Last night I witnessed an interesting event while I was hanging out before bed that I thought was blog-worthy, so I wrote it up. Here's some background. There is a young (mid 20s) woman in our village (let's call her Sue) who has an ~18 month old child. She moved here a few years ago when she married her husband. When she came, she brought one of her younger sisters (let's call her Betty) along to help her run her new compound. Sue and Betty generally relatively equally share the burdens of running their portion of the compound (cooking, cleaning, laundry, etc) and caring for Sue's child. Most of the time, this set-up works fine, but occasionally Betty loses patience with having to do all this work and runs off to play with her friends like the elementary-school kid she is. Naturally, this is when problems arise.
Last night, Sue decided she wanted to hang out with her friends instead of watching her child, so she assigned Betty to babysit. Betty was in the middle of playing a game with her friends when she received this unwelcome news, so she refused. This situation quickly escalated into Sue hitting Betty with a large stick and ranting about it not being fair that she had to watch her child by herself all the time. At this point, something cool happened. As I've mentioned previously, corporal punishment is very common here and generally witnesses stand by and let it happen without batting an eye. This time, however, something about the situation triggered the other women in the compound to run over to stop the beating. One of them even jumped on Sue's back and took the stick away from her. Once they had successfully stopped the beating, the women turned on Sue and gave her a serious tongue lashing, among other things, accusing her of being a bad mother for always trying to push her child-watching duties off on Betty.
This intervention in defense of a pre-teen girl (the generally accepted work-horses of any compound) really surprised me. My initial reaction was that the trigger must have been that Sue was so hugely and obviously in the wrong. But, after further thought, I started to wonder...how wrong was she? Well, of course, corporal punishment is not a strategy I support. And after all, she made a choice when she decided to have a child and now she has to live with that responsibility. But wait...I don't know for sure, but chances are very good that she had little or no choice in the matter when she was married off, sent to a new village, and subsequently, in part because of limited to no access to birth control, became pregnant (this is after she spent years watching all her younger brothers and sisters enjoy the privilege of attending school, while, as the oldest daughter, she had to stay at home and help her mother run their compound). Having a child is just as life-changing here as it is at home, and given the low use of family planning here and the minimal role women play in decision-making, chances are she had very little choice in when to have a child. After considering all this, while I still disapprove of Sue beating her sister, I have trouble blaming her for being bitter about the responsibility of her child. However, I have one more wrench to throw into this scenario. Most women here do want to have many children. At least once a week I have a conversation with some “Gambian women about how many children Jacob and I want to have (2 or 3), in which they are absolutely horrified and insist that having many children is “very good” and we should have at least 5 or 6. So, why do the women want so many children? My understanding is that it is to: 1) make their husbands happy by boosting their social status; 2) reduce their own daily workloads by adding extra pairs of hands to share the work; and 3) provide security that they will be cared for when they grow old.
Sorry the paragraph above is so stream-of-consciousness, but I haven't fully formed where I stand on all this yet. Lots of food for thought. So many shades of grey and so many layers of "root causes" and challenges. Living here truly makes me reassess my perceptions of "right" and "wrong" on a daily basis...
Today I attended a workshop at the local health center targeting servicemen (military and police personnel). Interestingly, the reason the workshop targeted the servicemen is they are responsible for the vast majority of blood donations in the country, due to the long-standing relationship between the servicemen and the health system. While the workshop did touch on promoting blood donation, the facilitators (local health workers) used it as an opportunity to do a sensitization on a wide range of reproductive health issues, including HIV, sexually-transmitted infections (STIs), family planning, and encouraging men to take responsibility for their children's health.
I was really surprised and thrilled that the participants were attentive, engaged, and had a lot of great questions about some of the more taboo topics. Some examples of particularly good questions were:
1) What are the long-term health risks of using different forms of family planning (both to a woman's overall health and to her fertility)?
A: While all drugs have risks of potential side effects, family planning is proven to be quite safe, both to a women's overall health and her fertility. Which method is most appropriate for a particular women very personal and should be determined through consultation with a doctor.
2) Do you have to have another STI before you can get HIV?
A: Having another STI makes you more vulnerable to HIV, especially if the STI causes open sores in the genital area, but you can certainly get HIV without having another STI first.
3) If a woman is not ovulating while taking family planning, and thus not “using up” her eggs, does that extend her reproductive life?
A: Very good question, but no, a woman's reproductive life does not end simply because she "runs out of eggs." A woman is born with far more eggs than she could ever use, but all the eggs slowly break down over time. That combined with many other factors, determines when she stops being fertile.
4) The Koran does not approve of family planning, therefore I do not approve of it.
A: This led to a lengthy discussion in Mandinka that I couldn't completely follow, but the gist was that the Koran, like any religious text, can be interpreted in many ways and needs to be interpreted in the modern context and weighing pros and cons. For example, a man is supposed to ejaculate into one of his wives every time he ejaculates. If he uses a condom when having sex with one of his wives, technically, he is still doing that, and at the same time protecting himself and his wife from the very serious risks of HIV, STIs, unwanted pregnancy, etc. Clearly pros outweigh the cons. Another one solid pro-family planning argument was that the Koran says that a man is responsible for providing for all his wives and children, and if he has more wives and/or children than he can provide for, that is very much frowned upon.
