical skills did save the woman's life, after it was jeopardized by others' on his team.  I also realize he is not the one that performed the sterilization without the woman's consent.  But, he is the one writing about it, and displaying a shocking nonchalance about this extreme breach of an individual's medical rights and human dignity.

In fact, the author displays a disturbing condescension toward the patient, and her rights to be informed, throughout the piece: in addition to not being informed of the sterilization, she is not told about her heart stopping, or the rib-cracking CPR.  The disdain that the author displays for locals who choose to go to the traditional healer displays further condescension.  "The Traditional Healer. Say no more. Straight away I knew this was not going to go well."  Yet, given the deplorable medical care the woman ultimately received, who could blame her or women like her for preferring to visit a traditional healer, or traditional birth attendant?  Perhaps, the woman knows that it is unlikely for a traditional healer to accidentally paralyze her lungs with excess anesthesia.  It's also unlikely that a traditional healer would sterilize her without her consent.  Aggregate statistics show that giving birth in a health center, even a bad one, is safer for the mother than giving birth at home, but for any individual woman, maintaining control over her body might be preferable to the marginal increase in survival rates.

But I promised this post was about more than just this case, so let's examine why so many people think it is okay to sterilize a poor woman without her consent.  It is a crime that has been committed across the globe, in America, Asia, sub-Saharan Africa, and Latin America, and continues to this day.  Note that the Fujimori-era forced sterilizations now being re-investigated in Peru often occurred under these very same circumstances: A woman arrived at the hospital to give birth, or for some other medical procedure, and left with her fallopian tubes tied, often never knowing the difference until she failed to conceive, or developed an infection from the hasty operation.

Sadly, forced sterilization programs often take root under the guise of progressive policy: expanding women's access to contraception.  Note the telling language Erik uses to refer to the non-consensual sterilization: "family planning."  The conflation of externally-imposed fertility limits with voluntary family planning is chilling indeed.  But this conflation is made over and over again, because people in positions of power, whether the Westerner, or the local, educated doctor administering medical services to poor women, believe they know what is best for their patients.  Naturally, a woman with five children should not have any more, the reasoning goes.  Or, a woman too poor to support the children she does have, even if only one or two, should surely be kept from having more.

No matter how benign this paternalism masquerading as benevolence might sound, forced sterilization is a crime that is committed against women (and sometimes men, such as in Indira Ghandi's India), stripping them of free agency and human dignity.  Patients get to decide what medical procedures are performed on them for a variety of reasons.  They get to decide because there is no medical procedure that does not have risks as well as benefits, no matter how enormous the benefits or how small the risks.  They get to decide because lots of things that doctors used to think were really good (e.g., hormone replacement therapy) are sometimes really bad.  They get to decide because what makes sense for one person may not make sense for someone else.  Fully informed consent, where someone is told of the risks and benefits of a procedure, and allowed to make their own, non-coerced, lucid decision, is one of the hallmarks of ethical medical care.

In the case of sterilization specifically, the stakes can be incredibly high.  For some women, being able to produce children may be their guarantee of economic security.  If they stop producing, their husband may seek another wife, and cut off spousal support.  In Zambia, infertile women have told of being divorced and treated as a burden by their community.  In South Asia, failure to produce children has been offered up as one predicator of bride burning.  In an environment where women lack access to many conventional forms of capital, their ability to produce something valued by society in the form of children may be vital to their physical and economic security.

But even if it is not, the decision to have or not have children is one of the most private and individual choices possible.  Who are these men to take away that choice?  The story says the woman is young. What if all her children pass away, and she then wants to have another child? Will the good doctors reverse this involuntary tube-tying for her?  Probably not.  Worse than that, she won't be able to ask, because she doesn't know it was done.  Or maybe she just really wants to have a massively large, irresponsibly large, family.  Guess what?  Being poor doesn't strip her of her rights to make these types of decisions--even if they are bad decisions--for herself.  If the doctor is concerned that it isn't really her decision, that the woman may not want children, while her husband does, he could offer her the option of sterilization, or a concealable form of contraception, when she is lucid and able to make an informed decision.  But he didn't, because no one in this story believes it is her decision to make.

