Partial Stories: Maternal Death from Six Angles 9780226816876

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Partial Stories

Partial Stories Maternal Death from Six Angles claire l. wendland

The University of Chicago Press Chicago and London

The University of Chicago Press, Chicago 60637 The University of Chicago Press, Ltd., London © 2022 by The University of Chicago All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief quotations in critical articles and reviews. For more information, contact the University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637. Published 2022 Printed in the United States of America 31 30  29  28  27  26  25  24  23  22  1  2  3  4  5 isbn-­13: 978-­0-­226-­81686-­9 (cloth) isbn-­13: 978-­0-­226-­81688-­3 (paper) isbn-­13: 978-­0-­226-­81687-­6 (e-­book) doi: https://doi.org/10.7208/chicago/9780226816876.001.0001 Library of Congress Cataloging-in-Publication Data Names: Wendland, Claire L., author. Title: Partial stories : maternal death from six angles / Claire L. Wendland. Description: Chicago : University of Chicago Press, 2021. | Includes bibliographical references. Identifiers: lccn 2021037139 | isbn 9780226816869 (cloth) | isbn 9780226816869 (paperback) | isbn 9780226816876 (ebook) Subjects: lcsh: Mothers—Mortality—Malawi. | Pregnancy—Complications— Social aspects—Malawi. | Pregnancy—Complications—Malawi—Case studies. | Childbirth—Complications—Malawi—Case studies. Classification: lcc rg530.3.m3 w46 2021 | ddc 362.19820096897—dc23 LC record available at https://lccn.loc.gov/2021037139 ♾ This paper meets the requirements of ansi/niso z39.48-­1992 (Permanence of Paper).

“Out of Bounds (or Our Maternity Asylum),” the epigraph to chapter 4, is from Jack Mapanje, The Last of the Sweet Bananas: New & Selected Poems (Tarset, Northumberland: Bloodaxe Books, 2004). Reproduced by permission from Bloodaxe Books, http://www .bloodaxebooks.com.

for the guardians, the witnesses, the givers of care and for the mothers, especially mine

Contents

Introduction  1 b o n n e x k au n d a : “There are too many goings-­on these days.”  19 1 Dangerous Modernities  22 ag n e s i k u n j i r i m a : “You can make your pregnancy safe.”  65 2 Knowing Bodies  68 lillian siska: “I help them right here at home.”  105 3 Ambivalent Technologies  108 c h i m w e m w e b ru c e : “Changes, yes, but no development.”  145 4 Abundant Scarcity  150 r h o d a na n t o n g w e : “By the time she comes to the hospital, it is too late.”  185 5 Countless Accountings  188 dy na n g ’ o n g ’ o l a a n d k e t t i e p e n s u l o : “Women in this community are very much concerned.”  228 6 Fragile Authority  233

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Conclusion  269 Glossary of Chichewa Terms  281 Key People and Places  283 Abbreviations  285 Acknowledgments  287 Notes  291 References  323 Index  345

Introduction

All I knew about her was that she was pregnant, almost at her due date, and that she’d been shot. An armed robbery at the place where she worked the night shift, the newspaper later reported. I didn’t learn her name until I read the article. She was pronounced dead in the emergency room. The chief resident and the attending physician on call had raced down the stairs when the call came, leaving us medical students behind. They had hoped to resuscitate her and to get the baby out. Doing both at the same time sounds like a bad idea, the chief resident explained afterward, but it isn’t. It’s nearly impossible to resuscitate a hemorrhaging pregnant woman who is still trying to send blood through her placenta to the fetus. Their efforts were futile. Neither mother nor child survived. Later, the chief resident wept quietly, her face turned away from us, at the nurses’ station. (She was cool, competent, a woman of steel: I was shocked to find her capable of tears.) The attending obstetrician put his hand on her shoulder tentatively. “You couldn’t have done anything. She just bled out.” Why did she die? At one level, it’s obvious: she bled to death. At another level, it’s not so obvious. It was 1989. I was a medical student then, just beginning an obstetrics clerkship in a grim urban hospital in Saginaw, Michigan, one of the rustier parts of the Rust Belt. Massive unemployment had transformed the city as the auto industry withdrew. Saginaw was afflicted by an epidemic of violence that fed on instability, racism, inequality, and the drug trade. Some thirty to forty homicides occurred annually in a city of less than seventy thousand people. It is likely that this young woman would not have died in a place less flooded with guns and despair. A place like Blantyre, Malawi.

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In Blantyre, fifteen months later and nine thousand miles away, I wrote in a journal: Updates: The lady with the jaw and abdominal lymphoma died, as did the one with advanced Kaposi’s and the woman with tetanus. The woman from Mwanza who had a huge swollen abdomen post C-­section, that we thought was abscess, bled out and died on the [operating room] table. The swelling was some kind of cystic blood-­filled structure—­?

Why did these four women die? At one level, each of these four deaths had an obvious explanation. The “cystic blood-­filled structure” was a huge hematoma, a collection of blood resulting from unrecognized vascular injury during her cesarean operation. Like the mother in Saginaw, this woman bled to death. The women with lymphoma, Kaposi’s sarcoma, and tetanus all died because they could no longer breathe. At another level, the explanations are again less obvious. It was 1990. No plague of gun violence afflicted Blantyre, Malawi. But another slow inferno burned through the hospital wards and smoldered in neighborhoods throughout the city—­this one, too, fueled by massive unemployment, racism, inequality, instability, and poverty. The human immunodeficiency virus (HIV) is strongly associated with both Kaposi’s sarcoma and adult Burkitt’s lymphoma. Both cancers respond to chemotherapy, where it is available—­ but a catastrophic deterioration in health care was also at work. It is rare for a woman to bleed to death from a surgical complication in a place where there is a robust blood bank. Anti–­tetanus vaccination campaigns have been highly effective almost everywhere. It is likely that not one of these Malawian women would have died had their pregnancies and births happened someplace where medical infrastructure was stronger. A place like Saginaw, Michigan. There is more than one way to tell the story of any of these deaths. We who construct explanations—­whether we attribute death to hemorrhage, to HIV infection, to the proliferation of guns, to poverty sustained by racism or inequality fueled by capitalism—­focus on particular scales of time (minutes, hours, years, decades) and of space (organs, bodies, communities, nations). Those scales of time and space in turn imply certain kinds of interventions while taking others off the table. Implicitly, our explanations determine who is responsible for intervening (clinicians, politicians, pharmaceutical companies, pregnant women themselves), and with which tools (blood transfusions, ambulances, chemotherapy, policies, economic development). Much is at stake in these stories, and for the storytellers.

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This book examines stories about maternal death, especially those told in the southeastern African country of Malawi by people who attend to pregnant women in the course of their work. Maternal mortality rates are high there, despite decades of interventions by the state and by nonstate organizations. Stories of dead mothers circulate through hospitals and villages, told by many different experts: herbalists and nurses, chiefs and doctors, epidemiologists and the healers called asing’anga. These stories offer competing explanations, making sense of catastrophe and allocating responsibility. Many point the way to strategies for averting future deaths. Stories of maternal deaths are used by elders seeking to educate juniors. Those elders may be national policymakers, the anamkhungwi who preside over initiation rituals and counsel pregnant women about what to expect, or faculty obstetricians at Malawi’s College of Medicine. In the Malawian context, as in all contexts, explanations for death are structured from available evidence—­evidence revealed through technologies that range from hematocrits to dreams to proverbs. Narratives are also built using available metaphors and rhetorical strategies. In making sense of loss, they reveal how people make sense of the world they inhabit. People in many parts of the world understand pregnancy as unpredictable and perilous. Proverbs and metaphors across Africa emphasize the contradictions and dangers of pregnancy. A Hausa proverb has it that “the world is a pregnant woman,” meaning that one can never know what to expect in life or in pregnancy.1 Malawians warn that “a pregnancy isn’t something to boast about”—­you can’t know how it will turn out.2 The anthropologist Jean Comaroff, working among Southern African Tswana people, has described human and agricultural reproduction there as liminal processes, “midway between society and the wild.”3 One Malawian expression for pregnancy, ali ndi pakati, indicates that a woman is “in the middle.” In the chapters ahead, I explore how people charged with caring for pregnant Malawian women explained maternal death and danger. Such people included hospital-­based nurse-­midwives and doctors, as well as herbalists who treated infertility and overdue pregnancies. They included azamba who once attended births in many Malawian neighborhoods—­and still did secretly in some, even after a law banning traditional birth attendants. Some of these experts had biomedical training, whether a little or a lot. Some called themselves, or were called by others, “traditional.” A few did not fit easily into either well-­worn category. Their backgrounds did not fully predict how they made sense of maternal death: the same explanation could appear, for instance, in the testimonies of elders without formal schooling and the diagnoses of obstetrical specialists with extensive postgraduate training.

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My task in this book is not to debunk certain explanations while validating others. It is, instead, to explore how these explanations work: what they do and don’t do, and for whom. Exploring meaning-­making about a single problem in a single place across a broad range of experts reveals unexpected commonalities, such as the moral messages embedded in accounts that appear to be purely technical. Experts’ narratives show how people make deaths into knowledge, how that knowledge becomes simple common sense, how alternative explanations—­and a host of uncertainties—­disappear along the way, and why those disappearances matter. In exploring accounts of maternal death, we also come to understand some of the ways in which social, political, and economic inequalities shape societies and bodies, and constrain people’s chances of survival. Ali ndi pakati. She is in the middle between life and death, and the world around her may push her one way or the other. Maternal Mortality Matters Maternal death matters most for the women who die and for the people who live in relationship to them. Such a death is grievous and consequential for families; most dissolve after a mother’s death. Maternal mortality matters politically too. National and regional leaders can be shamed over terrible statistics and applauded for improvements. Politicians attended more closely to maternal death during the early 2000s in many places, including Malawi, because of the fifth Millennium Development Goal: MDG-­5 called for reducing maternal mortality by three-­quarters from its 1990 levels. As 2015 approached, newspaper articles and public speeches often pitted one country’s achievements against another’s failures. Maternal mortality appears especially important for politics in southeastern Africa, where smooth processes of reproduction have long been read as testaments to legitimate leadership and a plague of deaths indicates a community gone badly astray. (You will read more about this connection in the book’s first chapter.) A tight connection between strong medical care and safe pregnancy means that for epidemiologists, maternal mortality matters as a sensitive indicator of systemic health-­sector dysfunction. Obstetrical emergencies are not always predictable. They happen—­ rarely, but catastrophically—­ even in healthy women with apparently normal pregnancies. They happen in out-­of-­the-­way places, in any weather, at any time of day or night. To prevent death, skilled clinicians must respond swiftly with a range of tools, from blood transfusions to surgery to antihypertensive medications. Maternal mortality is typically low when health systems are strong: reliably supplied with essential tools and

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medicines; adequately staffed with well-­trained and attentive workers; readily accessible 24/7/365; well integrated with effective referral systems. I have practiced obstetrics in two countries; neither meets all these criteria. In the United States, women can nearly always count on a well-­supplied hospital, and usually on a reasonably staffed one. In Malawi, women cannot. In both countries, access and referrals are chronic problems. Historians and physicians often quote a study suggesting that if healthy women were left alone with no medical care whatsoever, roughly nine hundred women would die for every hundred thousand births.4 Where pregnancy is safest, at this writing, three or four women die for every hundred thousand births. With high-­quality medical care and good general health, maternal death is almost entirely preventable. The same cannot be said for cancer, stroke, heart attack, suicide, homicide, or many other common causes of death. Thus, even when maternal deaths are quite uncommon, they can be what some Malawians call “the ears of the hippo”: a small clue to a big problem. By one common estimate, for every woman who dies of pregnancy complications, seventy suffer serious long-­term injuries. Where women die at greater rates, so do newborns, and far more often. Where the shortcomings of medical care allow high maternal death rates, other vulnerable people will suffer and die from that inadequacy too. In addition to inadequate health care, at least two other underlying factors contribute to maternal mortality. First, overall well-­being affects survival. Malnourished, anemic, immune-­ compromised, or addicted women face disproportionate perils in pregnancy. So do women beleaguered by racism, abuse, exploitation, and economic hardship. Second, too much obstetrical intervention can also be lethal. In the United States, many public health analysts believe that excess use of cesarean delivery is one factor behind a rising maternal mortality rate. Maternal mortality matters as testament to injustice. Women’s health advocates understand high rates of maternal death to indicate both gender inequity and a widespread disregard for the lives of poor people. Health disparities between the poorest and the wealthiest nations in the world are greater in the realm of maternal mortality than in any other measure, including life expectancy or infectious disease burden. Globally, maternal deaths are concentrated in Africa south of the Sahara and in southern Asia, with hot spots elsewhere (Afghanistan, Central America). Within many nations, these deaths track with social marginalization. Aboriginal women in Australia have death rates much higher than those of non-­Indigenous women. In the United States, black women—­across educational levels—­are far more likely to die than white women.5

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A Changing World This chapter opened with five deaths, all of black women: one in Saginaw, Michigan, four in Blantyre, Malawi. In the three decades since these five women died, much has changed. In Malawi, estimated maternal mortality rates worsened substantially in the 1990s and early 2000s, reaching some of the highest levels anywhere in the world. For a time, these numbers suggested that giving birth by oneself in the middle of the forest would be safer than giving birth in Malawi. Terrible metrics and rankings hit the news regularly. Midwives, doctors, chiefs, and politicians weighed in with explanations and prescriptions. Legislators passed new laws. Activists began new initiatives. Health officials instituted new trainings and campaigns. Some of these new approaches were exemplary: for instance, Malawi pioneered methods for expanding antiretroviral treatment among pregnant HIV-­infected women. Maternal mortality fell sub­stantially, although perhaps not to the levels of neighboring countries. At the time of this writing, epidemiologists estimate that maternal mortality in Malawi is declining slowly. It is roughly back to its early 1980s levels. As maternal death rates fell in Malawi, they rose in the United States. For a long time, few people took notice. National vital statistics centers and the Centers for Disease Control published few official metrics.6 The topic rarely arose in journal articles or professional meetings, although obstetricians and epidemiologists occasionally noted that pregnancy-­related complications and deaths were disproportionately affecting black women. California public health officials began to pay more serious attention when statewide statistics indicated that maternal death rates had more than doubled from 1999 to 2006. Nationally, it was not until 2016 that the problem of maternal death in America really hit the news and aroused public consternation. At the time of this writing, epidemiologists estimate that maternal mortality in the United States continues to rise. Rates of death are about a twentieth of those in Malawi, but the numbers trouble many people. They tell a story in which the United States is a more dangerous place to be pregnant than all other wealthy countries and many middle-­income ones: in 2019, childbirth was safer in Kazakhstan or Turkey than in the US.7 Ratios and rankings like these are usually treated as facts. There are compelling reasons to believe that the trends they describe reflect real dangers to real women. Quantifying maternal mortality is not easy, however. Even in the places where maternal deaths are most common, they are still sporadic events. Many American physicians have never seen one. Even the highest estimates of maternal death in Malawi calculated sixty live births for every maternal

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death; in the great majority of cases, birth goes well. To calculate reliable rates thus requires either accurate recording of deaths among large numbers of people or accurate recording of deaths among smaller numbers over a long time span. Definitions—­what counts as a maternal death? what counts as a pregnancy-­related death?—­have changed over time and vary from one place to another.8 Deaths related to pregnancy are easily misreported or misclassified. Almost any given death, as you will see, can be explained in many ways. These uncertainties and ambiguities do not stop people from coming up with explanations, or from proposing interventions. On Methods While this book touches on experience in the United States and on scholarship from other places, it mostly explores how people in Malawi have responded to the problem of maternal death. I became interested in this question during an earlier research project. Between 2001 and 2003 I studied the experiences of doctors-­in-­training at the University of Malawi’s College of Medicine, as a lens on the larger phenomenon of African biomedicine. Because I am an obstetrician as well as an anthropologist, I also volunteered a couple of days each week at the teaching hospital, Queen Elizabeth Central Hospital (or Queens). That project was not about maternal death or danger. Still, I observed many more maternal deaths in those months spent at Queens than in years as a doctor in the United States. I listened as my colleagues and our students analyzed particular cases, interpreting some deaths in order to prevent others. The American obstetricians I knew located risk within pregnant women’s bodies. Our professional journals featured algorithms designed to calculate just how at-­risk any given pregnant woman was by weighting factors such as age, weight, “race,” or blood pressure. Malawian clinicians also sometimes located risk in the bodies of women—­especially women pregnant for the first time or “chronically ill,” a euphemism for HIV infected—­although I did not see them using algorithms. Often, they located risk in traditional practices and traditional birth attendants (TBAs), or in government neglect and political malfeasance. Both Malawian and American approaches seemed to downplay iatrogenesis: the damage we ourselves inflict.9 In both places, iatrogenic injuries stemmed from hospital-­caused delays in care, complications of unnecessary operations, or blunders made by inexperienced and poorly supervised trainees. In Malawi, additional dangers included high postoperative infection rates related to limited access to soap and water on the postpartum wards; in the US they included complications of elective labor inductions.

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I wondered how expert discourse on maternal risk changed in a place where childbirth appeared—­to me—­so full of danger. What led biomedical providers in Malawi to see traditional practices as major threats to pregnant women, and their own practices as benign? And what about the TBAs and other nonbiomedical healers—­what were their explanations for maternal death? sources I have recorded many stories of maternal deaths in field notes and journals since my first journey to Malawi in 1990. Intensive work on this project began in 2007.10 I returned for shorter visits in 2010/11, 2013, 2014, 2015, and 2017. Beginning in 2007 I gathered narratives in English and Chichewa from well over a hundred people consulted as experts by pregnant women. Twenty-­six were azamba, or “traditional birth attendants” (TBAs); twenty-­four were nurse-­ midwives; nineteen were asing’anga, or traditional healers; fourteen were alangizi or anamkhungwi, counselors involved in initiations into adulthood or motherhood; the remainder were community health nurses, herbalists, doctors, health extension workers called health surveillance assistants (HSAs), and midlevel clinicians called clinical officers. Twenty-­six fit more than one category; for instance, two-­thirds of TBAs were also herbalists, asing’anga, or anamkhungwi. Ninety-­two interviewees allowed me to digitally record our conversations. I also spoke with officials who tracked maternal health problems, and with community leaders who mobilized popular support for safe motherhood. Interviews with biomedical personnel were all in English, save the occasional Chichewa phrase. All but one of the interviews with people who worked outside the formal medical sector were in Chichewa, augmented by an occasional English word or phrase; the exception was an interview in Tumbuka, with an interviewee who was not comfortable in Chichewa. My Chichewa is slow and mediocre. The language is rich in euphemisms, allusions, metaphors, and oblique references to folktales, most of which elude me. Bilingual research assistants helped with all Chichewa-­language interviews and double-­checked all transcriptions and translations. Ethnographic observations flesh out this work. During prolonged stays in Malawi in 2002/3 and 2007 I was a participant observer, working part time as a doctor on the wards and in the operating theaters of a large public hospital, welcomed to the meetings at which maternal deaths were discussed. In later years—­mostly in connection with other projects—­I spent time in district hospitals and health centers, at rural healing ceremonies, and in the workplaces

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of traditional birth attendants in densely settled urban slums. Observations and conversations in these contexts add to the analysis. Malawians who spoke with me were extraordinarily heterogeneous. Their ethnic backgrounds were varied and often mixed; they spoke eight different first languages. Those who knew their ages ranged from twenty-­three to seventy-­four years old at the time of the first interview. A few, like the TBA Loveness Mandawala, provided birth years instead: “I was born in 1935, so I think I now have so, so many years. Do your own sums; then you will be able to know how old this is.” About a quarter of those who worked outside the formal medical sector were unsure of their ages. Educational experiences varied. Most TBAs, asing’anga, and counselors had completed three or fewer total years of schooling. Those who worked in the biomedical sector, in contrast, had all finished secondary school; many had college or postgraduate educations. Some held medical degrees, including a few with specialty training. Others had completed doctoral studies. They had trained in Cuba, Canada, the United Kingdom, Russia, Norway, China, Germany, and South Africa. They were multilingual, cosmopolitan, urbane. Even people with little or no formal education had sometimes lived abroad for work, or with migrant relatives, or through marriage to a foreigner. Yet others—­often, people with rich insight into the complexities of social life and the dangers of childbirth—­had little geographical exposure beyond their own villages. I remember walking several kilometers from the road down a footpath to a leafy rural compound, to talk with a mzamba then in her seventies wearing a neatly pressed housedress and a string of plastic pearls. She explained how herbal treatments and marital precautions could safeguard pregnancy, and how one needed to be flexible about these strategies in the face of the many social changes in the community over the preceding fifty years. When our conversation wound down, she brought a little tray of delicious roasted groundnuts for us to share and asked me to replay the interview on my digital voice recorder. We sat for an hour with our recorded voices in the air around us as—­with evident delight—­she called friends and neighbors over to listen. Experiences with birth ranged widely. Some interviewees had delivered thousands of babies. Others had attended only a few births. Several men who treated pregnant women had never seen a child born. Almost everyone I interviewed had children of their own, although not all had children living. One does not stop being an anthropologist outside the moments officially marked as research, any more than one stops being a doctor outside the clinic. Whenever I interviewed someone or recorded a discussion, I asked

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permission, explained the purpose of the project, and answered questions before proceeding. Many observations from Malawi and all observations from the United States, however, happened outside the formal context of research. So did casual conversations that provided insights. These were times and places where people knew me as a friend or student or colleague rather than—­or in addition to—­a researcher. In all cases, I have taken pains to keep identities untraceable.11 Everyone I interviewed—­whether in Chichewa on reed mats under a tree or in English on a wooden bench in a clinic room—­knew that they were speaking to a mzungu doctor, and that this project was about death and danger in pregnancy. That knowledge unquestionably shaped the stories that they told. I present the full range of explanations people gave, but I have given particular weight to discussions with people I knew over several years and observed in action. Their accounts seemed less likely to be produced solely for an audience of one. The experiences of people who provide maternity care were my focus; I learned only a little about the experiences of people who seek it. While I have often spoken informally with pregnant women and their kinfolk, these conversations were never systematic. Other books will be much better sources for readers who wish to understand how women and their families make decisions about care, evaluate danger, and cope with loss.12 In this introduction, I am quite present. That is deliberate: you should know what perspectives and limitations an ethnographer brings to her project. For the most part, in subsequent chapters, I will recede from the page—­ but readers should keep these methods and caveats in mind. Other researchers would have learned somewhat different things, and would have arranged those things into somewhat different stories. m y p at h t o m a l aw i Why study maternal death in Malawi? By the turn of the twenty-­first century, the odds of death there were reported to be among the highest in the world. The most commonly used public health metric for maternal risk is the maternal mortality ratio, or MMR: the number of maternal deaths per hundred thousand live births. One widely disseminated article estimated Malawi’s maternal mortality ratio in 2000 to be 1,662:100,000, more than three hundred times greater than the world’s lowest ratios. Lifetime risk is probably easier to grasp: where birth was safest, epidemiologists calculated a woman’s lifetime risk of dying from a pregnancy-­related complication at roughly one in thirteen thousand; in Malawi it was one in ten.13

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Epistemology was as compelling as epidemiology. In southeastern Africa, bodies in general—­and maternal bodies in particular—­had long been linked with the harmonious functioning of society and with the fertility of land. Treatments for infertility, for recurrent pregnancy loss, and for crop failure could involve similar processes of divination and therapy. Songs and proverbs in several local languages used farming images for sex and pregnancy: the hoe used to plant potatoes in the anthill was the penis used to sow semen in the womb. During the course of this project, I would learn that people often explained sexual practices around pregnancy in agricultural terms. Couples must have regular sex in the early part of pregnancy, for instance, just as growing maize fields need frequent applications of rain. In later months they must stop having sex so that the child can ripen and dry in the womb. Biomedical interventions into reproduction also had long histories here. Many early written accounts from the region came from Scottish missionary doctors, who carried forceps and ergot-­derived medicines in their bags, and whose journals and letters referred to mothers lost to—­or saved from—­ pregnancy complications. The Scots soon began training African assistants. Africans learned, taught, practiced, and adapted biomedicine for nearly a century and a half in Malawi, since well before the country had that name. This book uses some primary source materials from archives at the World Health Organization, the Malawiana collection of Chancellor College, and several European collections of materials on mission and colonial medicine in the British Nyasaland Protectorate—­later, Malawi. It also draws on an exceptionally rich body of historical and social science scholarship grounded in this place. Malawi had practical attractions too. I’d spent time there. Trusted colleagues could help me understand puzzling issues. I already spoke some Chichewa, the local lingua franca, and could deepen my knowledge of it rather than starting from scratch with a new language. Previous local experience allowed me to live comfortably in a dense city neighborhood where few expatriates came, and to get around by foot and by minibus to a wide range of people who dealt with pregnant women professionally. Once, I would have characterized my long connection with Malawi as random: as a nerdy medical student interested in parasite life cycles, I had jumped at an opportunity to go to Blantyre in 1990 in the company of a generous and well-­known malaria researcher. I’d never been on the African continent, knew little regional and no national history, and spoke not a word of any local language. At a big public hospital, I did not ultimately learn much about parasites other than malaria. But I learned a great deal about scarcity, injustice, political repression, grief, and my own appalling ignorance and

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ineffectiveness. Later I understood that I had been following paths trodden by colonial medics, missionaries, and researchers—­including ethnographers—­ for more than a century. I wore those paths a little deeper, and others have since followed my own footsteps. Wounds, Scars, and Partial Stories Why pay attention to people’s stories about maternal death? Don’t medical science and epidemiological evidence explain what we need to know? If you are asking yourself this question, consider three points. • First, the question introduces a misleading dichotomy between stories and medical scholarship. Medicine is full of stories, and even a statistical model can be usefully analyzed as a narrative. Unearthing the claims about truth embedded in these diverse stories allows us to explore why some kinds of interventions come to seem self-­evidently valuable even though they repeatedly fail, and why others are never considered. • Second, “what we need to know” to support maternal health intervention depends on what we want to do—­or put off doing. Narratives authorize action, but desired actions also authorize particular narratives. Social scientists have gathered compelling evidence to show that neoliberalism, racism, and misogyny kill an inordinate number of women. Efforts to act against these powerful social forces have tended to find less institutional backing than efforts to “educate” the poor or to distribute pharmaceuticals. • Third, stories do cultural work simply by being told. Even a narrative that many listeners find implausible may have real material consequences. Careful examination of many different narratives provides insight not only into maternal death but also into the ways people navigate the changing world around them.

The power of stories to remake the world and our experience of it is reason to pay attention to them. It is also reason for caution. Over the years, as I read about maternal death in Malawi, I began to notice a recurring metaphor: calls for intervention in Africa made by powerful outsiders often used the image of a wound or a scar. In the 1850s, the explorer Dr. David Livingstone, urging European missionaries to come to the southern end of the Rift Valley to blot out slavery there, referred to it as the open sore of the world.14 In 2001, Tony Blair, then prime minister of the United Kingdom, claimed in a speech that “the state of Africa is a scar on the conscience of the world.”15 In 2010, Richard Horton, editor of the Lancet, called the lack of

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progress in reducing maternal mortality, particularly pronounced on the African continent, “one of the most deforming scars on the body of global health.” Africa as scarred, deformed, bearing a wound that outsiders must heal. The metaphor is remarkable not only for its repetition over more than a century; it is remarkable because the image itself is wounding, its repetition a scar. Chimamanda Ngozi Adichie has famously warned about the danger of a single story.16 The representation of Africa in a way that calls for pity—­a representation Adichie identifies as recurrent in Western literature—­is a single story that characterizes the continent again and again as a place of catastrophe, poverty, disease, and suffering. Yes, catastrophe, poverty, disease, and suffering are abundant in Africa, as they are on every continent where human societies proliferate. So are innovation, complexity, and intellectual ferocity. “The problem with stereotypes is not that they are untrue,” Adichie says, “but that they are incomplete.” To create a single story is the privilege of those in power, who can tell the definitive story about less powerful others, while in turn having diverse stories told about themselves. A single story of African suffering does damage. It reinforces a long history of black pain as spectacle.17 It positions the story’s listeners as witnesses and voyeurs, producing an enjoyable righteousness—­or a righteous enjoyment. Such a story renders its subjects abject. It undermines their dignity and conceals their heterogeneity. Yet the invisibility of black pain also does damage. Founding figures in obstetrics and gynecology learned on black women’s bodies, their fame resting on black suffering that disappeared from the journal articles they wrote. Founding figures in anthropology produced research made possible by violent colonial conquest, extracting theory while obscuring African oppression. As the inheritor of two disciplines still struggling with the consequences of these concealments, I am attentive to the harm done by telling single stories, and the harm done by hiding stories. This book does not present a single story. In writing of maternal deaths I have tried, even when the text becomes graphic, to be wary of the abject, the grotesque, and the sensational. No righteous intervention is demanded. No white-­savior expatriates rescue African women. I am sometimes visible in these stories, but only because concealing my presence would be a deceptive distortion. Nearly all the protagonists are African, and black. Among them are committed advocates for women’s health, disgruntled clinicians going through the motions of work, frightened young women, and scolding elders. Not one of them is reducible to the stereotypes these brief descriptions suggest. The whole point of the book is to undermine the notion that any of the single stories we already think we know is definitive. All stories are partial,

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meaning they are all incomplete. And all stories are partial in the other sense of that word: they reflect preference; they incline to a particular sort of explanation because something is at stake for the teller. Partial in both senses applies no less to my stories than to anyone else’s. The Path Ahead Global health literature on safe motherhood includes six familiar tropes that also came up during my interviews: dangerous traditions, vulnerable bodies, magic-­bullet technologies, portable “best practices,” explanatory statistics, and sound policy. Spiraling roughly outward from particular bodies and stories to national metrics and international policies, each chapter ahead opens up one of these six ideas for examination. Each can stand more or less alone. Readers well versed in regional history could skip chapter 1; mathophobes could skip chapter 5. The unique contribution of this book, however, is less in any one chapter than in the layering of them all, providing multiple perspectives on a single problem in a single place and weaving biomedical and nonmedical analyses together. Chapter 1, “Dangerous Modernities,” shows how explanations for maternal death reflect visions of the past and express concerns about social change. Some stories are exhortations to be more modern. Many are indictments of modern times. When a traditional birth attendant recalled a golden age of easy birth, or a nurse-­midwife grumbled that “times have changed,” or a sing’anga explained a mother’s death by saying “our women have become pompous,” or an urban obstetrician and a rural chief both linked teen mothers’ deaths to democracy, they illuminated longstanding linkages between problematic modernities and problematic pregnancies. This chapter interrogates “tradition” while situating the problem of maternal death in time—­both in linear history, and in the circular time in which each generation succeeds the last. Biomedically trained people typically look for the secrets of an individual’s body by investigating ever-­smaller parts of its interior. Chapter 2, “Knowing Bodies,” considers bodies as clinicians learn to interpret them, and also as biosocial phenomena shaped from before birth by history and social inequality. The chapter introduces readers to aspects of ordinary life in a large Malawian city and its surrounds, and ordinary medical care in the hospitals and health centers where formal-­sector health workers labor. Building on the first chapter’s examination of time, this chapter grapples with space. Vulnerability and resilience manifest at scales from the molecular to the global, with cells, organs, neighborhoods, and nations in between. A close investigation of a single death reveals how these scales of injury and healing matter for the individual.

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15

Prescriptions for safer motherhood often require essential technologies. Chapter 3, “Ambivalent Technologies,” examines tools used to ward off the dreaded pregnancy complication of obstructed labor—­among them abortifacients, measuring sticks, and labor charts called partographs. Some technologies are powerful social actors, marking people who use them as either backward or modern. Even “magic bullets” presented as safe, inexpensive, and material are often also dangerous, expensive, and social. Discussions of the drug misoprostol and of cesarean section show how tools can be lifesaving and lethal, and how these tools get caught up in disputes over “appropriate technologies”—­second-­best measures intended to reduce deaths in resource-­ strapped places. Absent technologies also act: broken blood pressure cuffs, on-­call doctors who cannot be reached, powerful medicinal roots that are now impossible to find—­all figure in stories about maternal death. Chapter 4, “Abundant Scarcity,” describes the power of what is not there. Some therapeutic possibilities exist nowhere within Malawi’s borders except in the pages of textbooks. Others are out of reach for most but available to a few, in enclaves such as private clinics or research projects. In this uneven landscape, experts protest, improvise, and dream. Their improvised practices of care, like the ambivalent technologies of the previous chapter, require a reconsideration of the “best practice” dogmas of global health and global bioethics. Chapter 5, “Countless Accountings,” considers analytical schemata used in Malawi to generate abstract knowledge about maternal death: a verbal-­ autopsy tool for assigning cause of death; the “three-­delays” framework for evaluating access to care; an influential model for estimating maternal mortality. Building on a burgeoning scholarship on metrics, I show that a statistical way of knowing death, while appearing to promise an objective certainty, is as partial a narrative as those offered by people who bear witness to actual deaths in their workplaces. The chapter also shows how maternal mortality metrics shore up political claims, and how—­and why—­these claims became particularly important when Malawi’s first woman president briefly held power. Practitioners’ narratives about death frequently bolster their own authority by depicting other kinds of expertise as dangerous: corporeally, socially, or spiritually. Women seeking safe paths to motherhood must navigate these claims and counterclaims. Meanwhile, policies intended to make motherhood safer sometimes can intensify patriarchal authority over women. Chapter 6, “Fragile Authority,” extends scholarship on reproductive governance and authoritative knowledge by showing how strategies that people use to legitimate their expertise can render care more dangerous and knowledge more partial (in both senses of that word) than it might otherwise be.

16

introduction

People looking for a study of how Malawian women navigate reproductive choices will not find it here. Other books provide more complex histories,18 clearer pictures of community life and gender relations,19 broader analysis of the political life of data,20 richer hospital ethnography,21 closer study of heal­ ing practices,22 and subtler analysis of technologies.23 My debt to many of these authors is evident, and deep. This book’s theoretical innovation is its synthesis of explanations for maternal death that usually circulate in different bodies of literature, different epistemic communities, and even different parts of the world. Considering them together allows new questions. Which approaches to a terrible problem are overdetermined by multiple interests? Who benefits and who is hurt? Why are some debates intractable, some wheels repeatedly reinvented? What possibilities never gain traction? Whose perspectives repeatedly disappear? Each chapter includes observations and interview excerpts that illustrate key arguments. I’ve tried to be scrupulous about selecting materials that represent common patterns while also revealing the wide variation among Malawians. The brevity of these snippets of primary data comes at a cost. They give little sense of the texture of ordinary life, the cadences of people’s speech, the complexities and contradictions in any given person’s reflections on maternal health, or the peculiarities of the interview context. To provide readers with a better feeling for these matters, I have introduced each chapter by describing a specific person. For a few pages each, you will encounter a sing’anga, a maternal-­child health coordinator, two azamba, a vimbuza healer, a nurse-­midwife, and a clinical officer. Each of these experts told a story about maternal health in Malawi. Each took up positions in other stories: of the nation, of expertise, of danger. Some also spoke as daughters, mothers, friends, spouses, or community elders. A few accounts may be uncomfortable to read. In the one just ahead, for instance, the sing’anga Bonnex Kaunda attributed maternal death to the morals of “our women today” in ways that echo racist stereotypes about African promiscuity—­but that also reflect longstanding indigenous connections between reproductive danger and a troubled society. Chakufa sichilankhula. What is dead cannot speak. Medical anthropology is a second career for me. The first, as an obstetrician­gynecologist, immersed me in medical ways of knowing for two decades before I became an anthropologist. I learned my trade in public hospitals at the rough edges of two poor states, and practiced for years in rural hospitals in two of America’s poorest counties. Women died in those places too—­albeit in much, much smaller numbers. The conditions leading to their deaths never seemed adequately captured in our mortality-­review meetings, or in medical

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17

journal reports. Some of these women’s stories appear briefly in the book. The minimal material from the United States and the much more extensive and systematic analysis from Malawi is not in balance. Moreover, the contexts of US deaths are quite different from those of the Malawian women who are at the book’s heart: the specific ways that injustice has been justified and racialized differ, although the damage that injustice inflicts on bodies can be similar. My intent in including material from the United States is to show that some of the processes at work—­such as the ways policies can make women vulnerable, or the analytical practices experts use to draw lessons from deaths—­are not so different. Maternal death is not a problem only “over there.” Each of the book’s six chapters includes at some point a narrative of at least one maternal death. Some of these cases are skeletal, told in three or four sentences. Others are more fleshed out. Woven throughout the manuscript is a single more-­detailed account, drawn from field notes, letters, and the recollections of clinicians involved. This story of Faith Chisoni—­this story, not the story, because many could be told—­shows how unstable any single story is. It also draws attention to an absence haunting the book: the inevitable and troubling absence of the voices of the dead women themselves. The first mention of Faith Chisoni I found anywhere took up seven short lines. I’ve added translations beneath each one. 23 G3P1 29 wks she was twenty-­three years old, in her third pregnancy, and had already had one child; she was about seven months pregnant previa, abruption her placenta was covering the opening to her uterus; it had begun to tear away from the uterine wall and was bleeding clinical DIC her blood was no longer clotting properly emergent C/S her doctor and midwife did an emergency cesarean section undiagnosed twins expecting one baby, they delivered two 1600g male 1/4 one minute after birth, among the newborn signs of life counted in an Apgar score, the boy had only a slow pulse; at five minutes, he had revived a little 1200g female 2/5 the girl was tiny, not even three pounds; at both one and five minutes old she was slightly livelier than her brother

*

18

introduction

Writing this book has often felt like looking through a kaleidoscope. Fragments of everyday life have gone by, placed in always-­changing juxtaposition to fragments of hospital scenes, of social relations, of tools and technologies, of geopolitics, of stories about good men and women or about people’s bad behavior. Cesarean section. Minibuses. A powerful herbal treatment called mwanamphepo. Health surveillance assistants and azamba. Hemoglobin. Malawi’s first female president. An initiation ceremony. Faith Chisoni. Each fragment would take a prominent place in one chapter, only to tumble to the margins in the next—­but never to disappear entirely. It is my hope that reading this book will feel less like peering through a kaleidoscope than writing it has. A more optimistic model for complex and ambiguous relationships among recurring elements is a southern African folktale. It is a form I have come to cherish, although it is not my own tradition; I see its elements in other kinds of stories. Apparently simple at first, folktales reveal layers of meaning as they are told and retold over the course of an evening, or of the years, in slightly different and more fully elaborated ways. Often they join a linear narrative with a circular movement: strategic repetition of the key elements permits regular return from specific parts of the story to the message of the whole. Together the linear and circular aspects of the story take on a sort of spiral form, each turn reaching out a little wider for insight into the strangeness of human experience. Each of us who reads these words arrived in this world through someone’s body.24 Those bodies become powerful and vulnerable in the experience; some are made more vulnerable than others. Ali ndi pakati. They are in the middle between being one person and becoming two. As the stories you are about to encounter are windows on birth, life, and death in Malawi, so the experiences of women in Malawi are windows on human life and human meaning-­making in all their fragility—­everywhere.

Bonnex Kaunda: “There are too many goings-­on these days.”

Bonnex Kaunda had asked to meet at a house near Tikhale minibus stop. It was going to be a nice place when the construction was finished. When we met there, the iron-­sheet roof was up, but several walls were incomplete. A stack of logs and a big pile of bricks flanked the front steps. Only one room was furnished, with a bench, a stretch of burlap on a smooth floor painted dark red, and a wooden table on which screwdrivers and pliers sat next to an electronic carcass that might have been a disassembled radio. “Ntchito yanga ndi African doctor yausing’anga,” Doctor Kaunda explained: my work is that of an African doctor, a sing’anga.1 I’d explained the research project and asked if he’d be willing to talk. My research assistant had checked to be sure he understood what the interview was for. Yes, that was all fine. Yes, he understood it wasn’t a test. Yes, we could begin—­after he started with a prayer. Bonnex Kaunda maintained a slightly crouched posture that gave him the look of a wrestler, an impression strengthened by his powerfully muscled neck and chest. Now he drew his shoulders together, bowing his close-­cropped head over clasped hands. Invoking the name of Jesus, he prayed aloud that each of us could learn how to make pregnancy safer for women in Malawi. I gave an amen with feeling. He’d been born to be a sing’anga, said Doctor Kaunda. “This job is in my blood line; I did not ‘learn’ it from anybody. My grandfather was a healer, my mother was a healer, so I was born right in the middle of it. . . . I was just really given a gift from God.” People came to see him when they felt that they needed traditional medicine, and he provided it. Some clients he saw only once; some came repeatedly, as needed. He did not deliver babies. Women should seek that kind of help from other women. But he had excellent remedies for pregnancies that went far overdue or for people who had trouble with

20

bon n e x k au n da

repeated pregnancy losses. His nansula treatments for infertility were known far and wide. Perhaps he was trying to reassure me, the visiting doctor, by hastening to note that he didn’t handle everything himself: “There are things that we cannot do, things that can only be done by the hospital personnel. For example, we cannot give a blood transfusion if someone has severe anemia and heart palpitations—­only the hospital does that.” Ultimately, the outcome of a pregnancy was not up to him or to the hospital workers. I teach and advise that during pregnancy the mother should place her destiny in the hands of the almighty God. While we as healers try everything within our power to help, just as our colleagues in the medical fraternity try to help as well, it’s important for the mother to be calm.

It was especially important to be calm because pregnancy was so dangerous these days. Back in his time, things had been different. I was born quite a while ago [in the mid-­1940s], and in those days there was nothing special about a birth. We were simply born. No hassle. You could even be born anywhere, on a path, on the road, on the bus. Sometimes a woman would go to fetch firewood, and while there she could receive her blessing just like that. That is not the case these days.

His own children had all been born easily, too, with a local mzamba. But things didn’t seem as easy now. Just recently, for instance, he’d given medication to a woman over in Mphambano town to bring on labor. But when her labor began, “we had to go to the hospital to fetch an ambulance to transport her to the hospital, because there were too many complications.” Why, I asked? “There are too many goings-­on these days.” For one thing, far too many young ones—­“schoolgirls, who are not mature enough to handle a delivery”—­ became pregnant early. “Their parents stand by and watch, and when she falls pregnant, then they start buying funny medicines with a view to having an abortion.” Even older women could run into trouble. For them as for the schoolgirls, that trouble usually involved unwise sexual choices. One thing that makes pregnancies a huge risk and grave danger is the fact that our women are very promiscuous. They have numerous men, they have an affair with a tailor, the salt seller, the maize miller. All this in search of money—­ small change at that, like two hundred kwacha or fifty kwacha2—­overlooking the fact that the men they are sleeping with may have HIV infections or sexually transmitted disease. The woman has only one body but the number of

bon n e x k au n da

21

men she is sleeping with! That is why we advise them to beware, look out, times have changed. If such a woman eventually falls pregnant, a problem will most definitely follow.

Women’s failure to follow advice was at the root of many problems. Couples should not have sex too soon after a woman’s menstrual period, a miscarriage, a birth. Violating these guidelines could be deadly. Bonnex Kaunda often prescribed periods of abstinence; physicians often advised contraception. Both, he said, were similarly disregarded by today’s women. The main cause of this problem is that our women today are too pompous, they think of themselves too highly. For example, if a woman is pregnant: she goes to the hospital and the doctor advises her that her immunity is not very strong and her blood quite weak, therefore she should not have any more babies, she must follow birth control methods. She goes home and falls pregnant. In her mind, she thinks the doctors just want to cause her marital problems if she denies her husband any more babies. As a result of this pregnancy, a maternal death may follow. Many people think it is witchcraft, bad spells cast on them by others of ill will. But that is not the case. Sometimes it is our own doing, missing or misunderstanding medical advice. If you follow medical advice, there usually is no problem . . . obedience is of paramount importance. I do not dispute that there is witchcraft. But the major cause of this problem is disregard for medical advice, not witchcraft.

While disobedience, greed, and promiscuity were the most serious problems, poverty was a piece of the picture too. Bonnex Kaunda spoke most plainly about poverty when he talked about food. He advised women to eat a varied diet to keep themselves strong, he said, but he didn’t stress that advice too heavily. Many women could not afford a healthy variety of food. There was no sense frightening them when there was nothing to do about it. “We are there to motivate them as our patients, not to instill fear in them.” The subject of food seemed to take him back to older times again. “There is a remarkable difference between now and then. Back then there was food; now all depends on money. We used to grow our own food. Like cassava, which [my wife] would roast or cook; or sugarcane.” They might have bought a few extras, perhaps oranges or bananas—­after all, a person couldn’t grow everything—­but they’d had enough good fertile land, and they grew most of what they needed. Now “for one to eat well, it all depends on the availability of cash.” In fact, Doctor Kaunda worked a side job to get cash for food. This nice house in which we were talking? Not his. He was the watchman.

