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."

Recipe Fridays: How to cook (and eat) Zambian food

The staple Zambian food is N’shima, a cooked maize product similar to grits or polenta. It’s dense and highly caloric, thanks to the cooking process by which a small amount of maize meal is cooked into a porridge, then additional meal is beaten in until the N’shima is thick and sticky. There are two kinds of maize meal, or mealy-meal, from which N’shima is made: Refined meal, called “Breakfast”, and whole meal, called “Roller” (pronounced Rollah). N’shima is eaten with a variety of “relishes”, such as vegetables, small dried fish (kapenta), beans, and/or meat with gravy. The major Zambian vegetables are: Rape, a dark green, slightly bitter leaf similar to chard; Chinese cabbage, a slightly lighter colored and more crisp leaf; Chabwawa (pronounced almost like Chihuahua the dog), pumpkin leaves, which are thick and often sandy if not washed enough; Kalembla, pointy, sometimes star-shaped leaves which can be slimy if over-cooked; and Bondwe, basil-shaped leaves with a distinctive fragrance. These vegetables are usually cooked with tomato and onion, and sometimes in a groundnut (peanut) stew called V’sachy.

Zambians eat with their hands, but this is certainly not an excuse for poor hygiene or table manners. Washing hands before and after meals is mandatory, and you’ll find most Zambians somehow keep their hands clean throughout the entire affair. This is managed by the process of taking a golf ball-size lump of n’shima, rolling it into a ball, and flattening it with the thumb before picking up any food. The n’shima and the thumb together are used to pick up vegetables and sauce, leaving the rest of the hand clean. For tearing apart meat and fish you will have to use your hand—but only one. The other rests on the table clean. Westerners seen grabbing food directly off the plate by the handful are considered just as uncouth here as they would be back home, so be warned—eating with your hands isn’t as simple as it seems.

Below are some Zambian recipes, starting with those that are most transferable to Western grocery availability.

Unlocking the puzzle: HIV in East Africa

Let me ask you this: Do you believe patterns of sexual behavior are the primary determinant of rates of HIV infection in the world?  If a country has more HIV, does that mean more people are having more unprotected sex with more partners?

Personally, I don't believe the above statement, at least without major qualifications, but there are plenty of people (and plenty of people in the HIV/AIDS advocacy community) who do.  What I would say, is that countries with higher infection rates probably provide the virus with more opportunities for transmission--perhaps in the form of unprotected sex, but also in the form of overall poor health, additional untreated infections, possibly lower rates of circumcision, and other so-called "open windows" (to borrow a phrase from Elizabeth Pisani) into our normally protected bodies.

On the other hand, I am also troubled by how HIV rates could be so high in relatively well-off East African countries (such as Botswana) and so low in equally poor Latin American countries.  What's the missing variable?  One theory that I've heard advanced is that East African societies tend to favor concurrent sexual relationships, rather than serially monogamous ones, which is more conducive to HIV transmission.  The idea is that HIV is most infectious after you've been recently infected, so if you have sex with someone for several months, become infected, and then start a new relationship a few months later, you're less likely to transmit the disease than if you have an ongoing sexual relationship that involves multiple instances of unprotected sex with two people during the same time period.  But is it the case that East Africans have more concurrent sexual relationships than people in other countries?  Honestly, I don't know.  Feasibly, it seems like something you could find out by examining DHS surveys, but I don't know of anyone who's done this.  So in the absence of facts, let's at least talk about why that impression exists.

Out of the pot, into the fire: How hierarchy defines our lives

I've just finished the first week of what will be a four-month stay in Zambia (and the reason femonomics posting won't be daily for a while).  The first time I was in Zambia, I was a cultural outsider.  I spent a lot of time just chatting with people, anyone who would, to try out my fumbling grasp of the local language (English is the language taught in schools, but other languages remain prevalent), and understand as much as I could about the place whose people made up data points in our research.  After three months spent working with Zambian women, living with Zambian housemates, cooking and eating Zambian food, and making Zambian friends, I felt integrated enough into the culture that when I returned this time, part of it was strangely like a homecoming--returning to an old familiar place and the memories it holds.

But as I felt less cultural separation between myself and the Zambians around me--of course we still came from different backgrounds, but I no longer felt like a complete outsider--I noticed a strange thing.... I was adapting more to the class hierarchies of Zambian society.  Instead of chatting with guards and bus drivers, I offered them curt greetings and hurried on my way, trying to avoid the inevitable discussion of my relationship status that I'd learned would follow.  I found myself referring to domestic workers in local terms, as a "garden boy" and "maid," despite finding these terms pejorative, and using "She doesn't even speak English!" to express that someone was uneducated to my housemate.  And honestly, I had no idea why.  The less I saw my middle class Zambian friends as separate from myself, the more I was adopting their way of organizing the world into "other" and "same."  As I saw things less in terms of me versus them, developed country versus undeveloped, white(ish) versus black, the more I saw them as educated versus not, laborer versus professional, economically comfortable versus poor.  I was absorbing a new set of hierarchies and division to replace the old, and it felt as natural as breathing.