Worse, the men in this story think that making these types of decisions for their patients, violating their patients' medical rights, makes them badass.  They're cowboys, trying to tame the wild wild East.  And they are so much smarter than the people they're trying to help.


  1. Thank you for posting my story on your blog, but like most colonial thinking individuals, your higher moral thinking has little or nothing to do with the realities of survival in remote areas of the world. In short, you didn't think this one out very well. While we weren't attempting to "tame" anyone, the decision to tie the woman's tubes came from sound medical judgement. If this woman got pregnant again, there was a greater than 50% chance she would die during or before childbirth. (this not even dealing with the economic reality that she couldn't even afford to feed the 5 children she had.) You are out of line here and off-kilter with your point. It appears to be an angry reaction to your own views of men rather than a well thought argument dealing with the facts. My advice is to go live in the bush for a while and then come talk to me about necessity and choice.

  2. Hi Erik, thanks for joining the conversation here. I have a couple of responses. First, if the woman's health really is in such dire peril from future pregnancies, then you could find someone who speaks Swahili, or her dialect, to explain the risks to her, including illustrations of how scarring on the uterus can cause future hemorrhages or other complications during delivery. You could then ask her whether she would like to undergo sterilization, or have an IUD inserted. If you really feel that this would have been her choice if she understood the risks and benefits, then I'm wondering why you didn't explain to her what was done, following the operation? That said, though, I'm not sure on what basis you're assessing that she has a 50% risk of dying during childbirth next time--surely through pre-natal care, health-center delivery, and third-stage management this could be drastically reduced? You could also inform her that her risks of death are very high unless she undertakes certain actions the next time she becomes pregnant. I'm really not sure why you're so certain she would be unable to understand these things? She is, after all, in possession of a uterus (and formerly functional fallopian tubes) that has given birth to 5 babies, so surely the pain and risk involved has somewhat entered her consciousness? She also, presumably, is better acquainted with the difficulties in supporting her five children than you are? I would be interested in knowing how many of the women in the village you work in you think CAN fully support their children to your standards? Do you plan to forcibly sterilize them all?

  3. Also, just to be clear, I am not arbitrarily deciding that forcible sterilization is wrong. It is, in fact, enumerated as one of the "crimes against humanity" over which the ICC has jurisdiction, in the Rome Statute: "Rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization, or any other form of sexual violence of comparable gravity;"

  4. I know this will come as a shock, but I'm gonna go with Femonomics on this one.

    Performing a hysterectomy without patient consent gets you slapped with a malpractice lawsuit, loss of license to practice, and possibly jail time in a developed country (like the one you're from, Erik). But since the legal framework of Tanzania doesn't have the same kind of rigor, cowboys like Erik can go around wantonly violating human rights in the name of "helping." WTF?

    Erik has wisely withheld the name of his employer during the episode in question. But on his website he claims to have worked in the field for Family Health International (FHI). I don't know for certain, but I'd be willing to bet that sterilizing a patient without her consent would get him fired, or at the very least never hired again... someone should follow this up with FHI...

  5. @Hester--welcome to the party, I guess this goes with your "If you train doctors in permanent birth control, assume they will do it to people without their consent" wisdom, huh? One small note, Erik was not the actual physician who performed the involuntary sterilization, although he was present at the surgery, he's just the one bragging about it and defending it.

  6. I'm usually against involuntary sterilization, but in this case, I would make an exception. I would support involuntary sterilization of Erik himself.

    I'm sure all the colonialist-thinking individuals here would object to sterilizing Erik, but such higher moral thinking has nothing do with the realities of family planning for depraved individuals like Erik. The decision to support sterilizing Erik comes from my sound utilitarian judgment. If Erik were to reproduce, there is greater than 50% chance his offspring would be as awful for the human race as Erik. Anyone who disagrees with me is out of line, angry, and not willing to look at the facts.

  7. Yesterday I was trying to remember where I had recently read someone who, like Erik here, had pathetically co-opted the language of colonialism's critics to support the continued dehumanization of Africans (e.g. accusing CC of exhibiting "colonial, higher moral thinking").

    Ah, but today's NYT reminded me: it was Newt Gingrich's PhD dissertation in which he accuses Congolese of exhibiting "black xenophobia" for not recognizing the "good aspects" of Belgian influence.