1

Dangerous Modernities

Why Did She Die? The woman from Tsoka lived for only a few moments at the referral hospital. A relative, a health center midwife, and an on-­call doctor provided fragments of her story. Not long before the rains, a twenty-­eight-­year-­old woman late in her seventh pregnancy worked preparing her maize field outside the town of Tsoka, a few kilometers beyond the western edge of one of Malawi’s largest cities. In a few years, the little town will probably be engulfed. For now, though, only the first tendrils of city life—­occasional brightly painted mini-­shops, bars, and battery-­charge businesses—­have unfurled into the dry rural landscape of brown fields and scarred baobabs, and the greener clefts where clumps of banana trees grow. The woman looked uncomfortable as she chopped at the hard dirt with her hoe. A sister asked if her labor was beginning; she said no. But soon the relatives working this field together realized she had slipped away. Worried, they began a search. She was not at home. She was not on the dirt road that led to Tsoka Health Center. She was not at the nearest mzamba’s shelter. They found her at about half past five, just as the short equatorial dusk was turning to night, lying alongside her crying newborn on a narrow path. Blood soaked the dirt, and she was still bleeding heavily. Perhaps an umbilical cord indicated that the afterbirth was still inside, perhaps someone recognized that no placenta lay nearby—­no one told me that part of the story. Clearly, however, she needed help urgently. Several family members picked her up and set off quickly to the nearest health center. It takes time to carry a heavy burden on an uneven path. Later, over the radio, the midwife reported that her patient had arrived at seven p.m.

dangerous modernities

23

The government health center where the woman’s relatives sought help was one of several dotted around the city’s edges. Tsoka Health Center had no blood bank or surgical equipment, but it had a maternity ward. The nurse-­ midwife on duty tried to remove the stuck placenta. It is usually possible to remove a placenta with your hands. You reach into the woman’s vagina and curve your gloved hand into its narrowest diameter to slide through the cervix. You are nearly up to your elbow; if your patient is conscious she feels excruciating pain. You find where the soft bulk of the placenta joins the tough wall of the uterus, and push your fingers gently into that plane to separate them. It is not unlike taking a nsima cake from the serving bowl with one’s hand, sliding and lifting while trying to keep one’s own serving and the remaining nsima intact. (In another country, I was taught to imagine my fingers as a spatula, sliding under a pancake and lifting it free of the griddle.) If you succeed in maneuvering your fingers in just the right plane and if the placenta is not abnormally implanted into the muscle, the whole thing comes free and you can pull it out. Usually, that’s what happens. And usually, the hemorrhage stops as the uterine muscle contracts hard, clamping shut the many torn spiral-­shaped arteries.1 That is what the midwife at Tsoka would have hoped for. But midwives, clinical officers, and doctors know to fear other possibilities. A failed attempt can make the hemorrhage worse. Sometimes the muscle won’t contract. And sometimes—­more often when a woman has had many pregnancies or has had prior uterine surgery like a cesarean section—­there is so much scarring on the muscle itself that the placenta sticks firmly to it, and either won’t come out at all or comes out only partly. Then your hands alone will not suffice. Your patient needs a surgeon and an operating room and surgical instruments, fast. This was one of those times. The midwife could not get the placenta out. Her patient was too medically unstable for a transfer by minibus, and anyway the informal public transit system did not run from Tsoka after dark. The midwife radioed for the single working ambulance that served the city and its surrounds at night. It was out at Mitengo Health Center, as far east of the city as Tsoka was west. Even though the driver came directly to Tsoka and then brought both the sick patient from Mitengo and the bleeding woman from Tsoka to the referral hospital, the emergency transport took several hours. The woman arrived at the hospital six hours after giving birth. Dr. Tembo, who’d been on call, reported later that the patient was unresponsive, gasping, her pulse rapid. She had no intravenous line. Perhaps the health center had run out of IV sets (not uncommon) or perhaps no one had considered administering fluids. She died even as a medical student tried to start an IV and Dr. Tembo drew blood to crossmatch for transfusion.

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chapter one

Family members added an unsettling postscript. The dead woman’s last three births had also happened outside, unattended, the mother hidden away. Those newborns had died. One of the nurses mused aloud: did she want these pregnancies? No one said it, but it seems likely that I was not the only one to wonder whether the woman from Tsoka had hoped this baby would die too. Almost any nurse or doctor would have shared Dr. Tembo’s conclusion: the primary cause of death was hypovolemic shock; the underlying cause of death was obstetric hemorrhage. True, no quantitative evidence supported this diagnosis. No one had measured the blood. Much of it had soaked into the dirt path. More was left on the dead woman’s chitenje, the nurse-­midwife’s uniform, the ambulance’s bench, and the doctor’s white coat. No one had taken a hematocrit, a simple test clinicians can use to estimate blood loss. Even if Tsoka Health Center had been able to run a hematocrit at night, doing so would not have been a priority; no test would have changed how the midwife managed the hemorrhage. At the referral hospital, the woman died before her blood reached the lab. One can estimate the severity of a person’s anemia qualitatively, by pulling down her lower eyelid to examine her conjunctiva, or by looking at her tongue. Both were “paper white,” said Dr. Tembo. Even without corroborating numbers produced by machines, it seemed reasonable to conclude that hemorrhage killed the woman from Tsoka by depriving her cardiac muscles of red blood cells, and therefore oxygen, and in that way stopping her heart. Many women hemorrhage. Few die. What other processes were at work in this case? Lack of emergency transport was a glaring problem. To assess other potentially contributing factors, however, was to raise questions difficult to answer. What about insufficient supplies? Intravenous fluids delay death from shock due to hemorrhage: the heart has something to pump, and the remaining red blood cells get out to tissues starving for oxygen. Might an IV at the health center have prevented her death? Or transfusion? Even at hospitals designated for comprehensive care, blood was often unavailable. When available, it was frequently inadequate: scarcity forced a brutal triage, pitting pregnant women against trauma victims or children suffering from acute leukemia. In a referral hospital, I’d been refused more than a single pint of blood for a hemorrhaging patient, told “the labor ward uses too much.” Blood was never available at health centers at all. The medical care the woman received, at the health center and in the hospital, was prompt, careful, and attentive. But was it adequate? A national survey of hospitals and health centers revealed that many had no staff capable of removing retained placentas. So was the placenta really stuck, or was the midwife unskilled in its removal?2

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What role, if any, did unwanted fertility play? If the woman from Tsoka had not wanted those last three pregnancies, did she have access to reliable contraceptives? If she had access, did she have authority to decide to use them? How did her own strange behavior fit in? Was it a tragic consequence of mental illness, as Dr. Tembo speculated? Or did it indicate bewitchment, as the dead woman’s sister suspected? Might blood, counseling by the elders, treatment by a sing’anga, a ready ambulance, or better roads have saved her life? Stories at Work Stories like the tale of the woman from Tsoka circulated in Malawi. They were woven into speeches made by chiefs mobilizing support for safe-­motherhood projects. They were narrated by nurses denouncing government ministers’ priorities, or village elders lamenting the unruliness of youth. Abbreviated versions appeared in the newspapers, in front-­page journalistic exposés on Malawi’s hospitals and “In Memoriam” sections at the back. Circulating stories made sense of the senseless. Why did the woman from Tsoka hide away from everyone while giving birth? No one who attended her understood, but everyone offered explanations. Many maternal deaths, including hers, contained puzzling elements or important unknowns. To make sense of deaths, one had to ignore such elements, either filling in the gaps with assertions about what must have been true (like explaining this death as a product of mental illness or witchcraft), or using a narrative framework in which gaps and puzzles didn’t matter (like explaining this death as an obstetric hemorrhage). Medical stories were used to guide action that could prevent future deaths. The plot in which a pregnant woman came in with swollen hands and a bad headache was one the experienced nurse-­midwife recognized as preeclampsia. It was a plot that moved toward seizures, brain swelling, and death.3 The midwife taught her students to intervene quickly and appropriately, changing the story’s ending. To recognize which tale one was in and to act accordingly was essential to good clinical care. But the really sharp clinician had to act while also keeping her mind open to other possible stories: swelling and headache could result from a malarial crisis instead. Witchcraft stories also guided actions to avert danger.4 Perhaps the expected time of delivery had come and gone and a woman was still pregnant. It had been ten months, or eleven. This plot was familiar too. A healer identified the witch afflicting the woman, and turned the witchcraft back upon its sender. That action—­on its own or alongside administration of a powerful medicinal tea—­could move the plot toward a healthy delivery. If no

26

chapter one

healer intervened, the plot could lead instead to the pregnancy’s disap­ pearance. In the worst cases, uncountered witchcraft might lead to a woman’s death. Hints of familiar plot outlines appear in the explanations people offered for the death of the woman from Tsoka. If she was bewitched, then her peculiar actions were the consequences of someone’s malevolent interventions and a skilled sing’anga might have remedied them. If she was mentally ill, the same actions resulted from a chemical imbalance that a skilled clinician might have treated with pharmaceuticals. Stories also allocated responsibility. Clinicians often blamed inadequate tools, medications, or staff (a charge addressed in chapters 3 and 4). But experts who diagnosed the problem of maternal death also frequently made moral judgments, often—­as in Bonnex Kaunda’s case—­explicitly gendered ones. The solutions they prescribed rendered particular groups of people responsible. Stories of dead mothers were woven by elders into the moral education of juniors—­whether in the flickering firelight under the stars at a coming-­of-­age ritual, beneath a corrugated iron roof at a district hospital’s mortality review, or in the reflected glow of a PowerPoint presentation at an international conference. Moralizing language cut across categories of experts. Bonnex Kaunda and several other asing’anga blamed maternal death on promiscuity; so did some nurse-­midwives. Both an urban doctor and a rural chief laid responsibility at the feet of multiparty democracy and the destructive “freedoms” it brought. Narratives of responsibility refracted maternal death through different moral lenses—­feminist or patriarchal, calling for ufulu (freedom) or for ubuntu (community solidarity)—­that often connected the fates of pregnant women with the state of the nation. Experts used stories to reflect on the limits or glories of the past, assess the disappointments or successes of the present, and chart moral paths into the future. Consider two examples. In one, a rural chief described his efforts to make birth safer. In the other, three urban doctors interpreted a death. a chief blames demo cracy In 2013, Chief Wyson Matengo explained a bylaw he’d implemented. He and several other chiefs had been called to the district hospital, he said; a doctor there was worried about maternal deaths. “They tell us, please, you chiefs encourage that in the village when a person is pregnant, she should not deliver there. They say it like that: should not deliver there.”5 Walking back from the meeting, the chiefs conferred among themselves. “It’s really true, what that

dangerous modernities

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doctor said. For him to speak like that, what has he seen?” They tried to look at their own villages through the doctor’s eyes: “Oh, he sees here, eh . . . here in the village there is not enough equipment.” The doctor was right. A village wasn’t a safe place to deliver. Together the chiefs “solved mathematics,” ultimately coming to a consensus solution: fines. Chief Matengo called his people together. All pregnant women were to go to the hospital in their eighth month and wait there for delivery, he announced. If a woman delivered at home, a two-­thousand-­kwacha fine was due to the chief.6 For the most part, Chief Matengo was pleased with the results. The doctor’s strong advice had been “good and helpful.” There was a name for women who died before delivery: chitambalala. “Chitambalala were many, but now are going down, down. Why? Because of the advice we get from hospital that nobody should be found delivering at home.” Not everyone listened to the advice passed from the doctor to the chief to the villagers about avoiding maternal death, however. A few women refused to go to the hospital at eight months. These willful women waited until things got out of hand, Chief Matengo said. (A woman sitting next to him broke in: “It’s because we don’t have money! Don’t just answer anyhow.” Chief Matengo ignored her.) In the past, these stubborn ones would have heeded him. Now? Democracy had changed it all. You know that this house has four children, my wife and I making six. Imagine they all have their own thoughts: would that house be orderly? Similarly, in democracy, everyone wants to do their own things. . . . If this nation has been destroyed, it’s because of democracy. That’s why the young girl wants to dress the way she wants. When you want to take responsibility to advise her to try to do this and that, she tells you, “That is of the past, today it’s democracy.” Everywhere you go people say it’s democracy, and yet it’s destruction.

In the end, Chief Matengo said, this destructive freedom killed people. “Because this world has been turned upside down, young girls and boys die.” t h r e e d o c t o r s a s s e s s t h e i r h o s p i ta l One morning in 2007, three doctors discussed a young woman who had been admitted to the hospital the night before with a miscarriage and subsequently bled to death. The sole nurse on a ward of sixty patients didn’t notice the hemorrhage at first. The intern couldn’t get the patient to surgery quickly enough; the on-­call team was already in the operating theater with another emergency. She sent for blood, but the blood bank—­following routine practice—­refused

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to provide any unless the patient’s family members came in to donate. The obstetricians who discussed this case the next morning, all Malawians trained abroad, all made different diagnoses. Dr. Paul Mbanda saw the woman’s death as one more reason to shut the hospital down. Call it a failed experiment. Surgical bandage material—­called plaster—­had also run out overnight, he noted. “We have here abnormal situations and we make them normal,” he said, eyebrows raised and palms up. “We see them as normal. The whole hospital cannot afford to have plaster, and we are still operating? I am really waiting for the day Queens Hospital closes down.” “To my mind, this is a useful reminder,” said Dr. Gray Bwanali in a more measured voice: “Women can die of miscarriage here.” Dr. Bwanali urged his colleagues and students to be flexible. Creative. “This woman came in, she was fine. Now she is dead. Yes, there is scarcity—­but much can be done. When our system is not so strong in terms of supportive services, we must rely on our hands and our brains.” Dr. Ian Jere read the young woman’s death as an unfortunate point on a path of generally steady progress. On this morning, Dr. Jere had the last word: “Of course this is far from ideal. It’s a learning process, and we will get there eventually.” All three doctors looked to the future in their comments. Dr. Mbanda was “waiting for the day,” Dr. Jere held out that “we will get there eventually,” and Dr. Bwanali pointed out that “much can be done.” others consider danger and time Other diagnoses looked to the past. Like the chief who described democracy’s lethal effects, many people evoked changes they had seen as they explained women’s deaths. When formal research for this project began in 2007, I asked most interviewees directly whether they felt that pregnancy was dangerous in Malawi (see table 1.1). The great majority responded immediately in the affirmative. Many added emphasis (ndithu! of course! koposa! extremely!). Here are two typical examples: Women are losing their lives often during that time. There is a remarkable difference between now and then—­during our time we were envious, even jealous if your neighbor with whom you were pregnant at the same time has beaten you to another pregnancy! There were no problems then as there are now; there are many maternal deaths now. (Annettie Manyunga, counselor and mzamba)

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ta b l e 1 . 1 . Are pregnancy and birth dangerous in Malawi? Interviewees

Yes

No

Equivocal

Totals

Formal sector Informal sector Male Female Age 40 and older Under age 40 TOTALS

17 53

53% 93%

6 1

19% 2%

9 3

28% 5%

32 57

36% 64%

14 56 50

88% 77% 86%

0 7 2

0% 10% 3%

2 10 6

13% 14% 10%

16 73 58

18% 82% 65%

20 70

65% 79%

5 7

16% 8%

6 12

19% 13%

31 89

35% 100%

Note: Table includes only recorded interviews during which I asked this question. Interviewees who worked in both formal and informal capacities have been listed only once, under their primary role. Interviewees who did not know their ages all appeared well over forty to me, and have been included in that group.

There are so many deaths. You will find, these days, that a woman has delivered and within three months, four months she is gone. Or the child is gone. (Immaculate Chikumbutso, health surveillance assistant)

About one in five either didn’t see pregnancy as perilous, or equivocated: under some circumstances, yes, pregnancy was dangerous; under others, no. Most were formal-­sector health workers, such as Takhala Kalimira, a community health nurse: “I would not say it’s dangerous. We are being trained—­I mean, we have in-­service trainings done by our district health office. So we know how to handle deliveries.” The nurse-­midwife Cecilia Phambala agreed: “Pregnancy and birth are not dangerous as long as they are properly handled.” Ruth Welemu, a wizened mzamba who described herself as being “of a great, great age,” was the only informal-­sector expert who contended that birth was not dangerous: “So long as you put your mind to the fact that you are pregnant, you will deliver without a problem.” She advised pregnant women to avoid the hospital, lest medical personnel fill them with fears. Several nurse-­midwives, like Sister Agnesi Kunjirima, differentiated between safe birth in hospitals and unsafe birth with TBAs. They don’t have enough equipment, eh? For instance, Claire, I can say that this lady have gone to TBA. Membranes ruptured, fully dilated, cord prolapsed. What can the TBA do? But in hospital, I can call for help: “Claire, there’s a cord prolapsed!” Then we can take the lady, whshh, theater. Whshh shh shh! And for certain we save the baby.

These examples illustrate two points. First, pregnancy was not just dangerous for mothers. Sister Kunjirima, for instance, imagined an emergency in

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which a loop of the umbilical cord that supplies oxygenated blood to the fetus slid out and was compressed by the fetal head. With hospital staff and equipment, speedy intervention could prevent a stillbirth.7 Immaculate Chikumbutso described deaths of both children and mothers as evidence of today’s dangers. Dual references to endangered mothers and endangered newborns were common. Second, discussions of dangerous deliveries often addressed space and time. Birth was dangerous only in a hospital where a woman was filled with fears—­or it was dangerous in the village without equipment, but not in the hospital. Birth was not dangerous “in our times,” but was now. Birth used to be dangerous, but it was not dangerous now that we had in-­service trainings. Almost half of those who characterized pregnancies as dangerous (thirty-­ four of seventy) specifically compared “today” or “nowadays” to times past. Chichewa speakers often used variations on the phrase kusiyana ndi makolo kale—­it was different in the ancestors’ time. Women then delivered well and recovered fast; women now lacked strength and stamina. Hannifa Pondani, an herbalist who treated postpartum women and their newborns, recalled her own nine easy births. She explained: There is a remarkable difference giving birth now and then. Some time back an expectant mother would go into labor, cook nsima, and just take a quick walk round the veranda and a baby was born. Nowadays pains and problems start from the eighth month through to the end.

Some time back, nowadays, in the time of my ancestors, then and now: assessments of pregnancy-­related dangers were often reflections on the past. Older people were especially likely to compare contemporary dangers to “our time.” • Getrude Gwalangwa (age sixty-­seven), who had been a birth attendant for thirty years and had delivered three of her own children unassisted, commented: “There is a remarkable difference between now and our time; it is [only] by chance now that one has a straightforward birth. It is far too dangerous.” • The elderly herbalist Salome Tamayenda concurred: “In our time, a woman would go into labor at eight a.m. . . . but by eleven in the morning she delivers her baby and goes about her chores, going to the well to draw water or even pounding maize. Can’t happen these days.” • “It is far more dangerous to deliver now than it was back in our time,” said Doriss Katembo (age fifty-­six, mzamba). “These days when you deliver,

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you may be bedridden for a good three weeks. In the past, during our time, you could deliver your baby and strongly walk around.”

In English and Chichewa, people contrasted “then” with “now” using expressions conveying marked difference. Experts who worked outside the formal sector—­TBAs, asing’anga, counselors—­frequently evoked wrong turns the present had taken when describing deaths in pregnancy. Painting a picture of physical, moral, and social decline, many spoke of “the disease that has come upon us now.” But they also talked about weakness and hunger, witchcraft and the willfulness Chief Matengo described as “destruction.” To understand how people connected maternal death with historical change—­why, for instance, Bonnex Kaunda attributed mothers’ deaths to “goings-­on these days”—­we must understand something about the changes they had witnessed, and those that their ancestors had seen. History at a Crossroads Any given story of maternal death is at once specific and emblematic of broader concerns. So is any given history. Malawi is a specific place. It is also a site in which global processes of imperialism, racial capitalism, exploitation, and neglect have played out. The abbreviated history that follows weaves together broader and more specific patterns that eventually affected women’s health—­and their power. This history shows why asing’anga, doctors, azamba, and others repeatedly identified remarkable differences between then and now, why elders for generations have made similar claims, and how their proposed solutions fit into larger patterns.8 Malawi’s history is often told as a political story, bounded spatially by national borders and divided temporally into three parts: precolonial, colonial, and postcolonial. This chapter reframes it as a region-­wide economic and social story. Centuries before British mapmakers laid out the boundaries of colonial Nyasaland, the area had been a crossroads. Borders remained porous. In the twenty-­first century, long, unmonitored stretches allowed Mozambican schoolchildren to cross regularly into Malawian classrooms to learn English, and farmers who harvested tomatoes in Malawi to walk to Zambia to sell them. Medicines, policies, and clinicians moved across borders regularly. Both linear and cyclic changes in economic and social life affected maternal health. I choose to begin with the burgeoning regional trade in goods and people in the 1800s, move to the imposition of a cash economy in the early

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1900s and the extraordinary rates of male labor migration that followed, and examine the impact of austerity measures from the 1980s on.9 Each of these changes was at once political, economic, moral, and social. Each was integral to global economic mechanisms that enriched some—­mostly white—­people at others’ expense. Each had analogues in other places, and together they shaped landscapes in which disproportionate numbers of black and brown women die today. Focusing on these changes rather than telling a history that pivots on the seven decades of British colonization is not intended to downplay the brutal imperial extraction of goods, people, and labor. Instead, it is to show how extractive processes preceded formal political rule and continued after its end.10 Throughout these large-­scale upheavals, the turning of seasons and generations produced cyclical changes. Farmers prepared fields, sowed crops, weeded and watered, harvested and hungered in seasonal cycles. People followed—­or violated—­cycles of sexual abstinence and activity. Generational cycles mattered as much as annual ones. Children grew, youths were initiated into adulthood, adults married (and divorced), women conceived (or didn’t) and gave birth (or didn’t) to children who in turn took their place in the cycle of generations. Some grew old enough to reflect on the changes they’d seen since “the time of my ancestors.” Key practices for ensuring successful childbearing and handling reproductive affliction persisted through the upheavals. Practices for managing community tensions over abundance, scarcity, and equity also persisted and evolved. Before describing the turbulence that transformed southern Rift Valley communities in the 1800s, I turn to four key ways of addressing misfortune. All four cross-­cut the history that follows, from the nineteenth century to the twenty-­first. “durable bundles” of healing and meaning Healing practices were never isolated or static. Ethnomedical histories involved migration, intermingling, and change well before the nineteenth-­ century influx of medical missionaries who paved the way for colonial conquest. Many proverbs testified to respect for outsider knowledge: “The visitor brings a sharp knife.”11 Nonetheless, several patterns of engagement with affliction—­in the historian David Schoenbrun’s phrase, “durable bundles of meaning and practice”12—­proved persistent. Four such bundles came up repeatedly in stories I was told. Loose groups of kin cared for the sick, making decisions about where and from whom to seek assistance. People faced with reproductive difficulties often sought specialist intervention for witchcraft.

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Many healers came to their craft through illness. And maternal death–­ prevention tactics relied heavily on careful regulation of sexual and reproductive cycles. When maladies did not respond to household remedies, a cluster of concerned kin (and occasional non-­kin) usually worked out when, how, and from whom to seek help.13 The “guardians” still expected to provide essential care for hospitalized patients were often part of these larger groups guiding therapeutic decisions—­including decisions about when to give up on medical treatments. Faith Chisoni’s mother, who accompanied her throughout her weeks of pain, fever, and decline in the hospital, was one such guardian. Bodily, material, and social afflictions had many causes, among them witchcraft and related spiritual dangers. Some witches deliberately used abomina­ ble secret practices to accumulate wealth and power. One could be a witch without knowing it, however, harboring jealousies that worked supernatural harm on neighbors whose childbearing was easier, whose crops were abundant, whose husbands had brought back new housewares from Johannesburg, or who tempted one’s spouse to stray. An envious person was as likely to be accused of witchcraft as was a person with unexplained or unshared good fortune. People were most likely to consider witchcraft and seek help from a sing’anga in cases of prolonged misfortune, such as infertility, chronic illness, business failures, or recurrent miscarriages.14 These specialists could divine who was to blame and what must be done. Their powers were inherently dual: the ability to move between human and spirit worlds meant that asing’anga could work both harm and healing. Healing powers often originated in affliction. Several doctors and nurses who spoke with me had been drawn to their professions during serious illness. The pattern was nearly ubiquitous among asing’anga.15 Doctor Mphatso’s healing career was typical. A placard outside her home touted her connection with Mozambican spirits, advertising her cures for problems with “bizimis [business], ufiti [witchcraft], fat,” and various internal organs. She’d been healed by these spirits (mizimu), she explained, after long suffering fits and paralysis. A fourth bundle of meaning and practice involved gendered strategies to maintain smooth reproduction and prevent complications. Like the others, it had origins in the nineteenth century or earlier. Among the peoples who farmed the fertile country at the southern end of what is now called the Rift Valley, women and men held complementary positions. Women tended most crops; men did most fishing and hunting. Men spun and wove cotton; women made salt and pots. Women procured water and gathered firewood; men procured thatch and smelted iron. Families in

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much of the region surrounding the large lake Nyanja (Great Sea) traced kinship through maternal lineages.16 Most chiefs were men, some were women. Other women were anamkhungwi, ritual specialists who installed and advised chiefs, and who initiated girls into womanhood and women into childbearing. Initiation ceremonies often featured warnings about the deadly consequences of irresponsibility among people becoming social and sexual adults.17 In Chewa chinamwali ceremonies for girls, frightening masked dancers dramatized these warnings. In Yao initiation rituals for boys, large painted clay forms built up on the ground helped initiates learn to be responsible adult men. Two colonial doctors in the 1920s described one of these teaching models, a figure of a dead woman—­the wâkongwe.18 Boys were told that the wâkongwe died while pregnant because her husband had sex with another woman. As the historian Megan Vaughan explained: The wâkongwe spoke to the problem of maternal death, and to preoccupations with health, fertility and reproduction in this region that operated at the level of political systems as well as of the most intimate relations. And strikingly, the wâkongwe delivered its message directly to young boys, reminding them not only that their sexual behaviour and their moral conduct could determine the success or failure of marital fertility, but that their future wives might die in childbirth because of their misconduct.19

Another such model, described by a later colonial doctor-­ethnographer, was the cilwa: a figure of a husband and wife who had died because they breached conjugal taboos (see figure 1.1). People still commonly carve the breast symbols prominent in figure 1.1 onto grain mortars; human and agricultural fecundity are—­and were—­ symbolically linked. Both were bound intimately with elders’ power to regulate agricultural and sexual cycles. Poems, songs, masked dances, and proverbs across many communities connected both reproductive bodies and fertile land to chiefly authority. Consider three brief examples. • After the rainmaking ceremony ended in southern Nyasaland, a Mang’anja chief and his wife were to rise and leave their home. The chief uttered invocations while rain clouds gathered. When they returned indoors, their act of intercourse brought thunder, lightning, and rain.20 • A similar chiefly sexual act at the end of the Chewa chinamwali initiation ceremony “unlocked” the girls’ fertility.21 • At a chief ’s installation, in central Malawi, his sister’s praise song included these words:

f i g u r e 1.1. Cilwa, a teaching model used in a Yao boys’ initiation ceremony, mid-­twentieth century (Sanderson, “Inyago,” 49).

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Let me tell you the secret of the land. Your head is the land, and the hair that grows on your head is the brush that grows on the land. . . . Let me tell you the secret of the land. Your navel is the land, and your penis grows up in the land. And it is your penis that owns the land and keeps the land.22

Chiefs, rainmakers, and other elders collectively managed a series of carefully timed annual practices coming under the broader rubric of mwambo, custom. Planting, hoeing, weeding, and otherwise tending gardens occupied most of the rainy season. The dry season was for harvesting and feasting, drying and storing. After farmers burned the drylands, the first rains of late November “swept away” the ashes to prepare the ground for planting again.23 The agricultural cycle of fire and water had a bodily analogue: sexual activity made one hot, while abstinence was cooling; each had its season. Adult women managed these cycles. They observed precautions about food preparation meant to maintain the appropriate flow of heat and cold. They regulated adherence to prescribed periods of abstinence and sexual activity—­ cycles that turned on a woman’s menses, just as agricultural cycles turned on timed burns. They taught their daughters and the daughters of others to follow these cycles in their turn. All these practices, well established in the nineteenth century, continued to affect women encountering reproductive afflictions in the twenty-­first century—­ although specific aspects changed as social and economic life did, and as alternative ideas spread about how landscapes and bodies should be managed. trading people Women’s positions became less secure in the early-­to mid-­1800s, as global pressures produced regional turbulence. Yao-­speaking traders, embedded in Indian Ocean networks that gave them ready access to guns, came westward seeking captives and elephant tusks. Markets pushed them. A craving for cheap labor on the clove plantations of Zanzibar and the grain plantations of Mombasa propelled trade in people; a craze for carved luxury items in Europe and North America drove rising ivory prices. Meanwhile, Ngoni raiders (themselves part of a diaspora originating far to the south) seized land, livestock, and lakeside farmers. Many people fled. Some were killed. Others were absorbed into Ngoni and Yao lineages. Women and girls were especially desirable captives. They could maintain

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households where sex, comfort, and home cooking were at the ready for itinerant men.24 Children born to these more or less disposable enslaved women became part of their father’s line rather than members of a matrilineage. Chiefs and merchants could accrue power by accumulating women, who also served as a sort of human reserve currency. If necessary, they could be traded—­often to be sold onwards to Zanzibar Island or the Persian Gulf—­ for guns, cloth or other goods. They could also serve as payment for fines, including fines stemming from maternal deaths. The story told by one such woman, Bwanikwa, illustrates the toll these practices took.25 Her father’s senior wife, a chief ’s daughter, died in childbirth. Bwanikwa’s father, presumed responsible, was fined three women—­but only came up with two. One of his daughters completed the payment. The chief who thus acquired Bwanikwa traded her for gunpowder. When the gunpowder trader offended another chief, Bwanikwa was again relocated as part of a fine. Traded for a gun, she bore her first child—­who lived three days—­to the gun seller. In total she was enslaved ten times, escaped at least three times, and moved widely across the region west of Nyasaland. Eventually, after purchasing her own freedom, she became known as a healer who specialized in treating women’s concerns. The slave trade’s social upheaval and sexual brutality harmed bodies and threatened reproduction in Africa, as it did in the Americas.26 Forced movement of women like Bwanikwa from one household to another, alongside the incursion of new and widely traveled men (whether of British, Ngoni, Portuguese, Yao, or other origin), ensured a rapid spread of sexually transmitted infections—­and endemic infertility. Medicines to promote pregnancy and protect childbirth proliferated in Central Africa, as did women’s healing cults.27 By the time Scottish missionaries made their way to the region in the 1870s, conquest and enslavement had eroded the position of women. Some remained powerful. Women within Chewa matrilineages, for instance, could divorce relatively easily and retained custody of their children. Some were chiefs or anamkhungwi. On the other end of the spectrum, enslaved women had very limited power, as Bwanikwa’s story demonstrates. Both valuable and constrained, they were essentially unable to petition for divorce or seek redress for abuse, and could rarely control their own or their children’s fates. Europeans described slavery in general, and the status of captive women specifically, as crucial justifications for mission intervention—­and soon, for colonization.28 European governments competed with one another over African territories in the 1880s. In Africa, they used trade networks, military

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conscripts, and leaders they took to be “traditional authorities” as footholds into communities.29 In Europe, they used assertions of white superiority to promote imperial control as a moral imperative. Colonial control could stamp out slavery; commercial agriculture could provide economic alternatives; Christianity could promote stable families.30 Britain claimed what is now Malawi in 1891, renaming it the Nyasaland Protectorate in 1906. Formal slavery ended. But soon, the colonial legal regime that had outlawed slavery constrained women in new ways—­and familiar ones. The widescale imposition of cash taxation furthered men’s mobility and women’s precarity in ways that ultimately would shape maternal death. the injuries of a cash economy Nyasaland offered colonizers few mineral resources: no veins of gold, no copper. It did, however, have fertile land and people who could work it. How to get them? Colonizers secured land through confiscation and treaties. Officials designated some land “empty”—­a term that did not mean “uninhabited”—­and lawyers certified it as property of the British Crown. Questionable treaties diverted more land from African farmers to European capitalists. The colonial physician Norman Leys, a fierce critic of imperialism, was startled to find that a financial corporation owned an entire northern Nyasaland district, “thousands of square miles on which some sixty thousand natives live[d]”—­and that not even the chief understood the implications of the treaty his predecessor had signed.31 Labor posed a thornier problem: how to induce Africans to work on Nyasaland’s plantations, on Southern Rhodesian farms, and in South African mines? Nyasaland’s governors imposed a yearly cash “hut tax” on all African households in the early 1890s, doubled it in 1902, and raised it still higher later. (Non-­natives did not pay income taxes for some thirty years.) Hut taxes financed infrastructure construction and officials’ salaries. More important, cash taxes mobilized cheap labor. To get cash, men worked for someone who had it. That someone—­perhaps an Italian coffee planter or a Scottish sugarcane grower—­was almost certain to be a European. Wages for workers on Nyasaland plantations went directly to the government until taxes were paid, typically two months’ work. Men who could not find wage labor did unpaid road-­building for the government instead. In short, colonizers extracted economic value from African laborers through racially justified exploitation: in Nyasaland, hut taxes and forced labor kept the wheels of racial capitalism turning.

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In the US at the turn of the twentieth century, sharecropping and convict leasing forced black Americans into arduous labor on white-­owned land—­ enforced by the threat of police and prisons.32 In Nyasaland, the British Colonial Office approach used coercive tactics too. District officials punished noncompliance harshly, burning homes, imprisoning tax delinquents, and seizing wives to be held until taxes were paid.33 These practices left marks on families and in the language: the Chichewa kugwirira means both “to seize for debt” and “to rape.” Women’s lives and bodies had once been fines for offenses against chiefs. Now they were fines for offenses against colonial officials. Migration Harmed Health The long subsequent history of male labor migration undermined family stability and women’s health. By the early 1900s, employment bureaus actively recruited Nyasaland men for foreign mines. Labor migration soon became the norm. Both the scale and the impact were extraordinary. By the 1940s, when Bonnex Kaunda and many others with whom I spoke were children, roughly a third of Nyasaland men were out of the country at any given time.34 New migration patterns brought new ideas, new commodities, and new threats to well-­being. Underground mining was notoriously dangerous, but tuberculosis and pneumonia took even more lives than accidents. Workers encountered new pathogens after long journeys that left them exhausted. Poor-­quality food and crowded housing made matters worse. Annual mortality rates among workers from Central Africa, including Nyasaland, could exceed one in ten recruits.35 Plantation work and road-­building left marks too. A Nyasaland doctor noted that he could always tell whether men on the road were leaving home or returning: grueling labor left their physical condition visibly worse.36 Households suffered. Men who were injured, or too sick to work, were sent home. Care became another family responsibility; contagions like tuberculosis spread. Even when men stayed well and sent wages, migration could hurt women and children and elders who remained at home in Nyasaland. Men had worked fields, cleared land, hunted and fished for additional food. Now more of the hoeing and chopping and weeding and harvesting fell on women’s shoulders. And that came on top of other daily chores: fetching water; gathering firewood, cooking meals, and heating bathwater; caring for the elderly, the small, and the sick. Long absences of husbands, fathers, and amalume—­mothers’ brothers, especially important figures in matrilineal communities—­also slowly eroded social controls over sex. Many men visited prostitutes or started second

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families while away. Many women took lovers while left alone. Jealousy, accusations of immorality, and sexually transmitted infections increased.37 Regulating Cycles Grew Difficult Ritual specialists had to adjust the already flexible guidance of custom—­ mwambo—­to address these serious social changes. Reproductive cycle regulation, a matter of life and death, became increasingly difficult in the first half of the twentieth century. Young people undergoing initiation learned practices of  hygiene, purifica­ tion, and abstinence needed for safe reproduction. Bodily fluids containing life—­moyo—­were simultaneously creative and destructive. Blood and semen, joined in the womb, generated new life. However, a woman’s menstrual or postpartum blood could slowly kill the man who encountered it during sex. Couples had to wash one another after sex, observe sexual precautions related to food preparation and hunting, and abstain at specified times. Sex could be deadly when inappropriately timed, even within marriage. Women especially were to take precautions. Women especially were to blame for deaths, including their own.38 Pregnancy-­specific practices protected parents and infants. Growing maize needed periodic rainfall; the mwana forming in the womb needed periodic applications of semen through intercourse. Near term, the mwana dried and ripened in a state of coolness while its parents abstained. After childbirth, another period of abstinence was vital. The infant’s parents resumed intercourse at a prescribed time, and only then could the child, safely warmed through their lovemaking, be brought from seclusion into the world of “hot”—­sexually active—­adults. Just as agricultural routines were disrupted by men’s labor migration, however, so were cycles of sexual activity and abstinence. Ritual specialists devised new solutions and new commodities, including protective man­ khwala that could substitute for the rite needed to bring an infant safely into the public world—­if, for instance, that infant’s father was off mining copper in Luanshya.39 Several people who spoke with me continued to provide protective commodities. Many worried, however, that disrupted cycles had endangered families and pregnancies. Over half the azamba, asing’anga, and alangizi I interviewed connected death with disordered sexual cycles. The sing’anga and mzamba Mayi Lemani, like others, blamed “the women of today” for abandoning precautions. “After giving birth, they wait for seven days to two months and resume sexual intercourse. No, that is not acceptable! Back in our day we used to abstain for

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seven to eight months.” Hospital workers occasionally advised shorter postpartum abstinence periods. The mzamba Mayi Wilson disapproved: “According to our parents, this is not right. You know that some of us are steeped in the ways of our forefathers: we do not disregard old counsel because of western values.”40 Such disregard could lead to a wife’s death, a husband’s chronic illness, a newborn’s failure to thrive. Concerns about the impact of western values and the lethal consequences of defying mwambo recurred from one generation to the next. They featured in the twenty-­first-­century analyses of Chief Wyson Matengo, Mayi Lemani, Mayi Wilson, and others, but they were far from new. Already in the 1930s, Nyasaland chiefs’ associations were inveighing against the country’s moral decline.41 Their complaints reflected changes in social authority. Social Power Shifted Cash-­based capitalism and the political grip of a faraway power changed many aspects of everyday life. By the 1930s, political leadership, healing expertise, and moral authority were all changing too, in ways that affected gender relations. Colonial agents had introduced new laws. Christian missionaries had introduced new ideals for sexual and domestic practices and blamed new sets of agents—­including Satan, germs, and tradition—­for deaths. Nyasaland’s Christian missions, despite doctrinal differences, all emphasized the establishment of “good Christian families” in which men were to labor industriously and take only one wife, while women were to uphold European middle-­class domestic virtues. Missionaries repurposed some customary activities: mbumba groups, which had sung and danced praise songs for the installations of chiefs, later sang and danced at the openings of churches.42 Women’s initiation rites were another matter. In these initiations, older women taught girls how to make sex pleasurable for both partners, and how to time it to one’s menstrual cycle in order to preserve both fertility and safety. Many missionaries tried to stamp out these “lewd” initiations. Knowledge that had once been central to the maintenance of a flourishing community was recast as evil, and the female elders in charge of maintaining that knowledge described as “The Last Fortress of Satan.”43 The power of some male elders increased, meanwhile. To minimize European staff and Colonial Office budget outlays, Britain used “indirect rule.”44 Most disputes among Africans were to be adjudicated by chiefs designated as “traditional authorities.” For a time, these chiefs became the most powerful Africans in Nyasaland. Male chiefs, often with the support of sympathetic European missionaries, reined in unruly women through once-­flexible

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guidelines turned into permanent “customary law.” The new laws made it harder for women to divorce unsatisfactory husbands, to seek help from their own lineages, to move to urban areas, and to control inheritance and child custody.45 Jealousy Produced Injury Moral panics over witchcraft further upset the social order. By the 1930s, many people perceived that witchcraft had escalated. Inequality spread with cash. Uneven distribution of money and the new goods it could buy; increases in chronic ailments among men and reproductive difficulties among women; and marital discord brought about by large-­scale, long-­term labor migration all provoked suspicions of witchcraft—­and desires for intervention.46 Intergenerational tensions played roles too. When the Great Depression threw many migrants back into rural villages, young men led anti-­witchcraft “cleansing” movements that targeted elders—­especially women.47 Witchcraft accusations and anti-­witchcraft interventions escalated again during later times of widespread and poorly explained suffering, including the worst years of the HIV epidemic. A number of interviewees discussed witchcraft prompted by jealousy. Asing’anga and a few azamba described it as a cause of infertility, disappearing pregnancies, recurrent miscarriages, or newborn deaths; several regularly treated these concerns. A powerful sing’anga could turn witchcraft back on its perpetrator. “If it is a genuine witchcraft case—­a spell,” explained the sing’anga Bernard Kaseko, “I can break it.” Not only did his patients improve, but “the person who is a witch will get even sicker than his victim. He may even appear naked, or he will apologize and say, ‘I was responsible for bewitching this person.’ I have the power to do that.” (Of course, the person who became ill or appeared naked in public was likely to blame witchcraft for his surprising misfortune. The line between witchcraft and anti-­witchcraft could be blurrier than it first appeared.) But few people proposed witchcraft as an explanation for maternal death, except in cases—­like that of the woman from Tsoka—­where apparent madness was involved.48 Hunger Worsened Hunger and weakness, however, came up often. Bonnex Kaunda exhorted women to “eat well, a varied diet.” In the next breath, he acknowledged, “But for one to eat well, it all depends on the availability of cash.” Bonnex Kaunda was initiated into adulthood in the 1950s. By then, the social upheavals people

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faced in Nyasaland often manifested as hunger, and who went hungriest had a lot to do with cash. Some women sold crops, or home-­brewed millet beer. Many had access to cash only through men—­husbands, sons, brothers, lovers. Farmers devoted more effort to plants they could sell, like tobacco and cotton, and less to those they could eat, like beans and maize. The strategy succeeded when harvests were good, but left little safety margin if bad weather or pests caused poor yields. Uncultivated land shrank; wild “emergency foods” grew less available. Communal food-­sharing practices dwindled.49 Many families suffered hunger annually in the lean months before harvest. In hungry times, children old enough to make their own way—­whether through labor or marriage—­were likely be sent off to do so. Broader famines revealed patterns of inequity. Famine in 1922/23, stemming from a drought in southern Nyasaland and the sale of “surplus” maize to the military, made plain that “the ability of the country’s British rulers to collect taxes far surpassed their capacity to feed the hungry.”50 Even during large-­scale famines, not everyone was threatened. After the 1948 rains failed, a mission nurse wrote that “the Governor has called a meeting of both Europeans and Indians and appealed to them not to waste food, or to give parties, or make a show of large quantities of our food in front of starving Africans.”51 A small number of wealthy people made substantial profits by buying up maize flour and cooking oil to resell at high prices. Poorer families, especially those headed by women, were much more vulnerable. Social ties were strained—­the devastating 1949/50 famine was called “the time of divorce”—­and bodies weakened.52 What about Medical Care? Many afflictions that came alongside cash could, in theory, have been treated during the colonial period. Biomedical care for returned migrants, nutritional rehabilitation for the hungry, and treatment for infertility were not on offer, however. Large plantations occasionally had basic clinics for workers. Physicians and nurses who came to Nyasaland’s Christian missions often provided some services.53 Physiology books had been written in Yao and Chichewa by 1914, and various (mostly mission-­run) training schools turned out some nurses, sanitary inspectors, lab assistants and medical auxiliaries by the 1920s. While these graduates often became important figures in their communities, they were few in number.54 Facilities for Africans remained extremely limited. Clin­ ics were geographically sparse and rarely free of charge. Government hospitals, run on the cheap, were primarily intended for white colonial administrators and their families.55 Keeping people healthy

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was not what the colonies were for. In 1918, Britain’s Colonial Office employed a full-­time mycologist dedicated to preventing crop diseases that might hurt Nyasaland exports. No officer was dedicated to public health, or to education.56 In general, African access to biomedicine remained quite limited throughout the colonial period, with maternity care an especially low government priority.57 Even British officials who thought colonial subjects should get medical aid seemed anxious to leave midwifery and childbirth in the hands of missions. Meanwhile, missionaries often regarded maternity work as the thin end of a wedge that would introduce European-­style domestic and hygienic practices into African homes.58 Medical treatment for Africans was often a way to do something other than caring or curing: it was about proselytizing, or changing domestic life. It was also about palliating unrest. Only in the late 1950s did government officials begin a hospital-­building spree—­accompanied by a flurry of promises for improving medical care and increasing opportunities for higher education. These promises, some of them fulfilled, were strategic attempts to demonstrate government goodwill in the face of increasingly vehement protest against British rule. National Development Changed Hands Many white European officials had justified colonial control with a racialized idea of national development. Taking the human life course (from infancy to adulthood, but not into senescence) as a model, they depicted themselves as guiding the modernization of black African nations. However, elite Africans soon came to believe that they could direct the nation’s development better than the colonizers.59 Anticolonial political leaders were often urban white-­collar workers. Nearly all were men. Many had been educated in mission schools, learning that scientific knowledge, philosophical principles, and the precepts of Christianity were universally applicable. Two prominent anticolonial activists were among those who had gone abroad to further their educations—­to the extent that racism and segregation allowed. Hastings Banda trained in the US at Meharry Medical College for black Americans. After independence in 1964, Dr. Banda quickly consolidated power. He became prime minister, then pres­­ ident, then life president, a position he maintained for thirty years as the leader of a one-­party state. Orton Chirwa trained to be a lawyer in South Africa at the Fort Hare University for black Africans. Chirwa was the new

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nation’s first minister of justice and attorney general, until a falling-­out with Banda led to his death sentence for treason.60 Banda capitalized on his status as a Western-­trained physician and an elder of the Church of Scotland, but he did not continue the missionaries’ efforts to stamp out initiation rites, secret societies, and divination rituals. Instead he invoked an idealized African past and repurposed (or invented) local customs to suit his aims. Mbumba dancers accompanied him to public speeches. For years he embraced the Nyau secret society of central Malawi.61 He ensured that Chirwa’s trial was held in a “traditional” court: defendants could not call witnesses; Banda’s appointees, without legal training, made up the majority of those ruling on the case. Sorcery and witchcraft were his to wield against enemies of the state—­that is, the enemies of Banda and his Malawi Congress Party. One elderly sing’anga I interviewed claimed she had worked for him in this capacity. When “my calling came upon me very strong,” said Liness Elijah, she’d come to Banda’s attention: “I assisted him until his death.” Chiefs and praise singers, traditional courts and asing’anga legitimated Banda’s rule and extended his reach. But most power had moved from their hands to those of the Malawi Congress Party and its leaders. This consolidated power was to prove lethal when Banda refused to address—­or to recognize—­a devastating epidemic. Medical Development Changed Hands Too The prestige and reach of biomedical care gradually rose following independence. Malawians continued to resort to a variety of healers: asing’anga, medical assistants, nurses, people who knew roots. Knowledge about herbal medicines became more esoteric, however, and increasingly confined to elders. Mayi Idah Mongolo remembered these changes. Mayi Mongolo called herself “a champion at treating asthma”: her treatments were so strong that people came for assistance from far away—­even from the referral hospital! Nonetheless, she regretted that she knew only six trees. When she’d raised her own eight children in the 1960s and ’70s, her grandmother had treated their ailments. But Idah Mongolo, anticipating a brighter future, had looked down on the old-­fashioned trade her mother and grandmother plied. She declined to go along on their journeys to “the bush” to find roots. “Had I known that times would be this difficult, I would have learnt,” she said. “When you are young, you are naive. My grandmother’s medicine was quite strong; it would have come in handy today.” Her story was not unique. Children spent more

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time in school, less in the bush. The forest itself shrank as charcoal-­burners cut more trees. Meanwhile, Malawi’s new government sought to expand clinics and hospitals. Progress was real but limited. Massive increases in medical, midwifery and nursing training would have been necessary just to keep up with demand; those increases would have required more secondary-­school graduates than the newly independent nation managed. The colonial government had left little to build on. Malawi started its political life already in debt. Not much money was available to strengthen social safety nets, build medical infrastructure, or train clinical staff—­yet neighboring nations Tanzania, Mozambique, and Zambia, which faced similar challenges, did more. Hastings Banda, a doctor himself, showed little appetite for health-­sector development. His early effort to introduce user fees for clinics was roundly rebuffed—­a rare domestic political defeat.62 Mphechempheche mwa njovu sapitamo kawiri: one does not go twice between the thighs of an elephant. His subsequent approach was largely hands-­off. Biomedical services expanded, but health facilities remained sparse, nursing programs limited, physician training nonexistent, maternity units dilapidated. A 1972 national health plan noted pressing needs on nearly all fronts. What little annual budgetary increase was available was “just sufficient to keep abreast of the population increase, the inflated prices on world markets of drugs and hospital equipment and of advances in medical technology.”63 Reproductive health care was especially limited. Banda’s administration was wary of outside funding for women’s health. The intense interest taken by the United Nations Population Fund (UNFPA) and others in the perceived threat of African population growth did not go unnoticed; efforts to provide contraception were quite often—­and quite often correctly—­interpreted in that light.64 Dr. Banda did not allow discussion of family planning at all for decades. Not until 1982 was this ban modified to allow dissemination of information on child-­spacing methods if mothers requested it.65 Patterns of pregnancy care were fairly stable by then. Roughly half of all births occurred in health centers or hospitals. Women in urban areas, or near mission or district hospitals, often sought assistance from nurse-­midwives (or, rarely, doctors or clinical officers). Women in rural areas frequently consulted “traditional birth attendants.”66 However, many women avoided both the azamba and the nurses to deliver at home. Chrissy Mphande, who delivered her children in the 1970s, recalled how it was rightly done: “My parents took me through the process as to how to conduct myself. I was advised against moving up and down wantonly. I was also advised against taking food offered by other people in their houses.” When labor began, “[my parents]

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took me in the company of some counselors to a place where I was to deliver my baby.” There they helped me into the proper birthing position; they monitored the progress of my labor and advised me what to do and when to do it until the baby was born. After that then we all went into a chikuta [space of seclusion]. After some days when we came out of the chikuta, then my husband and his parents were called in together with me and parents and counselors at which meeting we were counseled regarding proper baby care and abstinence for eight months.

