Over the past few decades, maternal childbirth injuries have become a potent symbol of Western biomedical intervention in Africa, affecting over one million women across the global south. Western-funded hospitals have sprung up, offering surgical sutures that ostensibly allow women who suffer from obstetric fistula to return to their communities in full health. Journalists, NGO staff, celebrities, and some physicians have crafted a stock narrative around this injury, depicting afflicted women as victims of a backward culture who have their fortunes dramatically reversed by Western aid. With Beyond Surgery, medical anthropologist Anita Hannig unsettles this picture for the first time and reveals the complicated truth behind the idea of biomedical intervention as quick-fix salvation. Through her in-depth ethnography of two repair and rehabilitation centers operating in Ethiopia, Hannig takes the reader deep into a world inside hospital walls, where women recount stories of loss and belonging, shame and delight. As she chronicles the lived experiences of fistula patients in clinical treatment, Hannig explores the danger of labeling “culture” the culprit, showing how this common argument ignores the larger problem of insufficient medical access in rural Africa. Beyond Surgery portrays the complex social outcomes of surgery in an effort to deepen our understanding of medical missions in Africa, expose cultural biases, and clear the path toward more effective ways of delivering care to those who need it most.
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About the Author
Anita Hannig is assistant professor of anthropology at Brandeis University, in Massachusetts.
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Injury, Healing, and Religion at an Ethiopian Hospital
By Anita Hannig
The University of Chicago PressCopyright © 2017 The University of Chicago
All rights reserved.
A Malleable World: Injury, Care, and Belonging
When Yeshi was on her second pregnancy in her early twenties, her husband bought her a leather amulet that contained what she called habesha medhanít (Ethiopian medicine), an herbal mixture that was to stave off another stillbirth, like her first one had been. This time, she had attended prenatal checkups at her local clinic in Sanja district three times before the labor pains set in. After being in labor for two days, it became clear that the delivery wasn't progressing. Yeshi made her way to the clinic, where she received a glucose injection and was told that nothing else could be done for her there. At great expense, her husband hired a private car to transport his wife — who had meanwhile lost consciousness — to the public hospital in the town of Gondar. Two hours after her arrival, a physician extracted the lifeless body of her baby. When she regained consciousness, Yeshi was shocked to realize that she could no longer control her urine.
Given her strained relationship with her mother-in-law, Yeshi and her husband decided to leave his family's compound to take up residence in a nearby town. "I was afraid she would start gossiping about me when she saw the leaking. She was jealous of our relationship," Yeshi said. At their new home, her husband fetched water, brought firewood, and washed her clothes, all traditionally female responsibilities in the household. "We sold cattle in the market twice to get the money for the transport to Bahir Dar," she recounted. "My husband had heard of someone who had been cured there and he said he would take me. He gave me hope that I would be cured also." Meanwhile, families on both sides were clamoring for a divorce. His family worried that she would never be able to give their son any children; her family accused her spouse of not being "a lucky husband for her." But, as Yeshi told me, "they couldn't divorce us because we have love [fiqir]." Against the wishes of both of their parents, she and her husband stayed together through her treatment. After what appeared to be a successful surgery at the fistula center in Bahir Dar, Yeshi was anxious to return to her husband and get back to her life, though she remained concerned about staying childless in the future.
This chapter explores how Amhara men and women deal with the advent of obstetric fistula in their lives against the background of normative kin, marriage, and social conventions. How do relationships of care play out in a context of adversity? What kinds of negotiations do spousal arrangements undergo when one partner becomes debilitated by incontinence? And how might Amhara women's enduring social obligations expose the inadequacy of the conventional "sick role" model?
The pages that follow complicate the widespread assumption that women's birthing injuries inevitably lead to the disintegration of their familial and wider social connections. The chapter examines mechanisms in Amhara society that bind people to larger collectives and elucidates how these ties are mobilized — and sometimes reconfigured — in the face of bodily injury. It shows how notions of kin ideology (which center around the provision of care in the form of food, labor, and support for the sick), flexible marital strategies, and principles of social reciprocity come together to destabilize the narrative of isolation that has so far dominated the publicity of fistula. What emerges is a more fluid picture of belonging that points to the productive potential inherent in bodily affliction. Following Jean Comaroff's (2007) insights on HIV/AIDS activism in South Africa, I use the term "productive" not to describe positive (or negative) outcomes as such, but — in line with both Marx and Foucault — to convey the idea of bodily injury giving "birth to significant forms of sociality and signification" (203), meaning an array of material and semiotic practices. As Laurence Ralph (2014) puts it in his ethnography on gang-related violence in black Chicago, "I saw how injury could be crippling, but could also become a potential, an engine, a generative force that propelled new trajectories" (17).