  8. Awesome post, Coca Colo! This is my first visit to your blog, and this is an excellent post.

    Also, @Erik--I think you misidentified the "colonial thinking individual" in this post (hint: it's you). Coca Colo is supporting bodily autonomy for all--even poor people in developing nations. You, on the other hand, are advocating forced sterilization in developing nations, thus colonizing the body of your patient by deciding that your "white wisdom" trumps her bodily autonomy.

  9. Erik,

    I sincerely hope you spend some time reflecting on what others are saying about this. I know you are a professional, used to having your clients substitute your informed judgement for theirs in extreme circumstances. I do the same, in a different field, and have a couple of doctors and many more medical professionals in my family (I'm the weird one).

    Let me make a simple observation. Unless you are perfectly, completely fine with the idea that someone might rewrite the legal agreements and financial arrangements you surely have in place without your knowledge and consent, then you should think very long and very hard about modifying other people's bodies, which is a much deeper violation, without theirs'.

    I'm very aware of how hard it is to do medicine, and I can only imagine what it is like in the circumstances you describe.

  10. Did you all read the same post on this man's blog that I did? Because it seems like you have completely misrepresented his situation.

  11. Erik took down his post, because he is a coward, but here is my comment on that post.

    Apparently, bodily autonomy is only for people in Europe or the Americas. Everyone else can just deal with whatever the dr dishes out.

  12. Wow, really important story. I think we should thank Dr. Erik for posting it, even though he doesn't seem to understand the significance of it. Might I also suggest contacting the Tanzanian embassy:

    I think they would want to know.

  13. Seriously? The white Western doctor who went to a third world country and took part in the forced, clandestine sterilization of a poor black woman is accusing others of being colonizers?

    Wow. Just wow. I'd at least think you'd defend this as "paternalism is sometimes good," but "Anyone who thinks a third-world woman should decide for herself if she wants to remain fertile is a colonizer" has the benefit of being easily dismissed.

  14. Hi Erik. I have lived in the West African bush and have a pretty sound idea of what sort of environment you are in, particularly considering I helped to establish a small medical clinic in a remote village there. It's rough, and medical conditions are far from ideal. That doesn't mean people living there should lose the rights to make decisions about their lives and their bodies.

    I am frankly appalled at your and your colleague's behavior and cavalier attitudes about what you did. You both showed complete disregard not only for this woman's body and her rights, but also for the culture of the people you have come to 'help.' As the OP described, for many cultures, women's ONLY 'capital' is their ability to produce children. For rural village life, having more children means having more help with farm, cattle, and house work. The woman you described has now been involuntarily capped at 5 children. That's a lot for our culture, but did you pause for a moment to consider what it means in HER culture? Did you pause for a moment to consider the shame and isolation she would/will experience when she is unable to produce more children?

    I could go on, but most of what I would say has been said by the OP and other commenters. I only want you to know that the rules are not off in the bush. People are people everywhere.

  15. The post has been taken down, so here is the google cache for reference. Sadly, it's cached before he responded to a critical comment by saying something like the doctor was a hero for helping a woman in a culture that demanded women produce children. First of all, since when do you have to help people without their knowledge? Second of all, how does it make her better off to eliminate her ability to be able to produce what the culture demands? Third, broad brush, much?

  16. "Anyone who disagrees with me is out of line, angry, and not willing to look at the facts."

    Oh LOL, DRDR. You know it!

  17. ... Let me get this straight, her labors were getting harder, and she nearly died during this one. You would rather him have just let her continue getting pregnant, under the care of mr. tribal doctor, let her die, and then have 5+ orphans? Wow, that's sure more humane than sterilization. I'm a woman. I have a hormone disorder and do not have the ability to have children, so anyone with a brain should know that I think that the ability to have children is precious, but enough is enough. Look past your feminazi mindset and look at the medical facts. For this woman pregnancy would have meant almost certain death. I applaud this doctor.


Commenting is now open, but we'd love it if you chose one username so other commenters can get to know you. To do this, select "Name/URL" in the "Comment as" drop down. Put the name you'd like others to see; the URL is optional.

Any profanity, bigotry, or synonyms for "[ ] sucks!" will be deleted. We welcome criticism as long as you're making a point!