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Questioning, Witnessing, Teaching

I wonder what it means to be called into action.
To turn an apathetic understanding of an issue and move it into an activation of energy and resources.
I read once that 'people are not moved to action by information alone'. We can hear of devastating things, but the fact alone will not produce change. We have to be 'moved' emotionally or physically. This is why 'Save the Children' campaigns show pictures of a lonely and sad looking child in the dirt- the point is to move us into feeling into action. It works. Affect is effective.

We do things because they feel good, or because they prick us, it hurts, and we think our action will make it feel better. I believe it is hard not be apathetic about issues that are 'larger' than us our outside of our immediate control. I have spent most of the time our country has been at war 'not really thinking or feeling' about it. It doesn't effect me personally, so I tend to ignore it except for the occasional "this has to stop" statement to no one in particular.... and of course, I plan to vote for Obama who also wants to stop the war, but ultimately this remains outside of my control and outside of my feeling place.

I have been pricked. Not by our war but by another countries war. Maybe the objectivity of the other makes it an easier entry into compassionate engagement than my feelings about the Iraq war, which quite frankly just brings up feelings of disgust and shame.
I have been an active witness to the effects of the war in Northern Uganda. Working with, breathing with, struggling with women giving birth. It was not romantic or pretty. Women were traumatized, terrorized. The pain and pressure of pushing a child out is often mirror like to that of being raped.
The hospital has no resources (no running water, watered down and re-used bleach, limited glove supply) and a staff of midwives who are victims of war themselves, traumatized and often apathetic since it is the only way to get through the day. At the time, my partner and I thought this was the way in. To work within the hospital system in an exchange of ideas and practice. The result was that we were traumatized and exhausted at the end of each day and the failing system did not shift. We were outsiders coming in and we would leave. This was the very thing I tried to avoid, instead of accepting its inevitability.

Upon my return I struggled with a number of questions.
Was my presence as an outsider an act of violence unto itself?
Had we really 'exchanged' anything at all?
My fear was that with the power dynamics such that they are, we really hadn't.

With Earth Birth trip the entry is different. I the point to facilitate spaces of safety in which culturally appropriate linkages and exchanges of information/best practices naturally occur. We all become simultaneously outsiders and insiders to the process of building as women, sisters, mothers, daughters, etc.
I guess the larger question is how does one stand active witness to WAR itself. I am now teaching an undergraduate class at Rutgers University on women's health issues in areas of war and terror.
The first question I asked the students was:

How does war effect women?

The answers were insightful and sparked a great discussion.

When women's bodies become political weapons.
When rape becomes a tool for political gain.
When children are bred to be turned into soldiers- women still must carry, birth and nurture.
When there is no food, women still have milk.
When shame and stigma are attached to forced sexual acts and reproduction is the evidence.
When resources are so low and poverty and malnutrition is so high that giving birth is truly risking life.
When trauma becomes set into the body and is ignored, sedimented.

The war in Northern Uganda has been a reproductive war.
It is literally about creating a new generation to fit the rebel armies vision and plan.
That creation takes place at women's reproductive cores and therefore the physical and emotional toll of giving birth and raising babies cannot be overlooked.

I think the next question is one for the women who are victims of war : What would radical intervention look like?
Feel like?

I don't think it's a question I can answer- but it's certainly been done before- the madres in Argentinas Dirty War, or the Women in Black in Israel/Serbia. Sustainable interventions created and led by women- I think the first step is to create a space in which it is safe enough to even begin the conversation. Apathy and silence are symptoms of trauma, violence and oppression.

Witnessing

I used to feel like it was enough to hold space and witness another as they transform through something.
I attended a birth the other day where a woman really worked through some deep psychic pain.
It was all I could do to stand present, hold space, witness, and ultimately make sure she was medically okay. In the end I wonder what it is that the presence of an 'other' does in the room. I can see how it can be both productive and destructive-perhaps at the same time.

In order to witness, one has to make arbitrary decisions about what is important to notice. Significance is produced through the gaze of one onto another. In order to notice one thing, there are other things that will get blind spotted. This is a characteristic downfall of critical theory-when light is shed on one thing, shadows fall elsewhere. I wonder what knowing this does to the role of the witness as a productive member in a room and how it can both make and unmake an experience of the one who is experiencing/embodying the event.

Labor dance

The question of how narrative is transmitted is to my understanding one of the biggest concerns of folklorists. For me, how narrative is interpreted and understood is perhaps a more fertile space for inquiry; However, I have not spent much time thinking about how one performs understanding. I was brought into this way of knowing when the TBA's spontaneously began to embody labor support techniques.
After a workshop where we spent a lot of time unlearning the World Vision model of women laboring lying on their backs with hands and knees flat, the midwives thanked us by improvising a labor support dance. I had chills when it was happening and I get chills every time I watch it.

On performing illness, part 1.

We break for lunch. The meal is a small piece of overcooked goat slathered in a salty brown sauce (quite literally salt, onion, water and brown coloring) and millet bread (actually kind of a dough) served on multi colored plastic plates. I get pulled out of the room by the chairman who complains that we have not purchased soda for everyone. I explain why I think buying sugary soda instead of clean water (in a camp that has no running water or sustainable food supply) is not something I want to do. Instead, we have brought raspberry leaf tea. The chairman is annoyed. He wants soda. I return back to the lunch area and Olivia explains the benefits of this herb for women and gives everyone some seeds along with their cup of tea, for their own harvest. We do a ‘raw foods’ demo- talk about the nutrient and medicinal value in eating raw veggies that grow in their area- like garlic and avocado- we make guacamole and it’s a hit. Women scramble on top of each other and argue about who had a bigger sample. Is this as good as the bliss of a cool, bright orange Fanta sipped from a glass bottle? It's all in how you look at it.