This chapter then also looks at the ways that women suffering from fistula struggle to reorganize their lives following the onset of their incontinence. For some, fistula resulted in bitter conflict with loved ones, divorce, and reduced social contact. But although their predicament might provoke a broad range of local reactions — such as sympathy, ambivalence, pity, fear, and disgust — women who incur fistula during childbirth don't become social outcasts. During my research, I never came across a single woman whose experience conformed to the social pariah template forwarded by activist and campaign narratives. While some women's relationships were severed in the wake of their injuries, others attained a new level of significance. The isolation women did experience was most often situational and self-imposed, in accordance with ideas of shame that carry different valences in different spaces. Women tried hard to navigate the anxious tension between ethical aesthetics of containment and social expectations of being a generous, engaged member of their community: on the one hand, they worried about being smelly; on the other, they were concerned about being seen as antisocial.
Kinship as Care
There is no question that the sudden incontinence of a wife, sister, or daughter — which is often accompanied by other physical disabilities such as foot drop or muscle atrophy — can place a major strain on relations of intimacy and provision. Amhara women's unexpected bodily impairments put their connections to others to the test. This section and the next focus on how fistula affected relations generally classified as kin relationships and sketch the mutual obligations pertained therein. Kinship among Amhara, I suggest, is actualized by a wide array of processes of caregiving, including the provision of food, duties of labor, and bodily care for the sick. Amhara women understand and talk about kinship in ways that foreground this ethics of care.
Contemporary theories of kinship have done much to draw our attention to the care-based logic that underlies a variety of global kinship forms, both within and without blood ties (Carsten 1997, 2004; Stasch 2009; Garcia 2010; Klaits 2010; Sahlins 2011a, 2011b). These studies have revealed the ways that kin relations are "made and unmade in action" through concrete, material activities that signify varying levels of attachment (Stasch 2009, 107). Stressing the processual, action-oriented nature of kinship ideology in Malaysia, Carsten (1997) writes, "Kinship is a process of becoming, not a fixed state. The process is brought about through a variety of means which include feeding, living together, fostering, and marriage" (12). She extends this insight to her work with adoptive families in Scotland who "strongly assert the values of care and effort that go into the creation of kin ties" (Carsten 2004, 150). More recently, Sahlins (2011a, 2011b) has gone so far as to suggest that "mutuality of being" through actions like caregiving is the basic essence of kinship.
Existing accounts of Amhara kin relations have not emphasized an ethics of care when it comes to kin dynamics. In fact, previous studies (Levine 1965, 1974; Weissleder 1965; Hoben 1970, 1973) have characterized the entirety of Amhara social relations as hierarchical, competitive, and individualistic — a system of patron-client relationships that permeates nearly all aspects of life. "The reports of all observers of Amhara society confirm the generalization that its social relationships are organized to an overwhelming degree on the basis of hierarchical patterns and individualistic association," remarks Levine (1974, 123; original emphasis). Even though Levine acknowledges that among kin (zemed) "a much warmer ideal of human relations obtains" (1965, 82), his sense of the household boils down to "a vertically ordered set of status-roles" (1974, 123). More recent work on Amhara love and kinship by Malara and Boylston (2016) challenges this narrative of authoritarian power and suggests that care is, in fact, an integral part of kin-related hierarchies (though this care is itself hierarchical).
Drawing on these insights, I contend that kin relations, broadly construed, are of critical importance to Amhara men and women and that the very concept of relatedness is articulated through the idiom of caregiving tasks of various kinds. Whereas care can indeed contain seeds of asymmetry and mask relationships of vulnerability, the care extended by close kin in times of need also offers unparalleled potential for protection and affection. I am of course not suggesting that kin relations are always idyllic or inclusive — conflicts exist here as anywhere. In Yeshi's case, her injury brought to the fore an already problematic relationship with her mother-in-law, prompting her and her husband to move to a new town. Still, the current tenor in Amhara kinship studies leans too much toward hierarchy and submission, and care complicates the picture. In what follows, I begin by establishing some key pillars of Amhara relatedness.
One prominent act and expression of kin relations is the common consumption of food. The Amharic term for family (béteseb) refers to "any group of people who live together in a single homestead and who depend on a common source of food" (Hoben 1973, 43). Béteseb thus does not necessarily refer to a discrete kin unit (although it can) but to those who dwell and eat together. The theme of food sharing threads itself through a number of Amharic kin designators, highlighting the importance of commensality for forging and affirming bonds of closeness. The terms for stepmother/father or stepdaughter/son, for example, are all prefixed by the word injera — the flat, round, sponge-like bread that is the region's staple food. The designation for stepmother is yeinjera innat — "mother of injera." Similarly, the term for a foster child is yemadego lij, with madego deriving from the word for hearth (midijja), thus translating to "child of the hearth." The act of consuming food together and providing for another person's bodily nourishment therefore index a primary mode of belonging. In this way, food provision becomes metonymic of kin relations.
For instance, as patients in our focus group discussions at the Bahir Dar center told me, when a girl becomes accomplished at baking injera, people in rural areas generally say that she is ready to marry and become the caretaker of a household of her own. Relatedly, when two families are merged through marriage, it is important that both parental households put on major feasts to properly seal the new affinal connection. During mels, the "return" visit of the bride and groom to her parents' house after the "main wedding" (yewanna serg) at his house, the bride's parents must try to match the groom's family's lavish provision of food. As one fistula patient put it, "Mels takes place to make the two families closer. If a groom doesn't have mels at his new wife's house, he will be like someone they know from the market." If the bride's family cannot afford to provide a proper feast for mels, the relationship between the groom and his wife's kin remains confined to one of social distance.
