Further Evidence of the Necessity of Safe Reproductive Health Services

Reproductive health, which includes access to safe abortions and contraception, is a controversial issue everywhere in the world. It is controversial in Uganda. It is controversial in the US. It is controversial in politics, made more contentious by religion, and I very much doubt that it will cease to be a controversial issue in my lifetime. It is therefore safe to assume that some of you reading this may find this post controversial.

A few weeks, ago a young woman came to the clinic miscarrying in her 4th month. After the fetus was delivered one of the midwives inspected him and noted that the skull was damaged, though she chalked it up to a fetal-development issue, perhaps related to the miscarriage.

Later in the afternoon, the woman was transferred to the local health unit in the center of Atiak where she died the following morning. An autopsy revealed that she had not miscarried, but that she had performed her own abortion – succeeding in terminating her pregnancy, but also in taking her own life.

This is an unfortunate and upsetting story no matter which side of the abortion debate one is on, but I will not keep quiet about my politics. Access to abortion is an essential resource for women across the globe. A young woman’s life would have been saved if she lived in country where abortions were legal and accessible across all economic classes and this is a large-scale reality. If a woman is desperate enough for an abortion, you damn well better believe she will find a way to get one in spite of the illegality. This was also the case in the US prior to the legalization of abortion in the 1970s and remains the case in areas of the US where woman simply cannot afford a legal abortion. It is estimated that an average of 1.2 million back-alley abortions were performed annually before the Supreme Court ruled on Roe v. Wade in 1973. Many of the women who received those abortions died as a result of complications or were otherwise gravely impacted by the procedure (http://www.prochoice.org/about_abortion/history_abortion.html).

This is the current case in places like Uganda. Criminalization is NOT a deterrent against abortion, particularly in communities entrenched in poverty and with a permeating history of war and rape. When a pregnant mother of multiple children has been abandoned by her husband who has been deeply traumatized by war; when a woman cannot get work because in rural Uganda the only work is to farm her own land; when a woman must fend for her children and herself on literally no income; when a woman has been repeatedly raped, forced to marry a rebel leader, and impregnated; when a woman can only afford to eat once every other day; when a woman is out of reasonable options; when a woman feels for whatever reason that she cannot give continue with a pregnancy- no government, no society, and no religion should blame or attempt to stop her from considering and seeking a termination to the pregnancy. She will find a way to end the pregnancy regardless and the likelihood that it will end without further incident is low.

The World Health Organization estimates that 21.6 million women seek illegal or unsafe abortions each year – 98% of them occurring in resource-limited settings. These women need options. They need access to and education about contraception. They need people to help them work towards developing a society that gives women more power over their sexuality and their relationships with men. In societies where men refuse to use condoms for cultural (or any) reasons and where women do not have the option to say no, these women need to find hope somewhere else. If that hope comes from knowing that she does not need to worry about feeding another child or reliving the pain of her rape or abandonment by delivering a child who is a product of that experience, that must be respected.

I understand that abortion is controversial, but abortion happens whether it is illegal or not. Please understand that societies that ban abortions take far more lives than they save. To consider oneself pro-life in the face of that fact is hypocritical.

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Tropical Diseases That Knock You Off Your Feet

My friends from grad school and I have often joked that you aren’t a true development worker until you’ve survived a disease endemic to a developing area. I’m both pleased and devastated to announce that I have received that badge of honor as a survivor of malaria!

I was, of course, never in any danger of not surviving this particularly nasty parasite (take a breath, Mom and Dad), but it has still rendered me useless for the better part of 10 days. Furthermore, the truth remains that malaria does take millions of lives each year – particularly effecting young children, the elderly, and the poor.

Contracted through a female mosquito carrying the parasite, malaria enters the blood stream directly and may sit dormant for up to two weeks before the body gives rise to the symptoms.Symptoms range from a high fever, an excruciating head ache, extreme joint pain, vomiting and diarrhea. As long as one receives treatment in time and enjoys an otherwise healthy immune system, death from malaria is not as common as figures may lead people to believe. In fact, every person I have met in Atiak has had malaria at one point (or many points), yet has lived to tell me about it. That is not to say malaria doesn’t take far too many lives.

According to the World Health Organization, 90% of malaria deaths occur in sub-Saharan African – also the poorest region in the world – taking the life of a child every 30 seconds (http://rbm.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm). Children are most impacted because they typically lack the strength of an immune system that can fight off the malaria parasite. Add this to the fact that very few families in poor communities can afford to feed their children more than once a day and fewer still can afford malaria medication where governments or NGOs are not providing it for free and, while tragic, it’s not all that surprising that malaria takes the many young lives that it does.  Malaria is also a problem for pregnant women and newborns, as malaria is one of the leading causes of severe maternal anemia cases, which presents a high risk for miscarriages and still births, in addition to low birth weight and neonatal death (UNICEF).

Malaria and other tropical diseases (yellow fever, typhoid, guinea worm, etc.) also play a profound role in economic development – or perhaps we should say economic underdevelopment. The fact of the matter is that disease and poverty are inextricably connected. Malaria can knock a full-grown adult on their backs for weeks, rendering them incapable of work or providing for their families to the extent that they need to. When entire communities are impacted by the disease it can become incredibly difficult to move forward as an individual, family, or village. Diseases pull children from school, either because they are ill themselves or because they need to fulfill the roles left empty by an ailing mother or father. Not tending to the crops is not an option – it is typically the only means of livelihood. Someone has to fetch water or there will be none. There is no “calling out sick” in rural Africa and when malaria takes its toll and one must stay in bed, you better believe a number of people will also be impacted.

There are a few methods of prevention that have been deemed largely effective. Foreigners traveling to malaria-endemic areas can take anti-malarial pills to prevent infection, though they aren’t necessarily 100% effective. Sleeping under insecticide-treated mosquito nets has largely been deemed the most effective way to prevent malaria, but people working in development have found ways to argue about that. Should the nets be provided for free or should they be sold inexpensively, say for a dollar? Studies have shown that when the nets are provided for free people sometimes use them inappropriately, often as fishing nets. The response was to put a small price on the nets, thinking that if people invested their own hard-earned money that they would have a sense of ownership over their health and use the nets correctly. But this marginalizes the very poor, who are left to decide between a net for each bed in the hut or food for that week. Nets also need to be retreated with insecticide and replaced every so often, adding to the cost for families. So what do we do? Provide a hand-out or put a cost on the nets? A hybrid solution in which those who can pay do and those who cannot receive nets for free  would exacerbate class divides by pointing out the very poor – many of whom wouldn’t come forward for their nets in order to avoid shame.

In my opinion the nets should be provided free of cost, but incorporated with the net should be a brief educational pamphlet in the local language as well as in images that instructs on the proper use and the necessity of the net. Some governments and NGOs have taken similar approaches and while there is not going to be a fool-proof solution to malaria, there are ways to start bringing the incident rates down. This will, in turn, have a positive impact on education rates and local community development.