The first more or less reliable estimates of maternal mortality come from this period. Malawi’s maternal mortality ratios in 1977–­1983 were comparable to the world average then, around four hundred deaths for every hundred thousand live births. This comparatively stable situation did not last. Maternal deaths were soon to escalate, not to return to their late-­1970s levels for four decades.67 hard neoliberal times The World Health Organization’s radical 1978 manifesto, “Health for All by the Year 2000,” signaled a new commitment to primary care. Scaled-­up health-­worker training, increased community participation, and integration of previously separated health services (such as malaria control, sanitation, and maternal health) were all to meet popular demand for expanded primary health care. In Malawi, these plans bore little fruit. Instead, medical staff, supply chains, and systems were devastated by economic policy measures beginning in the early 1980s. These prescriptions were called “austerity” measures when they were applied in Europe and North America in the 2000s. In the 1980s, they were pioneered in the poorest countries of Africa and Latin America under the name “structural adjustment.” Both labels are expressions of an economic dogma known as neoliberalism. Structural adjustment, interacting synergistically with a terrible epidemic, had profoundly destructive effects on maternal survival in Malawi. Like the expansion of trade in enslaved people, the spread of a cash-­based economy and the increase in migrant labor, structural adjustment originated with processes and actors beyond the nation of Malawi—­in this case, actors gathered at a grand New Hampshire resort hotel some eight thousand miles northwest of Blantyre in 1944. An end to World War II appeared imminent. In Bretton Woods, representatives of forty-­four nations devised measures

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intended to prevent any future tragedy on such a scale. Terrible poverty had laid the groundwork for the Nazi party: anxious, unemployed, hungry Germans were vulnerable to a demagogue promising a return to national greatness through expulsion or extermination of people identified as alien others.68 How could this kind of destabilizing poverty be avoided in the future? Among other measures, the Bretton Woods Agreement established two lending institutions, later named the World Bank and the International Monetary Fund (IMF). The IMF was to provide short-­term support, preventing disruption of state services when a country’s currency was devalued on international markets.69 The World Bank would provide long-­term loans aiding development. No bank loan comes without conditions. In 1981, both lenders changed theirs. For countries dependent on IMF and World Bank loans, the new structural adjustment terms dictated national economic policy.70 Structural Adjustment Six principles guided structural adjustment: government budgets should be small; taxation should be low; regulation should be restricted; capital should flow easily across national borders; currencies should be worth what foreign investors would pay; and functions traditionally understood to be the province of government should be privatized wherever possible. These principles were the backbone of neoliberalism, a once-­marginal political philosophy that in the 1980s became the global norm.71 Powerful Western politicians like Thatcher and Reagan presented neoliberalism as simple common sense, to which there were no alternatives. (There were alternatives. Unpalatable to the wealthy, they were depicted as impossible when they were mentioned at all.) In their own countries, they and their successors gutted support for the poor through “welfare reform” practices, while escalating policing; in other countries, they encouraged structural adjustment loans and aid cuts. Images of undeserving, lazy poor people—­often imagined as black, often women with too many children—­undergirded these interventions. Neoliberalism made governments responsible for keeping markets open to investment and resources available for extraction—­but not really responsible for the well-­being of citizens. The quality of governance itself was measured against these principles, which still underpin the “Worldwide Governance Indicators.”72 Malawi, deeply indebted and under pressure to agree to lenders’ terms, was one of the first nations to sign on to the new agreements. After the country

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took its third annual structural adjustment loan in 1985, the World Health Organization publicly congratulated Malawi for “a record unmatched in Sub-­ saharan Africa, demonstrating its strong performance in effecting policy and institutional reforms, and in managing the economy, toward achievement of desired stabilization of fiscal and current accounts, and long-­term growth of the economy.”73 The abstract language sounds good. The concrete reality for most Malawians was grim.74 Inflation shot up. Jobs were scarce. Wages stayed flat—­when they were paid. The university library lacked books and journals. Public schools lacked chalkboards, teachers, and buildings. Damaged roads went unpatched, broken bridges unrepaired.75 By 1991, WHO officials no longer saw Malawi as a laudable example of stability and growth.76 Minimum wage had dropped 4 percent each year from 1980 to 1989, they noted. Private-­ sector workers had seen real wages drop by almost half during those years; civil servants’ wages dropped by more than half. Small-­scale farmers and other people without formal employment—­the majority of Malawians—­had suffered even more. Structural adjustment meant that hospital administrators with falling budgets faced rising prices for drugs and supplies. Pharmacy shelves were often bare. Health workers reused materials—­like gloves and syringes—­not designed for reuse. Equipment that could no longer be repaired was not replaced. Nurses and doctors were woefully underpaid, frustrated by dwindling resources, and tasked with more and more work. Not enough new medical staff were trained to replace those who quit, emigrated, or died. Sick and injured people struggled to find care: for-­profit, mission, and humanitarian organizations could not fill all the gaps of public medicine. By the early 1990s, the full effects of the HIV pandemic were becoming clear in hospitals and clinics ravaged by structural adjustment.77 Especially in the long years before any antiretroviral drugs were available, patients who would never get better were crammed into every corner of understaffed and undersupplied hospitals. Meanwhile, Malawians who had dreamed of bringing medical care to their fellow citizens were faced with extraordinarily difficult working conditions. They knew that staff, medications, and supplies available elsewhere could help their patients, and yet they couldn’t reliably access the tools they needed—­not just costly resources like fluoroscopy machines and neonatologists, but basics like bandages and nurses. Perhaps it is not surprising that Dr. Paul Mbanda simply wanted to close his referral hospital down. These everyday failures of health care condemned many women to die of treatable pregnancy complications. I’ve documented case after case in which an ambulance, a thermometer, a blood pressure cuff, a nurse might have

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prevented a death. Any experienced Malawian clinician has presided over such cases. Perhaps the woman from Tsoka would not have died if her health center had intravenous fluid, or her sprawling city had more than one on-­call ambulance, or her nation had the functional primary health care system that had once been planned. It would be a mistake to focus only on what happened within hospitals and clinics, however. What happened outside them was probably even more important for maternal mortality, which was soon to reach extraordinary levels. Poverty spread. Malawi’s government stopped subsidizing fertilizer and removed price controls on basic foods, as lenders demanded. National agricultural policy focused on export crops: tobacco, cotton, and tea provided the hard currency needed for loan repayments. Structural adjustment did for African (and Latin American, and Asian) nations what cash taxation had done for African (and Latin American, and Asian) families: it forced many, simultaneously, into markets where they competed on unfavorable terms. Malawi was not the only country flooding the market with tobacco, cotton, and tea. Production rose. Earnings fell. Shoppers far away benefited from low prices, as did multinational companies that transformed commodities into consumer goods. Farmers suffered. An agricultural sector focused on export left a thin margin for domestic food production. Throughout southern Africa, by the 1990s household incomes had dropped, rural families—­especially those headed by women—­had come to rely more on remittances and less on their own crops, multiple sources of informal employment had replaced formal jobs for many, and people were spending more on health care and less on food.78 Once again, the time of hunger was at hand. Once again, poor women were especially vulnerable.

* 23 G3P1 29wks previa, abruption

Many years later, the midwife vividly remembered Faith Chisoni’s mother. High cheekbones like her daughter. Grave and quiet, though not as quiet as her daughter. Slender and slight, though not as short as her daughter. Dressed simply in a blouse, a chitenje, and a headwrap, she was always there. Mostly she was in motion, helping her daughter up to wash or use the toilet, cajoling her to eat. Sometimes she was still, sitting next to the cot in which Faith Chisoni struggled with infection and anemia.

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Had the midwife seen history in their bodies? They looked so alike. But Faith Chisoni’s mother had grown to adulthood in the heady years just after independence, a time of possibilities and good harvests. Her daughter—­ smaller, thinner—­had grown during Malawi’s “lost decades” after structural adjustment, and was pregnant in a time of hunger. Cycles of Hunger Elias Mandala, describing the demise of communal food sharing in south-­ central Malawi, considers both linear and cyclical patterns of history.79 Hunger takes two cyclic forms, he argues. The harvest cycle always includes a hungry season that may or may not tip over into famine. In the daily meal cycle, everybody gets nsima, the starchy maize-­meal staple, but men and elders get most of the ndiwo, the “relish” that contains the meal’s protein and fat. The family cycle includes a hungry time too: the time of women and children. I saw evidence of both cycles, as any clinician in Malawi does. Even in years of decent harvests, February and March for anthu wamba—­the ordinary people—­were the time to eat green mangoes and to tie up one’s trousers with a rope. From time to time, hunger could be much worse. In 1991/92, a terrible drought coincided with the influx of more than a million refugees from the Mozambican civil war. A telex sent to the World Health Organization reported that people were digging up lily roots from riverbanks to eat.80 Even then, hunger was uneven and some people were spared. Annettie Manyunga, one of the many women who’d described pregnancy as easier during “our time,” recalled that she had been one of the lucky ones in that year: I was still finding the same day-­to-­day stuff to eat like nsima and relish, vegetables, maybe meat. At that time my husband was working so we could afford to buy nice food, and the times were good, and over the weekend we could have some chicken and rice for the children to be happy.

For her, hunger began only when her husband lost his job the following year. In 2002, I worked at Queens during another famine. Deregulation of maize marketing—­a loan condition—­had facilitated markups: maize prices had risen more than threefold that year. AIDS was wreaking havoc on food security through multiple paths. Sick people could not work the fields. Healthy people were needed to care for the sick. Money for food was spent on health care and funerals. At the famine’s peak, nearly a third of Malawians were relying on food aid. My field notes record a day during which I’d diagnosed twins unexpectedly in two women referred to high-­risk antenatal clinic.

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Both women, thin and tired and dressed in ragged, much-­washed chitenjes, looked distressed at the news, and one burst into tears. One of her three kids has just gotten out of the peds ICU for severe malnutrition, and is in Moyo House [the nutritional rehabilitation unit] starting Phase One nutritional rehabilitation but still losing weight. “How can I eat? We have no food.”

I had no trouble accessing food that year, nor did my physician colleagues at the hospital. Many of us met for a feast on the date of the American Thanksgiving holiday. But for some of the hospital’s cleaners and other low-­wage workers, and for many of our patients, the situation was dire. Even in ordinary years, food could be difficult. People recalled easier times with specific memories of food. Mayi Idah Mongolo—­whose herbal treatments for asthma brought her a steady but small income—­wistfully described a little tin in which she’d kept groundnut flour to fortify the morning’s maize porridge. Her husband was working then, she said; he would buy not just her favorite nsinjiro flour but margarine and eggs “for the wife’s well-­being and happiness. . . . [At] that time I was doing very well, happily married, but now my husband died and I have a host of orphans to look after. . . . You know,” she reflected in 2007, “it’s such a long time ago. It was nothing like now.” That same year, the sing’anga Bernard Kaseko explained that while he taught women carefully about which foods were safe and which posed ritual dangers, these customs needed to be broken for many pregnant women. “The biggest hurdle is poverty,” he said. “I can advise them on what to eat, but should a time come when the only food they have is what I advised against, then she must eat.” By 2016, climate change was worsening cycles of drought and flood. After a terrible harvest, newspapers proclaimed that 70 percent of Malawians were going hungry.81 The effects remained palpable the following year. In 2017, nurses at two health centers mentioned that they slipped protein supplements to malnourished pregnant women. Yes, supplements were intended for children. But some of the poorest women were so thin! Sister Delhia Msukwa, a nurse-­midwife, circled her own upper arm with a thumb and finger to demonstrate. “They have really got nothing.” New Diseases, but Few New Medicines It was not just famine; AIDS hit Malawi—­and maternal mortality—­hard. For a long time, Dr. Banda did not allow discussion of the disease, safe-­sex education, or condom distribution. He was known for saying, “My people do not get AIDS.”82 By the late 1980s, it was nonetheless evident to many people, health workers and not, that something was badly awry.

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Initially, some people suspected that the strange array of illnesses resulted from witchcraft: “AIDS” was serving as a cover for witches’ secret activities. Or perhaps it was one more excuse for Westerners afraid of African population growth to push condoms. Or perhaps the so-­called new disease was actually the old kanyera that came from violating abstinence customs, as some healers in the late 1990s in the Lilongwe area believed.83 By the time I began interviewing asing’anga and azamba in 2007, those who spoke about kanyera drew clear distinctions. The sing’anga Jackson Sambani explained, “It is dangerous to start having sex with your wife soon after the baby is born because maybe the woman may still have blood in her womb from a fresh birth. There is however a difference between that danger and the danger of HIV/AIDS.” The epidemic had become undeniable reality. AIDS was not the only “new disease.” A few healers counted off other matenda wa masiku ano like suga (diabetes) or hypertension. Mercy Kamowa was one: “To deliver these days is different from the old days. One did not see people dying at birth all the time back then, but these days one finds endless trouble with the diseases of the times.” The sing’anga Bernard Kaseko agreed: “What poses this danger is the coming of these new diseases,” he explained. “For instance, the sugar disease—­long ago it was nonexistent. Even BP [high blood pressure]: in the past BP was referred to as mutu waukulu [major headache], but it was curable using our traditional herbs.” If AIDS wasn’t the only new disease, it was the one that people most frequently cited as a contributor to maternal death. Jackson Sambani noted “a huge difference” from days past: “The HIV/AIDS epidemic makes it dangerous for women to have babies.” Sister K. J. Nyirenda worked in an urban health center. She walked me through the tiny labor ward—­a few beds pushed together, a trolley with sterile gauze and other key tools. It was cleaning day. The ward, which she had described as always busy, was weirdly quiet and smelled of bleach. Buckets and mops stood ready. Nowadays? In the past, people were having maybe their first pregnancy after eighteen years, or maybe after twenty years. But nowadays you could see a child, a girl maybe twelve years, thirteen years, pregnant. That’s why maybe we are at risk. Yeah. And this virus also. You know, when the woman is pregnant, the immune system has got a big load. And with this virus, if the woman is infected, ahh—­everything is worse.

Immaculate Chikumbutso, a health surveillance assistant, had seen pregnancy become more perilous as the HIV epidemic matured. “This time it is dangerous because of the HIV/AIDS. Because most of the women have got

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HIV. Soon after birth there are problems. Problems—­the child and even the mother. They end up dying.” Nurses, midwives, and doctors saw pregnant women with complications of HIV daily. A field note excerpt from 2003 describes a morning in the antenatal clinic: Three women had just been diagnosed—­today—­as HIV-­positive, including one who understood more English than she let on and whose lip began to tremble when Mrs. [Waya] said to me in English, “It breaks my heart when it’s these young ones—­what will happen to them? And the first pregnancy too, and she is a single mother with a history of domestic violence.”

We had little to offer these women. Antiretroviral treatments were available only to a few cash-­paying patients then. Malawi saw a dreadful drop in adult lifespans, at one point estimated as the world’s worst.84 Many people sickened in what should have been prime adult years. They were parents, nurses, teachers, bureaucrats. The toll on families and institutions was extraordinary. Healing treatments of all sorts were expensive, needs for care substantial in the disease’s late stages, grief debilitating.85 A decent funeral typically cost about a year’s income. Households often dissolved after a mother’s death, and parents left behind children who were absorbed into wider family networks. In 2002 and 2003, every family I knew save one had taken in orphans. Young people faced hard decisions—­about schooling, apprenticeships, marriage—­in precarious times. Life was unpredictable, needs were overwhelming. It was hard to know what to do. Dyeratu, Chidza Sichinena: Better Eat Now—­ What’s Coming Doesn’t Announce Itself Predictably, many people affirmed the social values of the majority by blaming the epidemic’s victims.86 Women who became ill were often suspected of adultery or prostitution. “Times have changed, things are not all right,” said sing’anga Solomon Knight in 2007. “Expectant women nowadays have no due regard for anything. Pregnant as they are, they sleep around with whoever they want.” Pregnancies for such women were dangerous. In the old days, a pregnant one would stay at home, not going up and down. They did not have numerous sleeping partners during pregnancy as is the case now. That is the major problem that we have now. When they come for consultation you can even tell that this one is promiscuous, she has slept with many men. We then have to give her medicine so that she can deliver.

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Each major change in the economy—­from the slave trade to the initiation of cash taxes, from the era of massive male labor migration to neoliberal times—­had constrained women’s options. Many women had limited access to cash, essential for everything from school fees to cooking oil to bandages. Some had little power to influence family decisions about education or marriage. While school-­enrollment and literacy rates rose steadily, few jobs were available to young women, even English-­speaking secondary-­school graduates.87 People without the social connections necessary to find paid positions resorted mostly to what has been called the “informal economy.”88 For girls and women who did not find steady work—­the vast majority—­ the situation could be very tenuous. Many relied on male support.89 Families often expected girls to marry once they had completed primary school. Those who continued schooling instead needed to secure fees. (Most also required housing, as secondary schools were not located in every community.) Especially among the youngest and poorest, in the age of structural adjustment, women commodified their bodies because there was little else for them to sell.90 Relationships with older men were topics of gossip, moralizing, and family worry.91 In 2003, for instance, a medical student told me he’d diverted his book stipend to his sister so she would not need a “sugar daddy” to pay school fees. These relationships probably explained why the prevalence of HIV infection among women ages fifteen to twenty-­four stayed about four times as high as that of male agemates.92 Witchcraft and Poisonous Relations It is hard to overestimate the disorientation of the 1980s and 1990s, Malawi’s “lost decades.”93 Structural adjustment, HIV, and sharp increases in poverty and inequality piled atop one other. Meanwhile, new images, new NGOs, and new talk of “rights” entered Malawi in a flood, for when Hastings Banda’s rule ended in 1994, his tight control over media did too. Local musicians dressed like hip-­hop stars. Pastors mimicked the cadences of the Nigerian bishops on television. Storefront video shows featured pirated action flicks, badly dubbed kung fu, Nollywood dramas, and porn. Advertisements for new consumer goods spread, but money to buy them remained concentrated among members of the small elite class. Was this democracy, to paraphrase Chief Matengo, or was it destruction? Inequality kept ugly company: unsatisfied wants, jealous quarrels, and witchcraft. A rise in witchcraft posed dangers for pregnant women. Disagreements could turn deadly. Temwanani Nduyo advised people to protect themselves during pregnancy by taking care not to displease others, but “the

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problem now is young girls have disregard for counsel.  .  .  . During pregnancy they are not afraid to pick quarrels with others. That is dangerous, for a pregnant woman to pick quarrels with others, because [the others] might cause problems for you during delivery. You never know what their ideas are.” Simply seeking antenatal care at all—­whether with a TBA or a nurse—­could make one’s pregnancy public knowledge, inciting the malignant jealousies of others.94 As Nurse Lea Chabwera explained, “Most of the people, they do prepare. But in secret! They do not reveal to others.” People often deferred clinic visits until the pregnancy could no longer be hidden—­and until it was too late to address important problems, as some clinicians lamented.95 When a problem did develop, some women sought explanations, protection, and defense from asing’anga. “Western medicine requires examinations to find out what the problem is,” noted Doctor Ulemu Jimu. “If the western doctors do not find the root cause of the problem then they refer the person to us traditional doctors.” Some root causes were diseases best treated in a clinic, Doctor Jimu explained: “TB has been spreading and people think they are being bewitched: that is not the case.” An ancestor—­aggrieved by inadequate care for a grave site, or failure to observe the mwambo—­could cause illness. And sometimes affliction was the work of a witch: an angry relative, a jealous rival. The sister of the woman from Tsoka had wondered whether witchcraft lay at the root of her strange behavior. Had a neighbor envied her many pregnancies, with disastrous consequences? Like other asing’anga, Doctor Wasema assisted women whose pregnancies had been made to disappear, or whose labors had been magically delayed. Pregnant women who suspected that “something funny is going on” sought her mankhwala. As she described her work, I recalled a recent consultation. A woman had come in with no menstrual period for seven months, a chitenje tied up over her breasts to signal pregnancy—­but no audible fetal heartbeat. Physical examination and ultrasound both revealed a small nonpregnant uterus. The woman seemed unfazed by my diagnosis. “Someone is causing me trouble,” she said. “They have hidden the baby so that I cannot feel it and you cannot see it, but I know it is there. I will go home and come back when I am in labor with this baby.” Mayi Abigail Daudi, a sing’anga and mzamba, told a similar story about her own pregnancies. “There were all the signs that I was pregnant, but the pregnancy could not be seen. It was just disappearing.” Her parents sought assistance from specialists, who diagnosed bewitchment. “They would go fetch some medicine for the spell. Then suddenly, people see that the pregnancy is back on me. A few days later, I delivered safely.”

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Witchcraft, and counter-­witchcraft measures, took material form in addition to spiritual and social ones. Poisoning cases wound up in court regularly. Azamba, asing’anga, and alangizi cautioned pregnant women to be wary of medicines. As one mzamba, Thokozire, warned: “You may damage something inside. You never know. Some people with evil intention can take advantage and give you poisonous medicine if you are in the habit of taking medicine just like that!” Rumors of homicides by witches circulated. Mob justice over witchcraft cases produced devastating, sometimes deadly, injuries. Suspicions and accusations were corrosive to communities—­one reason some Malawians refused to seek assistance from asing’anga—­and could easily flare when a woman died. Modernity: Cure or Disease? This long history provides perspective on the “remarkable difference between now and then” so many people described. Recollections of a sturdier past, exhortations to leave damaging traditions behind, laments about the problems of “nowadays” were diagnostic narratives with therapeutic implications. They linked maternal death with Malawian life. And they charted moral paths for practitioners, patients, and society that had to do with time and modernity. women must be infor med; o r, n ot e n o u g h m o d e r n i t y Nurse-­midwives and other medical personnel described many contributors to the plague of maternal deaths in Malawi. I asked Nurse Evelyn Nkhoma, who’d worked for many years at a large urban health center, why she’d characterized birth in Malawi as “very dangerous.” Her answer incorporated several themes raised by others. Knowledge deficit. That is a very serious problem. [pause] And poverty. They are not able to eat enough; even the medicines you suggest they cannot buy. And there is illiteracy. That is a real problem, so many of them are illiterate that it is harder to overcome that knowledge deficit. Then also most of these mothers are HIV-­infected. The resources also, they are really deteriorating. Sometimes we don’t even have gloves.

Like Evelyn Nkhoma, medical personnel often blamed ignorance—­along­ side inadequate resources, poverty, and HIV—­for maternal death. The clinical officer Bernard Goodwell believed that pregnancy was dangerous because

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women insisted on delivering out of the hospital. When I asked why he thought that happened, he said, “My theory is, mainly it is ignorance. Ignorance, yeah. That’s the main problem. That’s the main cause of everything is ignorance. . . . ignorance among our women.” Bernard Goodwell, like other clinicians, understood his own paramount duty as the provision of information. Tradition, willfulness, and ignorance were often entangled in these discussions. The nurse-­midwife Cecilia Phambala had noted that people found it “difficult to grasp the information you tell them” and “maybe they just ignore it for no reason.” The other thing is ignorance. Let’s say a patient has got a tear, maybe during the delivery. And you tell her to suture it. She says “No, I will just put local herbs on it and it can heal on its own.” So these are the problems, I think.

Medical staff argued that traditional labor practices caused infection, traditional food taboos undermined nutrition, and traditional birth attendants caused obstructed labor. These problematic traces of the past could be remedied, if people listened. Some clinicians found grounds for hope. Nurse Meria Gomani, like Chief Matengo, attributed maternal mortality largely to women’s recklessness. Unlike the chief, she saw things improving “little by little” as technologies like ultrasound spread and as medical personnel educated the community. Her own family was an example. When her sister gave birth, she recalled, their mother had recommended homemade remedies to apply to the drying umbilical cord stump. Nurse Gomani’s sister had come to her, unsure what to do. They told me about flowers, green leaves. . . . And they told me about cow dung. I said “No. Don’t worry. I will look after your son. The cord is going to heal, and that is when you will learn a lot from me!” Those are past things. We have learned new things.

Nurse Gomani’s sister followed her advice. In the aftermath of this small family struggle, their mother stopped providing herbal treatments, referring all questions to her daughter the nurse. “Me? I have retired from it,” she’d say. Medically trained people who located risk in women’s ignorance and the practices of nonmedical experts had a clear imperative: to educate Malawians away from the unsafe traditional birth attendants, unsanitary homes, and unnourishing food taboos of the past and toward the modern nurses, clean clinics, and balanced diets of the present. Only then would women be able to follow the treacherous pathways from conception to birth and beyond without mishap.

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Social historians have often described biomedicine as a mechanism for disciplining bodies.96 Anthropologists from Mary Douglas on have noted that people use risk to avoid or assign blame: talk of risk may protect institutions, while riskiness readily attaches to people already perceived as deviant.97 The narrative that links maternal death in Malawi with ignorance and tradition calls for medical discipline of a deviant body politic. Such a project likely comes easily to a place where bodily discipline and social order have long been intertwined. women must be obedient ; o r, t h e w r o n g m o d e r n i t y But other analyses were quite different. What if the problem was not a lack of the modern, but a modern that had gone wrong? Azamba, asing’anga, and other informal-­sector experts were more likely to describe pregnancy’s dangers with language that evoked social and moral decline. The problem was insolence, not ignorance. Nowadays people did not listen to counsel—­whether that of the elders, or that of the nurses. Ganet Banthu’s lament was typical: In our time, we were healthy and strong. Look at me: do I look sick? There is a remarkable difference between now and then. We used to follow procedures then, which is not the case now. These days when a young girl starts messing about, when we talk to them, they are rude. In our time, when you started menstruating, the elders used to tell you that if you sleep around, you will get pregnant and will die in the process, so we feared men. Not in this day and age!

Patterns of sexual and reproductive cycle regulation had been broken. Girls did not wait for initiation to embark on reproduction. For a few kwacha, a girl got friendly with a man, and soon she was pregnant, infected, or even dead. Despite “total disregard,” claimed a mzamba, “we do not give up. We still give counsel to safeguard their day-­to-­day life.” Or as another said, “Someday they will recognize the value of our advice and they will understand we told it like it is.”98 Chrissy Mphande, like others, distinguished between thriving obedient girls and ill-­fated stubborn ones: “If they follow what they are being told, all is well; but there are those that disregard counsel. It is just in their nature to be disobedient.” Girls were not the only the only rule-­breakers. Women continued childbearing past the age where it was wise to do so. Men and women alike violated postpartum abstinence guidelines, and children were born far too close together. The sing’anga Lazarus Frank, chairman of a local traditional healers’

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organization, spoke earnestly about the troubles that could arise when a woman did not take a break between births. There are problems these days, especially in situations when the woman has babies without spacing them out. Such a mother loses a lot of blood often, so that is a problem. Really. . . . For the mother who has many children, frequently she reduces the quality of her life; she diminishes her life span.

Abstinence customs were the best way to alleviate danger, but some informal-­sector experts also recommended contraceptives. (Others suspected contraceptives of weakening women’s bodies, contributing to prolonged labors and threatening women’s lives.99) The herbalist Salome Tamayenda reassured her clients that “there are lots of women who have adopted birth control and they are doing just fine.” Contraceptives could even be lifesaving. There are some women who have been advised against having any more children but they go ahead and get pregnant anyway because their husband insisted. I stress to these women . . . that their life is their own, not their husband’s, and if she dies her husband will go ahead and marry another woman. Some do listen and take advice!

The sculpted image of a pregnant woman killed by her husband’s sexual recklessness had once been an object lesson for initiates. Nearly a century after two colonial doctors described the wâkongwe, stories about the deadliness of irresponsible behavior were still central elements of the transition into adulthood.100 The initiation counselor Wezie Njerengo described a young woman in her village whose parents would not retrieve the dead body of her baby from the hospital mortuary for burial: “It’s just six months ago that she had that baby. Her parents advised her to go for birth control because her children are too young and she is not spacing them, but she refused.” Elders like Wezie Njerengo still provided instruction on the pleasures and dangers of intimacy during initiation; initiates learned how to please their partners, when to refrain from sex, and why inappropriate sexual behavior brought death upon wives, husbands, and children. Some parents put together Christianized and medicalized versions of these initiations, renamed “advisory sessions.” Much of the content was different, but the dangers of sex and disobedience remained central. Nurse Catherine Chaluwa, sister-­in-­charge at a busy urban health center, recalled that her own traditional initiation had been of little use: “I was just pleasing my mother!” Now, in her role as counselor during girls’ initiations at the church in her home village, she explained to young women what labor and birth would be like—­and how to avoid danger by obeying the nurses.

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blurring div isions To draw a sharp distinction between the narratives of formal-­and informal-­ sector experts would be misleading. Yes, people who worked in medical facilities generally stressed ignorance more, while people who worked outside them stressed willfulness. Nurses and clinical officers often blamed tradition for maternal death, while azamba and asing’anga blamed modern life. But both linked bodily (and sexual) discipline with social order. True, informal-­sector experts often contrasted their superior treatments, deeper insights into the causes of suffering, and customs of “welcoming people nicely” to goings-­on at the hospitals. But some—­at least, when speaking to a white doctor—­described their work as complementary to biomedicine. TBAs, advisors, and asing’anga sometimes described biomedical advances positively, praising vaccinations, malaria treatments, and iron pills. TBAs expressed pride in their cordial relations with hospital personnel. Interviewees mixed biomedical and spiritual explanations for maternal death, as when Bonnex Kaunda prescribed divination for witchcraft, transfusion for severe anemia, and prayer to bring God’s mercy upon pregnant women. Meanwhile, although hospital workers stressed ignorance, many—­like the alangizi and asing’anga—­spoke nearly as often about willful women who failed to heed counsel. The clinical officer Alex Kadzombe said of his patients, “They are the ones who are having problems! We are just there to assist them. So if they are actually not taking your advice, then I think there is nothing you can do about them!” “We are in town,” explained Nurse Lydia Bungalo at a health center that saw many women with HIV. “And mainly people, especially the girls—­they are after money. Instead of trying to do something for their own, they depend on men.” Another nurse, Meria Gomani, ticked off on three fingers the factors she saw as contributions to Malawi’s problem of maternal death, blaming women for all three: These women tend to have multiple partners, of which they don’t know who infects them. We have HIV. Secondly, they get pregnant so early. Thirdly, maybe ignorance. Because they don’t want to say, “I will have three children, or two.” They don’t want to plan. They just bear children, bear children.

While her words emphasized ignorance, the implication of recklessness was clear. When a physician linked mortality to democracy, or a sing’anga explained mothers’ deaths by saying, “Our women have become pompous,” they connected dangerous pregnancies with problematic modernities. In Malawi,

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stories about death could indicate shared concerns about social change even when they promoted divergent prescriptions for social reform. If headstrong behavior was the problem, then obedience was the solution. Elders outside the biomedical sector often proposed adherence to longstanding customs of appropriate behavior as the way to safe reproduction. If ignorance was the problem, then education was the solution. People working in health centers and hospitals often proposed education: on nutrition, for instance, or on danger signs in pregnancy. In each case, the idea was that a properly instructed woman would behave in ways that would safeguard her family’s health and her own. Both kinds of solutions placed the responsibility for maternal death on women themselves. g o l d e n - ­a g e s t o r i e s a n d u s a b l e p a s t s ; o r, a r e t h e s e s to r i e s t ru e ? One last question deserves consideration. Should we believe these stories of easy births in the past—­in a field, on a bus, after a walk around the veranda? Maternal death is clearly not new. People have long sought to explain and prevent it. The wâkongwe initiation-­teaching model makes that clear. So does the story of Bwanikwa, whose captivity began with a fine for a maternal death. Even the tales people told about their own pasts did not always fit their golden-­age generalizations. People who lamented teenage pregnancies had often been teen parents.101 A mzamba recalled that in her childhood years, there was plenty to eat and money wasn’t tight. Five minutes later she said she had never gone to school because her parents could not afford the ten-­ tambala-­per-­semester fee. (When we spoke, this amount was less than a tenth of a US cent; at its highest value, ten tambalas would have been about twelve cents.) Several people who claimed that today’s weakened women could not deliver well compared to “our time” also described their own multiple stillbirths or miscarriages—­or, in one case, a hair-­raising tale of hemorrhage, in which the storyteller’s death was averted only through a massive transfusion at a mission hospital. It seemed as if an idealized imaginary past sat alongside experiences of the actual past, like a shadow or a double. Talk about a better past can be remarkably stable over generations, notes the sociologist Amy Kaler. Malawian elders she interviewed in the 1990s depicted marriage as fragile, much degenerated from their own day of strong bonds. Archived interviews from the 1940s, when these elders had themselves been children, revealed that elders then also compared fragile contemporary marriages to a golden age of long-­lasting unions. “Golden-­age” stories should

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not be taken as simple truths about better pasts, Kaler concludes. Even pasts not experienced as wonderful at the time could be recalled positively to comment on tensions among generations and between genders.102 Perhaps the world is steadily getting worse. Or perhaps middle-­aged people tend to see the apocalypse in the passage of generations: it heralds our own mortality, our transition from elder to ancestor. To me, these stories of a bygone age of trouble-­free birth should be heard less as descriptions of things that happened and more as attempts to understand a troubled present. Whether people attributed maternal death to the passing of a golden age of harmonious life or to harmful cultural practices, the stories they told had morals, and those morals depended a great deal on the narrators.103 This chapter began with an account both simple and unfathomable. The woman from Tsoka died of a hemorrhage. She also died of poor transport. But what else was to blame: mental illness? Witchcraft? A disappointing life? Structural adjustment? Did she face overwhelming responsibilities accompanied by overwhelming constraints on her ability to meet them? I have my speculations, as will you. As we speculate, we create possible pasts for the woman from Tsoka, and “if only” stories leading to alternative past futures—­ presents—­in which she would still be alive. These alternative pasts, presents, and futures are not the same for everyone who tells stories of maternal deaths. In Bonnex Kaunda’s past, women listened to advice. Fertile land and women’s labor (for women hoed the fields, tended the plants, fetched the firewood, and roasted the cassava) ensured abundant nourishing food. In Idah Mongolo’s past, a loving and supportive husband with a decent job provided her the pleasures of margarine and groundnut flour. Plenty of living kin meant that she had no “host of orphans” to look after all alone. For Bonnex Kaunda and Idah Mongolo, had things simply gone on as they once had, the present would have looked better. But think back to Dr. Paul Mbanda, outraged by a hospital that could neither supply bandages nor prevent a young woman from dying of a miscarriage, awaiting the day it would shut down. Like Doctor Kaunda and Mayi Mongolo, Dr. Mbanda identified a failed present. Each remembered a past in which things were different—­but they were not the same past. Paul Mbanda was part of a generation of young Malawian doctors groomed to be the country’s new medical vanguard. They were to bring first-­world medicine to a nation that was shaking off the traces of its colonial past and its long history of one-­party rule, a nation looking to a bright future. Twenty years on, that future often seemed as far away as ever. Dr. Mbanda’s past was a time in which a different future had seemed imminent. Medicine is often characterized as a reductionist science. But as the stories

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here show, even medical practitioners used maternal death to critique illiteracy, poor governance, public education, and health care, the corruptions of commodification induced by cash, austerity or democracy—­all embodied, along with dangerous tradition and intractable willfulness, in the dead mother. The next chapter turns to the specifics of that embodiment.

Agnesi Kunjirima: “You can make your pregnancy safe.”

Sister Agnesi Kunjirima’s white nursing uniform was set off by a small white cap pinned to her short hair. Slender and tall, she’d spent her early years in another country, where her father had a good job and the family had eaten well. Her attire was impeccable, her smile warm, her presence reassuring. Over the years I knew her, I rarely saw her perturbed about anything, except once when the hospital had run out of chlorine bleach again on the eve of a Ministry of Health inspection. At the time of our interview, she was working mostly in the antenatal clinic, a two-­minute walk from the wards. Twice a week she ran a clinic inside the hospital, where women with antenatal complications or high-­risk conditions (such as triplets) awaited delivery. We see these mothers; we do antenatal clinic there because they can’t go to their clinics. . . . We do this because once we miss them, it misses some they can have IUDs [intrauterine deaths]. Their baby can stop breathing. . . . that’s why we have to listen.

The nurses would go to “each and every bed, each and every!” They would measure uterine size, assess the fetal position. “Whatever we do in antenatal clinic, that’s what we do in that appointment as well.” They even trundled the heavy scale out from the office so the women could line up to get weighed. “Yes. Then after that, BP. They come in the office and we do it.” Taking blood pressure was no simple matter. Two postnatal wards, the gynecology ward, and the antenatal ward had all been sharing a single cuff—­ which had recently broken. “We were depending on that one! Now, that was on Monday when I came, it wasn’t working.” Fortunately, she’d just found an older blood pressure cuff that was in reasonable working order that the wards could share.

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I asked her how she’d advise a relative, a young woman expecting her first baby. Her answer was swift. “You can make your pregnancy safe,” she said. Eat a variety of foods. Get educated on dangers. Most important, go to the antenatal clinic starting in your fourth month. Because at the antenatal clinic? They can tell her everything there. Like, they will take her weight, as what I have said there that we do at the antenatal clinics. They will take her weight. They will know her blood pressure. They will take blood for VDRL [a syphilis screen] to send to laboratory. They will take FBC [full blood count], ah?

Someone with a positive syphilis test could get penicillin, averting the risk of a miscarriage or a sick newborn. Malaria treatment would prevent complications too. If a woman’s hemoglobin was low, Sister Kunjirima said, the nurses could give her ferrous sulfate. If it was very low, she could even get a transfusion. And then there was delivery: ak : She have to deliver in hospital. She can’t—­she can’t come to my home, no-­no-­no! c w: [laughing] Why not? a k : [also laughing] Ah, because I have—­I don’t have any instrument, you know? She can deliver, okay? But! Sometimes, hah? We need to resuscitate the baby. I don’t have a resuscitator there, you see? She can bleed. She can have a tear, tear her cervix there, she will bleed, but I can’t do anything at home. The most important place is the hospital delivery. She hoped I’d stress the importance of adequate equipment when I provided results of this research to people in power. “The nurses should have everything! All the equipments should be ready with them. For instance, say that, eh, she have delivered the baby.” She wagged a finger at me. “Not so? See that all the equipments are there. Maybe the baby have swallowed something? They can resuscitate the baby. Yes. And too, the mother, hmm?” Nurses needed the necessary tools to deal with the many problems they encountered. “Commonly here, here what I see there, there is trouble with the edema. And amakhala PIH chanja, ndi amathamanga take blood pressure, it’s high, and some it’s malungo or anemia.”1 Sister Kunjirima knew the dangers of pregnancy not only through work, but also through a grief that had struck five years earlier, when her daughter had died. Not long after childbirth in South Africa, the young woman had felt ill. On the phone with her mother, she’d dismissed her symptoms: “I

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am having a cold, what, what, what.” But within days she became very sick. Friends took her to hospital, where she was admitted for pneumonia. Sister Kunjirima went to the capital city and withdrew her entire pension, then pleaded by phone with the doctor in South Africa to transfer her daughter. It didn’t happen right away, but once the young woman had stabilized, she was flown back to Malawi and taken directly to the hospital. We stayed two weeks, and thereafter she was all right. We were discharged. We went back home. Ah, then I said, “Maybe I should be checking this and that.” I brought her to the hospital. I did, we did this test—­HIV, what? Which, it wasn’t done there. We did everything.

Sister Kunjirima’s voice wobbled here; the pauses in her story grew long. Her daughter had seemed to rally. She’d even talked of returning to South Africa. But one night, matters took a turn for the worse. “Around two a.m.? Not breathing all right. Dyspneic.” She imitated the ragged breathing that clinical personnel call dyspnea. “Wsh, wsh, wsh. So I took her to the hospital. After some hours [pause]—­peacefully.”