5) What steps does the health system take to make HIV/STI testing and family planning available to commercial sex workers?
A: By law, the health system is required to provide HIV/STI testing and family planning to anyone who requests it.
6) What is the difference between HIV1 and HIV2?
A: HIV1 and HIV2 are two different viruses, both of which lead to AIDS. HIV1 is more aggressive, easier to pass on, and harder to treat. HIV1 is more prevalent than HIV2 (both in The Gambia and throughout the world). About half of the people HIV2 can control the virus without medication, while almost all people with HIV1 need medication to control it.
7) How is it that researchers have not been able to come up with a cure for HIV yet?
A: Diseases that are caused by viruses, which can be very difficult treat and cure because the viruses can mutate very quickly. As soon as we come up with a treatment, the virus mutates so the treatment doesn't work anymore.
8) Since there is no cure for HIV, this is a very scary disease...what can we do to control it?
A: Education is the most important thing. People need to understand the risks and know their statuses so they can make smarter decisions about their sexual health. We also need to work on destigmatizing the disease so people are not afraid or ashamed to get tested and treated.
9) I heard HIV came from animals. Is that true? How can that be?
A: Like we said, viruses can mutate very quickly, and sometimes those mutations allow a disease to jump from animals to humans. This is what happened with swine flu, for example, and that is what doctors think happened with HIV. However, at this point, it really does not matter where HIV came from. It is here and can be spread among humans, so we need to focus our efforts on controlling it.
10) Should there be agreement between husband and wife before starting family planning? It seems the hospital just gives it out without the husband's consent, when the woman just wants to go "play outside."
A: Like we said, by law, the health system cannot deny family planning to anyone who requests it. Ideally, yes, a woman should have discussed her desire to use family planning with her husband before visiting the health center, but we cannot force her. (The men were quite displeased to hear this.)
11) Which method of family planning is least disturbing to the womb (i.e., least likely to have a negative effect on long-term fertility)?
A: All methods of family planning are safe, but, as we said before, which method is most appropriate for a particular women very personal and should be determined through consultation with a doctor.
12) Why is it that women don't donate blood here?
A: Women should not give blood if they are under 17, pregnant, breastfeeding, or anaemic, which, given the high fertility rate here, includes most Gambian women.
13) Why can't we immunize babies by giving the immunizations to the mother before they are born?
A: Good question, but unfortunately it does not work that way. Some antibodies can be shared with the baby through the umbilical cord and some through drinking colostrum immediately after birth. Colostrum is a very nutritious type of milk produced by the mother in late pregnancy. Unfortunately, however, the colostrum only protects against some diseases, so we still need to immunize babies against a lot of diseases after they are born.
I also was very impressed by the creative techniques the facilitators used to tailor their messages to their overwhelmingly male servicemen audience. Here are a few examples:
1) The facilitators stressed that family planning is NOT used to encourage prostitution and is NOT just western medicine used by white people to ensure that they only have one or two children (which is exactly the opposite of what most Gambian men want). They encouraged the men to think about it literally as a technique for ensuring that their families shape up the way they want them to (birth spacing-wise), whether that means having two children or twelve. They also cited several local practices women use to try to encourage or discourage pregnancy (wearing or placing jujus under their pillows, drinking holy water, eating certain herbs, etc) and said, look, Gambians already have their own methods of family planning...this is just another (more effective) way to go about it.
2) The facilitators encouraged the use of family planning as a preferable alternative to simply cutting off sexual contact for an extended period of time after a baby is born, which is what many women do as a birth-spacing strategy. The reminded the men that not only is that strategy frustrating for them, but it also can lead to problems like infidelity, unwanted pregnancies, STIs, etc.
3) The facilitators stressed that letting STIs go untreated is risking future infertility (which most Gambian men definitely want to avoid).
4) The facilitators encouraged condom use as a helpful tool for men who suffer from premature ejaculation, and thus have trouble satisfying their wives, leading them to "stray" (very interesting comment on several levels).
5) The facilitators pointed out that the common practice of wife inheritance (a brother marrying is brother's wives and caring for them and their children if his brother passes away) is a huge concern for the spread of HIV. Since people don't actually die of HIV, but instead die of pneumonia or tuberculosis or some other disease once HIV has weakened their immune system, a brother can inherit his brother's HIV-positive wives without knowing they are HIV-positive.
6) The facilitators used the analogy of HIV as invaders attacking a country's soldiers, making the population vulnerable. In someone with HIV, the soldiers and invaders are constantly fighting. CD4 count is how many soldiers are in the country and viral load is how many invaders are in the country. Logically, then CD4 goes up, viral load goes down, and vice versa.
Those are just a few tidbits from what was a fascinating and very successful workshop. Funding for the workshop was provided by the World Health Organization. I am encouraging the public health team to request more funding to do another one very soon!
