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.