2

Knowing Bodies More than half of maternal deaths are due to just two causes: hemorrhage and hypertensive diseases in pregnancy. When sepsis and unsafe abortion are added, more than three-­quarters of maternal deaths are accounted for. Cost-­effective interventions exist for each of these conditions. — m e l o d y e c k a r d t , Roy Ahn, and Marisa Nádas, “Maternal Health,” in Essential Clinical Global Health

Along the highway connecting the cities of Blantyre and Limbe, on the sprawl­ ing grounds of Queen Elizabeth Central Hospital, in a brick teaching annex down the hall from the Gogo Chatinkha Banda Maternity Wing, every other Wednesday morning for an hour, the interns and students and faculty met for a morbidity and mortality review. Teaching hospitals all over the world regularly hold such “M&M rounds” to review patients’ deaths and serious illnesses. The purpose is twofold: to better understand life-­threatening pregnancy complications, and to develop strategies that might prevent future deaths.1 At Queens, these meetings served a third purpose: one attendee com­ piled records for the District Health Office, where they could be coded and analyzed to detect patterns of mortality. In New Mexico, where I did specialty training, we’d held M&M rounds monthly. Our high-­acuity hospital was the state’s major referral center. We typically had two or three maternal deaths to discuss each year. Most of our M&M meetings concerned morbidity: surgical complications, unusual illnesses, “near-­miss” cases in which a patient had almost died. Malawi was different. Over the course of thirty-­odd M&M rounds I attended across the years, I heard only about mortality, never morbidity. There were too many deaths for a one-­hour biweekly discussion to contain. My field notes contain terse comments: “Eight cases today: we got through five.” Not all deaths even made it to the review. We hardly discussed deaths if the patient’s case file had gone missing. We rarely discussed deaths that happened outside the maternity unit, like that of Sister Kunjirima’s daughter. This chapter examines how medically trained people construct stories of maternal death. I begin with four case studies. Drawn from interns’ presentations at various meetings, these cases are roughly representative of the usual

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mix of maternal deaths.2 My goal is not to identify a single medical truth about any given death. It is to bring to light the kinds of truths that can and cannot be read from the dead in clinical contexts—­where important parts of many stories remain unknown, and the parts that are known often do not add up to a single clear diagnosis. The medical explanations given here depend on customary ways of producing knowledge, including acceptable tools, familiar metaphors, and professional habits of writing and speaking. A closer look at one case reveals that these medical customs focus clinicians’ attention on specific times (hours or days, not years or generations) and spaces (cells and organs, not neighborhoods and nations). That attention shapes the kinds of interventions imaginable. Four Case Reports case 1 RC 28 G3P2L0 15 wks GA HIV+ GBP, cough ++ T 38, B crackles ? pneumonia —­> CXR, MPs, amoxyl HD #10—­> XPCN + cotrimoxazole CXR wnl HD #14—­> incomplete ab

By the end of an obstetrics clerkship, even the dullest intern could shoehorn the odd particulars of any actual patient’s course into the expected case-­ presentation formula. These nine lines of acronyms and symbols summarized a patient’s entire hospital course, from her initial presentation, through admission and treatment, to her death two weeks later. Shorthand accounts like this one—­projected onto a screen or written on a whiteboard when the power was out—­were all that appeared in writing at an M&M meeting. They were mnemonics for the intern, and frameworks for discussion and diagnosis. What they included and omitted was important. The doctor’s notes on Faith Chisoni given in the introduction, for instance, omitted any mention of her mother—­who was essential to all her care. The report’s first line provides the dead woman’s initials, age, and obstetrical history. G3, for “gravida three,” indicates that she had been pregnant three times. Para two, P2: she had given birth twice. L0: no living children. The

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intern speaking from these notes typically mentioned at this point whether or not the patient was married, and from which neighborhood or referring facility she had arrived—­two rough indicators of relative social and economic stability. Next came an estimate of how far along in pregnancy the patient had been—­gestational age (GA), counted in weeks or estimated in months—­and why she had come to Queens. Major chronic medical conditions might be men­­ tioned too. This particular twenty-­eight-­year-­old G3P2 was fifteen weeks pregnant and known to be HIV-­positive, the intern reported. R. C. had gone to a health center in her neighborhood, complaining of a week’s generalized body pains (GBP) and a worsening cough. She’d appeared acutely ill, so the nurse sent her on to Queens. A student had evaluated R. C. in the triage area with an intern. They’d recorded that she looked ill, and that both lungs sounded abnormal: “B [bilateral] crackles.” No pulse or blood pressure had been noted. Her temperature was 38.0 degrees Celsius—­right at the cutoff point between fever and normal. Their tentative diagnosis, “? pneumonia,” was a common one on our wards. The intern ordered a chest X-­ray (CXR), the oral antibiotic amoxicillin, and a malaria test—­since malaria parasites (MPs) often cause fever and body aches. R. C. seemed sick enough to warrant hospitalization. From the bench where she had awaited her initial triage, she must have walked to the ward to be assigned a bed. Then there was nothing at all in her file for nine days: no temperature or blood pressure or pulse, no chest X-­ray, no evidence that she got her antibiotics. No indication that she was seen by anyone—­student, nurse, or doctor—­although she probably was. Writing was often a lower priority than doing.3 Sometimes the latter happened without the former. Sometimes neither happened. On R. C.’s tenth hospital day, an internal medicine consultation note appeared in her file. The consultant, another intern, recommended that a second antibiotic be added, and that the oral amoxicillin be switched to an intravenous equivalent—­XPCN, crystal penicillin. The note provided no rationale, but it was not hard to guess. World Health Organization guidelines recommended adding co­trimoxazole for severe pneumonia in someone with HIV.4 Intravenous drugs were used judiciously because IV sets—­tubing, bags, fluids, needles—­and nurses to manage them often ran scarce; R. C. was likely unable to keep her oral medications down. These recommendations painted a picture of a patient who was doing poorly. So did the intern-­consultant’s plan to transfer R. C. to the medical ward “for closer observation.” The transfer took place. The chest X-­ray finally did too; a radiologist read it as normal.

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If closer observation happened, it was not matched by closer documentation: her medical file was blank for the next four days. On hospital day 14, R. C. began to bleed vaginally. Back on the gynecology ward, examination by a third intern confirmed an “incomplete abortion”: an ongoing miscarriage.5 “Incomplete” meant that part of the pregnancy remained inside, leaving R. C. vulnerable to infection and hemorrhage. The gynecology-­ward intern scheduled a curettage to scrape out remaining tissue. R. C. looked pale, however. Her pulse and breathing were rapid. Was she so anemic that the stresses of surgery and anesthesia could kill her? The intern ordered blood for a transfusion, and a hemoglobin level to assess anemia. R. C. was found dead on the ward several hours later, still waiting for both her blood and her hemoglobin test. Why did R. C. die? To the team filling out the death review form, hemorrhage seemed the most likely cause of death, although pneumonia remained a possibility. Was HIV a contributor? If she died of hemorrhage, no. But if pneumonia killed her, yes: infection with the human immunodeficiency virus would have made her much more vulnerable to other microbes. The form included yes-­or-­no checkboxes for a list of “associated factors that contributed to death.” Those answers were not obvious either. We had a lab, although it did not provide timely results: “lack of laboratory facilities” did not seem quite right. Neither did “lack of availability of blood transfusion,” although the blood bank never delivered R. C.’s. “Lack of antibiotics”? It was unclear whether she’d actually received the intravenous antibiotics. She was never offered antiretroviral medications. “Lack of qualified staff ” or “inadequate monitoring”? No one more experienced than interns cared for this very sick woman. The few papers that made up her file suggested that even they saw her rarely. But it was difficult to be certain of anything from a patient’s file. diagnosis: hemorrhage

case 2 DV 15 P1 spontaneous labor at 9/12 SVD liveborn M at [KHC] transfer 2º fits—­> died en route

This fifteen-­year-­old girl had come by ambulance from Kamudzi Health Center, some fifty kilometers away. Health centers were outpatient clinics with

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maternity wards. The first line for antenatal care, uncomplicated medical cases, and routine pediatric visits, they were also to handle normal births—­normal, because they lacked capacity to provide surgery, anesthesia, transfusion, and other essentials of comprehensive emergency obstetrical care. Most health centers were run by nurse-­midwives or medical assistants. A few health centers also had clinical officers on staff, but Kamudzi was far too small for that. D. V.’s “health passport,” a small booklet in which her medical records were written, recorded two antenatal visits at Kamudzi. Her first visit was for fever and general body pains. She’d been given oral antimalarial tablets, a “presumptive” treatment that was common practice. The second was a routine antenatal visit. D. V. had been weighed: normal. The nurse-­midwife had heard a fetal heartbeat and measured fetal growth: also normal.6 No blood pressure was recorded at either visit. When D. V. returned to the health center next, she was nine months pregnant—­“9/12”—­and in labor. The report’s next line indicates spontaneous vaginal delivery of a baby boy. Immediately after, she began having seizures—­ “fits.” Kamudzi Health Center’s nurse-­midwife had few of the essentials needed to intervene, and none of those needed to make a diagnosis. She had no drugs to stop fits. Her laboratory equipment was limited: she could spin hematocrits and get HIV tests, but not much else. Kamudzi had no working thermometer, and the “BP machine”—­blood pressure cuff—­was broken. The nurse called for an emergency transport. During the two hours it took to arrive, the young mother had five more seizures. She was comatose by the time the nurse-­midwife bundled her into the ambulance, and dead by the time she arrived at Queens. Why did D. V. die? The health center’s nurse-­midwife suspected eclampsia, in which swelling of the brain and seizures complicate hypertension in pregnancy. An intern pointed out that cerebral malaria can also cause seizures.7 A faculty obstetrician proposed another explanation, noting that D. V. was fifteen and that teenagers were especially prone to eclampsia. “We didn’t see this much in the old days,” he said of teen pregnancy. “Some people believe this is a new problem with the advent of so-­called democracy.” diagnosis: eclampsia

case 3 One intern had told another that he’d had a patient die of a septic abortion. By the time of the M&M meeting, the first intern had begun a clerkship in

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another city. The patient’s body had gone to the mortuary. Her file was missing. The gynecology ward’s head nurse was out sick. No one at the meeting remembered the dead woman’s name, age, or any other relevant details. Why did she die? Most women with septic abortions had “interfered” with untimely pregnancies, using techniques both common and risky.8 Malawian law made abortion illegal in nearly all circumstances. More than once (although not on this day, with so many cases to review), discussions of septic abortions turned to debates over the law and whether doctors had a responsibility to advocate for its change. Assuming this woman tried to abort, why? Was the sex that led to her pregnancy consensual? Did she have access to contraception? If she did try to abort, how did she do so and why didn’t it go smoothly, as it often does? Nurse Rhoda Nantongwe had seen a rise in septic abortions, for which she blamed women’s poor nutritional status and HIV. Was this woman malnourished? Did she have HIV? Would better nutrition or an uncompromised immune system have allowed her to fight off infection? Would access to legal abortion have prevented it entirely? This information was unknown and unknowable. There was space for none of it, except HIV status, on the review form. We all agreed: the form should indicate that an unknown patient had died of a septic abortion. The stark limitations of information made the diagnosis simpler. diagnosis: septic abortion

case 4 DA 25 G1P0 ? wks GA twins fever, cough ++, chest pains fresh SB twin A SVD twin B 1.5kg ↑ P and RR loud B rales hct 13% → frusemide to ICU for O2 therapy

D. A. had arrived by minibus in active labor, referred from a health center a few kilometers away. Health center nurses often sought reasons to transfer women in their first pregnancies. In D.A.’s case, grounds for transfer were plain. She’d had chest pains and fever for a week. She was “coughing plus

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plus.” She looked gaunt and ill. No HIV test had been done, because she’d been seeing a traditional birth attendant.9 The TBA had told D. A. she was carrying twins. That, too, justified referral. D. A. barely made it to Queens before delivering her first twin in the “admitting area.” This small room lay between the labor ward’s two main parallel corridors near the entrance. Heavy wooden benches lined the walls. Open doors and large windows on each side allowed passing nurses to see anyone awaiting evaluation. A nurse-­midwife was usually readily available down the hall, but D. A. had the misfortune to arrive at eight on a Monday morning when everyone was in handover rounds in another room.10 The nurse-­midwife arrived to find a “fresh SB,” a baby presumed to have died shortly before birth.11 The tiny second twin, born alive soon after, was whisked off to the newborn nursery. The new mother labored to breathe. Both lungs sounded raspy—­the “loud B rales” of the case report, the “wsh, wsh, wsh” that Sister Kunjirima remembered so painfully. Even with IV fluid pouring into her, her pulse and respiratory rate were rapid, her blood pressure low. This was shock; but was it septic shock from infection, or hypovolemic shock from acute blood loss complicating anemia? This time the laboratory came through quickly. Normal hematocrits in reproductive-­age women were between 35 and 45 percent.12 Below 21 percent was anemia severe enough to warrant transfusion.13 D. A.’s hematocrit was 13 percent. A blood transfusion was essential. Hypovolemic shock now seemed likely, but not certain. Sepsis complicating pneumonia still seemed likely too. A chest X-­ray might have clarified matters, but the portable X-­ray machine was out of order and D. A. was far too sick to be wheeled down to the radiology department. The intern faced a dilemma: without a clear diagnosis, what should she do? She and the faculty obstetrician on call suspected that fluid building up in D. A’s lungs was hindering her breathing. Most clinicians would probably have agreed with their decision to rid D. A. of excess fluid by administering a powerful diuretic—­if the diagnosis was correct. If fluid in the lungs was not the cause of respiratory trouble, however, the increased dehydration caused by furosemide treatment could kill a patient who was already in shock.14 Over the next hour, D. A.’s difficulty in breathing continued to worsen. Because there were then no oxygen concentrators in the obstetrics and gynecology wing, she was transferred to intensive care, where she finally got oxygen and a unit of blood. They were not enough. Her blood pressure dropped further. She died, gasping, eight hours after her arrival. At the morbidity and mortality conference, one of the doctors who had seen D. A. pointed out, “This one was likely HIV-­positive; she had spots on her skin all over her body, and looked quite ill.”15

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Why did D. A. die? Sepsis due to pneumonia? Pneumonia related to HIV? Heart failure caused by anemia and blood loss? Shock worsened by furosemide treatment? Inadequate supplies? Oxygen, chest X-­ray, and adequate blood transfusion would have helped—­but would they have saved her? Was substandard care a part of the problem? Perhaps if a nurse had attended D. A.’s first delivery, she would have lost less blood. After that, though, her interns and nurses were vigilant and careful, and a faculty member was involved. One of the gynecologists summed up as others nodded: “To me this looks like a case that came to the hospital rather late—­she may not have been salvageable. The problem with admitting [no nurse being available], that is a problem, but this care otherwise I think was rather commendable.” diagnosis: sepsis

thinking with cases Anyone deciding on the best explanation for a maternal death had to rearrange an unruly accumulation of knowns, unknowns, and uncertainties into a plausible story. For clinicians, the rigid format of case presentations helped prune and shape information. Details expected in other contexts were excised from case presentations. Life stories told by people who had attended school, for instance, typically featured birth order, childhood home, and education: “I was the second-­born in a family of five, and we stayed at Ntcheu until I was in standard eight.” Case presentations never included these key life-­story elements. Other details, however, were so important that they were integrated into the presentation’s first line, directing the listener’s thinking from the start. Everywhere I have worked as an obstetrician, elements in that first sentence included a patient’s age, number of pregnancies, number of deliveries, and estimated gestational age. Formulaic as case presentations were, other vital elements varied from one place to another. In the United States, we immediately categorized our patients by race or ethnicity: “black,” “Hispanic,” “white,” “Navajo.” In Malawi, I never heard ethnicity or race mentioned, but neighborhood or home village almost always was. By the mid-­2000s, so was HIV serostatus. The review form further directed our analytical focus. Each maternal death was to be given a single “immediate” cause, with room for one “underlying” cause. Potential contributing factors were binary: yes/no. The assembled doctors and nurse-­midwives, students, and clinical officers ultimately

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assigned causes to these deaths as follows: case 1, obstetric hemorrhage; case 2, eclampsia (hypertensive disorder of pregnancy); case 3, septic abortion; and case 4, sepsis. These causes conform to the four major etiologies of maternal death laid out by the WHO. To pinpoint a cause of death, reviewers had to be both selective and reductive. Case presentations and review forms helped with both by obscuring unknowns and uncertainties. They also confined medical explanations of maternal death to brief moments of time and narrow slivers of space. Scales of Space and Time Let’s take a closer look at case 4, the twenty-­five-­year-­old woman I have called D. A., who died of sepsis, or maybe of pneumonia, or perhaps of heart failure caused by anemia and blood loss, or possibly of her furosemide treatment. Her case provides an opportunity to think about spatial and social scales from the tiny scale of the molecular to the vast scale of the transnational, with cells, organs, individual humans, family groups, neighborhoods, regions, and nations in between. It offers an opportunity, too, to consider the time scales of fast and slow injury. Everyone has methods for comprehending the world: go-­to metaphors and accepted techniques that help us to interpret the flood of sensations we experience. We learn these interpretive tools. They are neither instinctive, nor the same for everyone. People training to be clinicians in Malawi learn approaches to “the body.” These standardized ways of understanding—­shared with medical people elsewhere in the world—­look inward from the skin. This section begins at the microscopic level with molecules and cells, then moves to bodily organs. It draws from textbooks that Malawi’s medical and nursing students studied.16 The ways of knowing learned there delimited medical explanations of death. in the cell Pathologists call it ischemic necrosis. Clinicians reviewing D. A.’s case knew that no matter which immediate cause of death they assigned, on the molecular level D. A.’s cells had died for lack of oxygen. Nurse-­midwives and doctors learn to think of oxygen as an essential fuel. Without oxygen, we animals make energy through a fermentation-­like process that breaks down glucose into pyruvate molecules. The process produces enough energy to keep a muscle going, but it is slow, and its by-­products are painful. (You have probably experienced the burning feeling of lactate

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in muscles when you’ve put them to hard use that outstripped their oxygen supply.) Oxygen makes a more efficient energy-­generation process possible. Within specialized intracellular structures called mitochondria, enzymes use oxygen to transform pyruvate molecules into adenosine triphosphate (ATP).17 Water and carbon dioxide are the painless by-­products.18 ATP is like a battery, I was taught: it stores and releases energy as needed. Medical school faculty sometimes called it the “molecular unit of currency.” Like currency, it facilitates essential processes in many places. A cell biologist would tell you that ATP powered the movements of the muscle cells in D. A.’s diaphragm. An anatomist would explain that as those cells contracted, the shallow basket of her diaphragm tightened into a flat sheet, opening up her lungs to pull in oxygen, then relaxing to expel carbon dioxide and water. A physiologist would add that ATP fueled D. A.’s cardiac muscles, whose contractions kept the blood pumping through her body. ATP charged the electrical impulses of her neurons, setting the pace for the rhythm of her heart and the slower pattern of her breaths. ATP allowed the routine maintenance of cell and organelle membranes, keeping D. A.’s tissues from dissolving and digesting themselves while she lived. A medical student, thinking as medical students are taught to think, could “zoom in” to D. A.’s body at the subcellular scale and imagine what happened when oxygen stopped reaching D. A.’s tissues and her depleted ATP could not be restored. These processes would all end. Cells everywhere would begin to die, the membranes that surround them disintegrating, mitochondria and other components bursting, leaking contents into the cell, causing irreversible damage. But why did the oxygen stop reaching her tissues, even when she was finally in the intensive care unit, with a plastic tube delivering oxygen to her airway? Moving back and forth from molecules to cells to organs, the review team understood three processes to be at work within D. A.’s body: anemia, pneumonia, and sepsis. in the body Physiology lecturers teach that cellular respiration takes place throughout the body: from the deepest basal layers of the skin to the shiny internal lining of the heart, from the muscles of the gut to the osteoblasts that slowly build and repair bones, from the neurons that produce our dreams to the ova and spermatozoa that reproduce our species. All these cells need access to a ready supply of oxygen, and a way of ridding themselves of carbon dioxide. Blood vessels provide both. The tiniest vessels of all, capillaries, form such an extensive

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network that nearly every place in a human’s body is within three to four cell lengths from blood. Erythrocytes—­red blood cells—­in these capillaries are packed with millions of molecules of hemoglobin, a specialized protein that contains four iron atoms. The iron in hemoglobin attracts oxygen and holds onto it loosely. When an erythrocyte reaches tissues low in oxygen, the iron releases the oxygen and takes up carbon dioxide instead. Nursing and medical students studying for first-­year exams in the College of Medicine’s cavernous new library drew the path of blood flow through the body, as I had done years before in my own school’s cramped Learning Resources Center. The sequence went like this: a carbon dioxide–­bearing hemoglobin molecule, in an erythrocyte, travels from a capillary through a person’s venous system into the right side of her heart. The heart pulls blood in and pumps it out. As a contraction pushes out blood, the erythrocyte moves into a network of pulmonary capillaries thinly spread over the lung’s air sacs. (Known to anatomists and medical personnel as alveoli, these sacs are each about the diameter of a human hair.) There the hemoglobin gives up its carbon dioxide molecule, which leaves the body on an exhaled breath, and takes on an oxygen molecule that has been brought in with an inhalation. The newly oxygen-­rich blood returns to the heart, now to the left side. The heart muscle’s next contraction pumps it into the body’s arteries, smaller arterioles, and capillaries. When it reaches peripheral tissues, it relinquishes oxygen to tissues and picks up carbon dioxide—­and the whole cycle starts again.19 Only later in their studies did students learn the many ways this system can go awry. Anemia Nurse-­midwives spoke often of women’s need for enough hemoglobin—­fa­­ miliarly called HB—­and the dangers of insufficient dietary iron. Bertha Elias explained how it ought to be: “She should have vegetables, meat, and fruit so that can help her to have enough blood, hemoglobin, yeah? She should be strong. When she comes in labor, at least if she loses a lot of blood and her hemoglobin is good, there is no problem.” Flora Sambisa noted, “People do not have adequate resources, like on the diet, so that they can have a high HB.” The pathology text explained that everyone loses iron daily through bodily fluids: sweat, urine, tears. If we bleed, whether from an acute injury or chronically—­say, through an ulceration in the gut—­we lose both hemoglobin and the iron it contains. Women lose blood and iron with every menstrual period, every pregnancy loss, and every birth. A person who cannot replenish her iron supplies rapidly enough to make up for these losses becomes anemic.

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She may have fewer erythrocytes, smaller ones, paler ones less well supplied with hemoglobin. D. A.’s hematocrit indicated that she was trying to get along with about a third of the hemoglobin expected in a healthy woman in late pregnancy. The exhausted grayish pallor that comes with severe anemia probably contributed to her look of illness. Her muscles would have felt weak and readily fatigued, using up oxygen faster than it could be replenished. She likely felt dizzy. Her heart raced to pump blood faster, to make up for the diminished amount of oxygen each beat squeezed out. Anemia this severe could even cause heart failure: the heart’s attempt to compensate for a lack of blood by pumping harder and faster requires a great deal of energy, and eventually one’s oxygen-­deprived cardiac muscle cells begin to weaken and die. As the College of Medicine’s standard pathology text notes, however, people commonly die with anemia but rarely of it. M&M reviewers saw another dangerous process at work: pneumonia limited D. A.’s oxygen intake, they surmised, even while anemia worsened her pneumonia.20 Pneumonia Immunologists describe many defense mechanisms that help a healthy person rid her lungs of microbes like viruses or bacteria. Each hollow tube in the finely branching tree of bronchi through which she draws air is lined with thin thread-­like cells—­cilia—­and coated with a sticky layer of mucus. Cilia move together in a coordinated way to propel inhaled particles out of the bronchial tree, up the trachea. Pathologists call this whole apparatus the “mucociliary elevator.” Specialized “dust cells” also circulate, engulfing noxious particles and then migrating to the opening of the trachea to be coughed up and out—­or swallowed and digested. If microbes make it past the mucus, cilia, and dust cells into the tiny sacs of the lung in which air exchange is to happen, a second line of defenses comes into action. The eight-­pound pathology textbook describes it in a boldface section: “Removal of the Offending Agents.”21 Chemical signals, from the microbes themselves and from the tissues they’ve injured, attract immune cells to the affected area. One kind of cell coats microbes with proteins that make them targets. Other cells, called macrophages, engulf the coated invaders, taking them away to be digested. As these various immune cells work together to destroy microbes, they release chemical signals that initiate fever, vascular changes, and other immune responses.22 The blood vessels surrounding the alveoli engorge, bringing along additional immune-­system components; white blood cells (neutrophils) squirm out of the pulmonary capillaries and into the alveoli in pursuit of the invading microbes.23

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Medically trained people find it difficult to describe the bodily processes of pneumonia without using metaphors of battle like those in the paragraph above: defense, invasion, targeting, pursuit. Like armies, immune responses cause indiscriminate destruction. Alveolar walls thicken with immune cells and dilated blood vessels. White blood cells and the bacteria to which they respond crowd the air sacs, already decreased in volume by their swollen walls. The lung becomes boggy, thick, filled with pus instead of air. It is harder and harder to breathe. At first, D. A. described chest pain, cough, and fever. As her condition deteriorated, she grew short of breath. Clinicians learn that these symptoms are classic for pneumonia. Patients know that it hurts. The pain in the infected parts of your lungs is sharp. If the infection has reached the lining of the lung, you feel as if something is catching and tearing with every breath. Your chest hurts from coughing. The muscles between your ribs and in your neck ache from working with your diaphragm to expand your lungs. Perhaps you are burning with heat or shivering uncontrollably as the fever crests and ebbs. The worst part is the panic: respiratory distress feels as if you are drowning on dry land. That sensation is probably worse among pregnant women, whose lungs and hearts work harder even when they are well, distributing oxygenated blood to fetus and placenta as well as all the other parts of their bodies. I hope that D. A. did not feel this terrible air hunger for long. Eventually you may become too exhausted from the sheer work of respiration to be so frightened. You just want to go to sleep. Perhaps you do. Inside a pneumonia survivor, afterward, enzymes digest the intra-­alveolar pus into debris that can be carted away by macrophages or coughed up and spat out. Only scar tissue remains. Many people do not survive, however. Some die from respiratory failure. Others die when infection spreads to other parts of the body. Sepsis Blood and air in a human’s lungs are separated by membranes only a micrometer thick, say histologists who examine them with high-­powered microscopy and chemical staining techniques—­one-­fifth as thick as a filament in a spiderweb. The evolutionary benefit: efficient exchange of oxygen for carbon dioxide. The evolutionary cost: a ready route for airborne hazards—­ bacteria, viruses, toxins, particulates—­to move into the bloodstream. Bacteria from lungs laden with infected fluid can easily be whisked to other parts of the body. The resulting widespread infection is a complex and often lethal

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process known as sepsis.24 D. A.’s rising fever and falling blood pressure led the review team to identify sepsis as her primary cause of death. In sepsis, students learn, the disastrous processes of invasion and defense happen everywhere. Bacteria release toxins, activate immune cells, and induce vascular changes. Capillaries dilate and leak. Blood pooled in distended capillaries or leaked into surrounding tissues does not get back to the heart for recirculation. Blood pressure drops; blood supply to tissues farthest from the heart slows. Blood that isn’t moving coagulates. Tiny clots form everywhere that blood has pooled, consuming proteins and platelets essential for coagulation faster than they can be replaced. Now any injured places begin to bleed. Meanwhile, fluid that has leaked out of blood vessels makes soggy sponges of the lungs and other tissues. Low blood pressure, swollen tissues, and clotted-­off capillaries collectively reduce the flow of oxygen, students learn. Decreased oxygen levels initiate additional cell damage. Anemia just makes it all worse, pathologists add. Clinicians trying to reverse this catastrophic cascade often fail. With abundant intensive care specialists, nurses, technologies, and medications, sepsis leads to death about one time in five. Without them, sepsis almost always kills. What the Inside Leaves Out At the most microscopic scale, biologists explain why tissues deprived of oxygen die. At a larger scale, pathologists explain how pneumonia, anemia, and sepsis deprive tissues of oxygen. Their explanations—­and textbook de­­ scriptions—­are in the present tense, as this part of the chapter has been. Their scales of space (inside the body) and time (now) attune reviewers to consider particular causes of death. An American death certificate stops with immediate cause of death (a) sepsis, due to (b) pneumonia. The person completing the certificate might add anemia under “other significant conditions contributing to death.” A Malawian maternal death review form goes further: it includes a broader range of “associated factors that contributed to death,” such as “wrong diagnosis,” “lack of essential equipment,” and “use of traditional medicine.” Both forms also include demographic details. In the American certificate, for instance, twenty checkboxes address race and ethnicity, which do not appear on the Malawian form.25 By attending solely to the most immediate times and the most inward-­ looking scales, this customary way of thinking evades larger questions about social injustices. Forces at work outside individuals are reinterpreted as innate and interior: the effects of misogyny are construed as female fragility, the

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injuries of racism misread as black pathology. A person who learns to see this way can imagine that health and justice are separate matters, and that one can work for the former without concerning oneself with the latter. The scholar Dorothy Roberts has argued that the persistent appeal of long-­discredited race science is, in part, just that: it allows medical scientists and clinicians to “see” biological difference instead of social inequity in the disproportionate rates of illness and injury faced by black people.26 Any gardener knows better. Mmera ndi poyamba, goes the saying in Chi­­ chewa: growth reveals what happened early on. Two seedlings sprouted from seeds of the same tomato will grow into very different plants if one is put in a sunny spot, watered, fertilized, and weeded while the other is set in the shade, left to gather what water it can from whatever rain falls on it, and neglected.27 If women these days were sickly and weak compared to days past, as many elders maintained, the proverb asks us to seek explanations in the world where they grew. The concepts of vulnerability and resilience are imperfect but useful for people considering how mmera ndi poyamba. The idea is that just as the sickly tomato grown in shade will be less able than the robust tomato grown in sunlight to fight off a fungal blight, conditions predispose some people to certain kinds of harm, while other people are made more resilient. Thin elderly American women like my mother are vulnerable to injury from falls, for instance. With age, joint flexibility grows more limited and bones more brittle, especially among thin women. Balance, already diminished by age, is often further impaired by medications. Compared to my mother, I am more resilient to injury from falls (I am stouter and more flexible) but more vulnerable to injury from air pollution (I am also asthmatic). Bodily specifics like age and weight and chronic illnesses, all modified over time, matter to differential vulnerability. Vulnerability and resilience add time—­beyond the moment now—­to the picture. However, they can still fit easily into a pattern of thinking that overlooks inequitable social structures.28 People who hope to identify patterns of responsibility and sites for intervention beyond the individual must consider larger scales of social space alongside longer scales of time. At the levels of cities, nations, and regions, one can begin to glimpse how forces as seemingly diffuse as global history and transnational policy produce vulnerability and resilience, protecting—­or cutting short—­individual lives in nonrandom patterns. Medical ways of knowing falter at these scales: the zooming-­in that medical students learn may go to molecules, but the zooming-­out typically stops at bodies. Here is where the accumulated knowledge of social epidemiology and history becomes critical. How do whole groups of people become vulnerable or resilient through processes that unfold over time?

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Why was D. A. so anemic? Why did she get pneumonia? If she had HIV, why? Why were anemia, pneumonia, and HIV all so much more common in Malawi than they were in many other parts of the world? How did life’s conditions work together to produce death? in the city A few neighborhoods in the conjoined cities of Blantyre and Limbe had been laid out by planners, sectioned into parcels, built up by developers, and sold piece by piece to middle-­income homeowners. D. A.’s neighborhood, like most, was more improvised. New arrivals would request building space from the “traditional authority” (TA, or chief). The TA would assign the newcomers a small plot of land, without a formal land title. Or a migrant to the city might at first share a house with relatives there, then later build a small home of her own in the family’s yard. These informal settlements were heterogeneous. Some residents were modestly comfortable. Their homes sat side-­by-­ side with those of the especially vulnerable. People built many homes from mud brick. If one could afford them, “baked bricks” hardened in charcoal-­fired kilns were sturdier. Temperatures stayed mild, so one needn’t arrange for indoor heating. A good roof to keep out the rain and a door for privacy and security would do. People with more money put in glass windows. People with less used an open lattice of bricks, or strips of rebar known as “burglar bars,” to let in ventilation while keeping out human intruders. Window screens were costly and easily damaged, and thus rare. Most houses featured a covered stoop on which one could shell beans, braid hair, play a bawo game, or do many of the thousand other things that kept Malawians in constant motion. Most had a chimbudzi (latrine) in a corner of the yard; a few had a toilet in a room inside the house, connected to a septic tank. The houses with toilets sometimes also featured bathtubs. Most had a bafa out back instead, a small enclosure into which one took a bucket of warm water and a bar of soap or a fragrant splash of Dettol, standing on smooth stones laid out as a sort of bath mat, tipping the water out a cupful at a time. These neighborhoods, vibrant with activity and color, were challenging for strangers to navigate. There were no street addresses and few named streets. Maps, virtual or paper, were of little use. Finding one’s way required frequent asking and attention to geographical and social features: “It is up a small, small hill—­you will pass the chief ’s house and then it is just there.” A single paved access road or city highway might pass nearby, but deep in the neighborhood most houses were separated only by footpaths, some of them very steep and rocky and doubling as small creeks during rainy-­season

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downpours. Walking these paths, one would dodge chickens and toddlers, and step over rivulets in which a neighbor’s bathwater ran until it soaked into the earth. In most such neighborhoods, any available scrap of land was given over either to tiny shops—­takeaway kiosks, hairstylists, cellphone repair—­or to agriculture. Even in the midst of the city, one could often find a stand of maize, or small patches of tomatoes, okra, or greens. Chickens bobbed and pecked for bugs; dogs nosed through drifts of trash looking for scraps of nsima or knobs of gristle. Where there was a stream, women would be washing clothes, spreading them on nearby rocks and shrubs and walls to dry in the sun. In the dry season in my neighborhood, two or three women usually gathered doing the household laundry near the opening of an enormous culvert that channeled a stream under a busy ring road. In the rainy season, that spot was a deep and dangerous whirl of frothy brown water, and the women moved farther downstream, where the torrent slowed. Safety, security, and everyday care for children and the sick were collective affairs in these dense urban settlements. Both gossip and small acts of generosity circulated, so that social life and social drama flourished. These neighborhoods also shared certain features that mattered for D. A.’s death: close quarters, pollution, poor infrastructure. Close Quarters Hospitality and equitable sharing were key tenets of being a good human in Malawi. Often I have squeezed in with six or seven other people in a tiny room, squatting haunch to haunch, sharing a meal and chatting about life. Nurses and doctors learned that when one person in such a space harbors a microbe in her lungs, the others are likely to breathe it in. Close quarters make pulmonary infections more likely. One reason tuberculosis ravaged Malawian mine workers in South Africa, for instance, was because the migrants lived in crowded dormitories.29 Add in malnutrition, anemia, and chronic stress—­all common among slum dwellers and migrant miners alike—­and the likelihood increases that these pathogens will progress to active disease. Pollution Contaminated air, earth, and water all made urban residents vulnerable. City dwellers’ lungs were stressed by smoke. Few people smoked cigarettes, although tobacco was Malawi’s major export crop; cook smoke and other pollutants were the trouble. Even the humblest house usually had a little kitchen in the yard, often a simple brick shed with three walls and a charcoal

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cookstove or a three-­stone hearth. A roof kept the cooking fire from going out in the rain, and ensured that the cook—­nearly always a woman or girl—­ would breathe in smoke and particulates. Adding to the injury were sources of pollution farther afield: neighbors’ cooking fires, charcoal kilns baking bricks for new construction, garbage that smoldered in ditches around the city in the absence of a reliable waste service, exhaust from vehicles that might have been retired from duty long ago in places with more money and more vigorously enforced standards of roadworthiness. The smell of smoke mixed with a whiff of exhaust evokes the city for me. As a fragrance it is not unpleasant. It does, however, have unpleasant consequences.30 Urban air pollution impairs the mucociliary apparatus that sweeps particles out of one’s lungs. It also leads to a loss of pulmonary elasticity: a city dweller’s lungs inflate and deflate less vigorously. She exchanges less air, and she has less ability to expel debris from her lungs with a really powerful cough. Polluted soil, meanwhile, contributed to anemia. Hookworm moves from one human to another via soil contaminated with feces. The hookworm larvae pierce the soles of bare feet and then travel via the bloodstream to the gut, where they latch on to its lining. The many tiny wounds that hookworms leave at the points of attachment slowly leach away blood; they can cause serious anemia. Hookworm’s prevalence, worldwide, maps well onto neglected sanitation infrastructure—­and neglected communities, from rural Alabama to urban Malawi.31 It was widespread enough in Malawi that a part of the antenatal routine was to give all women a drug intended to kill the adult worms. Polluted water made people vulnerable too. Health center personnel kept vigilant watch for cholera outbreaks, especially in the rainy season, when water contamination was harder to avoid. The women who stood in the stream to wash laundry faced another, slower risk: schistosomiasis. Schistosome parasites pierce skin immersed in contaminated water, and through a complex set of life stages eventually injure the liver, the kidney, or other organs. They, too, cause chronic blood loss. While schistosomiasis was thought to be less common in the city, in areas nearer to Lake Malawi it infected well over half the residents.32 In the US, particulates and pathogens concentrate in segregated, formerly redlined black neighborhoods.33 In Malawi, they concentrated in urban slums. Residents were rendered vulnerable to lung damage, cardiovascular disease, pregnancy loss, and parasitic infections. D. A.’s anemia was overdetermined. It was probably caused by many different pathways, any one of which might have been enough: malnutrition; malaria and the accelerated destruction of erythrocytes that it causes; hookworm; and schistosomiasis. The clinical officer Chimwemwe Bruce, like the two nurse-­midwives quoted earlier,

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described anemia as an important and inescapable danger of pregnancy: “Like in Malawi, in a developing country, most of the women run—­they all run anemically. They just go anyhow with low, low HBs. When they get pregnant, it lowers their HB as well.” Poor Infrastructure Infrastructure was patchy. Health clinics might be nearby in urban neighborhoods, unlike in rural communities, where they could be very far away. But clinics were not always reliably staffed, supplied with water or electricity, or open. Telephones to call for help had once been scarce. That had changed, thanks to the rapid spread of cellphone technology. Calling for help was only the first step, however. Ambulances were few. Roads were often difficult. The paths that turned to rivers, the unmarked houses, the challenges of winding one’s way through an urban settlement all hindered emergency transport. Even within city limits, it could take hours to get a very sick person to adequate care. Bertha Elias, a nurse-­midwife with more than thirty years’ experience, conveyed the desperation of sitting with a critically ill woman in an urban health center at night: Even during the day, it’s one ambulance. Yeah. But really, we have problems at night. We are really being in pain, in trouble. . . . Alone. Alone, and you are trying to call [by radio], or to phone. And there is no ambulance, it has gone to Chikwawa, Chabvala [a rural health center]. So you are just trying to—­you just pray to God that “please, God help me!”

These infrastructure limitations were all consequences of political decisions at local, national, and international scales. They all hurt women’s chances of surviving a pregnancy complication. D. A. came by minibus from Mwenimweni Health Center, gravely ill and so advanced in labor that she delivered moments after arriving. Mwenimweni was only a few kilometers away, but the journey required a transfer. The shortest possible transit time would be about forty minutes; D. A.’s trip might well have taken longer. Minibuses were privately owned vans, interiors stripped and then packed with benches. The profit margin was very narrow: petrol was expensive, repairs of these hard-­used vehicles were often necessary, and owners paid both a driver and a “conductor” who called out destinations and collected money. On many routes, buses did not leave without a full complement of sixteen passengers to ensure that fares would exceed expenses. I have sat on a minibus, waiting to depart for Queens from

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an outlying neighborhood, next to a man breathing well over sixty times per minute—­a sign of imminent respiratory failure. Would a quicker departure and an earlier arrival have made a difference for D. A.? It is impossible to know now. One line on the review form asked reviewers to check yes or no for a “transport problem between health facilities.” Although I do not know, I think it likely that the “no” box was checked on D. A.’s form. The city’s infrastructure made her journey unremarkable. i n t h e n at i o n Epidemiologists and demographers concluded that processes occurring at the national level also contributed to death rates. Limited access to high-­ quality health care was probably most significant. Demographers often identified Malawi’s high fertility rate as another contributor. Malnutrition and malaria afflicted women throughout the nation, as did HIV.34 Malnourishment Epidemiologists did not usually stress malnutrition; experts in hospitals and communities did, as you saw in chapter 1. Many spoke of the role played by inadequate food in women’s deaths—­even if biomedical workers typically referred to malnutrition, policymakers lamented food insecurity, and those with other pathways to healing expertise called it njala, or hunger. The primary textbooks that Malawi’s medical and nurse-­midwifery students used noted that poor maternal nutrition causes anemia—­especially when it occurs alongside malaria, hookworm, schistosomiasis, or HIV—­and that anemia worsens maternal danger.35 International observers often described Malawi as food insecure.36 Insecurity was not distributed evenly. Some communities were particularly at risk: a family referred up from Chikwawa in February with children who were “failing to thrive,” for instance, was probably going hungry. Within those communities, some families lived closer to the margins of starvation. Within families, women and children got protein less often.37 Within bodies, some tissues—­such as muscles and bone marrow—­were profoundly affected by mal­­ nutrition, while others—­like the brain—­were relatively spared.38 Medical textbooks often described these differential effects within bodies, but not people’s differential vulnerabilities at larger socio-­spatial scales. Manuals and reports intended for humanitarian medical workers did address broader patterns. The solutions they proposed often targeted individuals

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and families, however, even when the problems they identified operated at larger scales. A widely used global health textbook, for instance, proposes this approach to malnutrition: It is important to recognize that chronic malnutrition is usually multifactorial, with its roots in poverty, inequality, and food insecurity. To address this problem adequately, the socioeconomics of the community must be examined, and increased awareness through counseling and education must occur.39

Note the disjuncture between diagnosis and treatment. To propose “increased awareness” as a solution to poverty and food insecurity reads a bit like counseling and educating the tomato plant that has been placed in the shade on the importance of sunshine.40 Fertility Epidemiologists who study maternal death expect strong correlations between high fertility and high mortality: the more times a woman is pregnant, the more times she is vulnerable to obstetrical complications and injuries.41 In the year D. A. came to the hospital, Malawi’s national fertility rate was estimated to be roughly 5.5, meaning that demographers estimated that an average woman who lived to the end of her childbearing years would bear five to six children. Some azamba described high fertility as perilous. Dyna Ng’ong’ola was one: “We advise them against having too many babies. We advise them to take up child-­spacing methods, because if a mother has too many children, the uterus becomes weak and worn out, and as a result, maternal deaths occur.” Lazarus Frank, a sing’anga, noted that “the mother who has many children frequently, she reduces the quality of her life; she diminishes her life span.” Several people who discussed maternal death with me—­disproportionately men—­leveled strong critiques against women who had many pregnancies. Alick Mambosasa, a sing’anga who provided nansula treatments for infertility, characterized them bluntly: “Women that have babies very, very frequently, they do not take advice.” These days a woman may have four or five or ten children. Eight or ten is really careless! These women assume that because they were able to have that many children, one more pregnancy won’t harm—­and that is an accident waiting to happen. For example, a driver cannot say, “Because I have been driving for the past fifteen or thirty years, then I cannot be involved in an accident.” Accidents happen!