Upon return to the workshop space there is a commotion. Everyone is huddled around a woman and speaking rapidly. It seems this woman’s money has been stolen. She brought her entire months earnings with her (20,000 shillings, or about $13), and it is gone. She is inconsolable. There is a group discussion about who and how. Someone suggests that we all give 500 shillings (30 cents) so that she can recover the $.
Everyone agrees but the woman refuses to accept it. She says it is gods will that the money was taken. Upon her refusal everyone turns to us to begin the workshop. There is nothing more to be done.

We begin with stories. The playback theater was so succesful we do it again. The first woman stands and delivers her tale in rich detail. As she comes to the climax of the story the woman whose money was stolen falls to the floor. She is unconscious. Everyone gathers around her and begins fanning her and a group prayer invoking jesus into the room is instantly organized. Olivia and I check her pulse- it is strangely normal for someone who has just passed out. The decision is made to move her to the middle of the room and out of the seating area. As we lift her, she becomes rigid. Not the body of someone who is unconscious. She is performing. And her audience is responding. Women are wailing and praying, others have run to get medicine from the nearest health unit, some sit and silently witness. Olivia runs some cold water through her hair and she opens her eyes. She moans loudly and everyone who was sitting to the side rushes to her again. A woman returns from the health unit with some sort of pill which she places in her mouth, washes it down with water.
What is that pill? I ask.
It’s for high blood pressure, the woman responds.
There seems to be no logic to the giving of the pill or its intended function in the body- instead it seems that the notion of medicine, any medicine, as instant healer, will work.
And it does. The placebo effect of the high blood pressure medicine takes immediate effect in this performance and the woman sits up and returns to her seat. Everyone is greatly relieved and we return to our regulary scheduled programming. By the end of the day she is smiling and laughing with everyone else and eventually announces she will in fact accept the offer of everyone antying up 500 shillings.

On the ride home I think about illness and how it works in the body. We know that most illness is indeed psychological and so is there ever really anything that goes on in the body that isn’t in some way performed through the will of the mind?I know this to be particularly true in childbirth. Once women are able to overcome any fears that are psychologically blocking labor and accept the support and love of those around her, labor tends to happen much more quickly and with fewer complications. And to what end do we need to perform our illness or pain (especially if it is ‘real’) in order to engage the necessary response of help and care from our community? As illness is an extremely isolating experience, it is also one that directly calls on the community to witness and to be present. An interesting juxtaposition.

How to do interventions with words

Return. Re-focus. Re-shape. Re-shift. Reflect.
Those 'Re' words all have to do with turning something around. The 'Re' is an intervention on the word itself.

People ask how the trainings went and I realize I am uncomfortable with the word because it sets up a necessary information hierarchy.
So, I have been using the word workshop, because I think it is more descriptive of the dynamic of Olivia and I as ‘facilitators’, not information providers.

It seems to me that issues of power are largely issues of voice and inherently, listening- who feels empowered to speak, who is listening when one speaks and how that voice shifts or effects change.

The last few workshops were magical. We were talking about how the war effected birth, and used playback theater techniques of having women share their stories and then other members from the group ‘playback’ and act out the story they heard. What happened was that as the stories came to life, more and more women wanted to share and the details in their narratives began to grow more and more vivid. Stories of pushing babies out while hidden in barns and gunshots are being fired down below, stories of running in labor to escape abduction, stories of giving birth alone in the bush while villages burned to the ground in the background, I could go on and on but you will all hear the audio soon. These stories were enacted with such talent and love and enthusiasm I was brought to tears many times.
Women in general and especially women of color and especially women of color in third world countries and especially women of color in third world countries that have been ravaged by war, have historically been and still are, an underheard population. In order to create a holistic health space where each midwife is an equal part of the team, I cannot think of anything more important than cultivating voice. Cultivating voice inherently cultivates listening, cultivating listening cultivates questioning, cultivating questioning cultivates best practices.


As the workshop continued I asked the questions: How can our stories act as a political intervention? How can what we do as midwives help to shape and shift this countries next generation?
Women broke off into groups and we discussed the questions and tried to come up with answers that led to direct action steps.
As I have written here before, apathy is a very real coping mechanism after severe trauma. Those who study poverty cycles note that ‘the sense that one does not have any personal power or ability to make change leads in their own lives is the key to the continuation of poverty’. Apathy, or a sort of numb waiting for others to hand you information creates the necessary conditions in which a community can accept with little resistence, gross violations of human rights.
So how can midwives create an active space? One in which there is a sense of individual investment in the work and therefore, community change.

I want to ask the same questions of anyone who might be reading this blog as well. How can we use our agency as women with voices/stories as both political intervention and as medical intervention? How can apathy be addressed and redressed, reshaped, redone?

