Kris Holloway’s story, Monique and the Mango Rains, tells of her two years in Mali working as a Peace Corps volunteer. Holloway works closely with Monique Dembele, the sole village midwife and general healthcare provider in Nampossela, a small, remote, rural village. What stand out to me from her experience are the systemic, structural, social, and cultural circumstances that force the village women into perilous health positions, particularly pertaining to pregnancy and women’s health issues. The shocking fact is that the women in Nampossela have virtually no control over factors that directly and negatively impact their lives and health outcomes. This is very much like the inhabitants of Flammable, an urban shantytown in Buenos Aires, Argentina, whose children have strikingly high rates of lead poisoning, simply because of where and how they are forced to live. It seems that in the 21st century, this circumstance ought not to exist anywhere on our planet—so, how can it be that this is the reality for so many women and children?
Take, for example, the story of Korotun, a village woman who is beaten repeatedly by her husband (Holloway 2006: 53). Korotun believes that if she can get pregnant, her husband will not be so angry with her, so he will not beat her. She has no way to protect herself from the beating, and the harsh reality is that another pregnancy might not ameliorate her situation.
Or consider the example of Oumou, who has lost four children out of nine. She cannot bear to have more children for fear of them dying, so she wants a form of contraception. But her husband will not allow it. He would refuse to use a condom, and would not allow her to take oral contraception, forcing her to obtain and swallow any pills in secrecy.
Third, consider Bintou, a village woman who passes away after the birth of her seventh child. Holloway points out that the factors that caused Bintou’s death are manifold. It was the rainy season, so she could not give birth in the village’s dilapidated birthing house. Bintou might have been malnourished, or she might have suffered from malaria. Or maybe, Holloway hypothesizes, her uterus could not handle a seventh labor. The list goes on. Whatever the cause, these were all circumstances out of Bintou’s control. Had Bintou known how critically important sufficient rest was for the safety of her seventh pregnancy, perhaps she might have tried to rest. But how could she have known? Her uninformed husband would not let her rest from work because of the prevailing cultural norms and economic need for Bintou to help out at home and in the fields. Her husband did not even let her see Monique for a prenatal consultation, Holloway assumes. So Bintou did not have any much-needed advice about prenatal care.
All three of these women suffer from structural violence—the prevailing social, political, economic forces that directly impact personal, individual health (Farmer 2013: 9). They are victims of this violence with severely limited ways of protecting themselves. Korotun is not choosing to get pregnant because she wants another baby, but rather because she wants her husband to stop beating her. (In addition to being beaten by her husband, Korotun will now have an unwanted daughter.) Bintou of course did not want to die during labor. Despite Monique’s best efforts, these women had none of the knowledge or access to resources that could have prevented these adverse health outcomes because of the culture, society, and economy in which they live. Similarly, the residents of Flammable did not choose to live on top of garbage and toxic waste dumps—where children and pregnant women would be exposed to high concentrations of heavy metals. But they had no other choice.
But there is good news. Researchers all over the world are working to design innovations that can create lasting change. For example, an injectable contraceptive that lasts for 3 months has been introduced recently in Burkina Faso (McNeil, 2014). As Monique explains to Holloway, villagers love injections, because they “represent the pinnacle of Western medicine, and Western medicine is good” (Holloway, 7). Perhaps this will be a sustainable solution, which would allow women to use contraceptives with less of a risk that their husbands may find out.
My older sister had a baby this past summer, and her most difficult decisions during her pregnancy were whether or not she should choose organic, non-GMO foods, or which of many options was the best stroller to buy. She could take endless prenatal supplements, and had months of maternity leave to look forward to. The women of Nampossela could not fathom these options. While my sister’s experience certainly was not universal throughout the US, the disparity between our privileged existence in the developed world and the Malian women’s experience could not be more stark.
I’m interested in the same question regarding Bintou’s death that Holloway poses on page 89: “If Monique had had access to more emergency medical care, could she have saved Bintou?” Monique successfully delivers so many babies with such simple tools—would investing in high-technology care be “worth” it? Would it be better to put resources towards other aspects of healthcare, such as malaria or HIV/AIDS prevention? Even if they were able to create a more hospital-like setting in Nampossela, would the villagers welcome the change, considering their cultural values that make their childbirth experience much different from the experience we are familiar with?
Who is responsible for these complex, multi-faceted problems? Who can help? Holloway, as a Peace Corps worker, certainly helped for the two years that she was stationed in Mali. And, there’s evidence that her and Monique’s work is making a difference: the number of women coming in for prenatal consultations has steadily increased over time (Holloway, 94). But will her work make a lasting impact? What kind of help would make a lasting impact? Will the village’s maternal health deteriorate again after Holloway’s two years there?
Auyero, Javier and Debora Alejandra Swistun. 2009. Flammable: Environmental Suffering in an Argentine Shantytown. New York: Oxford University Press.
K. Holloway. 2006. Monique and the Mango Rains: Two Years with a Midwife in Mali. New York: Waveland Press.
McNeil, Donald. “New Contraceptive Shot Being Released in Africa.” 14 July, 2014. http://www.nytimes.com/2014/07/15/health/new-contraceptive-shot-being-released-in-africa.html?_r=0
P. Farmer, A. Kleinman, J. Kim and M. Basilico, eds. 2013. Reimagining Global Health: An Introduction. Berkeley: University of California Press.