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A few of the women azamba and asing’anga were more sympathetic, and some described pressures women might be under. Male partners and in-­laws often supervised women’s fertility closely. To characterize high numbers of pregnancies as a reckless choice was to obscure the extent to which it might not be a choice at all. Fertility “choices” that look like carelessness or stubbornness to some observers seem more patterned to demographers who view them on a broader scale. Internationally, fertility rates track inversely with women’s opportunities for education and employment: where women readily complete higher education and find paid work opportunities, they are likely to bear fewer children. Where they can access safe abortion, fertility and mortality decline. Within Malawi, wealthier and more urban women were more likely to have access to reliable contraception, and to use it to delay childbearing. Among poorer people, big families had once been especially desirable: a family might be a resource drain, but it was also a crucial social safety net. In recent years, however, desired family size had dropped even among the poorest Malawian families. Obstetric Care Prompt access to high-­quality health care was challenging enough in cities, worse in the rural areas where most people lived. Like the medical system in most countries, Malawi’s had a pronounced urban bias. Four-­fifths of doctors and nurses worked in urban areas, where only one-­fifth of the country’s residents lived. Outside cities, maternity-­care facilities were few and far between. Working ambulances were scarce. Few people had access to cars. The minibus system that people relied on to manage longer distances could be very slow even in daytime.42 After dark, it was unreliable and unsafe. Minibus trips cost only twenty US cents to a couple of dollars, depending on the distance, but that was expensive in a nation where more than a third of citizens got by on under a dollar a day, and three quarters survived on less than two dollars. Women might be delayed by the need to access funds, gather essentials for a hospital stay, delegate pressing home duties, or arrange child care. Problems did not end when a woman reached a hospital. You have already seen that public-­sector infrastructures nationwide were in rough shape. When D. A. died, only a third of Malawi’s skilled birth-­attendant positions were filled.43 Smaller and more rural facilities were especially understaffed. Few medications were reliably stocked. Supplies were perennial—­if perennially changing—­problems. Queens was the country’s biggest and best-­equipped public hospital. In 1990, when I was there for the first time, the delivery ward saw about forty

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births each day. Midwives and medical students had a single pair of scissors to cut every umbilical cord; we swished it through a pan of disinfectant between births. In 2002 and 2003 the power was often out. The water was on most of the time, but we sometimes ran out of soap. Four years later, water and electricity were much more reliable, but both were still occasionally out, as was soap. The scissors problem had been solved, in a way: in 2007 there were no scissors readily available. Midwives used scalpel blades held between two fingers—­a technique unlikely to keep patients or health workers safe—­ and asked pregnant women to provide clean razor blades to cut the cord. For two weeks, the national Central Medical Stores ran out of sutures. At Queens we got by with donations and expired sutures. Not everyplace did; at least one woman at a district hospital bled to death from a uterine rupture, a complication of obstructed labor, because there was nothing with which to sew her up. The state of Malawi’s public maternity wards raises an important question: was birth at home in Malawi actually more dangerous than birth in the hospital? Nearly everyone, including me, assumed it was. Health officials knew that skilled birth care reduced morbidity and mortality, and presumed that a woman would more likely find skilled help inside a health facility. Public health campaigners pushed facility birth hard through radio programs, drama groups, billboards, and various punitive strategies discussed in chap­ ter 6. The jury was in, but the evidence wasn’t. This empirical question lacked an empirical—­as opposed to a hypothetical, ideological, or modeled—­answer. in the region Much of Africa southeast of the Sahara experienced worsening maternal mortality in the 1990s and 2000s. Epidemiologists calculated, and clinicians and families knew, that HIV was a major factor. From the epidemic’s onset to the time I write, most of the people living with or dying of HIV in the world have been African. Southern Africa is the epicenter.44 Like its neighbors in the region, Malawi documents more HIV in women than in men, and at younger ages.45 In 2019, demographers estimated, one in ten childbearing-­age women had the virus; in the year that D. A. died, one in seven did. These women were especially vulnerable to lethal pregnancy complications.46 My own impression is that the steep region-­wide increase in maternal deaths had everything to do with the one-­two punch of structural adjustment and HIV.47 Economic, social, and epidemiological changes worked together to devastating effect. Structural adjustment programs were at their height just when HIV was exploding. Three mechanisms worsened viral spread: expanded

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sexual networks; a disintegration of health care that meant illness went untreated; and unsafe therapeutic practices. Sexual Networks In the 1980s and 1990s, life for many people became more precarious. The value of the kwacha plummeted. Wages dropped. Prices soared. New civil service jobs essentially disappeared as government payrolls shrank. Because ordinary Malawians simply couldn’t afford to buy much, jobs in business, trade, and manufacturing were also threatened. People found comfort and support where they could, and took what they could get to survive day to day. Sex became key to socioeconomic survival for many women. A woman might become involved with someone who paid her school fees, or offered her a place to live, or provided support for her child. Some social scientists called this kind of relationship “transactional sex,” and some Malawians called it uhule, prostitution. Others disputed both terms.48 These relationships lasted much longer than the liaisons of commercial sex work (another way that women and some men managed survival in hard times). Like many sexual relationships, they typically combined material exchanges with affectionate emotional attachments. Still, when intimate exchanges increase among people who are moving from place to place seeking work, any given relationship may be shorter and the total number of relationships higher.49 Untreated Illness Sex wasn’t the only factor worsening HIV transmission: the crumbling of public health care across southern Africa also played a role. Wages in government hospitals, clinics, and community health programs were not only frozen, but often went unpaid for months at a time. Vacancies went unfilled. Morale collapsed. Clinicians left for other countries, found work in NGOs or research projects, or died. Those who remained were stretched ever thinner. Prices for medications and supplies rose and inflation shot upward, but budgets were stagnant. Nurses and doctors worked without tools they deemed essential. In some clinics, frequent stock-­outs led patients to suspect wrongly that staff was stealing medicines, further depressing morale and raising tensions. In other clinics, staff really did pilfer and sell medications—­or institute “informal charges” to patients who wanted treatment—­to supplement their wages. Meanwhile, a deadly epidemic swept the region. Deteriorating public

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hospitals were packed with gravely ill patients who were not going to get better. AIDS added a huge draw on resources—­hospital beds, lab tests, nurses, pain medicines—­that were already seriously strained under the budgetary rules demanded in structural adjustment agreements. In addition to their profound effects on the experiences of people who sought help in hospitals and clinics and people who worked there, deteriorating health systems probably directly worsened both HIV rates and maternal mortality. Infections like schistosomiasis or chancroid were more likely to go untreated, either because those who had them couldn’t access a clinician or because the clinician lacked medication. Genital sores from these infections increase vulnerability to HIV: a person with sores is more likely to contract—­or transmit—­the virus during sex.50 Well into the 2000s, anyone newly diagnosed with HIV, and everyone providing care, knew that people elsewhere could survive a diagnosis that Malawians could not. In wealthier countries, the first antiretroviral drugs were in use by 1987. Highly active antiretroviral therapy came on the scene in 1996, producing both near-­miraculous clinical effects and exorbitant profits. Malawi’s government could not afford to purchase these medications. Unaffordable treatment was a terrible epidemiological problem as well as a brutal emotional burden. People with HIV could not reduce the amount of virus circulating in their blood; their high viral loads increased the likelihood of transmission markedly. Dangerous Treatments Transmission happened within health facilities too. Limited supplies of needles and other sharp instruments, and inadequate replacement of sterilization equipment, produced unsafe medical practices in clinics and hospitals.51 When I as a medical student rushed from one birth to another, bearing a scissors that had been swished briefly in disinfectant between one patient and the next, did the scissors and I bring a deadly virus along? If D. A. was HIV-­positive, as her medical team speculated, might she have contracted the virus from a reused needle when she went to get treatment for malaria or bronchitis? Unsafe therapeutic practices outside hospitals may also have contributed to the spread of HIV. Some asing’anga reused razor blades for a common treatment in which they rubbed ash into fine cuts. Some health workers took syringes home to reuse within family networks, as trust in official health care broke down and demand for injectable medicines stayed high.52

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Structural Violence and Clinical Negligence Structural adjustment and the HIV epidemic came together in another way to kill people: neglect. I spent a great deal of time in Queens Hospital before treatment for HIV was available. The place was overwhelming. The epidemic outside the hospital was bad enough. The epidemic inside was much worse, as people with the opportunistic infections and aggressive cancers characteristic of an immune-­system breakdown sought aid. General medical wards were inundated. Even on the obstetrics wards, a third of our patients were seropositive and many were very sick. In wards overflowing with patients for whom little could be done, it was all too easy to lose track of those—­with or without HIV—­for whom something might have been done. Anemic patients can be transfused, pneumonias can be treated, people with severe hypertension can be given medications to prevent strokes. These people were often simply lost in the shuffle, as far too many sick patients encountered far too few health workers. Mistaken diagnoses and misguided treatment decisions were easy to make when time and resources were under such pressure, and clinicians were exhausted and demoralized.53 Negligent care was probably inevitable, and probably a serious contributor to maternal mortality. One clue to its importance is that between the mid-­1980s and the mid-­1990s, expected urban-­rural discrepancies in maternal mortality reversed: despite the dearth of emergency obstetric care in rural areas, mothers were more likely to die in cities.54 Anthropologists use the term structural violence to indicate the ways social structures—­institutions, laws and rules, even the built environment—­injure bodies. Patent-­protected pharmaceutical costs and structural adjustment loan conditions wounded many people. An ideology about the proper roles of governments and markets, known as “the Washington consensus” because it had been developed in Washington DC, became a set of rigid political-­economic principles enforced through international lenders. Those principles changed how Malawians—­and Tanzanians, Argentinians, Haitians, and many others—­ found or failed to find work; the extent to which their work would be fairly compensated or exploitative, safe or dangerous; the prices they paid for life’s essentials and life’s luxuries; their access to health care, and the quality and safety of that care.55 These changes made some people very rich, and many people very vulnerable. Through a series of mediating steps that moved from the transnational to the national to the neighborhood and on down ultimately to the subcellular scale, an ideology inflicted harm—­sometimes lethal harm—­on people’s bodies.

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Moving across Scales: Fractals, Cycles, Lines I find it useful to think about structural violence in terms of fractals—­geo­­ metric forms in which patterns repeat at progressively smaller levels. In the world, the African continent has greater maternal mortality than any other region. On the continent, certain nations are more dangerous for women. In Malawi, some regions seem less safe. In those regions, some towns and neighborhoods are specifically worrisome: interns in Lilongwe expected laboring women from Chinsapo, a large urban slum, to be more malnourished or anemic than those from the middle-­class Area 10 neighborhood. In neighborhoods, some families are at greater risk. And in families, certain individuals may be more vulnerable than others. Vulnerability sometimes unfolds in a fractal pattern; the individual is just one level.56 Malawi is one of the poorest nations on a continent whose poverty was produced and maintained by a brutal sequence of extractive regimes. Its economy depends heavily on a few agricultural exports; its people mostly depend on food they grow. Land is precious, unevenly distributed, and insecure. When a relationship breaks up or a husband dies, women and children often lose access to agriculturally productive land. Many become economic migrants to the nearest city in the hope of eking out a living another way. In the poorer neighborhoods of Blantyre and Lilongwe, migrants concentrate in crowded living quarters. Some do well there. Plenty do not. Women like D. A. get by on marginal amounts of protein-­poor food, depleting their immune systems and reducing their capacity to produce new erythrocytes. They walk the mud paths barefoot or in cracked shoes, the soles of their feet picking up hookworm larvae that eventually migrate to their intestines and contribute to blood and iron loss. They repeatedly encounter various other pathogens, some borne by insects, some sexually transmitted, some in food and water, some on the breath of a neighbor. Rendered vulnerable by their nutritional and economic marginality, many get sick. HIV may have contributed to D. A.’s anemia, and HIV may have made it harder for her to fight off pneumonia. But even without HIV she might have been unable to survive the combination of pneumonia and anemia. I have recorded similar cases in which women who died had negative HIV tests. Once she realizes she is ill, a woman must decide whether this particular malady is serious enough to warrant expert help. Many people put that decision off. Seeking help will cost time away from whatever “income-­generating activity” she engages in, whether selling fritters or minding children or teaching school. Reaching help will cost money: for transport, a new health passport, a prescription, or perhaps even a bribe. Finding “help” may or may not

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actually help. If and when a sick woman finally gets to a hospital, her treatment may be disrespectful or neglectful, and will be constrained by national budgets. In D. A.’s case, that meant insufficient staff to attend the birth of her first twin, no chest X-­ray, little oxygen, and a barely trained intern managing a complex and confusing clinical situation. It also meant a hospital so chronically depleted that we all assessed this care as “rather commendable.” This chapter’s discussion of scale has mostly involved social and geographical space, as the fractal image implies. But structural violence and embodied damage also unfold over time—­linearly, and cyclically. Sometimes it seems to me as if time moves faster in Malawi than it does elsewhere, in a sort of punctuated equilibrium in which many aspects of everyday life change suddenly while some change very little. In 2001, literate people wrote long letters because only a few had phones, and the phones that did exist often didn’t work. Few people agreed to being tested for HIV, since there was nothing to do about it. I scoffed at a WHO recommendation that Queens raise money by charging for parking. Ridiculous! There were hardly any cars at the hospital. Even doctors usually came by foot or minibus. • By 2003, umbrellas at city street corners marked “phone bureaus” where young women placed calls for a fee. Groundnut shells and fragments of sugarcane had once littered footpaths; now shreds of thin blue plastic were underfoot everywhere instead. Still, few people tested for HIV, and few doctors recommended it. • Middle-­class people typically had cellphones by 2007. The hospital parking lot began to fill. Real traffic jams often afflicted the main road between Blantyre and Limbe city centers. HIV testing was more common. Some people—­even a few health care workers—­had gone public about their antiretroviral use. • The phone bureaus had vanished by 2014: most people had a friend or family member with a cellphone. Texting and social media had largely replaced letters. Business suits were a little old-­fashioned; now thumb drives marked one’s up-­and-­coming status.57 The plastic trash piled up into drifts. Traffic jams were routine, and not just on the main road. • By 2017, open spaces behind the hospital’s clinics and annexes had been turned into informal parking lots. The WHO recommendation about parking now looked prescient rather than preposterous. New wards and research units had been added. Almost all the faces were new too. The idealistic young medical students I’d known were now department chairs and hospital administrators. Young people had become parents; those closer to my age had become grandparents. Too many people had become

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ancestors. Meanwhile, the labor ward still looked, felt, smelled, and sounded much the same as it had almost thirty years earlier—­still filled daily with the joys and terrors of birth.

The impression of dramatic change and long stasis is probably created by my periodic stays in Malawi. Life in Malawi, like life everywhere, changes in slow accretions, cycles—­and yes, occasionally, sudden bursts. All these temporal rhythms were visible in the hospital, in individuals’ bodies, and in the land itself. Some changes made life a bit easier. Others hurt. Rob Nixon uses “slow violence” to describe the damage caused by accumulating toxins, climate change, deforestation, oil spills, and the environmental aftermath of war.58 Slow violence of the sort Nixon describes takes place gradually and invisibly. It can manifest years or decades later, often in communities that are already vulnerable. Slow ecological violence pushed people from rural farmsteads to urban slums as Malawi’s land became increasingly less able to sustain rural livelihoods. Emphasis on raising crops to sell began more than a century ago. It escalated when British rule made cash critical. After independence, Hastings Banda promoted commodity agriculture, devoting the best arable land to tobacco plantations that brought in foreign money. When loan conditions demanded more exports, crops were the answer. Petrochemicals aided growth, punished weeds, and accumulated in bodies. People chopped trees for charcoal and cleared land for tobacco and cotton. Forest cover decreased. So did access to medicinal herbs and roots. Specialist knowledge of these medicines dwindled slowly. Depleted by heavy fertilizer and pesticide use, rarely allowed to rest through fallow cycles, divided up into ever-­smaller parcels as demand grew and land grabs continued, eroded by droughts and floods, the land itself was slowly battered. The gradual depletion of Malawi’s rich agricultural land became embodied in the thin frames of rural folk. Within families, children born in a year of bad harvests were likely to be smaller, born earlier, less nourished from the start, at higher risk for infection and developmental problems. The processes of selective nutrition that began even before birth set them up for later injuries and delays: consequences played out over years, even decades. Meanwhile, hunger drove people to the city to face new opportunities and dangers. Economic violence manifested slowly as well. The clinic without medicines, the ward with sixty patients and one nurse, the needles that weren’t properly sterilized because the autoclave hadn’t been replaced—­these, too, accumulated gradually. Malawi never had a really robust public health sector. Still, it took decades of underinvestment and diversion of people, money, and medications to bring health centers and hospitals to the state they were

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in when D. A. died. Just as toxins accrete slowly, moving from soil to crops to particular humans, infrastructure damage moves from national budgets to hospitals to specific patients. Slow violence happens in linear and cyclical time. In some cases, these cycles are more like spirals—­they go around and around, but they also morph with linear time. Cycles of drought and flooding are intensifying as the climate changes, for instance, eroding land and threatening harvests. The public health sector is funded on annual fiscal cycles that affect workers’ pay and supply delivery; it also oscillates through slower booms and busts as domestic pressures and international funding interests reshape it.59 Many projects that temporarily offer important services—­fistula repairs, cervical cancer screening, male circumcision—­run on grant cycles. They scale up and down with funding, and sometimes disappear. Even human bodies may show changes that are both linear and cyclical. Black women in the US are weathered by repeated encounters with a racist society.60 In Malawi, poor women are likely worn by repeated stressors too. Interviewees often noted that pregnancy took a toll; if women did not get time to recover, depletion accrued.61 Elders described social change in terms of generational cycles, “our time” versus “nowadays.” Some of the asing’anga and azamba commented that the weak mothers of these days produced weak infants—­thus putting the next generation in danger. Customary Knowledge The goal of this chapter was not to unearth a single truth about D. A.’s death by considering her embodiment. It was to show how medically trained people came to read various truths from bodies, and how those readings attended to certain scales of time and space over others. The first half of this chapter, much of it drawn from medical textbooks and epidemiological studies, presented evidence about bodies and communities as stable truths laboriously uncovered by scientists; one can build on them, but they do not need revisiting. Unless I actively remind myself of its contingency, this is how I—­and perhaps most people—­tend to imagine medical knowledge. It is a shortcut, helpful for getting through the world. It is also a distorting simplification liable to foreclose new understandings. Some points I presented as facts, for instance, are matters of contention. Does the buildup of lactate really cause muscle pain?62 Is living in a city slum truly bad for one’s health, or is it healthier than life in rural villages?63 According to an apocryphal tale, Michelangelo claimed he’d made his beautiful sculpture by chipping away everything that did not look like David. This slyly

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simple account obscures not just the artist’s imagination—­and the many conscious and unconscious choices Michelangelo made that enabled him to build on and go beyond prior artistic traditions—­but the work of curators and marble quarriers, the errors and cracks and repairs of subsequent years, the marble’s erosion and discoloration. Medicine’s knowledge, its narratives and facts, are like Michelangelo’s David. They do not lie in wait to be exposed. They are produced by assemblages of interested people, in particular spaces, using specific tools and customary (or rarely, novel) practices of imagination. They change over time.64 This chapter and the previous one presented many explanations for anemia and pneumonia and hemorrhage. Those I provided, the ones that asing’anga and azamba gave, and those given by interns at teaching rounds drew on habits of thinking and techniques for knowing. Knowledge about how embodiment works came from their own embodied experience, from perception through the senses or other tools, from analogy, and from orientation to particular temporal and spatial scales.65 People use their own bodies to comprehend those of others. When I described what pneumonia felt like, I wrote using my own embodied memories: the lived experience of pain, exhaustion, and air hunger as pneumonia takes hold is one I know. Enough patients have described similar sensations to provide confidence that they are common. Clinicians have other bodily ways of knowing. We are oriented sensorially—­explicitly trained, attuned over long experience—­to read others’ bodies. Mayi Wilson, the herbalist and counselor, noted that she could see by the way a woman walked that she had sustained a tear during her delivery, even if the woman said nothing about it.66 A short patient raised worries among azamba and nurse-­midwives; a gaunt patient with a bumpy skin rash raised others. (You may remember that one of the doctors who saw D. A. suspected she was infected with HIV because she looked ill and had such a rash.) Clinicians use senses beyond the visual. The intern who heard a galloping, whooshing heart through her stethoscope knew that D. A. was trying to compensate for her anemia by cycling the remaining erythrocytes through as fast as possible. The obstetrician who felt Faith Chisoni’s blood on her gloved hands during the emergency cesarean section recognized that it was thinner and less sticky than healthy blood, a bad sign of an impaired ability to clot. When a patient is badly infected, the tissues of her opened body will be hot to the surgeon’s touch. Seriously infected tissue has a distinctive texture under one’s fingers or scalpel. It feels both mushy and gritty, not firm and resilient like ordinary, uninfected flesh. I have not operated for some years now, but my fingertips remember this sensation with dread. Many cancers feel rock hard. Bodies also smell. Surgeons, midwives, and obstetricians often learn to identify a pathogen by its scent—­anaerobic infections have a distinctive rotten stink, for instance.

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Medically trained people are not alone in using noses, fingers, ears, and eyes to understand pregnancy and its dangers. Azamba often assessed the progress of labor by feeling a woman’s lower abdomen to determine whether the head of the child was descending properly; nurse-­midwives used the same technique. Nurses and azamba both sometimes taught women how to read their own bodies sensorially. One mzamba and counselor, Phillipina Macheso, showed a group of young women how to know their labor was beginning by breaking an egg: the feel of the raw egg white between one’s fingers was very much like the feeling of the mucus drainage that can indicate early labor. She told them, too, that later on in labor “you will feel like something else is coming out, and your body will heat up—­that means your baby is about to be born.” Some knowledge requires tools beyond the senses. To see the folded inner surface of a mitochondrion, a cell biologist must use a powerful electron microscope. To see that a jealous neighbor is causing one’s pregnancy to go past ten months, a sing’anga must dream or throw bones. To identify the spirit afflicting a woman who has suffered many pregnancy losses, a vimbuza healer must go into a trance to the rhythmic pounding of drums. One’s tools for knowing delimit—­and are delimited by—­the explanations one understands to be possible, plausible, or true. One organism can be a model for understanding others. Malawian physiologists studied a powerful herbal labor-­induction treatment, mwanamphepo, by feeding a purified version to rats.67 Researchers used inbred rats to study immune-­system responses to pneumonia. Many of the molecular processes described in the College of Medicine’s textbooks—­and in this chapter—­were worked out in nonhuman animals. In the 1930s, biologists watched rabbit-­ muscle fibers contract when dipped into fluids extracted from rabbit-­muscle cells. Hans Krebs, experimenting with pigeon muscles, concluded that the chemical making contractions possible was ATP.68 In the Chichewa language, hundreds of proverbs use the closely observed behavior of other animals, including birds and rabbits and rats, to teach lessons about human character and society. Mbalame ikakula siikhala pa phira: a big bird cannot sit on a millet stalk. Adults should not act like children. One of these ways of knowing gathers knowledge through experiment, one through observation. Both use reasoning from analogy: what is true for other animals is a pretty good way of understanding what is true for humans.69 Evolutionary biologists, too, reason from other animals to humans.70 Describing R. C.’s fatal miscarriage, I wrote that pregnancy loss in the seriously ill might be an “evolutionary adaptation to preserve scarce maternal resources.” The statement drew on a hypothesis made by the evolutionary biologist Julienne Rutherford, based on research with marmosets.71

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Analogies aren’t always to other animals. Science writers often use machine metaphors for bodies.72 Consider this description of cellular respiration: Mitochondria are the cell’s powerhouses, the living equivalent of an electrical generating station. Just as the power company takes various forms of energy (coal, oil, gas, nuclear, etc.) and converts it into one convenient form that everyone can use (electricity), mitochondria take the energy from digested food—­the pyruvate—­and convert it into a form [ATP] that all parts of the cell can use.73

If a cell is a city, the mitochondrion is its energy company and ATP its electricity. If the body is an economy, ATP is its currency. Both these analogies conjure social templates for human biological life—­just as the analogy of the chief ’s hair to the brushland and his semen to the rain conjured a bodily template for a generative landscape. Metaphors and tools, analogies and models, customs for writing journal articles and presenting cases—­all work to focus attention on specific processes while sidelining others. Even when few specialist tools are available, part of becoming an expert involves attunement to particular kinds of thinking, including a focus on specific scales and processes of knowing, and an understanding of the kinds of explanations that are generally accepted in one’s epistemic community. Epidemiologists and demographers analyze populations rather than individuals; the quirks of individuals are statistical noise. Biomedical work, in contrast, does not generally address the larger scales of analysis, rarely moving beyond individuals’ bodies and behaviors into patterns of neighborhoods and nations. As an American doctor, I observed some of these patterns but rarely considered them systematically, and generally viewed them as outside my scope of action. Malawian doctors and nurses often saw political and social factors at work, as their comments on democracy and abortion law at M&M reviews reflect. Still, diagnostic categories and review forms pushed them toward explanations for maternal death that were short term and individual. Customary practices of knowledge production also shape what can be thought and who can be seen. Scientific writing uses the passive voice almost exclusively, stripping events of their human agents. In the study of how mwanamphepo affects pregnant rats, for instance, “the mothers were observed for 3 days to check for mortality or labour-­associated complications and thereafter killed. The uterus was isolated and checked for any ruptures.” Who observed them, and how? Who killed them, and how? Who dissected the dead rats and looked for uterine ruptures? This writing strategy makes researchers disappear. It implies that whoever did the feeding, tending, observing, killing,

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and dissecting—­and how they did so—­the effects would have been the same. It imparts objectivity to scientific knowledge by sleight of hand. The way we write about time may have similar effects. Once, anthropologists wrote ethnographies in the present tense, as pathologists and other students of bodies write articles and textbooks now. The “ethnographic present” made our research sound scientific. It also took observations—­made by specific researchers, in company with specific people being studied, at specific historical moments—­out of time. Other people’s lives appeared dictated by timeless tradition. Communities seemed static, divorced from history. So did knowledge. Does the pathologic present share the limitations of the ethnographic present? Many confident present-­tense pronouncements in my older textbooks have been superseded by later research. By writing that pneumonia makes “alveolar walls thicken with immune cells and dilated blood vessels,” do I reinforce a sense of timeless biological truth that divorces bodies from history and knowers from known? Biomedicine’s focus on bodily interiors makes it easy to ignore how people’s vulnerabilities and sources of resilience are produced at larger social scales, from the transnational to the familial. The focus on a singular temporal moment—­now—­makes it easy to ignore the slow accumulation of harm. Our spatial and temporal orientations have produced a powerful science that almost inevitably falters at larger scales. Public health practitioners, who do focus on larger socio-­spatial levels, do not always include longer time horizons. Since the 1960s, many have used “the web of causation” as a metaphor to describe situations like D. A.’s, in which many different strands lead to a single endpoint.74 But practitioners tend to prioritize “cutting the strands” that connect individuals’ behaviors to pathological outcomes: for instance, educating D. A. and her neighbors on the dangers of washing clothes in streams and cooking over charcoal. Counseling poor women about balanced diets seems as important as tackling inequitable food distribution, and more feasible. As the epidemiologist Nancy Krieger points out, the web metaphor has two dimensions. It excludes time and therefore history. It cannot address how health inequities develop, or who benefits from injury to others. Without history, it too easily characterizes urban poverty and illness as problems attributable to certain people, often black people, rather than to processes of racialized accumulation and exclusion.75 Why Think across Scales? Nobody’s body is stable, unchanged from one moment to the next. From conception to death we are constantly transformed by the specific biological

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and social environments of which we are part. Nobody’s body is an island, separated by skin from an outside world. We are porous, composed in part of chromosomes from our parents, bacteria and viruses and fungi from our surroundings, even living cell lines from previous pregnancies. Our chemical composition, our microbial communities, our life chances are records of where we’ve lived and with whom. Experts who made medical sense of maternal death acknowledged this porousness tacitly. It was why a woman’s neighborhood of origin and marital status oriented listeners at case reviews in Malawi, and why a woman’s race was always mentioned in the United States. Each was a critical social marker in its specific setting. Each mattered, deeply, for embodied vulnerabilities. Experts also recognized that ordinary, nonspectacular harms accumulated to become lethal. Doctors describing deaths like D. A.’s spoke of how HIV and poverty worsened one another, much as azamba spoke of hunger and hard times as drains on women’s strength. Yet case-­review practices made it difficult to consider cumulative processes and impossible to assign causes of death beyond the individual’s body. Death could be due to hemorrhage or abortion, but not both; sepsis or cardiac failure, but not both. Death could never be due to constrained autonomy, exploitation, political negligence, or poverty. Attention to a particular woman’s death and body was accomplished in part by inattention to her life. Relationships of loving care did not appear, nor did relationships of violence. Unlike Sister Agnesi Kunjirima’s tale, these stories were free of grief and of life. Malawian clinicians often disputed this narrow, asocial approach to understanding death.76 But such analytical practices were embedded in tools for mortality review used worldwide. Death certificates, expert review panels, and computerized “verbal autopsy” surveys all aimed to generate one definitive cause for each death.77 This individualizing model of lethality has an appealing clarity and simplicity. It makes possible claims like that in this chapter’s epigraph: more than three-­fourths of maternal deaths arise from just four conditions, and “cost-­effective interventions exist for each.” That analysis provides reason for hope and priorities for action. It also leads policymakers to focus on quick and easy “fixes,” like distributing iron tablets to pregnant women. Iron tablets are often helpful and usually cheap. But their cost is extraordinary if they lead people to ignore problems—­like endemic hunger, or chronically deficient hospital care, or traumatic austerity—­that underlie many different single-­cause-­of-­death diagnoses and that are ultimately more powerful explanations for a community’s burden of untimely deaths.78 Social scientists and biological scientists don’t share much language; nor do nurse-­midwives and politicians. Occupational groups divide practical ex-

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pertise, as academic disciplines divide theory, between spatial scales within and outside the body. It is easy to overlook what moves between. A yawn, a blow, a meal, a virus, an embryo that becomes an infant: these are generated by bodies, but also move among us along the pathways of our social lives. Many of the phenomena described in this chapter—­anemia, pneumonia, hunger—­also move along those pathways. Thinking across scales forces us to attend to pathways along which harm travels, rather than to pathological objects. Death is no longer a multiple-­ choice question with one right answer. Across space, some processes affect one individual; others affect more individuals, some of whom will die from them and some who will not; a few affect nearly everyone in a given society. Across time, rising heat, falling water tables, leaching environmental toxins, and mobilizing airborne particulates damage human cells, injure growing organisms including fetuses and plants, scar landscapes like cities and agricultural fields. These processes originate somewhere. Many have effects somewhere else. Each accumulates over years or decades and, unless something happens to reverse it, eventually reaches a tipping point of catastrophic damage. Hemorrhage can kill in moments or hours; sepsis may take days or weeks. Immune suppression and weathering, which render particular women in particular communities especially vulnerable to these deaths, take years.79 The processes that determine how such vulnerabilities are distributed are slower yet. Medical researchers know surprisingly little about the social and political determinants of maternal mortality operating at the largest spatial and slowest temporal scales.80 What are these determinants, how have they developed, what could change them? Who wove the web of causation? As Krieger asks: has anybody seen the spider?81 Or to bring it back to D. A.: who breathes easier when others can’t breathe? Social inequities wound bodies. That is why some analysts see social structures as violent: they leave partially healed injuries and indelible scars. But the damage from structural violence can easily be misread as pathophysiological phenomena emerging from within individuals’ bodies: effects of behavioral, genetic, or even “racial” difference. Anyone who benefits from the status quo will be tempted to see defective biology (or foolish choices or bad luck) instead of inequity. An analytical focus on the body’s interior in the present moment makes such misinterpretations easier. To treat the cumulative wounds of injustice solely as individual pathologies amenable to technological solutions is to layer political erasure on top of structural violence. Thinking across space and time is one way to resist this political erasure. It is not a replacement for thinking with structural violence; it is a step-­by-­step

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elaboration of it. Space reminds us to consider not just the health, suffering, or death of an individual, but those of her neighborhood, her nation, the ecosystems and communities of which she is part. Time encourages us to investigate both bodies and social structures as ever-­changing processes—­ shaped over months and decades. Considering both space and time forces us to recognize the scalar mismatch between a diagnosis of poverty, inequality, and food insecurity and a proposed treatment of counseling and education, to ask whose interests that mismatch serves, and to refuse its cruelty. Mmera ndi poyamba, as gardeners know. Thinking across space and time has implications for developing research questions, for designing interventions, for demanding political action, for collectively building a world in which the girls who are growing to adulthood in D. A.’s neighborhood as you read this sentence might welcome their own children safely.

Lillian Siska: “I help them right here at home.”

Steady foot traffic had maintained a clear path to Mama Lillian Siska’s place, outside the small town of Kwinakwake, twenty minutes’ walk from a main road leading north. I first went to see her at the recommendation of Mr. Pious Muleko, Kwinakwake’s health surveillance assistant. He knew two asing’anga nearby. One, he said, was dangerous: she treated people with serious mental illnesses, patients who should go to the district hospital. But the other, Mama Lillian Siska, the one who’d also been a TBA before the government ban? She was a different matter. A cooperative woman. Reliable about referring difficult cases to him. She didn’t attend births anymore, of course—­not since the ban seven years ago in 2007—­but she helped many people. Mama Lillian’s hands flew and her eyes widened as she described her work. She’d begun in her thirties, in 1999, when stricken with a grave illness. “I wasn’t eating any food for about six months. I was not eating, not even drinking water. I was really sick! I became very thin. Even my husband told me that I had HIV.” She knew that she needed to drink water from a sacred pool where spirits resided, and that she needed to get a blood test at the hospital. In the outpatient department, they started her immediately on medicines to prevent opportunistic infections. She stopped at the sacred pool on her way home. “When I drank those waters, I began to see!” It was not ordinary eyesight—­it was dream vision. “That was the beginning of my sickness, and from there I was made to heal people. . . . [From] the time I drank those waters, I was dreaming the kind of medicine that can be used to heal certain diseases. I began to dream the disease and the kind of medicine to use.” The dreams typically came a night or two before the client first appeared at her door. “In the morning that same day, a person could come. I go in the bush and give the roots to the person and they get well and go. In the

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night I also dream for another person . . . so they happen daily.” She recorded the dreams in a notebook, to better remember them when people came with problems. The half-­inch-­thick ruled notebook was nearly full, all but five or six pages covered with penciled notes; but in the dim light of her thatch-­ roofed home, I couldn’t make out the writing. Mama Lillian explained: each note reminded her how to identify and prepare roots for a specific condition.1 Some problems she’d seen many times. Alcoholism, for instance: “I have a brother who was a drunkard but now has stopped because of the same medicine. The person permanently hates beer; even the association changes because he begins to hate even the smell.” Her infertility treatments were well known, as were her asthma remedies. Mama Lillian’s therapeutic toolkit went beyond roots. A Malawian from the country’s north where vimbuza spirits were common, she was also an experienced vimbuza healer. Spirits in a heated state could possess people and cause illness. Cooled down through trance dancing, however, they could work on the body to produce a cure.2 Drums, rattles, and whistles helped Mama Lillian “to see the problem of the person,” she said. Each spirit had a characteristic rhythm, and the rhythms to which her body responded could diagnose the spirits at work. Dancing, like dreams, gave access to invisible truths. Vimbuza was complicated, however. It required paraphernalia and people: whistles, a special outfit, a rattling belt of shells, at least one drummer. It took energy and time. A session could last hours, and it didn’t always work. I had attended two vimbuza healing ceremonies, and at one the healer and patient alike were clearly frustrated when the spirits didn’t show up no matter how many rhythms they tried. For Mama Lillian, vimbuza was a lot of trouble. She tried to limit it to two days a week. If she suspected malaria, tuberculosis, or HIV, Mama Lillian said, neither vimbuza nor roots would do. Instead she’d walk her client over to Mr. Muleko, the HSA. She could diagnose witchcraft, but she took pains not to name witches. “We do not tell that you are bewitched by a particular person; we just look for the medicine, that is all. The government does not allow this to happen. When you say, ‘This one is the witch,’ then you pay fifty thousand kwacha and also work in prison.” She preferred not to treat marital troubles either: “When they fight, they have to go to the chief and discuss the matter there and see the way forward.” The chief gave good practical counsel. Mama Lillian was also a mzamba, although since the ban on TBAs she referred women to the local hospital if there was time. Mr. Muleko had told me no women delivered outside the hospital anymore. Mama Lillian disagreed; some women still came to her so advanced in labor that they required

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delivery right in her small nyumba. “If the person comes, I help them right here at home. Even today.” Once, she’d received government assistance—­ gloves, steel pans, and “all the necessities for the deliveries.” Why was it, she wondered aloud, that they’d stopped? She described how to remove a stuck placenta, curving her long fingers in just the way that I curve mine. It would have been better to have gloves, for sure, but those were hard to get now. Plastic bags had to do. (I looked around at the packed earth floor on which we sat, my fingers resting on the warm chicken that had chosen my lap as a nice place to relax for a while, and thought about deliveries and hemorrhages and tetanus shots.) Pregnant women also sought her out if a mwana was turned wrong-­way round. “I get those medicines, pound them, add some water to make the medicine, and rub them on the womb by my hands.” She illustrated her discussion with her hands, the way many midwives and obstetricians do, showing how she turned a fetus from breech or transverse to vertex. “When I am done, the baby inside turns to a normal position. There are many women for whom I’ve performed this, and they get better—­they are many!” She named a few clients who could testify to her skill. “Some go to the waiting place there at the hospital, but they come to me first before they deliver. When I give them my medicine, you will find out that they deliver their babies very well.” People brought small gifts—­a little maize meal here, maybe a chicken there for a particularly troublesome illness or a birth. But they did not pay her: “They do not give me money! It works as if it is the government hospital. If I’d gotten money from those people, I could have put iron sheets [roofing] to this house of mine. I could have put a cement floor here. What I do is just to help people.”

3

Ambivalent Technologies

Kettie Pensulo and Dyna Ng’ong’ola shared a busy clinic on the city’s outskirts. Long ago, each had been chosen for “traditional birth attendant” training. They’d joined forces, building up their practice together over decades. With evident pride, they showed me their kit of essentials: two metal basins, some gauze, a rubber apron, and a pictorial logbook designed to accommodate nonliterate birth workers. The basins, the gauze, and the book were essentials, too, for Thomas Gondwe, the medical assistant at Pankhuyu Health Center in rural central Malawi—­although his logbook featured written records rather than checkboxes and pictures. Like the two azamba, he wore a rubber apron. Unlike them, he had a manual suction pump and a scale to weigh newborns. Two layers of rubber mats covered the bed in Pankhuyu’s tiny maternity unit. Handwritten posters taped onto the wall reminded Thomas Gondwe of the key protocols he had learned for managing hemorrhage and high blood pressure. It is to specific tools—­posters and basins, plastic bags and pounded roots, scales, and forms—­that we turn next. For the purposes of this chapter, I will use tool for a single material object—­a medical assistant’s basin, a mzamba’s logbook, a sing’anga’s gourd—­and technology to refer to an assemblage of tools and practices used together in some task.1 A blood transfusion is a technology, for instance: it bundles together (among many other things) a donor’s blood, a needle and the person trained to slip it into the recipient’s veins, an intravenous tubing setup, a sterile plastic bag, a refrigerator, and laboratory cross-­matching techniques. A set of fine incisions—­cut into a supplicant’s skin with a razor blade and rubbed by a sing’anga with the ash of herbs from a stoppered gourd—­is another healing technology. Some tools and technologies intended to ensure safe motherhood have already appeared in previous

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chapters. This chapter considers such implements more closely, with the goal of understanding what exactly it is that they do. A single tool or technology often accomplishes more than one goal. Conversely, almost any given diagnostic or therapeutic goal can be accomplished in more than one way—­just as Mama Lillian Siska identified her affliction through both a blood test and a drink from the sacred pool. Consider the patients in earlier chapters who were diagnosed as anemic. D. A., whose labored breathing and failing heart were described in chapter 2, was a rare case: her anemia was a laboratory diagnosis. An intern asked a nurse to get a hematocrit. The nurse used a syringe to draw up a tube of D. A.’s blood and set it in a tray in the labor ward’s hallway alongside a photocopied form indicating that the blood was D. A.’s, that she was on the labor ward, and that a hematocrit was wanted urgently. Someone—­likely a student—­carried the blood tube to the laboratory, where a technician put it into an automated analyzer and then wrote the results on a slip of paper. Someone, probably the same student, took that paper back to the ward. This cumbersome procedure could fail at many points. The automated analyzers were prone to failure too: they required a steady electricity supply, refrigerated reagents, a substantial up-­front investment and ongoing operating costs. These requirements made them impractical in many Malawian hospitals. Occasionally, a spun hematocrit made the diagnosis. As a medical student I spun hematocrits in 1989 during a month at a rural clinic in a double-­wide trailer in northern New Mexico, and in 1990 on a visit to a district hospital in Malawi. I pricked a patient’s finger and waited for a blood drop to well up. Then I held a thin, straw-­like glass tube against it until the tube filled, stoppered the tube with clay, spun it in a centrifuge until the blood cells separated from the plasma, and lined it up against a spiral-­shaped chart to estimate the proportion of red blood cells to plasma. This process still required electricity for the centrifuge, plus glass tubes, lancets to prick patients’ fingers, and a little square tray of clay. Still, the overall cost was low. The triage nurse at a Blantyre blood bank used an even cheaper technology: a hemoglobin scale developed by the World Health Organization. She applied a drop of a prospective donor’s blood to a special piece of paper, let it dry for a minute, and then lined it up behind a set of holes punched in a colored scale. Sliding the bloodied paper up and down, she looked for the closest match between the red of the scale and the red of the dried blood on the test paper. The darkest crimson was reassuring evidence of a robust store of erythrocytes, adequate for donation. The lightest color, a salmon tone, indicated profound anemia.2 Without these technologies, the clinician’s senses became critical tools.

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Dr. Tembo’s eyes and fingertips diagnosed anemia in the woman from Tsoka, who hemorrhaged after giving birth alone. There was no time to send a blood sample to the lab. Dr. Tembo looked at her tongue and her conjunctiva (inside her eyelids) instead. They were very pale: she was very anemic. He found further evidence of severe anemia in her fast and thready pulse. The philosopher Annemarie Mol would argue that the various techniques I have described here enacted anemia.3 Her observations in a Dutch hospital have shown that the processes people used to diagnose atherosclerosis, often using particular tools and technologies, enacted different versions of the disease. Clinicians had to coordinate these versions in order to determine what to do next. If we follow Mol’s logic, anemia—­like atherosclerosis or any other diagnosis—­is not a thing already existing out there in a person’s body, waiting to be identified more or less accurately. It becomes an actionable diagnosis only through how it is understood, whether that be through the dizziness and rapid heartbeat a patient feels, a doctor’s assessment of pallor, a nurse’s comparison of dried blood with a color scale, or a medical student’s lineup of a glass straw against a chart. Like the technologies Mol describes for atherosclerosis, those used to enact anemia in Malawi—­each involving specific tools, specific people, and specific actions—­were not exact substitutes. Which of these technologies to use depended on a number of contingencies. It might not be worth an intern’s effort to order a hematocrit if everyone was too busy to draw a tube of blood, or if there was no one to take the blood to the lab. Or the intern might not bother if she knew that an inept technologist was on duty in the laboratory, or if the power was out and she knew the analyzer would not run. The midwife in a health center might rely more heavily on her visual assessment and her patient’s pulse if the special paper for the hemoglobin color scale had run out and she had to make do with a torn bit of office paper. The alternative chosen depended on one’s training and preference, the timeline on which one needed the diagnosis (assessment of pallor was very fast), and the technologies one had at hand (the WHO’s color scale was not consistently available in Malawi). In general, however, clinicians shared a hierarchy of preference. No one spun hematocrits when an automated analyzer was reliably available. No hemoglobin color scale graced any clinic or hospital—­no matter how small and rural—­anywhere I worked in the United States. And while I have taught Amer­ ican medical students how to make a rapid assessment of pallor, they likely read that as a nostalgic throwback to older times, or perhaps a show-­offy reminder that I have worked in distant places. The students and I knew that none of them would use pallor assessment as their first-­choice diagnostic technology. Why do so when you can send your patient’s blood to the lab and

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get a precise number back, along with other numbers—­such as iron levels, or measures of erythrocyte shape and size—­that may help pinpoint the cause of her anemia? Policymakers have a name for options lower on the preference hierarchy: appropriate technologies. Appropriate technologies are substitutes used in some places but not others. Visual assessment is an appropriate technology in a Blantyre triage unit but not a Milwaukee emergency room. The WHO color scale is considered an appropriate technology for Phalombe, Malawi, but not for Chinle, Arizona, a rural American town about the same size. I will turn at the chapter’s end to the implications of this linkage among technologies, places, and (in)appropriateness. Why study these enactments, implements, and hierarchies in a book about explanations for maternal death? The stories that Malawian experts told were full of tools: intravenous drips, medicinal ropes tied around the waist for contraception, iron tablets, razor blades and threads, wild fruit poultices to “enlarge the [birth] passage,” and more. Deaths were often attributed to unused tools, misused tools, or absent tools. Prescriptions (especially those made by outsiders) for averting maternal death often relied on technologies, including apparently simple “magic bullets.” Medical training teaches people to think of tools and technologies as either diagnostic or therapeutic. A diagnostic tool like a hematocrit or a prophetic dream reveals what is happening to a patient. Therapeutic technologies, whether blood transfusions or the medicinal incisions cut by a sing’anga, alleviate the problem. To categorize healing technologies this way, however, is to risk missing or misunderstanding some of the key work that they do—­ work examined in this chapter.4 To focus the discussion, I organize it loosely around tools used to address a common pregnancy complication, cephalopelvic disproportion (CPD), and its dreaded consequence, obstructed labor. Obstructed labor as a cause of maternal death is vanishingly rare in wealthy regions of the world but persists as a major cause of maternal death in poorer areas. CPD is a term that describes the difficulty of getting a fetal head through a mother’s pelvis. As a diagnosis, it is common worldwide, but it is a vexingly fuzzy phenomenon. Clinicians often disagree about its prediction, prevention, identification, and treatment. Most—­perhaps all—­of the diverse technologies people used to predict, prevent, diagnose, and treat CPD had two valences: they healed and they harmed. They might be essential and dangerous at the same time and for the same patient, lifesaving at one moment in a woman’s lifespan and life-­threatening years later, or vital for one woman and lethal for another. Technologies used for CPD predicted a likely future, and in some cases by predicting that medical

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future they made it real—­they enacted CPD. They forced or forestalled certain courses of action. They shifted responsibility to other places or people. Some were powerful social actors: they marked clinicians and medical spaces as backward or modern. Examining these technologies closely provides a better sense of the kinds of work they do, and the complexities that a phrase like appropriate technologies hides. Obstructed Labor Malawi’s nurse-­midwifery and medical students learned that obstructed labor usually resulted from cephalopelvic disproportion. This bit of medical terminology indicates a mismatch between an oversized fetal head and an undersized maternal pelvis, so that even strong uterine contractions cannot push the fetus through.5 Obstetricians often tell a story in which CPD is a “painful Darwinian reality,”6 resulting from humans’ evolution to both bipedalism and big brains. It is generally assumed that efficient bipedalism requires a narrow pelvis, whereas a wider pelvis is more advantageous for childbirth. The likelihood of cephalopelvic disproportion and obstructed labor has increased along with the increase in brain size, and changes in pelvic morphology.7

Biological anthropologists who study the human pelvis have moved away from this simple tale.8 It persists among obstetricians, perhaps because it makes of us—­and our forceps and cesarean sections—­an evolutionary necessity. Only our timely actions prevent death and disability. If no one intervenes with effective treatment, CPD can cause obstructed labor. The cervix stops dilating. The fetus stops moving downward in the mother’s pelvis. Stuck in a single position, it presses so hard against the mother’s tissues that blood cannot flow through them. Some cells begin to die. Contractions may peter out. Or contractions may continue so powerfully that the muscle itself tears apart—­a dangerous and often lethal uterine rupture. Women whose labors become obstructed typically develop serious complications; but not all die, even if they never reach a hospital. The stresses of a prolonged labor eventually kill the fetus. After days, its body may soften enough to deliver vaginally. Damage to the mother is often irreversible by then: infection, fistula, chronic incontinence, and permanent infertility are common sequelae of obstructed labor.9 In Malawi, medical and nonmedical experts knew obstructed labor as a terrible danger, responsible for nearly a quarter of all maternal deaths and much debility.10 In the capital city, Lilongwe, a hospital wing for fistula repairs stayed full to overflowing.