Title reference:

Menstruation and Goats and TV; Aka, random post

Internet has been down, power has been in and out, and we have all had the flu. I am sitting in an internet cafe where they are blasting Annie Lennox and the computer keeps turning on and off.
Ahh, what a week.
We have launched 'The Moon Project'. The issue of menstruation across developing nations is becoming bigger and bigger. Women want to use sanitary napkins because they are modern and yet they are often purchased in place of food in communities of extreme poverty. Secondly, there is no sanitation department coming around to collect trash- pads are filling/clogging up pit latrines. Last week at St. Monicas they pulled out TWO WHEELBARROWS full of used pads that were clogging the pit latrine. So pads are a burdensome cost, and there is no way to properly dispose of them. Women don't want to burn them because of a belief that if one burns menstrual blood one will become infertile.
Third issue is chlorine bleaching of pads- that chlorine when warmed against skin can emit dioxin gas which studies are showing leads to increased risk of cervical cancer, heavy bleeding and cramping and infertility.
So the moon project is a sewing collective of Child Mothers who are making re-usable cloth pads. They are AWESOME. Made with sofr terry cloth with inserts for lighter or heavier days. They have 'wings' that button under the underwear and are cute- sewn with bright aftican prints and are able to be folded into a little square for storage. We are making 'kits'- each kit includes a bucket for washing pads, five pads (three small and two large), a bar of soap and an information booklet.
The kits sell for the same cost as 3 month supply of disposable pads, but will last for 2 years. We completed our first order yesterday, which was sold to a dance troupe called 'Undugu Family'. The child mothers are taking home 2/3 profit after supplies, and the cost of the kits are still affordable to the community. We now have orders from boarding schools all over region. It is an exciting venture into a truly 'holistic vision' for Earth Birth and for women's health in general. We will post pictures on the website soon.

What else....Trainings have been amazing. Figuring out how to get creative when we hit information blocks because of language or cultural understanding. We have been trying to work on counting fetal heartrate, but are finding multiplication is a challenge (you have to listen for 15 seconds and multiply the number by 4 in order to get a full minute count)- so we have created a colored bead system. Strings of bead that you count off on your fingers as you listen. If you are in the white zone the heart rate is too slow, in the green zone it's good, in the purple, it's too high. When we were making them last night a priest asked if we were making molyo beads- which he explained are what women traditionally used to count the days of their cycle and know when they were most fertile.
Tomorrow is our workshop on labor management. We have made a large vulva puppet (out of bright african prints) that women can reach into and check cervical dilation and the position of the babies head, which we fashioned out of paper mache. It works really well and gets a laugh every time we whip her out.

In non midwifery related news, Chioke slaughtered a goat. They asked him to do it and without any apparant fear he took the dull knife he was handed and slit its throat. It was so dull he had to saw for a while until the goat stopped moving. I watched. It was both repulsive and impressive. The goat was then skinned and BBQed for a large feast. I made ground nut stew and stuffed peppers which were a big hit. The next morning, Sister Rosemary placed the roasted testicles of the goat on a plate and presented them to Chioke. For virility. He didn't say a word, just ate the rest of his meal around the jiggling balls. Finally when nothing remained but the testicles, everyone looked to him and he said 'no thanks sister rosemary' and everyone burst out laughing.

There are a number of American funders staying with us for the opening of a new counseling center. One of them is the host of a Cathlolic television show in the US called 'Focus'. She interviewed Olivia and I about the project. It was a difficult interview- I ended up having to sidestep a lot of questions like "tell me Rachel, are these the worst conditions you have ever seen for women giving birth'?
Which is a difficult question because yes, they are, but at the same time I feel a deep commitment to avoiding the Western Gaze onto poverty and the struggle of 'the other'. I know that evoking emotion in others creates commitment to change, but it's playing into a difficult and complicated discourse of 'west saving Africa' that I feel we need to more actively address in any kind of activism/outreach work.
Anyway, this is a national TV show and will probably bring lots of good attention/funding to the project- I suppose I will need to live with and write about my complicated feelings as it airs.


That's it for now. I am off to make broth for Chioke and Olivia who were both sick in bed this AM.

great north roads

It is still dark out but the alarm is blaring from Olivia's room and I can hear it through the tin walls as if it is were in the bed with me. I roll over in hopes of blocking out the noise but soon there is a knock at the door. It's 6:00. Get up.
We are driving to Atiak this morning for our first workshop with the Traditional Birth Attendants who will staff the clinic.

Breakfast is dry white bread with peanut butter and hot water with lemon.
Chioke has volunteered to drive the old white truck that Sister Rosemary has given us (now that she has a fancy Safari vehicle). Better him than me. It is a stick shift, but the gear shifter is up by the wheel, and there only appear to be two gears. We cannot find reverse, so our first moment involves Olivia and I jumping out and pushing the car out of the driveway.

'The Great North Road' stretches from Cape Town to Cairo. The stretch from Uganda to the Sudan is a thin strip of unpacked red dirt that has more pot holes and puddles than actual road. It is the kind of road that would make a chiropractor rich and makes a girl wish she had a better bra. There is never a moment of relief in which one can shift into a higher gear and just drive, it is a constant navigation of holes, bumps, puddles, mud and of course, people, chicken, cows, goats, motorcycles and huge trucks and busses carrying dry goods, soldiers and villagers alike, into the Sudan.
After about ten minutes on this road, Chioke turned to me and said 'Why are we doing this alone?'- to which I had no good answer.

One hour into our two hour journey we were flagged over by soldiers with guns. I realized as soon as Chioke slowed the truck what they wanted, but it was too late.
"Please, help these refugees get to the next town". We looked over to see about fifty people, babies, luggage, animals by the side of the road.
"How can we take all of them?"
"Please, just take the women and children"- and who can say no to that?
If in doubt, always play the women and children card to passing Americans.
So suddenly there was a rush of bags, pots of water, babies, women (and a few sneaky men), chickens loaded up into the cab of the car, piled on top of one other and spilling upward so that the final passengers rode on top of the truck.
Chioke, who now had the grave responsibility of driving smoothly enough to not knock any of these people onto the road, placed his face in his hands and took a deep breath. I felt bad, but not that bad as I was also hysterically laughing at the madness of it all.