There are many misconceptions about developing countries, especially African ones, that I hope to address in a future post.  But one of the most pernicious is that everyone is poor, destitute, and miserable.  Far from it.  Plenty of Zambians, especially urban ones, are middle class, comfortable, and caught in between the same appreciation of their good fortune and striving dissatisfaction that so many Americans face.  And very often these individuals seem to define themselves in contrast to those that are not, just as much as we define ourselves in contrast to our vision of them.  Why is that?  Is it human nature for us to make sense of our landscape through hierarchy?  Does our wealth mean nothing if we are not richer than?  Is our education useless if we're not smarter than?  Or is it the insidious effect of Colonialism, still boiling away, in which class and ethnic divisions were often encouraged in order to better control Colonial lands?  (For more on this, see Mahmood Mamdani's wonderful book Citizen and Subject, about how the British encouraged hierarchical and authoritarian local rule in South Africa in order to better oppress the Africans they sought to dominate.)

If we rid ourselves of one form of oppression, will another replace it?  Is hierarchy truly as natural to us as breathing?

Some good news for HIV prevention

A randomized controlled trial in South Africa has revealed a microbicidal gel spread inside the vagina to be effective at reducing HIV transmission by 39%.  Women who complied closely with the treatment recommendations, to use the gel before and after sex, experienced a 54% reduction in transmission.  What's so revolutionary about the gel, versus orally taking anti-retrovirals as prophylaxis, is that it acts on site, so doesn't flood the body with powerful medications that aren't safe for long-term use.  This means both that the user won't experience side effects and, as reported by ERV, the virus itself is unlikely to become resistant to the particular anti-retroviral used in the gel, since it is not present throughout the body where HIV multiplies.

Unfortunately, 39% is a far cry from the virtual 100% protection proper use of a condom offers.  I have the same concerns about this drug as I have about circumcision, that it may make people feel protected when they are not, and therefore actually decrease or fail to adopt condom usage.  The first thing I'll say (in response to my own concerns) is that as much as we'd like "just wear a condom, darnit!" to be the solution, studies show that people simply like sex without condoms, and so there will continue to be a market for products or treatments (circumcision) that reduce risk without condom use.  Much of this aversion to condom may be social, and that's why I hope there continues to be just as much focus on upping the sex appeal of condoms as there is on finding alternatives.  The second important thing to keep in mind is that this gel is for use specifically by women, and can be used without her partner's knowledge or approval.  This is incredibly important, given that men are more likely to report experiencing a decrease in sexual pleasure with condom use, and therefore may be the ones objecting to prevention practices.  This gel allows a woman to protect herself if she is in a violent or unequal relationship, or simply if she wishes to have sex with someone who refuses to wear a condom.

I'll be interested to see further trials on the gel, and how marketing materials are developed to encourage use with condoms (I hope it's been tested for compatibility!) rather than in place of.

Nicholas Kristof offers a welcome shot of honesty, now I want action

Earlier I discussed my roller-coaster relationship with Nicholas Kristof. His recent comments in response to reader criticisms have gotten to the heart of my issue with him, and why even though I'm glad he's talking about developing countries, I think he needs to take a serious step back and reevaluate his work, before he risks doing more harm than good.

From NYTPicker:

Kristof -- a two-time Pulitzer Prize-winning op-ed columnist who focuses much of his attention on Third World problems including rape, prostitution, hunger and lack of education - has been praised by presidents and world leaders for his compassionate and determined effort to help the destitute.

But to some of his readers, Kristof has demonstrated, at times, a condescending superiority over those he wants to help -- portraying himself, and other Americans working on these issues, as seemingly necessary to the process of bringing about change.

Those feelings bubbled over into public discussion late Friday afternoon, as Kristof answered questions from readers via YouTube. The columnist found himself on the defensive from a reader who rightly observed a pattern in his standard narrative -- one that often focused on the foreign, typically American "savior" helping the poor Africans in need, to the exclusion of efforts of black Africans themselves to bring about change on the ground.