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Predictions Imagine Thomas Gondwe in his one-­bed maternity ward in Pankhuyu, forty-­ five minutes’ drive from the district hospital once someone had located a car. Or consider Dyna Ng’ong’ola and Kettie Pensulo in their clinic on the city’s periphery, a long walk from the nearest road. Well aware of the awful consequences of obstructed labor, what if they could predict CPD ahead of time? Then they could transfer women likely to develop obstructed labors to places where surgeons and operating rooms were near at hand. Predictive technologies used in Malawi assessed a woman’s pelvic shape, her stature, or the progress of her labor. These approaches were often frustratingly inaccurate. Even worse, they could be self-­fulfilling prophecies. Out-­of-­ hospital practitioners sent women deemed too small, too young, or both to hospitals—­where they were scared, alone, and even more likely to develop dysfunctional labors. An in-­hospital clinician who assessed her patient’s pelvis and judged it to be contracted was more likely to be watchful about labor progress, quicker to make a diagnosis of CPD, and readier to proceed to surgery, with all the danger that entailed. p e lv i m e t ry Faculty in Malawi taught trainees how to predict trouble by assessing the bony architecture of a woman’s pelvis. Clinical pelvimetry is one of several techniques through which doctors and midwives repurpose our own bodies as measuring tools.11 Aware of a few crucial dimensions of his own examining hand, the clinician builds a mental image of the pelvis from the tactile evidence of his patient’s body and his own. Figure 3.1 shows one major dimension of interest. Imagine a woman lying on her back, knees apart, on a narrow metal table covered with a plastic-­coated mattress. Now imagine an examiner who stands at this patient’s side, leans over her knees, inserts two gloved fingers into her vagina, and tries to reach the place where her sacrum pushes farthest into the pelvic opening—­the sacral promontory. The examiner’s fingertips move to each side, feeling for whether the woman’s pelvic sidewalls are curved (roomier for a fetal head to move through) or flattened. The examiner also feels for the ischial spines—­the sharp bumps on each side of the pelvis—­and for the shape of the pubic arch, which the examiner worries can pose difficulties in labor if it is narrow. We call these “bony landmarks,” but they are covered with flesh. The examiner’s fingers push against the patient’s vaginal walls to try to feel the bones beneath. Readers imagining this examination will probably not

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f i g u r e 3.1. One measurement made during pelvimetry (Cunningham et al., Williams Obstetrics, 64).

be surprised that pelvimetry is really uncomfortable. It is particularly painful for a woman already in labor, especially if her fetus’s head is partially down in the pelvis and the examiner is trying to reach around it. One review article characterizes clinical pelvimetry as “in danger of becoming a lost art”12: it is not easy to do, to teach, or to interpret. Midwives and doctors with short fingers may not be able to take some of the measurements at all. Clinicians with long fingers, conversely, may be able to reach every “bony landmark” easily. They may have to discount advice like that given in many obstetrics texts, which teach that when an examiner can reach his patient’s sacral promontory, he should worry about CPD. (This advice presumes that patients’ bodies are variable but physicians’ bodies are not.) Two examiners’ results often differ. Finally, clinical pelvimetry does not predict CPD very well. In 1990, as a medical student in the labor ward at Queens, I described in my notes “a primigravida with a contracted pelvis” that I was confident would be unable to deliver vaginally. (She did.) Later that year, during internship in New Mexico, I learned to be more circumspect. An elderly obstetrician who had learned pelvimetry during his own long-­ago internship taught us how to measure a

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pregnant woman’s pelvis carefully, but cautioned that measurements might not help much for clinical decision-­making or for counseling patients about what to expect from labor. Occasionally someone proposed an X-­ray of the maternal pelvis to predict CPD and prevent obstructed labor. I never actually saw X-­ray pelvimetry used in Malawi, however. The technique has serious disadvantages. Pelvic X-­rays expose the fetus to radiation, increasing the risk of childhood cancer. Often unavailable where women are laboring in poorer communities, they are expensive and time consuming in wealthier ones. Most disappointing of all, X-­ray pelvimetry predicts problem labors no more reliably than measuring by hand. These failures have not stopped doctors from pursuing the elusive goal of useful pelvic measurements. Computed-­tomographic, ultrasonographic, magnetic-­resonance-­imaging, and 3D-­camera pelvimetry have all been studied as ways of assessing the fit between a fetal head and a maternal pelvis. So far, these approaches appear to be costlier but no better than clinical pelvi­ metry. No method reliably improves outcomes. Several increase the likelihood of cesarean. All reveal a commitment to the idea of measurement as a way to control what seems uncontrollable. height What was a birth worker to do? Experienced birth attendants regarded pelvimetry as unreliable but still worried that too-­small mothers might develop obstructed labor. A practical shortcut used in many places was to predict CPD by measuring maternal stature. Stature was an imperfect substitute for pelvimetry. A woman’s stature could—­rarely—­be normal even when her pelvis was not. Some cases of CPD were related specifically to healed pelvic injuries or childhood diseases: rickets, which softened bones and allowed them to fracture and heal in abnormal positions; or polio that deformed the pelvic architecture. Far more often, however, small bones simply reflected small mothers. Short stature increased the risk of CPD and of other poor obstetric outcomes. Many birth workers in Malawi used height measurement as the primary technology for deciding whether a woman could deliver safely outside a major hospital. Women who came to the clinic in shoes took them off for stature measurements. People undid tall head wraps or hairstyles that added height. In a hospital, they stood against a scale with a movable arm; the midwife lowered the arm to the top of her patient’s head and read out a number in centimeters. In a health center, there might or might not be a scale with a measuring arm.

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At some health centers the cutoff mark, painted on a wall, reduced height to a dichotomous measure: too short / not too short to deliver here. TBA trainers in Malawi advocated a simple wooden stick with a crossbar placed at 150 centimeters: women shorter than the crossbar were to be referred. At least one district hospital used shoe size as a substitute. A popular brand of cheap shoes in Malawi came in three sizes, and women with the smallest were observed especially carefully for CPD. The threshold for taking these women to cesarean section was so low that in a village nearby, women—­including a nurse—­believed surgery was “automatic” for people with size 1 shoes. Some birth workers used their own bodies as informal measures for a woman’s height, much as an obstetrician might use her hand as a measuring device for a woman’s pelvis. A woman much shorter than the mzamba should seek assistance elsewhere. The mzamba Mayi Lemani explained her practice: “When these little girls come to me during their pregnancies and I go and see their size, I just say no—­go find someone who is capable of helping you. I send them off to the really big hospital where doctors are in attendance; I do not want to delay them here, thereby putting their lives in more danger.” A rural health center nurse-­midwife drew on both professional and personal experience. She sent away short women in their first pregnancies, but kept those with prior deliveries: “Look at me, even I am short! But I deliver easily.” Worldwide, researchers predicting CPD from maternal stature found greater risks among smaller women no matter where short was divided from not-­short: 160 centimeters, 155 centimeters, 150 centimeters. How was a mzamba, a nurse-­ midwife, or a Ministry of Health official to choose a height at which a woman was too short to deliver outside a hospital? Set the cutoff too low, and many short women at increased risk for bad obstetric outcomes would labor far from a place where surgical intervention was possible. Set it too high, and hospitals would be overwhelmed.13 Zimbabwe’s national health protocols used a height below 160 centimeters as an indication for hospital referral. Malawi’s did not: far too many women would have been relegated to the hospital, completely swamping services. Even with a cutoff of 150 centimeters (about 4-­foot-­11), 10–­20 percent of Malawian women would be referred to hospitals to deliver for short stature alone. Faith Chisoni, small and slight, could have been referred for her stature had she not been referred for bleeding. Wait, you might be wondering: one out of every six pregnant Malawian women is below 4-­foot-­11? Are they genetically short? Are they teenagers? Malawian women’s stature—­and CPD risk—­was more likely economic than genetic. Many of the nurses and doctors at Queens, who mostly came from well-­fed families, were my height (5-­foot-­8) or taller. Their patients were typically much poorer, and much shorter. In crowded public hospital wards at

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visiting hours, when relatives brought in meals, clean clothes, and prophetic healers, I could see easily over the sea of heads. Height correlated with wealth in a place and time when adequate food was not a certainty outside the upper classes, and nutrition-­impairing microbes and parasites disproportionately afflicted the poor. By six months of age, a quarter of Malawian children were stunted: more than two standard deviations below expected mean stature. By three years old that number had reached 45 percent.14 When Faith Chisoni was a child, over half of children had been stunted by age five. In this place, the biological normal was statistically normal only for the relatively elite. Youth was probably not the reason for short stature either. True, teen pregnancies alarmed many birth attendants. Nurse-­midwives often reasoned that pregnancy undertaken before a girl’s pelvis was fully formed was especially likely to end in CPD and obstetrical catastrophe. The nurse-­midwife Meria Gomani put it this way: “These young primigravidas, their pelvis, they don’t match together with the size of the baby’s head.” She took both hands and grasped her own head to make sure I got the point. People with years of formal medical training and those with no biomedical education whatsoever shared forebodings about too-­young first-­time mothers. When I asked Rosena Twalibu, a village counselor, what problems she encountered among pregnant women, she didn’t hesitate for a second: There are quite a lot of problems. Small, small girls go to get operations because their passages are too small, mainly because girls as young as fourteen or seventeen years are getting pregnant. It is very difficult to assist such young mothers because of the age; in most cases their delivery is through an operation. This is the most common but major problem that we are faced with.

The sing’anga Martha Mwaseko agreed: “It’s the younger girls these days who end up dying way more than is normal.” Epidemiologists’ studies of stunting, however, did not support narratives about short teenagers with dangerously small bones. Most women reached adult height by thirteen or fourteen; adolescence predicted neither CPD nor stature.15 What did? People typically grew shorter when they were born to a mother who was malnourished, illiterate, malarial, HIV infected, or more than one of those. Or if they were born during the rainy season, when food tended to be especially scarce and diarrhea especially common. Recurrent gastrointestinal infections and high parasite loads stunted growth.16 Total food and protein consumption in childhood predicted adult size. Low weight during a woman’s own infancy and childhood increased the odds she would be a short adult, increased her likelihood of CPD, and increased the chances her own children would be stunted in turn.

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The common ground for these factors was poverty, not genetics or age. Poverty kept people short. Short stature then endangered reproduction. Those women who were shortest, and thereby most likely to need hospital care for CPD, were also least likely to be able to access referral services readily. Studied as a population, Malawian women were biologically different from the Western European women least likely to die in childbirth. Poor Malawians were biologically different from rich ones. But the difference was produced by social marginalization and political choices made across generations, not by youth or genetic ancestry.17 a g e : d a n g e r o u s y o u n g p r i m i g r av i d a s Whether adolescence caused CPD or not, experts often used age as a tool to predict problem labors—­especially among young women becoming first-­time mothers (primigravidas, in medical terminology). “If it is their first pregnancy, then I send for the parents,” claimed the mzamba Chifundo William, “and I advise them to take her to the hospital—­because she might not be able to handle delivery away from the hospital. But if she has been pregnant before then, I know that I can deal with her here.” Physically and emotionally unready teenagers with no previous labor experience were not only objects of moral disapproval, but clients to be dreaded.18 Mayi Lemani, an elderly mzamba (and sing’anga) who sent away short women, also avoided young mothers. “Here in Malawi we have children, really small children, yes? They just don’t deliver well, underage children.” The sing’anga Martin Ndhlovu, who worked in the same sprawling peri-­urban settlement as Chifundo William, had much the same opin­ ion: “Some young girls rush into early pregnancies. As a result, because they are not ready or mature to handle giving birth, they lose a lot of blood. And in some cases even the birth canal [literally, “the path”] is not ready.” Nurses working at health centers were equally likely to look for reasons to send away the youngest first-­time mothers. Many anticipated labors that would not progress normally. For years, policymakers had concurred, directing health center staff to refer primigravidas to hospitals capable of surgical intervention. In 2003, however, that recommendation changed. Hospitals were overloaded, explained a Ministry of Health official who had worked on this and other maternal health initiatives, and it was not clear that referral improved a primigravida’s safety. A ministry letter circulated to all health centers: even young primigravidas were no longer to be considered high risk. They were not to be referred without other indications for hospitalization.19 District and referral hospital staff mostly greeted the new directive with relief, not sorry to miss out on panic-­stricken teenagers sent from faraway

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health centers. In those health centers, though, the letter did not convince everyone. Many nurse-­midwives felt the official institutional blessing of health center deliveries for first-­time mothers was dangerous policy. Nurse Gomani, an experienced senior midwife who worked at a health center an hour’s walk from Queens, was one such midwife. Years ago she had worked at the hospital herself. We’d been colleagues for a time. She still had friends there. But she disagreed vehemently with the new policy: They are saying at Queens we should not send the primigravidas. They should start at the health center. But still, we are having problems. . . . You can identify a primigravida at the antenatal clinic, saying that ah, she won’t deliver normally, you will still have to go straight to Queens. She is sent back. She comes here. She starts her labor. You look after her, you will find the labor has not progressed. She needs maybe a cesarean section. Then she is sent late!

Bernadette Kasongo, a health surveillance assistant working far north of the city, regarded pregnancy in Malawi as generally safe. Like Nurse Gomani, though, she made an exception for primary and secondary school students. These girls were problems for health centers: “They are not of childbearing age, those teenagers. They are not of the age. And we find they are referred to Queen Elizabeth and they do undergo cesarean section there because they are not ready. Their labors are very slow.” Other health workers echoed this description of young primigravidas as “not ready” for birth—­they were scared, unable to hear a midwife’s advice, too immature to settle into the work of labor, and likely to end up with a CPD diagnosis and a surgical delivery. Prediction of CPD in this case served other agendas. By insisting that age and primigravidity did not put a woman at significant risk, officials lightened the burden on short-­staffed district and central hospitals. By insisting otherwise, health center workers staked claims to authority and expertise. Nurse Gomani, like her colleagues, could see trouble coming even when policymakers could not: “That midwife is very sure that her delivery will be difficult!” Diagnoses In sum, prediction of CPD was fraught. Predictive tools and technologies accomplished other purposes but did not reliably identify which mothers would develop obstructed labors. As the authors of textbooks and review articles reminded readers, CPD was best diagnosed by labor, rather than predicted. Only a fetal head was a reliable pelvimeter.20 But why? In the abstract, CPD may seem as simple as an equation, H >P = CS: if the diameter of a fetal head is larger than the diameter of the aperture in a

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mother’s pelvis, then vaginal birth is as impossible as a ten-­centimeter ball getting through a nine-­centimeter hoop, and cesarean section is in order. In life, the equation fails. The fetal head is nowhere near as rigid as a well-­inflated ball. Fetal skull bones are much more flexible than those of older humans, and the joints where they meet are not yet sealed together. Under steady force from uterine contractions, the plates of bone can bend, even overlap slightly, to make the crucial dimensions of a fetal head a bit smaller. Neither is the maternal pelvis—­several bones joined together tightly by cartilage—­anything like a hoop. Its shape is complex. No single pelvic measurement can really be compared against a fetal head. Its dimensions are not quite fixed. The joints between bones have a little give, more during pregnancy than at other times.21 Both mother and infant are dynamic. During a typical vaginal birth, the fetus flexes, extends, and rotates its head from side to side, then wriggles its shoulders through the birth canal.22 Diagnoses of CPD were often attended by real uncertainty. Clinicians recognized it easily when the mother’s pelvis was unusually small and misshapen. It was clear, too, in cases of fetal hydrocephalus, when blocked drainage of cerebrospinal fluid meant the liquid-­filled spaces within the brain enlarged, the flexible skull expanding with them. When a woman came to the hospital exhausted, having pushed for hours, with a swollen head or even a dead fetus stuck in her vagina, the diagnosis was obvious. Midwives and doctors usually agreed on CPD when a woman’s cervix stopped dilating entirely for a period of hours and the fetal head no longer descended despite strong contractions. But when labor was just prolonged, or difficult, or a woman’s uterine contractions were desultory, the diagnosis could be vague and troublesome. One midwife might enact CPD when the fetal head stopped descending for an hour; another might wait much longer.23 t h e pa rto g r a p h In Malawi’s health centers and hospitals, a tool called the partograph (reproduced in figure 3.2) was intended to clarify diagnosis and avert obstructed labor.24 The x axis marked time in hours. The y axis was for charting the mother’s cervical dilation (measured during a vaginal exam by the examiner’s spread fingers) and the fetus’s descent in the mother’s pelvis (estimated during an abdominal exam as the examiner felt how much fetal head—­in fifths—­remained above the mother’s symphysis). Birth attendants could also record fetal heart rate, maternal pulse and blood pressure, and an impression of contraction strength.

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f i g u r e 3.2. Partograph (Khonje, “Use and Documentation of Partograph in Urban Hospitals,” 21).

The partograph was an administrative tool, designed to function as a complete record of a woman’s labor and of any clinical interventions. It was also a safe-­motherhood tool. Key to that purpose were the “alert” and “action” lines: dark diagonal lines on the graph that indicated when attendants should start to pay closer attention and when they should intervene. The obstetrical consultants from the World Health Organization who developed and advocated for it intended the partograph to save mothers and infants from obstructed labor by prompting timely diagnosis of CPD. Health center and hospital staff in Malawi used partographs widely. When clinicians noticed that the marks indicating cervical dilation or fetal head descent were crossing the action or alert line, they often did something: I observed people starting dextrose drips, beginning oxytocin, recommending cesarean, and taking other actions in response to the partograph. In interviews, however, people described it more as a tool for recording and for referral than as a tool for medical intervention. Bernard Goodwell, a clinical officer at the large urban health center in Kumanja, put it this way: To have a safe delivery, mainly we help and advise. We monitor their progress with the use of the partograph. That is, eh, listening to the fetal heart as is indicated, we do health assessment and vaginal examinations at the required time, and we are plotting accordingly on the partograph.

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Eliza Singano, an enrolled midwife, explained that the partograph helped her assess “the progress of labor: how is it going, the fetal heart rate, monitoring of contractions every hourly, assessment of the dilatation of the cervix.” It also allowed her to triage patients who should be sent elsewhere. We report, we record everything we are doing in the labor on the labor graph—­that is the partograph. So we actually ensure that we note the time when the patient is coming, and how long has she been in labor? If she has stayed in long, for example, after eight to twelve hours, after anything above eight hours, it means that this one have got some problems which can make [her] have difficult deliveries.

This piece of paper, like the line painted on the wall to measure height, could justify moving responsibility for a patient to someone else, somewhere else. Nurse Singano continued: So if after consultations—­let’s say I am a enrolled midwife, I refer to my seniors, that one who is registered—­and if that one feels, “No, this one cannot be delivered,” we are communicating to our transport officer. So we can always call an ambulance to refer our patient to a big hospital like Queen Elizabeth for proper management there.

Like hospital records in the United States, however, partographs were often completed retroactively to justify key decisions that had already been made. Many described the past instead of altering the future. Occasionally they were fabricated.25 Most were incomplete, and often they were not filled in at all.26 One young woman in her first pregnancy, for example, had been transferred to a district hospital from a health center because labor was progressing slowly. At the hospital, oxytocin strengthened her contractions. Eventually her cervix was fully dilated; but after two hours of pushing, she had not delivered and the fetal head was not descending. The doctor on duty used a vacuum extractor to try to pull the infant out. When the attempt failed, he took his patient to the operating theater for a cesarean section—­but the sole anesthetist had been called away for a trauma case. When the exhausted patient finally got her surgery after a delay of more than an hour, the doctor pulled out a “fresh stillbirth.” This was a doubly terrible outcome. The young woman had no live children, despite an abdominal wound and all the additional pain and infection risk that went with it. She also had a uterine scar that posed risks in subsequent pregnancies. Forever after, she would be advised to deliver only in a hospital equipped with an operating room: no mzamba, no health center. The doctor, his head hanging, recounted the story later that day in a low mumble—­and entirely from memory. The partograph

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recorded everything from the young woman’s arrival at the health center to her hospital transfer, but the remaining five hours to her delivery were blank. Once the transfer was done, the partograph had done its duty. technolo gies in action A hand, an X-­ray, a stick with a crossbar at 150 centimeters, a scale with a moveable arm for height measurements, a line on a wall: all were tools to assess a particular woman’s risk of obstructed labor. A partograph was a tool to diagnose trouble and encourage timely intervention. These tools were not equivalents, but they were intended to accomplish similar ends, and some were substituted for others. Distinctive assemblages of people, skills, and procedures joined with these tools to make technologies intended to identify dangerous labor, whether by predicting it ahead of time or by identifying it as it happened. We could say that each worked. They predicted something that might happen; they enacted a diagnosis, or a risk category. But then what? Technologies justified action. They also delayed it. When there was too much to do and too little time to do it, requesting a lab test or X-­ray or ultrasound could justify postponing intervention for a while—­perhaps even to another shift. Delaying technologies seemed to be especially common in cases of miscarriage. Doctors were taught that a woman with bleeding and tissue coming through an open cervix (“incomplete abortion,” in medical language) needed prompt curettage—­in which the contents of her uterus were either suctioned or scraped out. As the previous chapter recounted, R. C. died of this condition while her doctor waited for a hematocrit. In hospitals where I have worked, both in Malawi and in the United States, an ultrasound was very often requested in such cases. Even though nothing it could show would change what the doctor should do next, the ultrasound was an effective stalling technology. In the United States, its use was one of many technologies that drove up the cost of medical care. In Malawi, its results were sometimes dire. A woman could die on the ward waiting for an ultrasound if everyone who knew how to use it was unavailable or the machine was down due to a power surge. Tools prompted actions too. Each could be used to call in a new assemblage of people and processes, thus justifying a displacement of responsibility that could be very welcome in busy settings or when a clinician felt inadequate to the task of care. The displacement could be from one person to another within a single workspace. Faithful charting on the partograph worked to let the enrolled ­nurse Eliza Singano call in her registered-­nurse supervisor, for instance: “I refer to my seniors.”

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Often, technologies permitted (or required) a pregnant woman to move to a different space. If the mzamba Chifundo William assessed a woman as too small, she could instruct that woman to go to the health center in labor, rather than come to her shelter. At the health center, if a midwife measured a woman against the line on the wall or the arm of the scale and the woman came up short, the midwife could tell her she must deliver in a hospital. If Nurse Singano’s partograph did not look good and her senior the registered nurse agreed that “no, this one cannot be delivered,” the on-­call team began the process of arranging transportation for “proper management” at a larger hospital. Asing’anga in a community on the outskirts of Blantyre assured me that another displacement technology was imminent: the Ministry of Health, they said, was developing a triplicate form that would enable doctors to refer mysterious cases to them for consultation.27 Even a technology as complex and dangerous as abdominal surgery could be used to move patients to another place. Pregnant patients were not allowed in the intensive care unit at Queens; I recorded one case in which a woman who desperately needed the respiratory support available only in the ICU was delivered quickly by cesarean so she could be transferred there. Interventions In the hospital, once other interventions for a stalled labor had failed and CPD had been diagnosed, it was time to deliver the baby. All possible technologies for doing so were medically and socially complex. If the mother was exhausted or had ineffective contractions, a midwife or doctor might be able to pull the newborn out with forceps or a vacuum extractor. These “operative vaginal deliveries,” which I will not describe here, allowed women a quicker recovery than the alternative of cesarean delivery. But they were not always options; sometimes the position of the fetal head made forceps or vacuum unwise, or the equipment was missing, or no one at the facility was confident in the necessary skills. They also had a dangerous reputation in the community. If a woman had needed assistance with these technologies once, people said, she would likely need it again. Mayi Abigail Daudi, a mzamba who was serenely untroubled by caring for women with scars from previous cesareans, flatly refused to take clients who had needed a vacuum or forceps extraction. Sometimes a woman has come to me for the first time. She tells me that she normally delivers in hospital and they have to assist to pull out the child with instruments. I advise her to go back to the hospital for her delivery. If she asks

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for medicine to help the situation, I give her some but still advise her to go to hospital, so that the hospital can use their skill as she explained. Do not cling to such a patient, because anything may go wrong.

When operative vaginal deliveries were unwise or unavailable, patients were taken for cesarean section. A terse excerpt from my field notes described one such case: “A primigravida came in with obstructed labor. She had pushed with a TBA from 6 a.m. on the day of admission, then was taken to a health center at 2 p.m. God knows exactly what they did there, but she didn’t reach [the hospital] until 11 p.m.” After an additional attempt at a vaginal delivery at the referral hospital she had a cesarean section. My notes on the outcome are brief: “3.2kg infant with Apgars 11/05.” These Apgar scores—­examples of a method used to quantify newborn well-­being on a scale of 1 to 10—­describe an infant who had a slow heartbeat a moment after birth but no other signs of life. At five minutes, even the heartbeat was gone. Doctors at the referral hospital wrestled with the appropriate course of action in cases like this one, where labor was obstructed and the fetus was in trouble. If it was already dead, was cesarean ever the best thing to do? What if it was not dead but very likely to die, as in the case just described? Even when surgery was readily available, many Malawians described it as a drastic, last-­resort remedy, for the cesarean operation was a technology that threatened lives as well as saving them. There were many potentially lethal missteps along the way, and even when the surgery was done—­and done well—­the dangers were not over. Most—­perhaps all—­healing technologies can also harm. Some can be deadly. Anyone who has pressed a scalpel into flesh and seen the bright beads of blood well along the cut knows that the classic clinical injunction “first do no harm” is not a very useful guide to distinguishing good medical options from bad. Much of what doctors do causes harm. Surgery wounds; radiation burns; chemotherapy poisons. We hope that the harm we do is for our patients’ overall good, and we try to weigh short-­and long-­term harm against short-­and long-­term benefits. Cesarean section—­used to treat many problems, not just CPD—­provides a sense of the dilemmas involved, for while surgeons sometimes say that “a chance to cut is a chance to cure,” it can also be a chance to kill. c e s a r e a n : a c h a n c e t o ____ 23 G3P1 29 wks previa, abruption

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The midwife remembered the aftermath best: Faith Chisoni, feverish and ghostly pale on the postpartum ward, her mother beside her. The surgeon mostly remembered the surgery. They differed on a few details. Which health center had she come from? Had she arrived with an IV? How long was she on the labor ward before the midwife hurried to track down someone, anyone, who could take her to the operating theater? Later, the nurse-­midwife had doubts about many things, but not about whether a cesarean section had been necessary. Faith Chisoni had come in trickling blood. Dr. Bwanali’s hasty ultrasound had shown a placenta that was covering her cervix and had partially torn free. By the time the trickle progressed to a rapid flow, Dr. Bwanali was in the operating room with another emergency. The midwife knew the placenta had to come out or both mother and child would die. “I remember a lot of blood,” she said. But it was an exceptionally busy day: “There was no help.” The only obstetrician she could find was in the middle of the high-­risk antenatal clinic. Those patients would have to wait. The doctor and midwife called for blood and an anesthetist, and rushed Faith Chisoni to the surgical theater. A dose of antibiotics would have helped stave off possible infection—­a danger even more significant with an emergency operation than a routine one. Later on, when Faith Chisoni got so sick, when her temperature spiked and her abdomen grew rigid, neither the doctor nor the midwife was quite sure whether she’d gotten the antibiotics (the midwife thought not) or whether they’d even been available on the labor ward (the doctor thought not). emergent C/S

The anesthetist must have used ketamine to induce general anesthesia. He was deft, but even he couldn’t put in a spinal quickly enough for this hemorrhage. The doctor and the midwife must have hastily put on their green gowns, soft with multiple washings, their stiff white plastic butcher aprons, their gloves. That was how it always went. Did they have methylated spirits, purple and explosive, to disinfect her skin? Did they just have soap? Was it one of those rare days when neither was available, leaving the team to use water alone despite the greater risk of infection? Later, no one remembered. “There was so much going on,” the midwife said. “She was bleeding, yeah?”

*

A lifesaving cesarean is also an act of bodily violence. A good surgeon tries to inflict this controlled abdominal stab wound with care and skill. Collectively, clinicians tweak their techniques to minimize damage, and rely on their

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patients’ bodies to repair the wounds they’ve made. The contingencies of a mother’s health, a surgeon’s experience, and the available equipment change the processes of damage and the possibilities for healing, altering the balance of harm and help. A surgeon begins by slicing through the skin over a woman’s abdomen, then the fat layer beneath, then the sturdy white connective tissue—­fascia—­ that sheaths the long muscles running from rib cage to pelvis.28 The tough fascia must be cut; the muscles can be stretched to either side.29 The surgeon next pokes a clamp or a finger through the peritoneum, a thin sac lining the body cavity in which the abdominal and pelvic organs jostle and slip. At this point in a cesarean section, the surgical team will usually see a little gush of fluid. If a woman’s uterus has ruptured from the exertions of labor, it will be bloody. If a woman has developed a serious infection, it will be cloudy and foul smelling. It takes about a minute with experienced hands, this cutting, stretching, and poking through from the patient’s skin through her glistening yellow fat, sturdy white fascia, meaty red muscle, peritoneum like a layer of plastic wrap. Faith Chisoni’s surgeon only “remembered” doing these things because she’d done them well over a thousand times. With a few variations—­mostly forgettable, sometimes interesting, rarely disastrous—­they were more or less the same each time. The surgeon cuts open the uterine muscle itself now, just above where the bladder connects. When labor has not begun, the muscle can be two centimeters thick. Slice carefully, though: after a long labor, the uterine wall can be stretched thin as a sheet of paper. Too deep and the scalpel will cut the fetus. The surgeon’s index fingers hook the corners of this incision. She pulls hard upward and outward to tear the uterine muscle along the line of its fibers, enlarging the cut enough to deliver the fetus.30 A typical fetal head is about ten centimeters in diameter. Another centimeter or so accommodates the surgeon’s hand, cradling and lifting the head out. The big uterine wound created in this way sometimes extends too far. Close by lie the arteries that deliver hemoglobin and oxygen and the veins that drain away deoxygenated blood. These vessels, which nourish the placenta and fetus as well as the uterus and cervix, enlarge substantially in pregnancy. If the surgeon’s cut or tear injures these engorged blood vessels, catastrophic hemorrhage can result. Several contingencies make such an injury more likely: a very large or unusually positioned baby, a uterine muscle stretched especially thin from a very long labor, a surgeon’s inexperience or clumsiness, a uterus that is infected and therefore mushy (“friable,” in medical language). Two of these contingencies not only make extension more likely, but also make

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it more dangerous—­the injury must be recognized and repaired promptly (more difficult for an inexperienced surgeon), and the uterine muscle must hold sutures well (more difficult with an infection). One maternal death I recorded at a district hospital resulted from an extension of a uterine incision: the patient died of internal bleeding before her doctor understood what had happened. After the newborn has been delivered and the placenta removed, the surgeon squeezes the uterus vigorously. The muscle contracts, compressing torn blood vessels. Bleeding slows. The surgeon then sews up the uterine wound with a heavy suture that the mother’s body will eventually absorb in the process of healing. The stitches join the edges of the uterine wound so that they are positioned well to begin healing together. A surgeon with adequate sutures and time may repair the uterus in two layers, folding the uterine muscle to thicken and strengthen the scar that will ultimately form. Suture comes in many different kinds of material—­silk, nylon, various polymers, and the purified collagen strands called “catgut,” also known as “chromic” if it has been treated with a chemical to delay its absorption.31 All are harder than muscle, especially infected muscle, exhausted muscle, or chronically malnourished muscle. Women with obstructed labor are often infected, exhausted, and malnourished. The surgeon must assess both the muscle’s strength and that of the available sutures, and pull the wound edges together snugly—­but not so tightly that the muscle tears. Eventually, the uterine wound is closed and the blood slows to a bare ooze. Too much bleeding is dangerous: it poses risks not just of hemorrhage and anemia but of infection. Inexperienced surgeons soon learn, however, that efforts to achieve a bone-­dry cesarean wound can backfire. Additional stitches create new puncture injuries, generate additional bleeding, and prolong the surgery, thus increasing the chances of infection. One aims for “hemostasis”: good enough. Once the uterine closure is deemed satisfactory and the bleeding acceptable, the surgeon stitches together layers of the abdominal wall with more sutures, sews together the cut edges of the patient’s skin, and applies a bandage, and the cesarean section is done. All this surgical damage and surgical repair typically takes half an hour from initial cut to bandage, “skin to skin.”

* clinical DIC emergent C/S undiagnosed twins 1600g male 1/4 1200g female 2/5

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Faith Chisoni’s operation had been different. Even the bandage was improvised on the spot, the midwife recalled: “We were short of things to hold on the wound. We were short of everything that day.” She’d rolled up a towel and strapped it over the wound with gauze, a makeshift pressure bandage. From the beginning there’d been unwelcome surprises. The uterine muscle was thick. The baby was even more premature than expected, the midwife recalled: “Really tiny.” Most of the equipment and medications necessary to sustain breathing and prevent infection in preemies was unavailable at Queens, but the life of Faith Chisoni’s little son might be the price of his mother’s. The surgeon lifted the infant’s head toward the operating theater light, taking care not to tear the uterine muscle with her knuckles, then pulled his shoulders through the wound. His body, coated in blood and amniotic fluid and slippery as a fish, followed easily. Two clamps on the cord and a snip in between, and the midwife handed the newborn off to a nurse to be wiped, dried, assessed, given oxygen, resuscitated. Another surprise: Faith Chisoni still looked pregnant. The midwife called out to the nurse: “There’s a twin.” In a difficult position too. They’d need to enlarge the incision to maneuver the baby out. The surgeon slowed her scalpel, avoiding the big arteries supplying the uterus. An injury to them would have been fatal, given how much blood their patient had already lost. She reached a hand in, slid around the twin’s buttocks, then pulled her out by the feet. Clamp, clamp, snip, off to the nurse. Had the midwife said, “Welcome, little one,” as she often did? Later, she didn’t remember. The surgeon was just relieved to have the twins out of the way. She was already separating the placenta with her fingertips where it hadn’t already torn away from the uterine muscle on its own, scooping it out into a metal basin, quickly feeling around the inside of the uterus to make sure they’d removed all the placenta and membranes. Yes. She stitched the uterine incision closed with coarse catgut suture. All immediate sources of bleeding were now dealt with. But the surgeon was disquieted. Faith Chisoni’s blood, pinkish and watery, was oozing from every little scrape and nick. She’d lost a lot of blood. Many of her red cells were in the soaked chitenje she’d arrived in, in a trail of drops and smears that the cleaners mopped from the hospital’s concrete hallways, on the ultrasound table, in the operating room pooled under her supine body, in the sterilized rags that the midwife had been using to keep the surgical site clear of gore. With the red cells in all those places were platelets and chemical coagulation factors. Was Faith Chisoni losing the ability to clot blood? Was this disseminated intravascular coagulopathy—­DIC?32 The anesthetist was running in fluid as fast as he could. He and the surgeon agreed: “Let’s give that blood.”

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Later, the surgeon described it all in a letter to a colleague: We crashed her, hauled out a scrawny baby over the edge of an abrupted placenta previa, only to find the uterus still full—­surprise second twin. Both resuscitated OK, though the boy has since died and the girl is struggling mightily. By this time our patient was just oozing from everywhere; we filled her up with chromic [suture], put pressure on the wound for five minutes by the clock, called it hemostatic and closed up. Only to find that the unit of blood we had was actually for the OTHER patient with APH [antepartum hemorrhage], and we didn’t even have a type and cross on this one. Fortunately she was a sturdy woman—­she seems to have stopped oozing, ultimately got two pints of blood and is doing OK.

The letter’s jaunty tone, full of slang and bravado, conceals deep worry. I know: I wrote it.

*

A surgical closure is rapid. A body’s repair takes longer. In subsequent months, the woman and those close to her can watch the outside heal. At first the skin—­cut, stretched, rejoined—­is bunched and sore. It seeps a little fluid, staining bandages. Eventually the seepage stops and the soreness ebbs. Eventually someone looking at the woman’s abdomen for traces of her cesarean will see only the scar: a thin, dark line when everything goes well; a knobbly raised ridge in other circumstances. No one sees the processes underway beneath the woman’s skin. The uterine muscle slowly knits together across the surgeon’s gash. But the site where the muscle was wounded never regains its full strength. Scar tissue, less well supplied with blood vessels and oxygen, replaces some of the original muscle. The healed area is thinner than the rest of the uterus. It does not stretch as well. If the sutures were poorly placed or if the woman developed an infection that altered healing, the uterine muscle may even have a gap—­a “window”—­where only a thin layer of clear peritoneum separates the abdominal cavity from the cavity of the womb. Even if healing has gone exactly as hoped, once a woman has had a cesarean section, she is more vulnerable to complications in subsequent pregnancies.33 The most dreaded complication is uterine rupture. If the scarred uterus breaks open during late pregnancy or during labor, both mother and fetus can bleed to death shockingly quickly. Note the paradox: the definitive treatment for obstructed labor, a cesarean operation, prevents uterine rupture in that pregnancy and precipitates it in subsequent pregnancies. My field notes from Malawi describe four maternal deaths that clearly resulted from uterine ruptures. Two followed obstructed labors; two resulted from prior cesarean sections.

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Because of these dangers, medically trained people encourage women who have had a previous cesarean section not to deliver at home or in the shelter of a mzamba but in a hospital, where speedy detection of signs that suggest impending uterine rupture is (at least in theory) more likely, and speedy transfer to a surgical theater is (at least in theory) possible. Risks of deadly complications increase with every subsequent cesarean. In circumstances where access to safe emergency medical care cannot be assured—­ whether because one cannot be sure a pregnant woman will be able to reach a hospital or because one cannot be sure the hospital will have nurses, surgeons, anesthetics, or equipment—­women who have had three cesarean sections are often counseled that they should never become pregnant again. It was once customary in Malawi for surgeons to permanently sterilize women at the third cesarean section. The practice was neither surreptitious nor elective; women were told what was happening but not given a choice. By the turn of the twenty-­first century, many younger clinicians (and some older ones) found this practice problematic. Malawian surgeons had largely replaced the expatriates, and perhaps they were less likely to make quick decisions about African women’s fertility, or more alert to the troubled global history of sterilization.34 Ethics discussions increasingly emphasized the obligation to respect patients’ autonomy over the obligation to protect against harm. In the years I worked at Queens, most people who were about to perform a patient’s third cesarean section would counsel women about the risks of future pregnancy, strongly urge a tubal ligation—­and follow a woman’s wishes if she refused one. A few made the cesarean section conditional on tubal ligation: no tubal, no cesarean. One midwife described a clinical officer at her district hospital who boasted of performing sterilizations against women’s wishes. All these factors—­the possibility of an unwanted sterilization, the long recovery, the risk of complications, and the implications for future childbearing—­ made cesarean section something to fear. Many Malawian women regarded “operation” as a technology to be avoided if at all possible. But cesarean was not the only alarming intervention. It was not even the most alarming one. s t i g m at i z i n g t e c h n o l o g i e s Clinicians’ options for managing obstructed labor were much reduced—­and much more controversial—­when a woman could not get to an operating theater. My own 1,400-­plus-­page obstetrics textbook does not mention such a possibility. The presumption is that a cesarean is always available. However, two other approaches to obstructed labor are described in the textbook used by

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Malawi’s medical trainees, and appear in texts intended for “tropical” (or international, or global) obstetrics: symphysiotomy and destructive delivery. Each is a different sort of desperate measure—­in more bloodless language, an “appropriate technology.” Clinicians considering whether to offer them, and women and families considering whether to agree, faced only dreadful options. Symphysiotomy and destructive delivery help us understand how technologies may be so stigmatizing that they do not get used, no matter how effective they could be and no matter how many lives they might save. Symphysiotomy The World Health Organization’s manual on pregnancy and childbirth complications describes symphysiotomy as “a life-­saving procedure in areas where caesarean section is not feasible or immediately available.”35 It involves cutting through the symphysis pubis, the fibrous cartilage that joins a person’s pubic bones together. (You can see the symphysis marked with an S in figure 3.1, or feel it on yourself as a slight divot where the pubic bones meet in front.) With this cartilage severed, a clinician can wrench the joint apart slightly, granting an extra smidgen of room that may allow a fetus to be pushed out with strong contractions or pulled out with forceps or a vacuum extractor. The procedure requires only a scalpel, a local anesthetic, a catheter, and a clinician who knows how to do it. The long-­term scarring from a symphysiotomy—­unlike that from a cesarean—­does not increase the likelihood of ruptured uterus should a woman become pregnant again. Indeed, the woman who heals well should have a very slightly wider pelvis than she used to, and subsequent deliveries may be easier. But a symphysiotomy may injure a woman’s bladder or urethra, and may leave her with chronic pain and an unstable gait. Even if all goes well, recovery is slow and painful. Symphysiotomy is never used in the wealthy countries of the world, nor is it used in urban hospital centers more generally. It is a procedure designated for a certain kind of place. The obstetrics textbook used at Malawi’s College of Medicine notes that “symphysiotomy has a place in especially distant areas where transport and the infrastructure are unfavourable, or where a caesarean section scar in a subsequent pregnancy may lead to uterine rupture.”36 In all my time at Queens, I never saw—­or even heard of—­one being done. Destructive Delivery If labor was obstructed and the fetus was already dead, clinicians had another option: they could damage the fetal body in ways that facilitated its removal.

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The most common was a procedure called craniotomy. Piercing and draining the head allowed the skull bones to collapse, making a stuck head smaller.37 Craniotomy did not necessarily require an anesthetist or an operating room. It did not leave a wound in the pelvis or uterus. The consequences for a woman’s body and fertility could be made much less severe by mutilating the body of her fetus. Colonial-­era obstetrics manuals provide detailed methods for craniotomy and other destructive deliveries. In Cronjé and Grobler’s textbook, they are marked as technologies of an older time. In the past, the destructive procedures were performed in cases of a dead fetus in order to deliver the fetus vaginally. Currently, with the free availability of safe, general anaesthetics and caesarean section, this gruesome procedure is now virtually in disuse. Caesarean section, which is undoubtedly a safer option, has now largely replaced destructive procedures. Consequently, this discussion is more of historical significance.38

The textbook goes on to outline the basic techniques, referring readers to other volumes that provide more detail. Using affect-­laden terms not found in the rest of the text, the authors warn that “this ghastly procedure has a severe emotional impact on the parents, as well as the obstetric personnel.”39 Craniotomies were extremely rare at Queens.40 The only description of one in my field notes used words that did not appear elsewhere: badness, rotting, stinking, splatters, wailing. Ghastly indeed. Lifesaving? Perhaps. Repugnant? Yes. Decisions about craniotomy and other destructive deliveries were tense. A few obstetricians refused to do them at all; craniotomies seemed so inhumane that some doctors avoided them even when a human life was at stake. Others pressed colleagues and trainees to use the techniques more often; occasionally an older clinician would refer to destructive-­delivery skills as lost arts. While these characterizations were laudatory, they put such techniques in the past: one person’s lost art is another’s marker of backwardness. Dr. Gray Bwanali often argued that destructive technologies, technically and emotionally difficult, were nonetheless the best choice in certain situations. Dr. Paul Mbanda was more inclined to look to high-­income countries for protocols and precedents: “What are they saying, what are they doing out there, and what shall we do here?” One day, the obstetrics staff reviewed the death of a young woman from sepsis several days after an emergency cesarean for CPD and fetal distress. She’d been hospitalized for pneumonia complicating HIV, and had gone into premature labor at thirty-­three weeks’ gestation. When labor had stalled and

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the fetal heart rate raised concerns, she was taken to surgery. Some clinicians defended the care as appropriate; this course of action would have been standard in most places. But Dr. Bwanali disagreed. A child born this small had little chance of survival in Malawi. Principles and protocols were all very well, “but the system fails. And we are a part of that system.” Our overliberal use of cesarean inflicted unacceptable harm. It would have been better, he argued, to let the infant die and then proceed with a destructive delivery. We know the risks that we are taking with someone who has got HIV, an active chest infection—­and then to add an emergency Caesar for what? For fetal reasons, for a 2.3-­kg baby! I think you all know my views on this issue. We may have to make the radical decision to look beyond the next week or two, to the real long term: what is best for the mother?

Both symphysiotomy and craniotomy could be calculated as better options in places with high fertility and low access to surgical care. One obstetrician worked out a number: when the clinical choice is symphysiotomy versus cesarean, the symphysiotomy will be safer for mothers wherever odds of death from cesarean exceed one in 175.41 Malawi fit that description, even when mothers were not the HIV-­positive women with active chest infections that Dr. Bwanali worried about. A third of postoperative women developed infections, postcesarean death rates were estimated to be between 1 and 2 per­­ cent, and rupture of a woman’s scarred uterus outside the hospital was typically deadly.42 Yet there was something beyond the reasonable and calculable about symphysiotomy and craniotomy—­for among medically trained people, these procedures carried affective weights of repulsion and desire. Both techniques were topics of fascination for some visiting doctors, eager to see procedures they would not in their home countries. On returning to the United States, I was often asked whether I’d seen or done them. Malawian professionals, in general, did not want to do either procedure. Most clinical officers and doctors who spoke about them considered them to be gruesome embarrassments, inhumane relics of the past that perhaps made their practitioners less human too. A cesarean section, a vacuum extractor, a pair of forceps. A craniotomy, a symphysiotomy. These were all technologies or tools used to extract a fetus from its mother and so to end an obstructed labor. Two of them, cesarean section and symphysiotomy, wounded the mother badly in order to do so. One of them, craniotomy, destroyed the fetus. In each case the consequences could be minimal or grave, and each could pose additional dangers over the long term.