The IDP camps of Atiak are located along the Great North Road (only great because of its length). Because of its proximity to this road and its proximity to the border of Sudan it is what most people call the 'pathway for the rebels'. It was the first village in Northern Uganda to be devastated by the war and the last to receive aid. The World Food Program only came in six months ago. There was a major massacre in this village on April 20th, 1995. Someone pointed out this was also the day of the Columbine Shootings which the entire world heard about, but very few have heard that on this day 250 people were lined up and shot while the rest of the village watched. In fact, this tiny Wikepedia article was all I could find on it.

We arrived 20 minutes late, to a group of thirty five traditional birth attendants (34 women and one man). More than we expected. They sang and danced to greet us and we soon settled into a comfortable circle under a large tree.
The training went amazingly well. It was a true sharing of practices, knowledge, ideas and stories. We began by having everyone speak about their first experience at a birth. Many of them had attended the births of their 'co-wives' as young girls who were first married. In all of the stories, history was reflected- they all got 'trained' in 1989 by World Vision and this was when they considered themselves official TBAs, and also the time they were taught to keep women lying on their backs throughout labor, to restrict them from food and water and to refer, refer, refer to the health unit (at that time the closest one was 7 miles away).

We then invoked an image of a large pot and asked for everyone's collective knowledge. Olivia and I enacted a 'normal' birth one of us in labor, the other the midwife, and we asked them to tell us what to do in order to manage it. We then acted out complications and asked for the same feedback. It was really fun for everyone (most who cannot read or write) and tt was an incredible tool for gathering what they do know and also seeing where the gaps in knowledge are (ie, when Olivia fake fainted from a hemorrhage they said, give her tea and wipe the blood).

We spent a lot of the day focusing on labor positions and comfort, which was also really fun. Massage, comfort and one on one support are arts that have been lost in the flurry of technocratic trainings and trauma of war- and yet were able to pull out some of their 'old knowledge' and also add a few of our tricks to the bag- and lastly, on our little laptop screen in the middle of a refugee camp, we showed a video of a home birth in America, which really caused some tong clicking and oohs and ahhs as the woman in the video squatted down and leaned on her husband for support as her baby was born.

I once again question the line between offering 'too much' information and allowing what they know to be trusted as well. I think we were as successful as we could be- allowing for a group knowledge that grows and builds on itself and where best practices are valued as those that are safest and most culturally relevant.

The drive back was pure misery. We got stuck in the mud and once again, Olivia and I hopped out to push the truck which slid and skidded all over the place, blowing black smoke and red clay like mud all over us. Eventually a truck stopped and with the help of a few more men we were soon bouncing down the road to Gulu. I can't quite imagine how we will do this every Monday.

A long update today. I suppose the great north road is a good metaphor for this project- it is something you can navigate, but it twists and turns in the most unexpected places, it is longer, it is deeper, it is more expansive than any one person, one project, could ever know.

ways of knowing

Sunday mornings are slow. I baked some eggs with fresh garlic and tomato and brewed fresh Ugandan coffee.
I have a moment to reflect and yet I can't shake this feeling of wanting to escape the process somehow. I have been thinking a lot about communication and its culturally embedded nature. Sometimes you think you are on the same page with someone but it turns out you are not. I had such an encounter yesterday with Lam, our connection in Atiak.
He was a generous host. He housed us, fed us, connected us to the chief of the village so that we could get his blessing, and helped us to coordinate the first meeting of the TBAs. We set up our first training for monday (tomorrow).
Yesterday I ran into Lam on my way to a workshop with the child mothers at St. Monicas. He was insistant that we meet that moment, even though I was rushing to begin the workshop. What came out was that he thought we should wait a week to begin the trainings because he wanted to be there for it and he had other obligations. I explained that I understood his frustration, however, since we are here such a short time, it is important to begin sooner and that he should rest assured there would be a place for him when he came. He then became very upset that I did not concede to him, stating a few times that my project won't be sustainable without him and 'This is Africa, you need to listen to the men". I explained that this sounded like it required a real meeting and I was running to a workshop so could we please meet later? He stormed off.

I left the room feeling shaky and uncomfortable. I spoke to Sister Rosemary who said he simply likes control and it is not a big deal, and ultimately, it is not- but it speaks to an overall issue of communication. We all have these different cultural narratives and ways of knowing that shape and shift the way we understand events- so the same conversation can be interpreted in a multitude of ways. I wonder how we enter into international dialogue in a way that nurtures some of these gaps and allows for perspective and listening. I wonder how women can navigate male spaces, and vice versa, I wonder what it will take to make it safe to allow men into womens spaces.

I saw Becky for the first time on Friday. For those of you who remember, she is the girl who lost her baby to an unmonitored cytotec induction last year. She came to the compound and we had a nice meeting, she is back in school and doing well. Then yesterday she showed up again. She said had been beaten by her landlords son, and kicked in the uterus and had been bleeding all night, soaking through pads. In reality she was bleeding very little and it came out later that this may have been her period, since she was expecting it. Not to discount her pain because I know it is valid and I believe she is indeed being beaten ( a cyclce I wish with all of my heart I knew how to stop), but I am interested in the need for women to present themselves as victims in order to get attention- even from other women. So many questions are coming up for me around how to advocate, how to heal, how to empower and how to represent in a way that speak to my earlier questions of communication and cultural difference. Robbie Davis Floyd has a great article on Ways of Knowing and thinking in midwery systems. She says that even cultural relativist thinkers (those of us who value each cultural belief as equal, not prioritizing our own), must move beyond to what she calls Global Humanism, a way of knowing that says yes your way is good and my way is good, but there are certain things, like the beating of women, which we ALL must move beyond, even if it is 'cultural'. I like this, yet the way into action is thickly layered and complicated.