Sometimes, the feasting doesn't stop there. One woman related the following during a group discussion on marriage: "In our area, after mels at my parents' house, we might stay with them for seven to ten days. Then there is something called asertu [the tenth]. There will be a big festivity at his house on the tenth day. His best men will be called again. They will bring ten injera each and we will receive a new name for us, yedabosim [the name of the bread]. They break the bread and we each get a new first name, though nobody really uses that name." These examples underscore the fact that in-laws don't become family without care. The sharing of multiple, elaborate meals between in-laws ratifies the new connection. As Boylston (2013) points out in his discussion of Ethiopian Orthodox food practices, "Sharing food does not just represent social togetherness, but produces it" (262).
As with food provision, kin relations entail duties of labor that express an ethics of care. The reciprocal side of parental care is most prominently contained in a child's duties of labor. The responsibility to assist with household chores is considered part and parcel of a child's position in the household, especially in rural areas: it is expected that young children work in the household or the fields of their parents or other kin (H. Pankhurst 1992). Girls usually fetch water, grind grain, learn to spin and cook, and herd animals, while boys help with the harvest, weed, herd animals, and learn how to plow. If a family has few means, parents may send their daughter or son as a worker to the household of a more affluent relative in town, where he or she can also sometimes attend school. In old age, parents then expect to be cared for by one of their children, usually the youngest.
The so-called gift (sit'ota) marriage further elucidates this principle of labor as care. If a son or a daughter comes from a family whose parents are either sick or divorced, he or she may initiate such a union primarily to gain access to a household helper to assist with daily chores. A sit'ota marriage is one of the only marriages that is usually not sealed by formal festivities or a priestly blessing. If a woman agrees to this type of arrangement, she will take care of a sick or dying parent-in-law and run the household. If a man enters a sit'ota union, he will take over the plowing needs of the homestead and help with heavy-duty farming activities. Once the in-laws pass away, the "gifted" spouse can lay claim to a large share of their inheritance.
Besides the provision of food and duties of labor, offering bodily and material care in times of sickness falls squarely within the domain of kin responsibilities. In our conversations, fistula patients routinely identified care provider tasks as clearly marked kin duties. The way they spoke about nurse aides who cared for them at the fistula center illustrates this obligation well. Some patients stated that the work of these women, who scrubbed their bodies, spoon-fed them when they were weak, and changed their soiled linen, amounted to — and sometimes even exceeded — the intimate bodily care required of close kin. In the words of Yashume, a seventy-year-old woman from the South Gondar zone, nurse aides "do work that not even our fathers and mothers would do." When talking about her own relationship with patients, Tigist, one of the Bahir Dar nurse aides, similarly remarked, "I am very close to my patients. They consider me as part of their parents." These sentiments reinforce the normative principle of caregiving among kin who are expected to look after you when you are unwell.
If they contain this central element of care, other interpersonal relations are — at times — likened to kin relations. When my research assistant and I visited Yashume at her home on Lake Tana, her neighbors reportedly told one another afterward that "Yashume's mother came to visit her." I must have looked confused when Yashume shared this detail with me a few months later, because she smiled and quickly offered an explanation: "They called you my mother, because you cared about me like a mother would, and you came to my home to see me and to check up on me." While everyone understood that I could not be the genealogical mother of a woman who was twice my age, the term was meant to communicate the assumption that I had come to look after Yashume in some "motherly" way, for instance by providing her with material articles, such as food or money.
Kinship and Fistula
The primacy of care in Amhara kinship ideology gains particular significance in the home care of women suffering from fistula. Ties to those considered kin, which can include godparent relationships as in Yashume's case, proved to be critical resources in the aftermath of women's birthing injuries. Most women returned to their natal home for the delivery of (at least) their first child, where they typically remained following the onset of their incontinence. In the face of their growing anguish over their relentless leaking, they recounted how parents and siblings volunteered to wash their bodies and clothes, fetched them holy water from the local church, procured expensive meats to speed up their recovery process, and expended large sums of money on various treatment options for them.
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Table of Contents
Part 1 Kin, Society, and Religion
1 A Malleable World: Injury, Care, and Belonging 31
Interlude: Yashume 57
2 The Pure and the Pious: Flow, Containment, and Transgression 64
Part 2 Fistula Treatment and the Institution
3 Mending the Mothers of Ethiopia: Institutional Roots, Logic, and Mission 93
Interlude: Poison 119
4 Clinical Tracks: Moving through Surgery 122
Part 3 Beyond Surgery
5 Healing and Reforming: The Making of the Modern Clinical Subject 149
Interlude: Conversion 176
6 From Orphan to Apprentice: Crafting Patient Entrepreneurs at Desta Mender 179