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Scholarship on reproduction often describes a “technological imperative” in obstetrics: doctors will use a technology that is available.43 Experts’ stories and actions in Malawi reveal a more ambiguous picture. A particular tech­­ nology can be so strongly associated with a particular kind of place that it becomes a metonym, standing in for the whole context where it is used.44 In the Congo, the historian Nancy Rose Hunt reported, a fetal craniotomy once stood in for the violence of mission medicine.45 In Malawi, even if a destructive delivery was the safest option for a young woman whose obstructed labor had gone on for hours or days, it was still a marker of a past proudly left behind. A clinician would use craniotomy or symphysiotomy only in spaces that were different in some negative way: remote, backward, past, poor. The stamp of the North made some technologies desirable, but the whiff of colonialism (and perhaps of colonial doctors all too ready to dismember black bodies) clung to these. They stood in for the difference of African medicine—­a difference that some Western visitors desired, that some African clinicians saw as necessary to recognize, and that others refused.46 Augmentations In the last third of this chapter, I turn to the ambivalence of another kind of technology: medicines. Just as surgery could save or kill, medicines could be cure or poison. People inside and outside hospitals used medicines to intervene when a labor wasn’t progressing as it should. Inside the hospital, people had remedies other than surgery for uterine contractions they deemed ineffective. Nurses often gave an intravenous dextrose solution, in the hope that it would supply energy to increase the strength of contractions. A clinical officer or doctor might try some oxytocin. Azamba often described labors that did not progress as they should, and they, too, had medicines. If a woman’s labor pains were strong but the child was still not finding the path, the mother might require a vulvar massage with a mash of boiled wild fruit. The mzamba Ganet Banthu frequently used herbal treatment for the youngest and smallest mothers: “They are so short that they have to be given herbs for the birth canal to open; otherwise the solution is an operation. Because the child is young.” If labor pains were not strong enough, other medicines were needed. One could procure mwanamphepo from an old woman who knew the necessary roots, or in the market stalls where herbalists sold barks and tinctures. A woman who drank a cup or two was likely to develop overpowering labor pains, often effective enough to result in a vaginal delivery.47

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Physiologists have a word that describes both oxytocin and mwanamphepo: they are uterotonics, agents that cause contractions in the uterine muscle. Both are powerful treatments that are also dangerous. In Malawi, both were repeatedly implicated in fatal uterine ruptures. Azamba and asing’anga who spoke of medicines often characterized them—­ at least in conversation with a mzungu doctor—­in ambivalent terms. Medicines had great power. It would not do to use them recklessly. One had to know which medicine was right for a situation. Even the right medicine, given in the wrong dose or at the wrong time or without proper activation by the right person, could be dangerous. It might not work, or it might work to cause harm. The duality of medicines—­healing and harmful, effective and ineffective—­was not unique to mankhwala achikuda, the treatments used by some out-­of-­hospital birth attendants. It was also true of pharmaceuticals, mankhwala achizungu. Consider misoprostol. Like oxytocin and mwanamphepo, misoprostol is a uterotonic. Like them, it can induce powerful contractions, useful in a range of difficult situations. Like them, it can cause fatal uterine ruptures. This pill exemplifies the ambiguity of medicines that hurt and heal, and the ambiguities of relationships that determine where medicines go and do not go, and why. While misoprostol requires a turn away from the theme of cephalopelvic disproportion—­for which it is rarely if ever used—­it helps us explore the complexities of simple technologies introduced as magic bullets. Excitement over their magic makes it all too easy to overlook the damages that bullets inflict and the interests of those who fire them. introducing misoprostol In the US in 2015, I could purchase a two-­hundred-­microgram tablet of misoprostol with a prescription and a dollar. In Malawi that year, I could buy it over the counter for the equivalent of ten or twenty US cents. This tablet had many useful properties: it didn’t need refrigeration; its efficacy diminished only slowly over time; at about the size of an aspirin, it was neither too small to keep track of nor too large to swallow comfortably. A quarter of a tablet, in a woman’s mouth or in her vagina, could induce or augment labor. Misoprostol could be given to a woman whose contractions had stalled. Occasionally it was used that way in a hospital, especially if other uterotonic medications were out of stock. But for this purpose, misoprostol was not at the top of anyone’s hierarchy of preferred technologies. Managing the dosage was difficult: it is not easy to break a small pill into equal-­size quarters. More important, midwives and doctors regarded it as dangerous.

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It could cause a woman’s uterus to rupture, or the blood flow to her fetus to drop precipitously. In our referral hospital, the doctor who most often used misoprostol for labor augmentation used it when she thought a fetus was unlikely to survive anyway. Misoprostol serves other purposes, however. Three or four tablets, held under a woman’s tongue postpartum, could work quickly to control bleeding. Bernard Goodwell, the Kumanja Health Center clinical officer, had attended a training session in which misoprostol was advocated for managing postpartum hemorrhage. He could not understand why the Ministry of Health did not distribute this simple and inexpensive medication. “To practice everything at a health center is not that feasible,” he noted with frustration, openly envying colleagues elsewhere who had access to necessary medicines. “I cannot fully effectively do [my job] because of lack of necessities.” Mr. Goodwell was not alone: health center personnel often sought the drug for treatment of postpartum hemorrhage. Misoprostol has another important use. Four tablets, placed under a pregnant woman’s tongue or in her vagina every three hours for a total of two or three doses, will induce abortion in almost all women under three months of pregnancy, and the majority of women farther along. The drug alone is usually enough.48 Some women abort partially, however. A woman with an incomplete abortion needs surgical attention, and occasionally even a blood transfusion. It is safest to induce abortion in the neighborhood of someone who knows how to empty the uterus completely. All doctors, all clinical officers, and some nurse-­midwives learned the relevant procedures in Malawi. But nurse-­midwives and doctors were scarce, and abortion was illegal. Most of the time, then, misoprostol induces a safe and uncomplicated abortion. Rarely, it exposes a woman to grave peril. Is this a lifesaving medicine? Is it a dangerous one? Who should have it, who should take it, where should that happen, and why? a magic bullet Misoprostol is a generic name. In the US, the medication has been marketed as an ulcer drug for more than forty years, mostly under a brand name—­ Cytotec—­that evokes reassuring notions of technology and protection at cellular levels. It is inexpensive, in part because it has been off patent for many years, and in part because it never worked terribly well for ulcers. It reduces production of gastric acid, which turns out not to be the principal cause of ulcers after all.49 When misoprostol was thought of as an ulcer drug, its uterotonic action

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was a dangerous side effect—­side because it was not the drug’s central purpose, and dangerous because pregnant women who took it might miscarry or develop preterm labor. Its packaging features warnings against use during pregnancy, outlined in black boxes; a pregnant woman’s silhouette, surrounded by a red circle with a slash through it, reinforces the warning. Studies of African hospitals have often shown improvisation with existing tools to be critical to the work of biomedicine. In earlier work, I described Malawian doctors who repurposed intravenous tubing as urinary catheters and nested cardboard boxes to serve as sharps containers for used needles and blades.50 The historian and ethnographer Julie Livingston observed an oncologist in Botswana who withdrew fluid and tissue from his patients’ tumors with a needle, spreading the samples on slides to make cytological diagnoses when he could not get “gold standard” histopathology.51 Repurposing of medical tools happens often, and not only in Africa—­although the art of medical improvisation may reach its most ingeniously elaborated forms there. It happens with medication too. Misoprostol’s manufacturers warned about strong uterine contractions, but many people wanted them. Women desired them to end unwanted early pregnancies. Nurses and medical assistants who attended births in places without surgeons or blood transfusions also wanted them. Imagine if misoprostol had been available to the midwife at Tsoka Health Center to help her control her patient’s bleeding. In a health center, a medication that helps expel uterine contents (blood clots or bits of placental tissue retained after delivery) could be lifesaving, preventing both hemorrhage and infection. There are times when misoprostol’s dangerous uterotonic side effect becomes its desired therapeutic purpose.52 Then it is the reduction of gastric acid—­with the diarrhea and nausea that can accompany it—­that becomes a side effect. In Malawi’s maternity units, other drugs were recommended to manage hemorrhage and to strengthen labor contractions. Every health center or hospital in which babies were born was to keep oxytocin in stock. Ergometrine, another uterotonic, was to be stocked for hemorrhage. Both drugs needed refrigeration, and both usually required injection. Intravenous administration of oxytocin needed skilled staff and an “IV giving set.”53 Even when skills, staff, and set were all available, oxytocin usually was not. In 2010, a Ministry of Health survey team studied Malawi’s capacity for emergency obstetric care. Only about one in eight health centers or hospitals had oxytocin. Ergometrine was also stocked-­out at nearly all facilities: only one in six hospitals and one in eight health centers had it. Misoprostol was different. As Bernard Goodwell noted, Malawi’s health ministry did not supply it. Nonetheless, the report noted, “misoprostol was

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commonly found in hospitals (83%) and health centres (78%) and this is despite the fact that Central Medical Stores has never stocked this drug in the last two years which raises questions regarding the source of misoprostol.”54 How did drugs like misoprostol get around outside official channels? For years, the drug could be readily purchased from private pharmacies in Malawi. Pharmaceuticals and small pieces of equipment—­blood pressure cuffs, stethoscopes, thermometers—­commonly crossed borders in the luggage of visiting doctors, or with nurses returning from the UK, or as donations from abroad. Misoprostol was cheap and widely used in Zambia, which shares a long open border with Malawi. A medical assistant or nurse could pick some up and simply walk across the border. This particular drug had travel assistants. The abortion-­rights group Women on Waves worked to get tablets and instructions to women in places (like Malawi) where abortion was illegal, and places (like Texas) where abortion was legal but so bound by restrictions that it was in practice unavailable. A loose coalition of women’s rights groups aimed to help women use the drug safely, wherever they procured it. In Malawi, the toll-­free “Aunty Jane hotline” offered information on misoprostol to anyone who called or sent a text message.55 The Malawian activists at Aunty Jane, like the hotline’s supporters from Women on Waves, described misoprostol as a tool for women’s reproductive autonomy. They also argued that its distribution reduced harm, given the alternative technologies that desperate women used to end pregnancies: cassava stems in the cervix, overdoses of antimalarial drugs, laundry detergent douches. Women on Waves was blunt about the purpose of the pills it put in the mail. Many of these packages never arrived, confiscated at postal stations. Other groups were cagier. A private American foundation called Venture Strategies Innovations (VSI) worked from 2008 to 2015 to promote misopros­ tol. Its slogan: “Every two minutes, a woman dies in pregnancy or in childbirth. Together, we can change this.” Misoprostol was the magic-­bullet solution. VSI’s leadership advocated for its distribution to out-­of-­hospital birth attendants, who were to be instructed how to use it to stop hemorrhage and thus prevent maternal death.56 While VSI failed to recruit local champions or introduce the mass marketing of misoprostol in Malawi, it had more success in neighboring Zambia, Mozambique, and Tanzania. The organization billed itself as “dedicated to increasing access to essential medicines” for women’s health; as far as I have been able to determine, misoprostol and another abortifacient, mifepristone, were the only medicines it worked on. Its parent organization was funded by the estate of Fred Bixby, a California rancher with a longtime concern about overpopulation in poor countries.57 Promoted as a

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tool to save lives, misoprostol may have also been intended to prevent certain kinds of lives. Actors often converge on a particular magic bullet even as they diverge on the reasons it is desirable. Misoprostol is far from the only technology to reveal this convergence. Consider the series of ineffective drugs for COVID-­19 that gave a US president nostrums to tout, doctors treatments to try, patients reasons for hope, and pharmaceutical companies sources of profit. Or consider nevirapine. Doctors, politicians, and researchers in South Africa once expected this antiretroviral medication—­slightly less effective, slightly more toxic, and much cheaper than other options—­to be a magic bullet, transforming the prevention of mother-­to-­child HIV transmission.58 Misoprostol’s simple white tablets were not always what they seemed to be. They incorporated contradictions and complexities. They were “essential medicines,” but not provided by Malawi’s Central Medical Stores. They were not stocked, but nonetheless widespread: sold in street markets, carried around in the pockets of clinicians responsible for birth, and far more likely to be found on hospital and health center shelves than drugs that everyone agreed were critical to safe maternity care. These tablets could kill and they could save—­sometimes at the same time, as when they saved a mother by killing an embryo. Interested parties ensured they moved to places where they were desired; other interested parties stopped that movement. To add one last ambiguity, the drug—­whether sold, stored, or sought as clandestine abortifacient, not-­too-­effective anti-­ulcer therapy, lifesaving treatment for hemorrhage, or dangerous labor-­augmentation tool—­might not actually be any of those things. Counterfeits also circulated throughout much of Africa, including Malawi. With about one pharmacist and one pharmacy technician for every hundred thousand Malawians, the nation had no effective capacity to detect and combat counterfeits.59 The tablet that appeared critically necessary to some and wholly evil to others could be innocent of both evil and efficacy. Bureaucratic technologies ultimately eased moral fears about misoprostol in Malawi. By 2017 it had been reclassified as a “dangerous drug.” In the district hospitals, it was kept under lock and key. In the three health centers where I asked, it wasn’t available. You could no longer get it without a prescription, and with a prescription a single tablet cost more than a dollar.60 A pharmacist approved: “We just realized that people were abusing that one”; the price hike had put an end to that. A public health student was less sure: “You know that most of the pregnancies they are in girls and they are unwanted. They don’t have that money.” She anticipated a return to more dangerous practices.

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What was the misoprostol tablet? Was it a second-­best treatment to be used by second-­best providers, in parts of the world where surgical care was scarce? Or was it better than surgical care for miscarriage? Was it a cheap and ineffective ulcer drug, or a cheap and essential piece of women’s health equipment? Was it a lifesaving treatment for postpartum hemorrhage, or a death-­dealing abortifacient? Was it a pharmaceutically active drug, or a counterfeit? Was it a vital tool of reproductive autonomy, or a duplicitous attempt at population control? Was it a medicine, or was it a poison? Conclusion: Ambivalent, Appropriate, and Innovative Technologies Medical tools and technologies have effects far beyond diagnosis and treatment. Technologies often enfold long histories and selective judgments, and not just in Malawi. In the US, the anthropologist Amy Moran-­Thomas shows that pulse oximeters build in racial bias, combining with clinical protocols to put black patients at risk for undertreatment of respiratory distress.61 In Germany, as the anthropologist Susan Erikson demonstrates, ultrasound software algorithms and the selective “forgetting” of conflicting evidence produce the systematic overdiagnosis of fetal growth restriction, justifying physician control over—­and profitable interventions into—­pregnant women.62 In this chapter, symphysiotomy and craniotomy have made clear that certain technologies can define people and places. As clinicians decide whether to use them or not, their medical effectiveness may matter less than the stigma of backwardness, or the aura of modernity, attached to them. Cesarean sections show that technologies can be critically necessary and also work tremendous—­even lethal—­harm. Partographs reveal that tools of bureaucracy can shift responsibility. Misoprostol tablets show that magic bullets are not so magical: their introduction is the product of complex preexisting relationships, and hidden agendas may contribute to the excitement surrounding them. All these factors matter for a technology’s uptake—­or rejection. Collectively, these examples show why the development, spread, and acceptability of technologies intended to safeguard women against maternal death cannot be predicted by their medical efficacy alone. With these broader effects in mind, I return to a term mostly avoided in this chapter: appropriate technologies. Appropriate technologies are those, among a ranked set of possible substitutes, that policymakers consider suitable for a certain problem at a certain time among certain people. The implication is that other possible interventions are inappropriate.

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If appropriate brings to mind something apt, proper, perhaps culturally sensitive, the term is a misnomer. Only expense really matters. In practice, technology is chiefly designated as appropriate based on its cost in relation to a health care budget. A substitution that is inappropriate in a context of abundance might be just the thing amid scarcity. A midwife overseeing a hospital delivery in the United States would not use a wooden fetoscope to listen to a fetus’s heart, a new piece of string to tie an umbilical cord, or a clean razor blade to cut it—­but these substitutes for electronic fetal monitors, cord clamps, and surgical scissors were considered appropriate tools in Malawi. Like medical instruments, medical workers also substituted for one another along a scale of cost. Cadres of medical workers, ranked by income and years of training, were not spoken of as “appropriate technologies”; moving a particular duty from one rank level to a lower one was instead called “task shifting.” At the chapter’s beginning, I described various technologies used in different places to diagnose anemia in pregnancy. The people deploying those substitutes varied too. In Chinle, Arizona, a doctor or nurse-­midwife would diagnose a pregnant woman’s anemia. At Queens it was typically a nurse-­midwife. Away from Malawi’s urban centers, as distances lengthened and budgets shrank, clinicians with less training identified anemia. In rural Kwinakwake, Malawi, it was Mr. Pious Muleko, the health surveillance assistant. He used visual assessment to check pregnant women for anemia, gave everyone iron tablets, and sent the palest ones for evaluation by the medical assistant in the health center some fifteen kilometers away. An HSA would not have screened women for anemia in Blantyre or Lilongwe, unless all the nurses were away. A medical assistant would not have handled referrals. Kwinakwake’s remoteness and poverty made this task shifting suitable. Both task shifting and appropriate technologies imply hierarchies that conflate the optimal with the expensive. If one technology or worker is unavailable, another—­less desirable but more affordable—­should be substituted. The most desired option is the “gold standard.” Financial, infrastructural, managerial, and human constraints frequently make gold standards unworkable. When Malawi began expanding antiretroviral provision in the mid-­2000s, the gold-­standard technology to monitor patients was a CD4 lymphocyte count. Doctors were to use a cutoff CD4 level to decide if a pregnant woman diagnosed with HIV should begin antiretroviral medicines. Yet the expensive machines were scarce, their sensitive electronics threatened by power surges and interruptions. Technologists to run them and doctors to interpret tests were scarce too. In many people’s judgment, neither doctors nor CD4 counts were appropriate technologies for Malawi.63 One danger is clear: the concept of “appropriateness” can serve as a bland bu-

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reaucratic mask for injustice. Early in his career, the physician-­anthropologist Paul Farmer spoke with a Haitian priest who told him bitterly—­and mem­­ orably—­that appropriate technology simply meant “shit for the poor.”64 After all, the constraints that make gold standards “inappropriate” can nearly always be traced to long histories of extraction and exploitation. Those histories produced inadequate training capacity and brain drain, leaving vacant most of Malawi’s posts for doctors and nurses as expansion of antiretroviral therapy (ART) began. They constructed pathways for laboratory technologists and trained managerial staff to leave the public sector for better-­paying jobs, many outside the country. They drove up prices for essential reagents, sutures, medications, and other tools. They ensured the fragility of infrastructure like roads, electricity, and water that threatened not only supply chains and CD4-­counting machines, but emergency transport and even basic infection prevention. These histories both endangered pregnant women and justified second-­rate treatments. Political injustices exacerbate historical ones. The people for whom a technology is labeled “appropriate” are inevitably poorer and less powerful than those doing the labeling. African political elites promote “traditional” medicine as appropriate for the masses while flying off to high-­end biomedical clinics in the Gulf States for their own care. Members of the US Congress, whose families benefit from comprehensive taxpayer-­funded health insurance, whittle away health care options for the poor. Politicians use low-­cost technologies, including magic bullets, to defer expensive but critical interventions like training adequate medical staff. Meanwhile, clinicians caring for poor people must adopt “not best practice but what, in the most favorable light, might be called good-­enough practice,” as the anthropologist and historian Steven Feierman explains.65 Another danger is less obvious. The scale of preference built into the notion of appropriate technology—­a scale in which poor-­quality tools are good enough for poor people, while rich people get top-­notch ones—­can obscure inefficacy in addition to injustice. Conflation of expense with value can lead people to overlook circumstances in which pricier options are worse, and to resist cheaper options that may lead to better outcomes. Occasionally, appropriate technology means shit for the wealthy. Examples in which the most profitable, most high-­tech, and most prestigious practices and people are less safe or effective are not rare. For healthy women with normal pregnancies, obstetrician care is costlier, likelier to involve unwanted interventions, and less satisfying to patients than midwifery care.66 Robot-­assisted hysterectomy is aggressively marketed, expensive, cutting-­ edge technology—­that results in more complications and a longer time to

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recovery than ordinary vaginal hysterectomy.67 “Kangaroo care,” in which moderately premature infants are kept nestled closely between their mothers’ breasts, reduces newborn infections, sepsis, and hypothermia. Infants treated with kangaroo care eat better, grow bigger, and survive more often than those treated in neonatal incubators.68 Yet incubators, robot-­assisted hysterectomy, and obstetrician-­led pregnancy care remain mainstream in wealthy nations. Proposals to use low-­cost technologies—­such as partographs for labor monitoring—­meet resistance in wealthy countries. Even the term used for such proposals, reverse innovation, marks movement of technologies from South to North as anomalous.69 As a former dean of the Harvard School of Public Health commented, “The notion that the United States might learn valuable lessons from care delivery in other nations—­particularly poor countries—­is instinctively counterintuitive to the pervasive belief that we have the finest health care on the planet.”70 But all that glitters is not a gold standard. Only those who refuse to conflate expense with quality can separate the gleam of potential profits, and the glitter of cutting-­edge technology wielded by highly trained subspecialists, from the gold of good medical care. In Malawi, low-­cost technologies and task shifting ultimately made an expanded public-­sector ART program possible. Instead of doctors using CD4 counts, nurses using staging criteria based on signs and symptoms determined when to initiate treatment. Instead of nurses doing HIV counseling and testing, health surveillance assistants took over. This national strategy came at a real cost. Nurses and HSAs were overburdened, their other clinical duties pushed aside. Supply chains were occasionally overwhelmed. Patients with particularly complex clinical situations or toxic side effects suffered, and some died. But almost certainly, thousands of mothers and newborns—­and many other people—­lived years longer than they would have otherwise.71 As the next chapter describes, antiretroviral medications for pregnant and postpartum women raised particularly acute questions, engendering heated international argument about gold-­standard ethical rules and oversight technologies. Malawi’s innovative responses to these questions became safe-­ motherhood technologies that traveled beyond the country’s borders.

Chimwemwe Bruce: “Changes, yes, but no development.”

I have known Mrs. Chimwemwe Bruce for almost twenty years. In 2002 and 2003, when she was a clinical officer in training, we worked together in the Queens surgical theater. Her hands were nimble, her judgment sound. She picked up the essential techniques of cesarean section quickly, and we moved on to the more specialized strategies one can use to get out of trouble. What to do if bleeding won’t stop? What to do with a malpositioned infant who won’t fit through the usual low uterine incision? What to do if one’s scalpel, or needle, or assistant has injured the patient’s bladder? After graduation, Chimwemwe Bruce was assigned a post where her good judgment was vital but her surgical skills were little used. Zibwalo Health Center was a busy place. When I interviewed Mrs. Bruce in 2007, she told me that over fifteen hundred births typically happened there each year—­more than some of Malawi’s smaller district hospitals, and more than either of the rural hospitals where I had recently worked in the United States. Zibwalo had a simple lab, basic medicines, and a small solid medical team that worked together well. It had such a good reputation that nurse-­midwives from other communities often arranged to deliver their own babies there. As a health center, however, it had no surgical theater. It had no blood bank. It lacked key medications—­including misoprostol for hemorrhage and magnesium sulfate for seizures—­that Chimwemwe Bruce considered essential for handling obstetric emergencies. She’d written to the district health officer to request these drugs. Even the specialists from Queens, especially Dr. [Bwanali] was even stressing that: “You should put it to your DHOs . . . the health centers should have magnesium sulfate, so that you can save many.”

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Mrs. Bruce had plenty to do, even without some treatments that would have allowed her to “save many.” As the most highly trained clinician in the health center, she oversaw the clinics and maternity ward, assisting the nurses with complicated cases. “I am consulted [if] maybe there is a PPH [postpartum hemorrhage]. Maybe there is an eclamptic patient. Maybe there is a patient with severe anemia. Those sorts of things.” In her own pregnancies, Mrs. Bruce had used the antimalarials and the iron supplements she got from the antenatal clinic, and also a treatment her mother recommended. It wasn’t mwanamphepo—­no “home pitocin” for Chimwemwe Bruce. It was “a fruit-­like thing.” Each morning in late pregnancy, her mother advised, she should roll the hard, round thing from her back to her pelvis to ensure smooth labor. “Like the way that labor starts. It starts from the back, eh? And then to the abdomen, and going down. So she was saying that each and every time you woke up, you should do these things.” Was it this treatment or her good health that gave her easy labors? Her births had been smooth and quick, unlike the difficult cases they often handled at Zibwalo. But complications had come afterward. Twice she’d been hospitalized: a serious case of malaria followed one pregnancy; a large hematoma requiring surgical drainage followed another. These harrowing experiences had convinced her that hospital delivery was critical. The first baby I was sick, the second baby I went to theater! So, that’s how it went. But that’s why I think we should encourage our ladies to deliver in hospital, and to report to the clinic afterwards. Sure. Because these things which I experienced, everyone can experience as well. But when you are illiterate and your guardians don’t know that you should go to the hospital first, you can have a sepsis.

Pregnancy in Malawi was dangerous even if one wasn’t illiterate, she said. Malaria, hemorrhage, eclampsia could strike anyone. But the really serious problems were chronic ones: anemia, malnutrition, and HIV. Mrs. Bruce’s patients were often very anemic. When they get pregnant, it lowers their HB as well. And in general, most of the people they are nutritionally—­[pause] suppressed. So with pregnancy, it contributes to malnutrition as well. And with the high prevalence we have of HIV/AIDS, with the pregnancy, a lot of babies here are born with HIV. And we experience a lot of ladies dying soon after delivery due to HIV/AIDS type of illnesses.

The health center could keep these women safer. The maternity staff sterilized instruments, wiped down tables and floors with bleach, and made sterile

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delivery packs for each woman. These delivery packs, Chimwemwe Bruce was sure, reduced women’s risk of infection. “So it’s really important to encourage these mothers to have the hospital delivery. Because in the TBAs’ [places], the traditional birth attendants, they don’t have the delivery packs. Yeah. And even the Jik, the HTH, is scarce in the TBAs’—­which is always available at the health center.”1

*

I last saw Chimwemwe Bruce on a chilly morning in 2017. Everyone out wore a cardigan, or a jacket, or at least a chitenje wrapped around her shoulders. Along the roadsides the sweepers were out, briskly whisking fallen leaves and bits of debris into heaps, leaving behind overlapping arcs of striated dust. None of the heaps was burning yet, so there was little to offset the pall of diesel exhaust that hovered heavily at chest level, pumped out of the battered trucks heading into the city. I hadn’t been to the health center in years. From the banks and office buildings of the city center, one passed through leafy suburbs, then an industrial zone, until with every kilometer there were more fields and fewer homes. At a dirt turnoff marked with the sign to Zibwalo’s primary school, the houses coalesced into a denser cluster. No sign marked directions to the health center. People just knew how to get there: turn in, go left at the fork, pass between two brightly painted taverns and through a gap in a broken brick wall. A large rusted sign stood near a low brick building at the far end of a vacant yard of bare earth. By squinting at it from an angle, I could read the traces of letters: Zibwalo Health Center. Was the place even open? I climbed three steep concrete steps, opened a narrow side door, and was suddenly in one corner of the waiting room. Several dozen people looked up. I realized—­how American!—­ that I’d only thought it deserted because there were no cars. Ten years earlier, I’d described Zibwalo in field notes as “more sort of switched-­on” than other health centers. To some extent it still was. All four health workers were interacting with patients: nobody looked bored, nobody was sleeping or selling shoes or trying on wigs, nobody was chatting with a colleague while ignoring the queue. The place was also literally switched on. A single LED bulb, high in the rafters, cast a thin bluish light on the waiting room; a clerk typed into a little computer that trailed a long extension cord. Simultaneously asking questions and peering at health passports, he was registering patients into the new electronic medical record. (At this point, the new system slowed everyone down—­rather than replacing handwritten health passports, it duplicated them—­but the staff felt hopeful about

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“graduating” from written records. Even the rolling blackouts would not stop them: plans for solar backup were in the works.) The clinic itself looked worn. An open door led to a spartan ward of metal cots. On the waiting room’s high walls, tattered posters overlapped one another: tuberculosis warning signs; HIV-­prevention tips; patients’-­rights notifications. Posters in Chichewa reminded people to take care of their latrines and wash their hands before eating. Signs in English proclaimed, “We Eat Together as a Family” and “We are Youth Friendly.” Some were half torn away. Thirty-­some people crowded the waiting room’s hard wooden benches: elderly women and one elderly man, a few visibly pregnant women, young couples with coughing babies. Several children explored the waiting room. A toddler in a grubby T-­shirt clutched a crinkling bag of bright-­red puffy snacks. All these people were waiting to see Chimwemwe Bruce, the clinical officer. Mrs. Bruce’s office was very clean and very shabby. The two chairs were split, stuffing showing. The desk’s surface had entirely worn away at the corner where she wrote notes and prescriptions into people’s health passports. Chimwemwe Bruce looked a little worn too, after the long queue had been seen. Maternity care had changed since we’d last talked, I commented. “A lot of changes, yes,” she said. “But no development.” Policy after policy had changed. If anything, she said, the situation was worse. More needs, less to offer. It wasn’t just the health sector: education faced the same problems. More people were going to school, but how much could they really learn? Students jammed the primary schools, where teachers were few and overwhelmed. Secondary schools were overcrowded, widely dispersed, and expensive. District quotas limited tertiary education: not even a third of the hopeful young Malawians who passed university entrance examinations would find spaces. How would there ever be enough health workers at this rate? Zibwalo was better staffed than many health centers, although it was still difficult to keep up with growing numbers of patients. But the problem with drugs and supplies was worse than it had been a decade ago, Chimwemwe Bruce said. “We do not have adequate tools to do the work for which we have the capacity, the capability.” Her appeal to the DHO had succeeded: they usually had magnesium sulfate now. They got plenty of contraceptives, more than their patients actually wanted. But other essentials were lacking. Drugs for TB and HIV often ran short. Mrs. Bruce found herself referring people she was perfectly capable of treating, because she’d run out of antibiotics and analgesics—­sometimes, even bleach. “Even in the maternity care area, there is not enough. We are telling people, no births at home, facility birth is really

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important. Well, then we should be sure that the facility has what it needs to be safe!” “The only reason we stay here is that we love this health system,” she said. “We have the passion for it! We could use our skills in the private sector—­but then who would come here to see these patients? But the quality has really gone down.”

4

Abundant Scarcity I was out of bounds, they insisted, outside The wards, where iron roof crumble under Rotting mlombwa leaves, green paint rusts To two decades of dead dust, windows are Covered in threads of matting (to stop our Scorpion pneumonia of June?) Inside, some Sixty inmates of spasming women top & tail On thirty beds, ninety others with infants Scramble over the cracked cold cement floor—­ A family under each bed, most in between. On a slab, a cramped enamel plate (with A piece of tripe she could not chew) labours But this is no asylum & no one is fighting The desert war here. These are refugees only From ‘Child Spacing’, atoning for the ghost Revolution twenty years ago, repaired in this Shrinking hospital God knows how. And I gather The doctors & nurses who toil twenty-­four hours (With blunt needles, without drugs, on a small Wage) offered to extend this wing: there was The usual hiccup about ‘official clearance’ Yet this was the rallying cry of the dais once Upon a time. And when the powers visit The sick at Christmas, some caesareans will be Prematurely discharged, others jostled into Neat lines, clapping their praises. The windows Will have been glazed, the blood bespattered Walls painted. They’ll borrow beds & canvases From the nearby hospital so Father Christmas Sees one patient per bed: another dream done! But I hear, I am out of bounds? —­j a c k m a p a n j e , “Out of Bounds (Or Our Maternity Asylum)”

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“Threads” Grace Mbewe was a trained community health nurse posted at an urban health center. Her nurse-­run facility combined outpatient clinics for children and adults with inpatient maternity care. Health centers like these were Malawi’s front line for what international monitoring bodies and health ministries called “basic emergency obstetric and neonatal care” (BEmONC), a term to encompass all the treatment one could manage without operating theaters, blood banks, or anesthetics. Mwenimweni Health Center stayed busy with some two hundred deliveries each month. Its spare little labor ward, about three by five meters square, featured three narrow metal beds topped with plastic-­coated mattresses. A metal basin of essential supplies sat near. I spoke to Nurse Mbewe in the radio room, three steps outside the labor ward, behind a perforated brick wall blackened by the smoke of burning rubbish. On the recording of our conversation one can hear the clucking of chickens foraging for scraps outside the wall, and the repeated calls of the radio operator trying to locate an ambulance. Technically, Nurse Mbewe’s job was community outreach. She was to walk the dusty burnt-­orange footpaths of Mwenimweni’s catchment area, providing health information. She was to organize ad hoc well-­baby and immunization clinics in spaces that were public or could be made so, such as churches or elementary school classrooms. Once, she was also responsible for keeping tabs on the community’s traditional birth attendants; but since the TBA ban, that part of the job was over. She did still supervise a group of health surveillance assistants. The HSAs were to have an even more intimate perspective on the neighborhoods. Each was assigned a cluster of some ten thousand to twelve thousand people. They were to know who was pregnant, whose children were failing to thrive, where people were drawing water and which boreholes had run dry, which tiny takeaway restaurants had dubious food, and where pirated pornographic videos shown in mud-­brick theaters were leading the youth astray. In practice, however, Grace Mbewe had little time for community work. One nurse-­midwife position at Mwenimweni Health Center was unstaffed. Another position was technically filled, but that midwife was mostly too sick to come to work. (Sick staff were typically kept on the roster so that their jobs were not at risk, and everyone adjusted around their absences. It would be impossibly cruel to abandon a colleague when she needed her salary the most.) Because the nursing staff was so strapped, Nurse Mbewe spent much of her work life on the labor ward. In fact, in urban areas in the late 2000s, every designated community outreach worker with whom I spoke, whether

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community health nurse or health surveillance assistant, was working primarily inside a clinic. Staffing was so short, “task shifting” so ubiquitous, and the demands of maternity cases and acute outpatient care so pressing that everyone pitched in. Birth these days was very dangerous, Nurse Mbewe said, and this constant making do with less was part of what made it so. She laid out for me all the ways she tried to keep women safe. Every new arrival got a detailed history and a careful medical exam, she said, describing each step: “From there we will check the edema. And from there we even have to check the BP—­” she paused and lowered her voice “—­even though we don’t have now a BP machine here.” The blood pressure cuff had stopped working some time ago, and there was no replacement. Nurses had to guess from other symptoms who might be at risk for life-­threatening hypertension. BP machines were not all that was missing, and the dangers weren’t all to mothers. “Like other health centers, we do not have enough equipments, like delivery packs. Even the cord clamps, those plastic ones, mm? Those ones we stopped receiving them a long time ago. We do just tie with the threads.” At the referral hospital, we used “threads” too. Soaked in methylated spirits for antisepsis and tied around the umbilical cord, these strings usually worked well enough. Unlike a clamp, however, a rough and narrow string could cut into the cord. “We tell the mother: whenever you go there you should be peeping [at the cord], because maybe the baby can bleed to death through this,” Nurse Mbewe explained. “But with those plastic cord clamps, whenever you will clamp it, you know that this baby cannot bleed through the cord.” Tying umbilical cords with thread was bad enough, but there was worse. She gave an indignant laugh. “Even the threads, we do tell the mothers: you should bring the threads. I mean!” Absences, uncertainties, and substitutions were integral to stories of maternal and infant deaths in the labor wards where Grace Mbewe, Chimwemwe Bruce, and many others worked. Absences could be lethal. Uncertainties could delay care. Substitutions could save the day. All of them frustrated clinicians. Threads mostly did the job, but not as safely as plastic cord clamps. Far more serious was the broken BP machine. Without it, Nurse Mbewe was much less able to predict the dreaded eclamptic seizures that could complicate pregnancy-­related hypertension, an important cause of maternal death in Malawi. Chapter 3 showed that the tools and technologies people used in caring for pregnant and laboring women did more than aid with processes of diagnosis and treatment. They could symbolize modernity or backwardness, and in so doing become emblems of professional pride or shame. They could

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make manifest, in concrete material form, complex networks of institutional and personal relationships. This chapter turns to scarcity. Absent tools and technologies—­or the presence of such tools in enclaves not accessible to ordinary health workers and patients—­also had important effects. Absent antibiotics forced Chimwemwe Bruce to refer patients she was perfectly capable of treating to a crowded central hospital. She knew well that some of those patients would not bother to go. Others would go, but not stay the many hours (sometimes days) necessary to get seen. In practical terms, absences could stop the delivery of care and hasten death. When the laryngoscope batteries went missing at a central hospital, a newborn died because the anesthetist could not see to suction the airway for resuscitation. When a nationwide shortage of sutures caught a district hospital unprepared, a woman died because her ruptured uterus could not be sewn up in time. When the phone system went down, a woman with a ruptured ectopic pregnancy died because the nurses could not reach the doctor on call who could have done her emergency surgery. My field notes from a yearlong stint in 2002/03 include a list of “reasons the theatres have been closed while I’ve been here: no gowns; no autoclave; no anesthetist; no Caesar[ean] sets; no soap; no water; no gauze; no sisters.”1 Absences and uncertainties undermined hospital workers’ arguments about the benefits of birth in medical facilities. Azamba reported that women languished in the chipatala waiting for supplies, or were chastised because they had neglected to bring along items on the list of essentials that the nurses rehearsed with them. The threads Grace Mbewe described were on the list. Phillipina Macheso, a mzamba without medical training, had delivered her own children in a chipatala in days past, but did not see much point in doing so now, given the limited supplies provided there: “Back then we didn’t have to bring our own razor blades, we didn’t have to bring threads. The hospital used to provide everything.” Going to the antenatal clinic for blood tests, or maybe even a scan these days, was a good idea. But delivery? Women in her neighborhood on the city’s edge might as well stay at home. Absent tools had other effects. They could be objects of desire, goads to invention or flexibility, sources of anger. They could make good medicine something that happened just around the corner, almost out of sight, or in sight but unreachable. They tempted professionals to leave the public sector for places where they could use their talents more fully—­but, as Chimwemwe Bruce asked, “who would come here to see these patients?” The indignation that rang through both the poet Mapanje’s “I hear, I am out of bounds?” and Grace Mbewe’s “I mean!” was about scarcity, and the frustrated aspirations to good care it produced. Clamps and threads that weren’t there still mattered.

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Clinicians often encountered absent tools in the abstract: described in textbooks, recommended in in-­service trainings, or included on the Ministry of Health’s list of essential equipment and staff for a facility providing maternity care. Hand-­lettered clinical protocols, taped onto a labor ward wall in a district hospital, spelled out the dose of calcium gluconate to use for respiratory depression, but the sister-­in-­charge—­who had worked there for years before I met her in 2017—­explained that she had never actually seen the drug. Some absent tools and technologies that medical workers spoke of with desire were those they had used in other times or places. Tools came and went. A new BP machine arrived from Central Stores. A visitor brought a plastic-­wrapped pocketful of misoprostol tablets or a box of not-­yet-­expired sutures. Grace Mbewe had once used umbilical cord clamps at her own health center, just as the mzamba Charity Liwanda had once gotten iron tablets from the community health nurse to distribute among her own antenatal clients. Evanescent tools posed challenges for patients and staff. Consider a woman who lived near Zibwalo and needed her tuberculosis medications. Should she go to Zibwalo Health Center, where Chimwemwe Bruce knew her and offered swift and capable care, but where medicines were often out of stock? Or should she bypass the health center and pay for a minibus ride to the central hospital, where the medicines were nearly always in stock but the wait was likely to be much longer and the care anonymous and perfunctory? Should a midwife take the extra minutes to look for antibiotics before an emergency cesarean even if she knew they were unlikely to be available on the labor ward? Was a clinician who worked without essential drugs and equipment commendably flexible and committed, or second rate and complicit with a bad system? Increasingly since structural adjustment, tools and technologies were absent-­but-­present in a different way: particular humanitarian initiatives or transnational research studies—­both called projects—­were well supplied and staffed, but accessible only to certain health workers and patients. A project might exist as space inside a public hospital, or in a separate building nearby. We could think of these places as enclaves: special zones insulated from the world that surrounds them. For patients and clinicians, these zones were significant but also very limited sources of care. Absence, evanescence, and enclaves all mattered for care. They meant that medical staff needed to be flexible, resourceful, and knowledgeable about the changing locations in which one might (or might not) procure necessary materials, from condoms to misoprostol to dialysis to antibiotics. Staff needed to resource essentials and improvise substitutes. They needed to “know the field of play,” in a phrase I heard more than once from nurses and doctors.

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Jack Mapanje published the poem that opened the chapter, “Our Maternity Asylum,” in 1993; it evokes realities of scarcity and fantasies of plenty—­ “one patient per bed”—­that persisted decades later.2 This chapter moves across those decades to recount how experiences of scarcity and dreams of plenty affected maternity care. I begin by describing the uneven medical land­ scape, riddled with absence and dotted with evanescent enclaves, that con­­ tributed to maternal death. The chapter’s middle third turns to the uneasy imposition of institutional bioethics upon this landscape. The final section returns to the effects of dreams. Abundant scarcity shaped and changed all of this: dreaming, critiquing, surviving one’s work and one’s illnesses, deciding what course of action was ethical. Enclaves did too. Enclaves, like dreams, left traces. Dreams, like enclaves, sometimes charted paths forward. “Outside the Wards”: Water Whenever I stayed in Malawi, I was more aware of water—­for drinking, for cooking, for washing dishes and bodies and clothes—­than I was in the United States. Water was in some ways abundant; a single large freshwater lake took up much of Malawi’s topography. But that didn’t mean water was easy to come by. In a village in northern Malawi where I stayed for a couple of weeks, each morning began with a half-­kilometer walk, lugging a large plastic bucket, to whichever of the two boreholes was working better. Positioning the bucket under the outflow pipe, you worked the heavy handle up and down until the water gushed forth. Nearly always, women and kids had already clustered around the borehole in the early-­dawn half light, and everyone took turns pumping and swapping out buckets for one another. When finished, you carried your heavy and sloshing water container home—­preferably on your head, although I never mastered that—­to begin the day’s washing and cooking. In another village, in a lowland rural area of central Malawi, piped water came to a public spigot from an escarpment above. The walk and the buckets were the same, but at the water source, one simply had to turn a knob to get water. Other parts of rural Malawi had neither boreholes nor piping. I’ve not lived in these places, but some of my patients have. Women went to streams or hand-­dug wells to get their water. Many had to begin trekking before the roosters crowed to draw water.3 Malawi’s major cities had running piped water, thanks to a series of dams that collected water and produced the hydroelectric power needed to pump

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it. In Blantyre, in the city’s many informal settlements, people got water at scattered spigots. The large urban settlement of Ndirande, with some quarter of a million inhabitants, had a hundred “water kiosks” where people paid small sums for fresh clean water from a standpipe.4 Drawing and carrying water was generally considered women’s work. Unemployed young men also appeared at some standpipes, however, doing ganyu—­any piecework they could scratch up. Women with more kwacha than time paid them to carry water. Boys sold water to minibus passengers too. At bus stops and intersections, passengers could exchange coins through the window for knotted plastic bags of water: to quench your thirst from a dusty ride you simply bit off one corner. In urban middle-­class and elite homes, water came through city pipes directly to the household. But it did not always run. Water was shut off for hours (and rarely, days) at a time. It happened when repairs were made somewhere in the system, or when demand exceeded supply, or most often when not enough electric power was available to run the pumps. Many households developed workarounds. In a shared house in Blantyre’s Njamba neighborhood, in a year when the water seemed mostly to be off, we filled a large plastic trash can with water whenever the city water was on, ready to dip out of with a bucket when the tap ran dry. The tricky part was remembering to fill the trash can. A tap left open in a central spot could allow one to hear the choke and sputter of the water coming back on, and rush to the tap to refill. Or one might rely on the timetables of expected water supply printed in the newspaper, although these were not always accurate. As I write these words, from a small Blantyre apartment near the hospital, I don’t have to plan ahead for water. The family from whom I’m renting has had a brick tower built, some five meters high, atop which a huge green steel water tank sits. When the city water runs, the container fills. When the city water is off, we have our own small water tower in a garden corner. The supply will last for days if necessary, and if we are careful with it. This setup is not cheap to install, but it is also not hard to maintain, and it ends the frustration of never knowing when there will be water. Households and businesses able to invest in water tanks mostly have them now. The maternity wing at Queens Hospital has a new steel tank outside the operating theater, for instance, so that if the water is out, the nurses can still sterilize instruments in the steam autoclave. Walk through the nearby neighborhoods in which business owners, senior doctors, and expatriates cluster, and behind the high walls topped with iron spikes or glass shards, partially obscured by the luxuriant foliage of beautiful tropical gardens, you will often catch glimpses of these big green or blue tanks.