We have just returned from Atiak.
It is a community of IDP camps 20 miles from the Sudanese border.
Literally the pathway for the rebel army and as such nearly untouched by resources.
We slept in huts in the camp and met with the elders of the community as well as the TBAs to do a needs assesment. It seems the largest issue is that Doctors Without Borders came in about 5 years ago in the height of the conflict. They provided tons of care but in the meantime, replaced the doctors and healers of the community. They left last month to go to Somalia and the community is without any formal healthcare system. The TBA's have jumped back in to catch babies but do so for no money and with no backup support should an issue arise.
Sister Rosemary is setting up her second school in this area and so we are beginning the TBA work here. The TBAs will work hand in hand with child mothers to create a model for safe birth that is realistic for their community.

Internet is in and out so I will have to be short again, but I promise some full throttle blog entries soon. They are collecting on my computer, just can't plug it in yet.

Arrival

It has been a journey.
Start with the getting here. It took us three days, four planes, one night in a tent and a six hour drive through the night to land us in Gulu. On the plane from London to Nairobi, Chioke fainted. I was fast asleep and felt a strong tapping on my shoulder. I looked at my seat mate to the left and he pointed to the floor where I saw Chioke's legs. At first I thought he had just fallen into a deep sleep and perhaps fallen out of the aisle seat, but it soon became clear that he was unresponsive. A few minutes later with some oxygen and some loud and unnecessary freaking out of the missionaries sitting around us (was he drunk? was he acting weird? do you think it's a seizure?), he was back into consciousness and had no memory of even feeling sick before he went down. We chalked it up to altitude, and I kept my hand on his pulse and plowed him with tea and power bars to bring his blood sugar and body temperature up.It was an intense experience for both of us, and for very different reasons. For me, it brought up feelings of impermanence and transition- moving from one space to another. Perhaps there is a necessary moment when we all must check out in order to make room the next space. I don't think this moment is one we often acknowledge or think about, but I think it is intrinsic to moving through time and space. Chioke provided me with a dramatic enactment of this. He made me take a picture of him with the oxygen tank on his mouth (that was when I knew he was feeling better) so perhaps I will post it and others soon with internet is more reliable.

The first night in Nairobi, sleeping in a tent, feeling the stars and the cool air around my body and in the words of Sister Pauline, deep in the belly of my blanket, I took a deep breath and allowed my arrival on the continent to sink into my body. The weight of travel, of moving through, and finally arriving somewhere is a process that inspires reflection and perhaps even eloquence. And yet what I found was that I had no words. The sound of the monkeys outside, the coyotes in the distance, a crickets at my feet provided a sweet lullaby and I fell into deep sleep.

I am going to invoke a 'fainting spell' into this narrative now, a necessary checking out and skip to our arrival in Gulu. It is beautiful. Perhaps even more than I remembered. The amazing warmth of the nuns and the hospitality they provide. Lush green grass layered over brick red dirt and trees that house animals large and small. The sweetest pineapples, the juiciest mangoes, the ripest avocados, stacks of fried dough and mushrooms that grow in abundance from termite mounds and melt the moment they meet your tongue. Perhaps the eating of meals offers a way of knowing a place that is as layered and diffuse as the hands that harvest, buy, prepare and eat the food itself. The contrast of course, is that most people are hungry here and that hunger or shall we say great need, pervades moments of intimacy, connection, genuine opportunities to achieve success. I find it hard to have anything to say. I'll call it an adjustment and processing period and hope that in a few days I will be able to describe the actual events that have unfolded. For now I will give a bit of a list.

1. Olivia has done a lot of prep work. She has selected 12 Traditional Birth Attendants to begin training immediately. The vision shifts a little every day as reality and needs come up and we work to create a project that is truly community centered.
2. The clinics walls are up and the construction is in full swing. It should be finished within two weeks.
3. Sister Rosemary has identified a group of women between Gulu and the Sudanese border who have been untouched by resources. She has purchased land in this area called 'Atiak' and will build another St. Monicas there. We are headed there this evening to meet with the TBA's and think about how all of our sites can connect to resource these child mothers. We will stay over night and conduct narrative interviews in the morning.
4. I am tired.
5. I am excited.

Preparing and Breathing

I am readying myself for another journey.
A year later and somehow no less complicated.
Last year in Uganda the goal was to work on a maternity ward at a government hospital serving mostly refugees of the war.
The trauma was deep (go back to the June 07 archives of this blog to read about the experience) and it manifested not only in the care that women received, but in the culture surrounding birth and intrinsically, death.

My partner and I worked in a hospital with no running water and unreliable electricity, and perhaps it was that our goals were not clear enough or that there really is a fine line between helping and hurting, or that we put ourselves in a traumatizing situation from which we had the privilege to walk away from, but ultimately we never managed to escape the dynamic of insider/outsider. I believe that both of us had radically different experiences of our time and of the ward itself.

I returned from that trip with post traumatic stress disorder. I began to have panic attacks and had to slowly peel back the layers of hurt and anger that I had pushed through in order to survive, in order to work, in order to be a healer to the best of my ability in that environment. Many things have come up in this process of reflection that have brought me to an innate trust that both personally and globally, change begins within. So how does a person, a group, an organization effect sustainable change in a space that so desperately needs help?

The Earth-Birth project has been a long time collaborative vision between myself and my co-midwife Olivia. Over the last year much has happened to turn vision into reality and without going into a long list, I will say that the turning point for me was when I realized I needed to stop pushing up against a system that isn't working. The question of why 'western' medicine is problematic in under-resourced areas is a subject of much fascination to me- and is the heartbeat of my work in academia, narrative medicine and midwifery. Right now it's all questions- but the main goal is to create sustainable birthing centers that allow women access to important maternal and child care while at the same time offering opportunities for emotional health, healing and empowerment.