It's Kristof's own words that bowled me over (transcribed by NYTPicker. He somehow managed to demonstrate both extraordinary self-awareness (about what he does and why) and shocking obtuseness (about its consequences) all at once:

...Very often I do go to developing countries where local people are doing extraordinary work, and instead I tend to focus on some foreigner, often some American, who’s doing something there. And let me tell you why I do that. The problem that I face -- my challenge as a writer -- in trying to get readers to care about something like Eastern Congo, is that frankly, the moment a reader sees that I'm writing about Central Africa, for an awful lot of them, that's the moment to turn the page. It's very hard to get people to care about distant crises like that.

One way of getting people to read at least a few grafs in is to have some kind of a foreign protagonist, some American who they can identify with as a bridge character.

And so if this is a way I can get people to care about foreign countries, to read about them, ideally, to get a little bit more involved, then I plead guilty.

Ok, well I guess that settles that. What makes Kristof write his columns the way he does is racism. Look, I really don't want to say that. Because I think Kristof is an ally. Or at least he wants to be. And I don't want to say it because by saying it, I'm making him out to be the enemy. But he's not. The enemy is racism. Racism that's inside of all of us, and integral to all of our geopolitical discourses, and yet unspoken, and unaddressed, and all the more powerful for it.

What makes Nicholas Kristof put white protagonists front and center in his stories, while Africans are depersonalized and turned into background players, is racism--both his own and (his impression of) his readers'. That description of how he gets people to stay on the page...he is admitting that he sells out Africans to save them. He erases the stories of successful, charitable, entrepreneurial, and independent Africans so he can better tell the story of the destitute and diseased. He is only showing one side of the African coin--the negative one. It is to get people to care. But it is sending the wrong message. If Africa is a place to be pitied, to be acted upon, to be saved, how can its people thrive? If helping them means you have to dehumanize them, thanks, but...no thanks.

Kristof's racism is unintentional, and I believe well-meaning. But it is damaging nonetheless. Now that he's admitted it, I'm asking him to change it.

My roller-coaster relationship with Nicholas Kristof

If I put up a facebook relationship status about NYTimes columnist Nicholas Kristof, it would be "It's complicated."  Me and Kristof started out strong, when I was a naive college student-wannabe-journalist, and he was one of the few prominent columnists talking about the BIG issues.  Chief among these big issues was AFRICA, a place we all knew was afflicted with all the world's worst problems.  And Kristof was talking about it.

Now, after working in Africa (specifically: Zambia), getting to know numerous sub-Saharan Africans, and reading countless papers on economic development, I find that talking about it isn't quite enough anymore.  I find myself sympathizing more and more with bloggers like Texas in Africa, who has a special tag for Kristof screw-ups, "The Kristof Strikes Again," and Africa is a Country, who first made me notice Kristof's awkward, me-centric (condescending, privileged, and imperialist might work, too) approach to interactions with Africans.

Still, sometimes I'm elated just to hear him talk about things that deserve ink, such as when he addressed cruel misconceptions about Haitian culture after the devastating earthquake there.  I was entranced to read his essay on women's role in developing country economies, and was willing to forgive him some oversimplifications for the public service of bringing gender to the forefront of Times' readers' minds.  But for every one of those swoony moments, there's a piece like his recent misinformed one on birth control in Africa (where else) that ended with the line, "So she may just keep on producing babies."

Kristof really hit a nerve, though, when he wrote a column about the "ugly secret" of development, that poor people don't spend their money wisely:

Saving "Africa"? Who said they want it?

People, generally, have good intentions.  This is one of my ingoing assumptions in most interactions.  Generally, people do not deliberately hurt others.  Generally, people would like to take actions that help themselves, but would prefer, all else equal, if these actions help others rather than hurt them.  But guess what?  It doesn't matter.  Because these well intentioned people hurt others all the time.  Especially when the people they are trying to "help" are low status groups (I mean based on societal hierarchies, not as a value judgment) who are given limited to voice to express what kind of help they actually need or want.

With that said, let me introduce the cautionary tale of #1MillionShirts.

Madonna's Malawi Girls' School: Is this how we help?

The BBC reported Friday that the 200+ villagers in Malawi set to be displaced by Madonna's new school have ended their protest and agreed to move.  Madonna's planned Raising Malawi Academy for Girls can now move forward.

Look, I'm all for empowering women in developing countries through education, but something about this whole thing strikes me as icky.  Madonna thinks what they really need on that land is a school; the people that live there think that what they need is to, well, live there.  Madonna has the money, so she gets to make the call.  But if she's doing this in the name in the name of philanthropy, shouldn't the preferences of the local people come first?  Couldn't she have negotiated with village leaders to find the most appropriate site for the school, that would displace the fewest people?  To me, this feels like vanity aid, which is the last thing developing countries need.

Madonna's money might have been better spent on a preexisting educational charity with local connections, but then she might have gotten less of a reputation boost, I suppose.

[Hat tip to the Msungu Malawian]