So how do I enter into this?
Midwives say its all in how you breath.
Find the center of it, go deeper, allow it to fill all the little spaces and then release. Expansion and contraction.

I am feeling the contraction after expansion. Perhaps it is the necessary tightening before opening wider. I wonder how a person stays open despite the past.

Turning Vision Into Reality

I am happy to announce the initial launch of the home site for The Earth Birth Global Women's Health Collective: http://www.earth-birth.com/
We are officially virtual.

Thank you to everyone who has supported our project. If I have not been able to send you a personal thank you it is because things have been blossoming quickly.
If you have not had the time to see how you can get involved and support this enormous effort, check out the website!

The site is a work in progress. Please check back for updates, podcasts, interviews and more.

Midwives reach out

This is a great little PSA for a better trained international community of midwives.
The problem, as I see it, is that we tend to train from one model (a western model) of care which fails to take into account the cultural needs and resources of a community. I think hand in hand with the medical training of midwives, we must do training's in critical risk assessment based on a community of cultural competent midwives. We have to start thinking about how culture effects medicine and inversely, how western medicine effects culture, if we want to have truly integrated approaches to treating women.

Abnormal agency

Twenty-four women sit cross-legged on straw mats that are laid out strategically to cover the dirt between two huts in Unyama, a camp for internally displaced persons in Northern Uganda. A plate of boiled yams is passed around and water is poured from a large gourd into tin cups. One of the women towards the back raises her hand and begins to speak. I cannot tell if she is young or old. Her voice is soft and we all lean in to hear her. She pauses between sentences so that the translator can speak into the recorder.
A woman came to me in the night. She was feeling strong labor pains. I stayed with her into the morning. Finally, she began to push. I leaned in close to her, placed my hands to catch, but instead of a baby… she pauses and glances around the circle, we are all silent in anticipation, imagining what could have come out in place of a baby…instead of a baby, a swarm of one thousand black flies flew out of her vagina into the hut in a thick cloud. Almost like smoke from a fire. After this there was no sign of a pregnancy. Nothing at all. Her belly became small and tight very quickly. We took her to a hospital and the ultrasound revealed nothing. It was as if it never happened. An American doctor for World Vision suggested we were crazy but I know what I saw. Tell me sisters. Tell me. Was this the Devil? Most women begin to nod their heads in agreement and one woman calls out “yes, yes, this is the work of the devil, I have seen something similar…”
Suddenly there is a rush to speak. Women begin rapidly telling tales of abnormal or ‘devil influenced’ births they have attended: a woman who gave birth to a large hairy eyeball, a child born with her foot attached to her head, and a baby born with a full set of teeth. Sitting in this circle I find myself wondering how narratives about the body and birth work to both create and heal the traumatized female body.

This particular incident was transcribed during a meeting of Traditional Birth Attendants, women trained by their mothers, sisters and aunties in the art of catching babies. None had been formally trained by Western standards, but all had attended hundreds of births and most were mothers as well. Supported by a grant from Mama Cash, an organization that allocates funds to bolster the position of women’s rights, I was one of two Americans, a midwife and a doula, working alongside Ugandan midwives with the intent to exchange practices, share techniques and understanding of the birthing body. I hold a Masters degree in Performance Studies, which framed my understanding of this circle of tales as a performance of it.

The ‘devil’ is one of multiple answers to the question of ‘what’ came out of this woman instead of a baby. The biomedical rationale for a swarm of flies disguised as a pregnancy could be that the laboring mother had a parasite. According to the American Journal of Infectious Disease ‘Gasterophilidae’ or ‘Stomach Botflies’ can produce a pregnancy like distension of the pelvis. Another biomedical explanation may be that, as the World Vision doctor suggested, the birth attendant was delusional and imagined the entire incident. The institution of medicine produces a certain story of the body, one that is skeptical of personal experience narratives. From the biocultural perspective however, the rationale will be as diffuse as the experiences of the women sitting in the circle. Religious belief systems, myths and ritual may be used to make sense of the world in ways that move beyond scientific explanation and offer points of entry into understandings of health. dimension of narrative and voice as intrinsic to women’s health care in particular.

In war torn Northern Uganda, the biomedical conditions of women’s reproductive health are mediated and created by the circumstances of cultural warfare. For twenty-years a group of rebel soldiers attempted to tear down the Ugandan government to replace it with one, it claimed, based on the Ten Commandments. In the name of those religious principles the ‘Lords Resistance Army’ kidnapped more than 20,000 children, who made up the bulk of their fighting army. Some academic attention has been paid to the stories of boy soldiers but fewer accounts have been published of what happened to the girls, although we know that rape and servitude - as well as murder - are part of the tale. Most of the women in Unyama are refugees who have escaped abduction by rebel soldiers and are now giving birth to their rapists babies.

Even in rural Uganda, birth is managed from a technocratic model. “Traditional” birth attendants are trained in practices that date back only as far as British colonization. The story of the cell is privileged over the story of the woman. In spaces such as Unyama, I posit that the biomedical explanation of an ailment is not always the most helpful. Knowing that the flies were a parasite might be useful in America where one has access to clean drinking water and hand sanitizer in order to change future outcomes. In Unyama, knowing the conditions of emergence does little to change the circumstances of transmission. It is not surprising that it is the abnormal birth stories that create the necessary conditions for narrative sharing among the group of women who are both refugees and birth attendants. The tales are bound to overarching themes of religious morals, sin and punishment; themes that are not unlike the conditions that produced the pregnancies themselves. These tales of the devil mirror cultural circumstances and can be useful biomedical tools towards understanding what women think about their own bodies, the babies that pass through them and how they care for one another. The vocalizing of the tales demonstrates a certain level of ownership and rationalization of the circumstances, making possible the potential for personal decisions and choices about bodies and babies, which may be inclusive of safer biomedical practice. The two models overlap and intermix, the story of the woman informs the management of the molecular tale.

In a medical context, interpretation of narrative is critical; the successful transmission of information becomes intrinsic to the care that a patient receives. A scientific explanation may have its place in the treatment of physical ailments- yet it does not address the integral nature of women’s understanding of her own experience and therefore her ability to heal or prevent future instances.

I am interested in intersection of these two tales of the body– the spaces between what a woman speaks and a doctor understands, what a human experiences and science explains. I am interested in exploring the multiple narratives or means of framing one story, and locating the cultural influences between these narratives that can lend agency to both medical practice and patient care. While science may offer some explanations for the social conditions, to privilege the biomedical tale of the body misses opportunities for understanding and thus changes of practice that might be accessed through cultural narrative. The spaces and gaps between the story that is narrated by a patient and the story that is actually heard and interpreted by a health care practitioner should be explored to determine impact on women’s bodies and agency.

Personal Narrative as Medical History?

I am the daughter of a storyteller.
Personal narrative has been alive in my cell memory since I was born.
My research as of late has been on the medical history- this charting of abnormality we all fill out at the doctor, which helps them to pathologize and diagnose, yet misses most of our actual history of 'health'.

About two years ago I had Cellulitus (a bacterial skin infection) on my face.
I recently switched doctors and so I had my medical records shipped to me. In the ‘notes section’ of this chart, my Doctor had written:
Patient presents with swelling and rash on ears (and face). Bumpy and hot to the touch. Skin is swollen to capacity and has burst… oozing a sticky yellow fluid, between water and puss. Left ear grotesque. Diagnoses: Cellulitus. Treatment: Penicillin and Benadryl.

Aside from feeling slightly woozy from the description, I was intrigued. Here was a history of my body that somebody else had narrated, and I had never seen. Not only that, I remembered the experience completely differently. In my memory it was not my ears that mattered so much, but my eyes, mouth and cheeks: a parenthesis in the Doctors description, but the most painful for me. I remember that all I wanted to do was cry, but could not because my eyes were swollen shut. I remember my cheeks stung and dirt kept collecting on the moist (pussy) skin so I had to lay with a wet washcloth spread across my face to keep from further infection

As Foucault points out in ‘The Birth of the Clinic”, “I cannot be present to a temporality that exceeds my own capacity for self-reflection, and whatever story about myself I might have to give has to take this into consideration. It constitutes the way in which my story arrives belatedly, missing some of the beginnings and preconditions of the life it seeks to narrate”.

Interestingly, a year before I received these charts, I had a flare up of the exact same symptoms that landed me in a Brooklyn emergency room. When my medical history was taken, nobody asked if I had ever had the same thing happen before. I was diagnosed this time with an allergy to Penicillin, the very drug that was used to treat the initial condition. It is hard for me to narrate the significance of these events on my physical body, in part because it is impossible for me to understand them apart from the context in which they emerged. Swollen to the point of having no facial features, my body became unrecognizable to my ‘self’. In order to give an account of myself in a way that was meaningful to the Brooklyn ER Doctors, I needed to remove myself from the actual experience; citing exact moments of swelling and symptoms, and leaving out the rest of the story. Reflecting on this experience and flipping through the charts that documented my medical history I cannot understand them as ‘mine’ without attaching experience to them. In my present embodiment I carry a mark of those stories. I still have a scar on my left ear from the broken skin that the doctor described as the biggest he had ever seen. Yet if asked for proof, ultimately, it is the charts that become the ‘official’ history of my body and not the scar. The scar, however, carries a story, one that is more ‘mine’ than the chart.

In a medical history form there are a prescribed set of questions that are meant to engage and evoke answers that fit into a prescribed way of understanding the body and its past or present malfunctions. The chronological history of the ‘event’ of malfunctions as well as a number of vague lifestyle questions such as overall diet and exercise lead the practitioner to a fuzzy framework of understanding the body they are treating.

The Health Care Financing Administration (those who decide what medical procedures will or won’t be reimbursed) and American Medical Association require the history component of the examination to the following elements (commentary in italics is written in a guide for medical students by chairwoman Donna McCune ).
• Chief complaint (CC)
“The CC states why the patient is in your office. It is a brief description of the reason for today's visit including symptoms, conditions, problems, diagnoses, physician-recommended return, or other explanation. It is usually stated in the patient's own words. This entry is an essential part of every chart note. There must be a reason the patient is sitting in the examination chair.”

• History of present illness (HPI)
The CC and the HPI have a similar connotation. The HPI is a chronological description of the present illness from the first sign or symptom or from the previous encounter to the present. It contains subjective symptoms not observable by another (e.g., pain and nausea) and objective symptoms that are observable (e.g., redness, swelling).

• Review of systems (ROS)
An ROS is a listing of any signs or symptoms the patient may be experiencing or has experienced organized by body system. The ROS is not a history. It is a review of systems directly related to the problem(s) identified in the HPI as well as any pertinent current medical problem(s). There are 14 possible systems: constitution (general health), integumentary, eyes, musculoskeletal, ears nose throat, neurological, cardiovascular, hematologic lymphatic, respiratory, allergic/immunologic, gastrointestinal, psychiatric, genitourinary, and endocrine

• Past personal, family, and/or social history (PFSH)
The PFSH has three parts:
Past personal (current medications, allergies, prior illnesses/injuries, operations/admissions) Family (members living, health status, hereditary conditions related to the present complaint or illness) and Social (marital status, employment, tobacco, alcohol, drug use).


The author of this guide may provide insight into why health histories of the last one hundred years are only concerned with moments of rupture. Unless there is scientific capital to be gained, liability says that it cannot be done.
This locks Doctors into a system from which they must obtain very specific information and ignore the information that doesn’t fit into the box of what insurance says is important. In relation to what she is suffering from, the patient becomes an external fact; the medical reading takes her into account only to place her in parentheses. This enables classificatory medicine to presuppose a certain configuration of disease. The above framework for taking a medical history is used by all Doctors who are members of the American Medical Association. It takes into account a certain history of the body and completely ignores or bypasses another, assuming that illness happens in a prescribed and methodological way. Arthur Kleinmen, in his preface to Patients and Healers in the Context of Culture (1980) offers, “Clinicians tend to be simplistic about clinical practice. Their tendency toward positivistic scientism and atheoretical pragmatism discourages attempts to understand illness and care as embedded in the social and cultural world. Their reliance on ‘common sense’ often masks ignorance of relevant behavioral and social science concepts that should be part of the foundation of clinical science and practice”. (7)

Just a whole slew of thoughts today....

Byllye Avery

I attended this talk last week, given by Byllye Avery:

Breathing Life into Ourselves: Personal Stories as Research

For the past 25 years Black women have been engaged in telling the stories of their lives, their struggles and triumphs as part of the Black women's health movement. These stories are liberating for the women who tell them as well as the women who listen. The process of sharing personal stories, some obviously related to women's health, some less so, allows women to become active proponents of their own health. Active listening to such stories develops awareness of shared experiences and helps to suggest answers for addressing health and social issues. It also provides information for conducting research and understanding the power of acceptance and self esteem in self care and self healing.

Byllye Avery is a busy woman. Founder of the Avery Institute for Social Change and the National Black Women's Health Imperative and The Birth Place

It was so overwhelmingly inspiring to hear not only about the incredible projects she has effected, but also to think about framing and creating solutions to women's health issues from a narrative as evidence perspective. Listen to a podcast of her speaking here.

A quick shout out to the conference Byllye is organizing in Boston next week. Details are below. I so wish I could be there but I will be helping my good friend Ame at the Umami Festival that night. Also something worth checking out for all you NY foodies!

» Women Must Lead Health Care Reform: National Health Care Conference April 17-18

BOSTON (April 10, 2008) Some of the nation's leading women's health advocates, including former U.S. Surgeon General Joycelyn Elders, will convene at a national conference April 17 and 18 at Simmons College in Boston, to help mobilize a grassroots movement for creating a progressive U.S. health care system that meets the needs of women and their families.

More than 300 national, state and local women's health care advocates will attend the conference, "Hear Us Now! Raising Women's Voices for the Health Care We Need," to engage in an array of panel discussions and training sessions on topics ranging from health care insurance obstacles facing women and girls, to the vision of health care for all from a policy perspective.

This event is open to the public, but R.S.V.P. is required. To register, visit www.raisingwomensvoices.net.

The national conference is organized by the Avery Institute for Social Change, National Women's Health Network, and MergerWatch Project of Community Catalyst, to launch a campaign of actively involved women's health advocates in health care reform. The "Raising Women's Voices for the Health Care We Need" strategy focuses on identifying policy issues related to women's health and healthcare reform; engaging a national network of key women's health stakeholders; developing a women's vision of quality health care for all; and engaging women to become actively involved in the national health care reform debate.

Joycelyn Elders, M.D., former U.S. surgeon general for health and human services, will deliver the keynote address April 17 at 9:45 a.m., "The Crisis in Our Health Care System: Why Don't We Have Quality, Affordable Health Care for All?" in the Linda K. Pareksy Conference Center, 300 The Fenway, Simmons College.

Other featured speakers include Judy Ann Bigby, M.D., Massachusetts secretary of health and human services; Claudia Morrissey, M.D., MPH, president of the American Medical Women's Association; Byllye Avery, founder and president of the Avery Institute for Social Change and founder of the Black Women's Health Imperative; Miriam Yeung, executive director of the National Asian Pacific American Women's Forum; Judy Norsigian, director of the Boston-based Our Bodies, Ourselves; Jessica Rojas-Gonzalez, policy director of the National Latina Institute for Reproductive Health; Judy Waxman, vice president of the National Women's Law Center; and Maureen Corry, executive director of Childbirth Connection.

Conference topic titles include:
• "Uninsured or Under-Insured: Who is Left Out of the System Now?"
• "Making Our Health Care Culturally Competent"
• "Why Isn't Health Care Considered a Human Right?"
• "A Call to Action"

Women's health care advocates say that women's input in the debate on health is crucial, considering their frequent role as the decision-maker for their family's health care. Additionally, with 47 million Americans without health insurance, certain groups of women, such as Latinas, are often disproportionately affected. Those women who do not have insurance, or whose insurance coverage is inadequate or too costly to use, often postpone care or do not get prescriptions filled for themselves or their children. The Institute for Medicine reports that more than 18,000 women die from lack of medical care each year. Women face special concerns such as the loss of dependent health insurance when they become divorced or widowed, and the refusal by insurers in some states to insure women who are pregnant.

To determine specific health care needs and problems of women and their families, organizers have been conducting small group meetings with targeted women's health audiences, particularly underserved groups that are often excluded from health care reform discussions.