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In Malawi, then, people’s access to water for everyday use is much like people’s access to maternity care.5 It varies along several axes, including time, expense, and safety. The time it takes to procure water ranges from seconds to turn on a tap in one’s kitchen to hours of hauling buckets to and from a faraway stream or borehole. The monetary expense may be nothing, or a few kwacha to buy a plastic bag of water or hire a boy for ganyu, or the substantial outlay needed to set up a private water tank. The risk of contamination can be high or low: streams and hand-­dug wells are most likely to harbor pathogens; boreholes and city water are better, although not fully trustworthy, especially in the rainy season. Some households scrimp to get by with little water, and that of dubious safety. Others are able to ensure they have plenty of clean water. Places like my rental apartment can be thought of as enclaves: locations largely protected from the damaged infrastructure that surrounds them. These are places that insulate some of us, while most people are left out of their protective bounds. I find the concept of the enclave useful in considering the uneven distribution of essentials for health (like clean water) and for health care (like trained clinicians and autoclaves and antiretrovirals). In the bounds of physical enclaves demarcated by walls, or in social enclaves without physical boundaries, some people are kept secure. Others, at the mercy of precarious infrastructure that cuts short lives, can only see in. “Out of Bounds” The anthropologist James Ferguson has used the idea of the enclave to analyze the effects of industries that extracted oil and mineral wealth from African ground.6 It is also helpful in understanding contemporary landscapes of health and medical care. Resource-­extraction sites, Ferguson notes, have often linked with one another across nations and continents while remaining quite disconnected from the African states in which they are geographically located and the African people in the “surround” outside them. They are enclaves: physically, economically, and socially secured against the world outside. Writing about enterprises like mining and drilling, Ferguson distinguishes between industries that are socially “thick”—­more integrated into the wider society—­and those that are “thin” enclaves. Zambian copper mining in the 1960s and ’70s, for instance, was socially thick. Huge numbers of officially employed and trained Zambians earned relatively good wages and decent benefits. The best-­paying jobs were nearly all held by whites; the copper mines were no postracial utopia.7 They were, however, part of a “national

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development” model in which extractive industries were to be engines of broad social change and prosperity. But the social thickness of the national model cut into the profit margin: social services, good wages, and benefits did not come cheap. Beginning in the 1980s, improved telecommunications, cheaper air transport, advances in automation, and militarized private-­security options allowed thinner (or “flexible”) models to flourish. Thin enclaves of resource extraction were less porous to the surrounding community, with fewer opportunities for interaction across boundaries of class, “race,” and nation. Industries often outsourced the dirtiest work of extraction. Corporate overseers, themselves insulated from the dangers of the outsourced work, took pains not to inspect very closely: consider, for instance, informal diamond mining in Sierra Leone or gold mining in the Congo. In other cases, industries bypassed local labor almost entirely to use mechanized extraction, operated primarily by well-­paid and highly specialized expatriates. Oil rigs in the Niger Delta, for instance, were fenced and guarded, thoroughly separated from the fishing communities in which they were physically located. Around enclaves, “unusable” territories could be left to their own devices. The whittling away of national regulatory systems that began in the 1980s facilitated enclaves. As many African governments crumbled or shrank under internal and external burdens that included debt, structural adjustment, and HIV/AIDS, they effectively withdrew from a great deal of the countryside, leaving resource-­extraction enclaves as sites in which the rules were set by outside forces. These more profitable models attracted investors. At the same time, multinational lenders further rewarded privatization of national enterprises—­evidence of “good governance” that made it easier to get loans. The phenomenon is not solely an African one. Ferguson has predicted that the enclave model of socially thin extraction would flourish globally in niches without stable representative governments, where domestic markets didn’t matter much, and where extractive industries were the major sites of capital investment. In such contexts, political disorder, endemic private violence, and the reliance on a patchwork of privately secured enclaves might well become (as they already have in many African nations) not temporary irruptions, but long-­term features of the political landscape.8

In 2006, this vision seemed to me dystopian. By 2020, it seemed pedestrian. Across the globe, enclaves created patterns of inequality and impunity that mattered for health. The people who caused damage—­through environmental destruction, occupational dangers, pollution, privatized violence, or

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other mechanisms—­were protected against it. Those most affected, meanwhile, often had little recourse. Protests against the fouling of the Niger Delta through repeated oil spills, for instance, were met with brutal repression and little remediation of the damage caused to human, livestock, and environmen­­ tal health.9 Consider Flint, Michigan. Flint’s poverty, like that of its neighbor Saginaw, deepened when the automotive industry withdrew. General Motors outsourced labor to countries where it was cheaper. Within the city, it mechanized remaining factories; automated equipment (controlled by a few elite highly trained humans) produced engine parts without the need for many workers.10 Manufacturing jobs had once opened up opportunities for economic stability and social mobility—­although automotive factories in mid-­ Michigan, like mines in Zambia, were racially stratified. As the jobs disappeared, so did the opportunities. Residents with financial and social capital often used it to move elsewhere. Property values fell. Neighborhoods pockmarked with empty houses grew ever more vulnerable to criminality, including the drug trade. Flint’s poverty then became justification for undermining representative democracy, when the state governor installed an “emergency manager” not accountable to the city’s residents. The emergency management team disconnected clean water from Flint, later reconnecting it only to the auto plants, where contaminated river water was corroding engine parts. With industry enclaves protected, managers turned a deaf ear to the protests of citizens even as Flint’s corrosive public water leached lead into the bodies of its residents and worked permanent damage on thousands of children.11 It isn’t unreasonable to characterize Flint in Ferguson’s terms: as a place where domestic markets did not matter much to corporations, where stable political order was deemed by the powerful to be too expensive, and where political disorder, economic dependence on privately secured enclaves, and endemic violence became the order of the day. “ t h e n e a r b y h o s p i t a l ” : m e d i c a l e n c l av e s Some enclaves damaged health directly. Toxins produced within enclaves were often dumped outside them, as they were in both Flint and the Niger Delta. Scarce resources like clean water, meanwhile, were often directed to the privileged within an enclave and denied to those outside. Other enclaves shaped access to care and possibilities for survival. Just as a separate connection to clean water protected auto-­parts manufacturers from corrosion, and steel tanks on towers protected politicians in Lilongwe from the chronic water shortages with which their constituents coped, so a dialysis

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ward at a private hospital in Blantyre insulated the wealthiest people from the deadly consequences of kidney failure. A woman who suffered renal failure as a complication of a ruptured uterus, or of eclampsia, might survive only if her family could pay for Mwaiwathu Hospital’s dialysis unit.12 Medical enclaves characterized health care and shaped health inequities. In Malawi, the national political leadership had for a time endorsed a model of high-­quality, universally accessible primary care, to be delivered in clinics not too far away from any citizen. This was the “Alma-­Ata” model, named for the site of a 1978 meeting in the USSR at which the WHO membership designated it as the best way to achieve “Health for All by the Year 2000.” In Malawi, socially thick primary care was—­in the language of Mapanje’s poem—­“the rallying cry of the dais, once.” But Alma-­Ata became Almaty in the years that followed. The Kazakh Soviet Socialist Republic became Kazakhstan. Neoliberalism’s apologists no longer needed to guard against perceptions that another philosophy of governance might better protect citizens’ well-­being. A model of care built around well-­trained primary care workers and adequate staffing and supplies in basic clinics did not serve the imperative of starving the state to feed business.13 The public sector, never robust, withered under structural adjustment. Other forms of health care provision—­ including “public-­private partnerships,” nongovernmental initiatives, private entities, and humanitarian interventions—­rushed in.14 Many new programs were enclaves. Consider an example from Thyolo, Malawi. The town of Thyolo was sickle shaped. Along its concave edge, delineated by the curve of a paved road, a line of brightly painted storefronts advertising headache remedies and cellphones faced a vast rolling plantation of deep-­green tea plants. The town’s convex edge disintegrated into a jumble of houses, small unpainted restaurants and bars, a maze-­like market of tiny wooden shops and kiosks, dirt tracks, and small gardens. In this place, Médecins Sans Frontières (MSF) got an antiretroviral program up and running in 2003. Many people associate MSF with short-­term disaster relief. But disasters can unfold slowly, and MSF clinics sometimes function for many years. In 1990, I traveled to an MSF-­run camp, a humanitarian enclave in Malawi for refugees fleeing the civil war in Mozambique. The camp had job-­training programs, craft-­production workshops, and extensive gardens. Its tidy clinic was well supplied with medications and equipment, and consistently staffed with nurses and medical assistants. The nurses in charge took pride in the refugees’ relatively good health status. One warned half jokingly that word had better not get out about how much better infant and child mortality were

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in the camps than they were in the country as a whole, or serious political trouble might erupt. The edge between a disaster and a long-­term crisis could be unclear, and the relationship between inside and outside a humanitarian enclave could be tense. The HIV/AIDS epidemic was the largest of the many slowly unfolding disasters that pushed MSF into longer-­term interventions, including one in Thyolo.15 Donors, who then provided an estimated five of every six dollars spent on health in Malawi, had refused to support the National Aids Control Programme’s carefully constructed plan for antiretroviral rollout, on the grounds that patients would not take medicines reliably.16 MSF aimed to show otherwise. They began an antiretroviral demonstration project in 2003, run by MSF staff, working in MSF-­built counseling rooms and clinics—­inside or outside of government hospitals, and governed under MSF rules and protocols. MSF’s Thyolo project succeeded spectacularly. By 2007, the program was supplying antiretroviral drugs to more than 80 percent of the district residents estimated to need them, a benchmark known as “universal access.” Confronted with proof that treatment was feasible, donors agreed to support the National Aids Control Programme’s proposal. The Thyolo demonstration project was eventually integrated into the national medical system, thanks in part to a persistent district health officer who built up good working relationships with MSF staff.17 I do not describe MSF’s Thyolo project here to critique it, but simply to point out how walled off it was, at the outset, from the Malawi that surrounded it. It was permeable to prospective patients who met eligibility criteria, but not to oversight, protocols, rules, or supplies. It employed Malawian workers, but their schedules, salaries, and benefits scales differed from those of government health workers working in adjacent clinics, and from those of the expatriate MSF workers in charge. Malawi’s situation was not exceptional. In the era of “global health,” many of the African health care programs run by NGOs—­and MSF was widely regarded as among the most responsible of the lot—­could be as geographically and socially secured from the outside world as were the resource-­extraction enclaves Ferguson described. Donors funded specific projects in particular places: an eye hospital in Mangochi, a ward for leprosy treatment in Blantyre, a cluster of voluntary HIV counseling and testing centers for youth in the Northern Region, a fistula project in the capital city. Private and mission clinics offered some treatments too. Eligibility for care in these enclaves varied by residence, diagnosis, and ability to pay. Research projects added layers of complexity. For a few years, for instance, women who met the study criteria could access cervical cancer screening through a research project available at two hospitals nationwide. When the research ended, so did the

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screening—­generating frustration and fear among patients who had been instructed to follow up regularly for borderline-­abnormal results, and anger among doctors who had warned that the project should not be approved without appropriate follow-­up plans. Expatriate specialists, trained at elite universities, medical schools, and residency programs, directed many medical enclaves. These experts brought along (and occasionally took when they left) any specialized tools they needed. Most were white. They were generally protected from criticism by their whiteness, by a layer of local elites who depended on maintaining good relations with them, and by the brevity of their stays.18 Many lived in gated, guarded compounds with other expatriates. They typically rotated through in quick succession, spoke little if any of the local language, and formed few long-­term social connections in surrounding neighborhoods.19 Some organizations de­ liberately encouraged such social separations—­which could be deeply demoralizing for local health workers. Research: “When the Powers Visit” Transnational research projects often functioned as medical enclaves. Like humanitarian interventions and NGO projects, with which they frequently overlapped,20 they were demarcated from ordinary public care. Some had their own wards or buildings. Even those that occupied the same physical space as public clinics, however, were differentiated by separate paperwork, supervisory structures, and salary lines. Research projects were especially interesting medical enclaves. They were not officially “care” at all. Furthermore, ethics itself operated differently within these sites than it did outside them. Ethicists worry about “therapeutic misconceptions”—­inaccurate beliefs among people recruited for biomedical research that they will be personally helped by studies intended to generate new knowledge. But in many contexts where medical care was scarce, including Malawi, the “misconception” was accurate. People really did access treatment within research projects that they could not find elsewhere. Consider a snapshot of Queens Hospital in 2002, which illustrates how medical enclaves built around research coexisted with nonresearch care. A parent in the city of Blantyre seeking the best care for his delirious and feverish child would have taken her to the pediatric Malaria Research Unit annexed to Queens. British researchers from the Wellcome Trust and American researchers from Michigan State University jointly ran the grant-­funded Blantyre Malaria Project of which this unit was part. By 2002 it had already been at Queens for years. The research unit was well staffed, with nurses

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hired and paid by the project. All nurses and several doctors were Malawians; Malawian trainees saw patients on the unit. Supplies and medications were reliably available. Care provided there was generally understood to be excellent. An adult with malaria who came to Queens sick enough to need admission had no comparable options. In the absence of a research project, she was stuck on a general medical ward of the same hospital. Drugs, intravenous fluids, and skilled nursing care were all in perilously short supply. These wards were packed with patients being attended by family members, church groups—­or no one. It wasn’t at all uncommon for patients to die unattended. A three-­minute walk north up a long hallway and a minute more west through an open-­air corridor, a pregnant woman seeking HIV testing had to approach research nurses employed by Johns Hopkins, separated by a folding screen from the rest of the antenatal clinic, their workstation a side room and a desk. For eight of the last ten months, the public hospital had mostly been out of the expensive reagents needed to run HIV tests. Pregnant women wishing to be tested could enroll in this conveniently located study assessing mother-­to-­child transmission of HIV and its prevention. Men and nonpregnant women had to make their way to one of three counseling and testing sites elsewhere in the sprawling city. At least one of those sites was also part of an American university’s research project. A couple of minutes’ walk northwest again lay the outpatient department, where clinicians triaged hundreds of patients each day in narrow, dim, high-­ ceilinged rooms, like shoeboxes stood on end. Imagine two patients presenting to the OPD with tumors. A child with Burkitt’s lymphoma could be admitted for chemotherapy in the pediatric oncology wing, organized by an energetic pediatrician who had wheedled funding for it from a soft-­drink bottling company and other donors. An adult with advanced breast cancer could not access such treatment. To get chemotherapy, she would have to travel to Lilongwe, four hours by bus, and try to get enrolled in a research study there. To get radiation treatment, she would need thousands of dollars, a passport, a visa, and a referral to a specialist in another country. These examples are a few among many ongoing in 2002, and should show how uneven care could be even within a single hospital at a single moment. The national landscape was similarly patchworked with projects—­humanitarian, research, or both—­where patients might get some kinds of treatment for some period of time. That year, HIV treatment clinics and research studies were enclaves. Doctors at Queens grumbled about a study in another Malawian city: a German research team testing a form of “triple therapy” (three drugs taken at once to combat HIV) had no plans for continuing treatment when the study was over. Meanwhile, an HIV vaccine trial was enrolling

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patients in a town not far from the MSF demonstration project in Thyolo. The vaccine might or might not work (it didn’t), but one could get condoms, testing, HIV-­prevention counseling, and good-­quality primary care if one enrolled in the trial. These enclaves made for uneven treatment possibilities; for years during the MSF project, for instance, HIV-­infected people who lived in Thyolo district accessed medicines that people in other parts of Malawi could not. People seeking biomedical care needed to figure out where that care might be, whether they would be eligible to access it, and how much they needed to pay. Clinicians had to know this complex and constantly changing landscape in order to assist patients who needed help that public clinics could not provide.21 In 2002, enclaves for specific conditions or specific kinds of patients, typically run by non-­Malawian organizations and led mostly by non-­Malawian experts, served as islands of equipment and staff in a sea of undersupply—­a metaphor that appears again and again in scholarship on health care and research in Africa. The chapter’s end returns to this example, and this metaphor, to show how such islands change over time.22 “This Is No Asylum” Ferguson saw in Africa “highly selective and spatially encapsulated forms of global connection combined with widespread disconnection and exclusion.”23 People excluded from enclaves, he noted, developed a painful awareness of the goods that wealthy elites possessed—­and of the diminished likelihood they would ever attain such goods themselves. Medical enclaves are no different. The anthropologist Noelle Sullivan has described how public hospital workers in Tanzania chafed at the contrast between their ordinary working conditions and those in a well-­equipped NGO-­funded clinic within the hospital; the enclave served as a perpetual reminder of government failure.24 Chimwemwe Bruce’s bitter comment about change without development, and Grace Mbewe’s indignation over the loss of plastic cord clamps, reflected the acute awareness Ferguson described. Each knew of resources that saved lives elsewhere but that were not available to them or their patients. Patients may die of these exclusions; clinicians may be injured. In a study by Veronica Maluwa, nurses in a central Malawian hospital described grief, remorse, and distress over their inability to help patients in ways that would have been possible with more staff and resources.25 Those resources were some­­ times agonizingly near, yet unreachable. One nurse described a recent expe-

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rience: “It was at night. There was a patient with PPH [postpartum hemorrhage], I did all what I could do. . . . The patient needed blood. There was a need to collect blood from the blood bank from another institution but there was no transport. Patient’s condition deteriorated.26 I felt very bad.”27

*

Faith Chisoni’s condition deteriorated for lack of blood too. In my rural American hospital practice, I’d used specialized blood products—­platelets, fresh frozen plasma, and cryoprecipitate—­to treat massive hemorrhage. (True, we had to send the police racing down the highway to bring back more in a cooler from the university hospital a hundred and forty miles away. It was terrifying. But barring the worst weather, it could be done.) My fellow obstetricians at Queens—­most of them Malawian but all of them trained outside Malawi—­ had used these tools too. In fact, a private hospital just a few kilometers away kept platelets in its blood bank. But they were not available where Faith Chisoni lay on the table unconscious, abdomen open, bleeding along every raw edge of tissue and every suture line. The only choice left was to press a sterile cloth hard against the seeping uterine wound. Sometimes when needles and sutures no longer work, pressure still does. It compresses small blood vessels, allowing the platelets and clotting factors that remain to accumulate at the injured edges of tissue. The trick is not to stop too soon, not to let up on pressure in order to peek under the cloth, not to dab and wipe at the fragile new clots. We’d been flying through the operation; now, no one moved. The nurse-­midwife recalled this moment vividly: “When I realized that you were afraid, I remember getting very calm.” The two of us stood across our patient’s open abdomen, pressing cloths saturated with her blood against all the places I’d cut and torn. It worked. When we carefully pulled the cloths away after an interminable five minutes of silence and hoping, the oozing had stopped. No platelet transfusion, no fresh frozen plasma, no cryoprecipitate—­just hands and cloth and desperation and time. But our patient was now terribly anemic, and we had little blood to give her.

*

As near as a blood bank in a private hospital or a research project down a long hospital corridor, or as distant as a radiation unit in another country, the enclave made a sort of mental template of what constituted good care that could be difficult to match in the surround. Enclaves could also make a mental template of ethics.

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“Without Drugs”: Two Deaths, Two Ethics To examine the ethics of enclaves, consider two maternal deaths that took place in the same ward many years apart. On a morning during her final year of medical school in 2003, Catherine Gunya reported to the group of nurses and doctors assembled for handover rounds that one of her patients had died overnight of respiratory failure. The young patient, about the same age as Catherine herself, had been admitted to the hospital a week earlier, complaining of coughing and shortness of breath following a recent miscarriage. Her story wasn’t all that uncommon. Typically, symptoms like hers led nurses and doctors to suspect pneumonia, or a cardiomyopathy that causes the muscle fibers of the heart to fail. Catherine’s patient had no fever, however, and no signs of heart failure on examination. Her chest X-­ray showed neither the patchy whiteness characteristic of pneumonia nor the enlarged cardiac silhouette and diffuse haze of pulmonary edema indicative of an overburdened heart. Instead, sharply demarcated, round white spots appeared against dark lung fields. Catherine had known right away what she was seeing: the “cannonball lesions” of a metastasized gestational choriocarcinoma—­an aggressive cancer that typically arises from placental tissue and can spread rapidly through a woman’s vascular system. At handover rounds, the senior doctor quizzed her: “What is the proper treatment for choriocarcinoma?” “First, you must give methotrexate,” Catherine responded promptly. Methotrexate, an inexpensive chemotherapeutic agent listed on the WHO’s Essential Medicines List, cures 95 percent of choriocarcinomas.28 Catherine continued, “But we do not have any. We just gave her oxygen therapy.” Like everyone else in the room, Catherine knew there were many places outside the country in which “the proper treatment” could be given. In fact, methotrexate was being given in research projects in Malawi—­but the research was not about choriocarcinoma, and the drug was not available to Catherine’s patient. Catherine’s report awoke memories of another death, one I’d witnessed with similar helplessness during my own final months of medical school, at Queens in 1990 before it was a university hospital. The bones of that story are equally spare. A young woman, about the age I was then, died shortly after delivery. Her premature newborn had gone to the nursery. His mother was taken to die on the crowded postnatal ward, in the bay close to the nurses’ station that was reserved for the sickest patients. Anyone entering the bay could smell how sick she was: a rank odor of rot was on her breath and seemed to emanate from the corrugated dark blotches on her skin. I remember she had several on her neck and face, and one on the roof of her mouth. It seemed likely that more were in her lungs.

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I knew little about the young woman even then. All these years later, I don’t even remember her name. She was one of many patients whom the nurses and doctors characterized in two short phrases: chronically ill, and too poor to buy soap. “Chronically ill” was local code for someone suspected to have HIV. “Too poor to buy soap” meant abjectly poor. Someone too poor to buy soap was really at the margins, even in the neighborhoods on the margins of the city where most of our patients lived, neighborhoods inhabited by people marginal to the affairs of state, most of them getting by on a very marginal dollar a day or less. To characterize someone as too poor to buy soap was to indicate that she could not sustain the basic elements of civilized life. Urban women too poor to buy soap often became chronically ill. We called the purple-­black patches on the young woman’s body by the name of a nineteenth-­century Hungarian doctor: this was Kaposi’s sarcoma, KS. It was not a biopsy diagnosis. The country did have a single pathologist at that time, but he was kept far too busy examining unusual and confusing specimens, and doing contract work with various research projects, to be bothered with something as suddenly commonplace as KS. No pathologist’s experienced eye looked at a detached bit of flesh, pickled in chemicals, dyed purple and crimson with more chemicals, embedded in wax, shaved so thin that a powerful light could shine through it as if it were some beautiful but terrible design in stained glass, magnified to look as if it were a hundred times its size, to see the anticipated wild profusion of spindle-­shaped cells. Instead, the nurse’s experienced eye looked at this young woman’s skin where it was blackened and thickened, illuminated only by the watery morning sunlight finding its way through a tall, grubby window. A diagnosis nonetheless, and not a hard one. Or rather, not hard in the sense of difficult, because there was enough KS around by 1990 that experienced medical personnel made the diagnosis quickly and confidently; but hard in the sense of grievous, because there was nothing to be done about it. Or—­there was nothing to be done about it in Malawi. At the American hospitals where I’d been learning, patients were experiencing dramatic improvements with a new drug. Zidovudine was the first medication demonstrated to be effective for HIV-­infected people suffering from opportunistic infections and cancers like Kaposi’s sarcoma. Approved in the US in early 1987 and soon in wide circulation there (where it was known as AZT), it was so expensive that it would not be available to patients in Malawi’s public hospitals for nearly twenty years—­with a few important exceptions. Those exceptions were research enclaves, including one that became infamous a few years after my patient died. In 1994, a large international clinical research project began to investigate low-­dose zidovudine use in pregnant women. One of the project’s nine

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US-­funded sites was in Malawi. The study’s goal was not to improve the health of mothers. It was to see whether a modest dose of zidovudine, given during the last weeks of pregnancy, might reduce the odds that mothers-­to-­be would transmit HIV to their newborns. Half the women enrolled in the trial received zidovudine; the other half got placebo tablets made to look exactly like it. Treatment stopped at delivery. Women in both arms of the study were to be left with a devastating diagnosis and no treatment. The details of the research protocol don’t matter much now. The study’s findings didn’t ultimately matter much either, whether to national policy or to international knowledge about HIV transmission and prevention. As researchers anticipated, low-­dose zidovudine was less effective than regimens used in wealthier places to reduce mother-­to-­infant transmission of HIV. As they also anticipated, low-­dose zidovudine was considerably better than a placebo. Even at a tenth of the cost of the medication regimen considered “standard” elsewhere, however, a small dose of zidovudine was still far too expensive; the protocol tested in this research project never became policy in any of the African nations in which the project ran. “official clearance” Scientific knowledge and health policy are not the only results of research. The perinatal zidovudine study made little practical impact on the prevention of perinatal HIV transmission, but it had substantial social and institutional effects. At research sites in Burkina Faso and Côte d’Ivoire, the study brought together large numbers of women who’d just learned they were HIV-­positive. Characterizing themselves as “discarded” by health systems and researchers, these women formed some of the earliest social support organizations for people living with HIV in both countries.29 In Malawi, the zidovudine study left a bitter aftertaste: when the clinical trial stopped, so did the zidovudine. Malawians were back to no antiretroviral treatment at all. Nurses, doctors, and policymakers began to voice more and more concerns about what happened to patients after research projects ended, and how research dovetailed—­or failed to—­with national health policy. Critiques of “parachute” or “safari” research grew. Tensions over such critiques also grew.30 The year the trial ended, Malawi’s College of Medicine Research Ethics Committee began reviewing proposed studies. The perinatal zidovudine trial also changed global bioethics practices. Three years after the study began, an enormous wave of negative publicity about it hit academic journals and the popular press. A great many American

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doctors and ethicists, appalled that the United States had funded the trials, wrote passionate condemnations. Their major critique was not about poor integration with national health policy, nor about lack of ongoing treatment for HIV-­infected mothers and children. The problem was the placebo. Many observers judged the provision of a placebo to African mothers unacceptable, given that clinics elsewhere in the world used a regimen known to be effective, if expensive. A smaller number of commentators, among them many Africans, defended the study. African authors typically drew on their own clinical and research experiences to support the trials. Their publications were often subtitled in ways that marked their local credentials: “A South African Viewpoint,” or, “The Ugandan Experience.” Opinion pieces and journal articles by Americans were not marked in this way.31 As unmarked voices from nowhere, Americans—­rather than Ugandans or South Africans or Malawians—­took on the mantle of global conscience. Global in this case turned out to mean what it often means. Institutional power gave a group of elites the tools to disseminate their judgments widely and the status that ensured their judgments would be taken seriously. Heated debate slowly gave way to fragile consensus. Committees revised several important ethical codes that governed international research to prohibit placebos when effective treatments were known to exist. Funders imple­mented new layers of approval. The United States National Institutes of Health brought African researchers to the US for training in bioethics. Once back in their home countries, those researchers set up the ethics committees that were newly required to certify American federally funded projects, and that provided the ethical governance and regulatory apparatus for research in Africa.32 The perinatal zidovudine trials are now well-­known examples of unethical research, incorporated into lectures on ethics given to medical students in many countries, written up in basic ethics textbooks and training manuals. A Malawian colleague collaborating on a research project with me, for instance, had to take an online training course—­developed in Florida and required by my university in Wisconsin—­that used the perinatal zidovudine trials in his country as an example of unethical placebo use now prevented by ethical codes: one more step in the march of ethical progress. “ n e a t l i n e s ” : e m p l a c e m e n t, d i s p l a c e m e n t, a n d e t h i c a l e n c l av e s The geographic place of medical knowledge matters, as the anthropologist Alice Street has noted.33 She describes researchers in Papua New Guinea

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whose studies were emplaced—­attached to a specific location with endemic malaria—­just enough to be valid. Their research knowledge also circulated in a displaced fashion among malarial sites in the Pacific, Asia, and Africa. Malawian researchers read New Guinean publications on malaria, for instance, and vice versa. Researchers working in each place circulated too, to international conferences, or to metropolitan sites of global health knowledge production in Liverpool or Baltimore. Emplaced research knowledge provided them both legitimacy and mobility. In contrast, Street found, emplaced clinical knowledge provided neither. It could even leave people stuck. The everyday knowledge that doctors needed to make diagnoses and manage therapy in Madang district hospital in New Guinea was usable only there. Neither the knowledge itself nor those who accumulated it circulated easily. In the arguments over the zidovudine trials, judgments grounded in emplaced knowledge about HIV care and prevention in African nations—­ including Malawi—­did not prevail. Displaced ethical knowledge and judgment were ultimately taken as better guides to right and wrong. The new “global” institutional rules paradoxically narrowed the rightful purview of bioethics to a scattered set of places. An archipelago of medical enclaves—­ connected by research-­funding streams and intellectual currents, but separated from the uncharted clinical seas that surrounded them—­also functioned as ethical enclaves.34 Ethics changed; the sharp separation between enclaves and the surround did not. Intensified oversight within enclaves was paired with continued abandonment without. The controversy over the perinatal zidovudine trials broke midway between the death of my patient from untreated Kaposi’s sarcoma in 1990 and the death of Catherine Gunya’s patient from untreated choriocarcinoma in 2003. Between those years, a great deal changed in Malawi and at Queens. A dictator, the “Father Christmas” of Mapanje’s poem, relinquished power in a peaceful transition. The first flourishing of multiparty democracy exhilarated many, especially at first, and disappointed many, especially as time wore on. A terrible famine wracked the country the year Catherine’s patient died, a famine exacerbated by IMF demands that Malawi sell its grain reserves to raise cash for debt service. A new medical school was founded, and Queens became a bustling university hospital. Many Malawian doctors were among the new specialists, returned from training abroad to work in Queens’ wards and operating theaters and to teach in the newly built lecture halls. Research at the hospital had taken off. Medical students and faculty studied questions varying from the pressing to the peculiar. So did an ever-­growing cohort of outside researchers, including me. Something called “global health” was a

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new object of philanthropic concern, and a new source of funding. Queens felt the impact. By the time Catherine Gunya’s patient died, several new research buildings clustered at the hospital’s southeast corner. Inside them, scientists and doctors peered through microscopes, ran assays, wrote up ethics protocols and grant proposals, and worked out preliminary answers to many important questions. Inside the maternity wing, less had changed. An ultrasound room had been partitioned from the courtyard where linens hung to dry in the sun. The old “first stage room,” where women had once labored on floor mats until they were ready to push (beginning the “second stage” of labor) was gone; women in the first stage of labor waited it out on the antenatal ward. But far too many patients still clamored for the attention of far too few nurse-­ midwives. Some births still happened unattended, especially at night. Many medications were not available unless one was enrolled in a research project. The conditions of pervasive scarcity punctuated by enclaves, like the deaths that resulted from them, were still not recognized as bioethical problems. If other women had accessed zidovudine through a clinical trial in the same ward where my patient died, but she could not enroll, her death would not have concerned bioethicists. If methotrexate had been available to patients in private clinics in 2003 but not in the public hospital where Catherine Gunya’s patient died, her death, too, would not have registered as an ethical problem. Ethicists attended to deaths that happened within enclaves of oversight; only if these women had been enrolled in research projects and allocated to placebo would their deaths be troublesome. Deaths that happened outside those enclaves remained invisible to a class of experts professionally concerned with the rightness and wrongness of medicine and the justice of its distribution. Ultimately, it is the wall between enclave and surround that explains why the placebo used in the perinatal zidovudine trial was so controversial. I think of the placebo here as another of the substitute tools described in chapter 3. Another stand-­in, as the line painted on the health center’s wall stood in for the scale with a moveable arm, and as both line and scale stood in for pelvi­ metry. In the research study, the pharmacologically inactive placebo stood in for active zidovudine. It gave the women enrolled in the trial something to take, the study nurses something to give, and the senior research team something to ensure that the acts of pill-­giving and pill-­taking—­or of attending a special clinic and being cared for by research nurses—­did not in themselves explain any improved outcomes. What is so interesting about the placebo, and what so troubled the critics of the trial, was that the placebo also stood in for nothing at all, the no-­medicine that all other pregnant HIV-­positive Malawian women got. It revealed that sometimes substitute tools are, in fact,

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nothing. It stood for hope and despair, inclusion and abandonment, something and nothing. And it troubled the separation of enclave and surround by bringing that nothing right inside the enclave. Many observers now see as grotesqueries the debates of medieval theologians who argued fiercely over the exact properties of angels, and whether or not one’s fingernails would keep growing after the resurrection, even as famine and war and disease afflicted those around them. No doubt the fine points of angels and corporeal resurrection were as genuinely interesting to those theologians as the fine points of consent forms and recruitment flyers are to ethics review boards.35 Important as many of these questions are, they are narrowly focused. They ignore broader realities in which people providing “informed consent” are often neither informed nor consenting; in which the process of recruitment for Big Pharma is turned over to corporate proxies who locate students, homeless people, and Eastern Europeans who need cash and health care; in which the “therapeutic misconception” is not a misconception at all.36 The overall effect: ethical governance and oversight are intensified within narrow spheres of action, and abandoned outside those spheres. Placebo controls have been banned: all is well. “Another dream done!” But the end of the placebo control did not accomplish everyone’s dream of ethically responsible research. Those who lived and worked in contexts where research enclaves contrasted starkly with undersupplied surrounds were especially likely to advance perspectives that troubled the enclave’s secure borders. African bioethicists pushed to get health equity on the ethical agenda, making a strong case for advocacy as an ethical duty.37 African scientists struggled to work out field-­data collection practices that recognized research as an exchange to be managed responsibly and respectfully, rather than pretending no exchange was involved.38 Many insisted that plans for posttrial benefits—­including expanded access to any care found to be effective—­ should be part of the ethical review process. In Malawi, doctors and ethicists repeatedly rejected a large HIV prevention study that they deemed inconsistent with both national policy and the long-­term interests of ordinary Malawians—­although it would have brought funding to a university that very much needed it, and would have advanced their own careers.39 Meanwhile, Malawian nurse-midwives and doctors tested a new approach to prevention of mother-­to-­child HIV transmission, one that guaranteed all HIV-­infected pregnant women lifelong access to antiretroviral therapy.40 Their pioneering approach has since become mainstream. Arguably, these actions fit within a long scholarly tradition in which African science has been driven by communitarian and liberatory agendas despite internal and external threats to its integrity. As the feminist scholar

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Amina Mama puts it, “African scholarly traditions have consistently rejected the liberal philosophical assumption that demands disengagement and distance from social context rather than engagement and action.”41 To fail to har­­ ness one’s research to an urgent project would be the unethical move, in this perspective. “This Shrinking Hospital”: Routine Crisis Medical enclaves—­whether NGO-­run projects, private hospitals available only to those who could pay, or research studies—­made certain kinds of diagnoses and therapies at once visible and inaccessible to most ordinary Malawians. Both for people who sought medical care and for people who provided it, enclaves held out the possibility of treatment, and exacerbated the frustrations of scarcity. For patients anywhere seeking relief from an illness, the knowledge that there is a research study in which they might enroll or a private clinic across the border to which they might travel, if they can only scrape together the funds, can be cause for hope—­and despair. I see that pairing of hope and despair in GoFundMe campaigns for medical treatment and in donation jars on the counters of stores in small American towns, where visitors just might put enough change to buy travel to a specialty hospital for the child whose photo is taped to the jar. The great majority of crowdfunding campaigns for medical aid fail.42 The countertop jars of change look very small against the great needs represented there. In Malawi, hope and despair also sat side by side. People with little access to good health care could always hope that an employer, a member of the extended family who had done well, or anyone else in the social network could help them “resource” access to an enclave. The anthropologist Benson Mulemi, working in an oncology ward in Nairobi, found that the uncertainties raised by evanescent therapies and tentative diagnoses could actually nourish hope where it otherwise might have withered.43 The diagnosis might be wrong, incorrectly pessimistic; the nurses might know a good Chinese medicine or African healing specialist; the chemotherapy drug might be avail­­ able at a different hospital or a research project. For health workers who worked in the sea of underprovision rather than the archipelago of projects, enclaves were places they knew to have cord clamps or HIV tests, well-­supplied blood banks or cephalosporin antibiotics. They were sites of dreams and of frustration, their presence a constant reminder that nurses and doctors somewhere else could offer more. The power of this awareness should not be underestimated. It pulled health workers out

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of public-­sector jobs in undersupplied hospitals and clinics, and into NGOs, or research jobs, or other countries. Proper medicine could all too readily appear to be something that experts did somewhere else.44 Scarce and evanescent staff and materials required clinicians to be flexible: to improvise a treatment; to resource a necessary drug or surgery, or to use one that might work even though it wasn’t the best; to send a patient to the private sector to buy bandages; to try to get her into a research project even though she didn’t quite fit the recruitment criteria. Evanescence also created many gaps in care. In 2007, my field notes recorded the frustrating guesswork involved in treating several women with postpartum infections without guidance from blood cultures or lumbar punctures. It was hard to know for sure what we were treating. The lab never got the samples (sitting in a box on the ward while the one nurse on duty takes care of the patient instead of running samples to the lab), or got the samples but didn’t have reagents to run the tests, or didn’t have lab runners to get the test results back to the floor. Or the intern thought we couldn’t do a certain test here, not knowing the lab had recently got a batch of reagents, so didn’t order it.

Weeks later, one of these women turned out have pelvic tuberculosis. Ordinary antibiotics had not helped. Surgery had revealed an abdomen full of pus. A biopsy of a possibly infected area took four weeks to get back instead of the two or three days it should have; as usual, stains and microtomes and pathology staff were concentrated on research projects, and the hospital patients got what was left over. The biopsy results finally returned late one Friday afternoon with an unexpected diagnosis of tuberculosis, but the tuberculosis medicines were already locked up for the weekend. Whether the additional three-­day wait for effective treatment really mattered, her family would never know; she died before it could start. Patients and families sometimes filled hospital supply-­chain gaps. Pregnant women were expected to provide equipment to keep themselves and their newborns safe and clean. Some supplies were to be ready at home. Others were to be brought along to compensate for what hospitals and health centers lacked. Over time, as hospital supplies shrank, the expectations for mothers grew. Almost thirty years ago, when I was a medical student on the central hospital’s wards, supplies and equipment were always short. The single pair of scissors available to cut umbilical cords, described in previous chapters, was an indelible memory. Years later, when I returned as a specialist, the ward offered no scissors at all—­each pregnant woman was expected to purchase her own clean razor blade at a market kiosk or a trailside mini

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shop. The razor blade was only one of the items required. Nurses counseled young women expecting a first child on what to have ready. Older women who did not bring along the necessary items were often scolded: they should have known how to prepare. A senior nurse sat and worked through the current list with me in 2017, shaking her head over how it had expanded since her early years in practice: • razor blade—­clean, wrapped, and new • basin—­a clean plastic or enameled metal tub in which a woman could wash her clothes and her infant • two clean chitenje cloths, washed and dried, one to serve as a mattress, one in which to wrap the newborn • a bar of soap • a mackintosh—­a clean waterproofed cloth to place under the chitenje to keep blood and fluid off the delivery table • thread—­clean and unused

Azamba provided very similar lists of the appropriate tools a woman should bundle together and bring to her birth, and the state they should be in. The list is reminiscent of, although not quite identical to, the “clean delivery kit” promoted by the United Nations for refugees and people in crisis settings. In 2012, the UNFPA solicited supporters to help with “saving the lives of pregnant woman and their babies” by buying kits containing “the most basic essentials for preventing fatal infections” to distribute across Syria. The organization described the kit contents: It includes a bar of soap, a clear plastic sheet to lie on, a razor blade for cutting the umbilical cord, a sterilized string to tie off the umbilical cord, a cloth to keep the mother and baby warm and latex gloves. The kit costs only three dollars. Thousands of these are shipped by UNFPA every year as part of a rapid response in humanitarian crises.45

The similarity of the UNFPA’s clean delivery kit for crisis settings to the list of items any Malawian mother was expected to bring for her child’s birth suggests that one person’s humanitarian emergency could be another’s ordinary workplace. Crisis could be routine. “the g host revolu t ion” A haunting double image emerged occasionally in interviews with people responsible for pregnant women’s care. As birth workers inside and outside medical settings discussed their work, from time to time they mentioned

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absent tools, medicines, practices, or people as if they were there. These double images—­of essentials both absent and present—­provide glimmers of insight into the lived experience of routine crisis and abundant scarcity. They illuminate a kind of dreaming that is at the same time almost unbearably modest and important to understanding how contemporary medicine works in the poorer parts of the world, where the daily labor of medical work is rarely studied and the “best practices” promulgated by professional organizations are rarely possible. Previous research led me to anticipate that people working in hospitals and health centers would talk about inadequate supplies, equipment, and staff. I had not expected that those medical tools and medical workers might first appear in discussion as if they were really, materially there. Nurses described the routine care they provided to keep pregnant women safe, for instance; like Grace Mbewe, they would discuss how they checked blood pressures every day—­or every few hours when a woman was in labor. Most health center staff also noted, however, that they had no working blood pressure cuffs; in April 2007, only one of six urban health centers around a major city had the equipment necessary to measure a blood pressure. A health surveillance assistant would describe handing out mosquito nets as part of an antimalarial campaign, but then it would turn out that the NGO supplying mosquito nets had been out of stock for a month. Two azamba reported that they gave iron tablets to pregnant clients, but when I asked for details, they said that it had been years since they had seen the iron tablets—­or the community health nurse who used to provide them. At a busy urban referral hospital, the nurse-­midwife Lucy James described her routine: listening to the fetal heart rate, assessing the maternal condition, checking pulses and blood pressures—­for her ward did have a sphygmomanometer. There was more to do than the physical examination. In the labor ward, many people were anxious. First-­time mothers, having the new experience of labor pains and knowing little about what to expect, were often frightened. So, Nurse James explained, “[we] have a chat with them. Tell them what is going to happen. So that their fears for labor are not there. Yeah. And do the back-­rubbing as well. To relieve the pain.” In many hours spent in this maternity unit, I had never seen a nurse rubbing a patient’s back and rarely seen anything that looked like a reassuring chat. So I asked Nurse James whether that really happened. She burst into laughter. “No! Because the staff, the staffing is quite short.” The midwives were forced to spend their shifts “going in circles! Just going this way and that way!” from bed to bed. She clarified: it was more that she would like to chat and give back rubs.

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Back rubs that didn’t happen, iron tablets that weren’t there: it is certainly possible that these double images were produced by the specifics of an interview situation in which the interviewer was a mzungu doctor, and despite all reassurances the interviewees felt tested. Perhaps these health workers were describing the actions they thought they ought to be taking, the tools they thought they ought to use, the best practices they thought they ought to follow. Yet at least some of the double images seemed less like correct answers on an exam and more like dreams of care. Owen Kamfoloma was a health surveillance assistant, a community health worker stationed in an urban neighborhood with a raucous bar scene. Even in the late morning, men seated at plastic tables outdoors drank kachasu together, shouting catcalls and invitations to women passing by. As afternoon first meandered and then abruptly stumbled into evening, tinny Afro-­pop or old-­style kwassa kwassa would pump on blown speakers out of plastered buildings or from behind board fences painted in English and Chichewa, with names like “Euro Club,” “The Drinking Den,” or “You Don’t Have to Be Alone.” You could just hear the catchy tunes sometimes from the waiting area of the health center. Not enough nurses were available, so Mr. Kamfoloma spent his working hours largely on outpatient care. Most days he ran the tuberculosis clinic. From time to time, however, his small team of HSAs made it out into the community to do the work for which they had trained. Part of the team’s job was to identify pregnant women in the surrounding neighborhoods, getting them mosquito nets when an NGO made them available. As he described his team’s net distribution, he also mentioned their role taking “starter packs” of diapers and baby clothes to the poorest pregnant women in his community. He singled out the girls abandoned by their lovers and expelled from the schools.46 These unfortunate young mothers especially needed practical material assistance because “they have got nothing to deal with that baby,” he said. But when I asked who provided the starter packs, he explained that there were none yet. It was an idea he’d had, an idea based on the popular starter packs of seed and fertilizer once distributed by government workers to subsistence farmers. The imagined intervention seemed to sit side by side in our conversation with a material reality in which it didn’t exist—­a ghostly double.47 Mr. Kamfoloma was not delusional. When I asked, he said clearly that he didn’t actually hand out starter packs and that there was no funding for them. But the idea was so alive that it painted a picture of action that seemed possible for a moment to us both. In some respects, this doubling echoes a pattern described in chapter 1. When elderly azamba and asing’anga invoked a happier past of good food, harmoni­ ous communities, and strong women, their nostalgic generalizations sometimes

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seemed at odds with specific memories of hunger, strife, poverty, and illness. Much as these golden recollections seemed to sit alongside difficult past experiences, so the hopeful imaginations of Owen Kamfoloma and Lucy James and others sat alongside their difficult present circumstances. In and out of hospitals, expert stories about maternal death featured gaps, dreams, doubles, and paradoxes. The way the real and the ideal bumped and blurred in these stories seemed to fit a larger pattern, a two-­sidedness in everyday life and work. Perhaps precariousness predisposed to doubling—­for the dreams and paradoxes that Malawian experts described have also appeared in other scholarship.48 “doctors & nurses who toil” Quotidian crisis was the usual state of affairs for medical workplaces where infrastructure was unreliable and scarcity abundant. “People become used to such problems and they don’t look at it as problems any more,” said Dr. Zebron Ching’amba, describing conditions of scarcity on the hospital wards where he worked. “The first few days when you are practicing, it feels very abnormal, but then there is very little that you can do, so—­” and here he shrugged his shoulders “—­it will become part of the system.” Dr. Paul Mbanda had another term for everyday crisis: the normal abnormal. “We have here abnormal situations and we make them normal. We see them as normal.”49 The flip side of everyday crisis was extraordinary normality: people aspired to an ordinary state of affairs that was in fact rare. The logo of the national electrical utility, “towards power all day every day,” was one such aspiration. Electricity supplies have improved over the years, but this goal still seems far away. Memorably, when I saw the logo most recently, it was emblazoned on a truck without power or lights being pushed along a dirt road late at night by four tired utility workers. Nurse Mbewe’s blood pressure checks, Owen Kamfoloma’s distribution of starter packs to abandoned teenage mothers, Nurse James’s back rubs and reassuring chats are examples of one kind of doubling, unreal routines: actions people reported as routine that in practice were rare or didn’t happen at all. Like “power all day every day,” these were aspirations to the ordinary. Dr. Mbanda’s made clear his dreams of a different ordinary. Speaking to the interns and nurses one day about their overstuffed wards, where eighty patients stayed in units designed for thirty, he said, “Don’t get used to eighty, eighty. It is not normal. It is very abnormal! In a properly functioning ward it should be twenty, thirty.” Present absences were also important doubles: persons or things that were not materially present could nonetheless direct action or explain the course

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of events. Deceased ancestors afflicted the living with illness or other misfortune if displeased—­over inadequate attention to a gravesite, for instance.50 Physically immaterial, they nonetheless made things happen. Ancestors came to healers in dreams to show them how to prepare mankhwala, or to guide other therapeutic choices. In biomedical worlds, too, absences had power. They could make certain therapies acceptable by making others impossible. The absence of radiation therapy for stage 2 invasive cervical cancer rendered improvisation with radical surgery a good and necessary clinical act, in doctors’ eyes, rather than the unethical human experimentation it would have been had radiation been available. At one of Malawi’s referral hospitals, the absence of a pediatric ventilator compelled a neonatologist visiting from abroad to fly home early because she felt useless. The absences of cephalosporin antibiotics and adequate nursing staff were the last straw for a physician I interviewed; these absences pushed him from the public sector to the private, where he could prescribe what a doctor should, and where he could have his orders reliably carried out. For both health care workers and laypeople in Malawi, a specific absence often functioned rhetorically as a damning indicator of a broken medical system. Think of Grace Mbewe: “Even the threads.  .  .  . I mean!” What was a health center that didn’t have threads? In Malawi’s Nyasa Times newspaper, a front-­page report made injectable epinephrine a present absence. Bingu wa Mutharika, then president of Malawi, had been rushed after an apparent massive cardiac arrest to the central hospital in Lilongwe. The article quoted doctors who claimed that resuscitation might have succeeded had the hospital had epinephrine, a basic medication available on any crash cart in a US hospital—­and in many a first-­aid kit, handbag, and glove compartment there. Instead, the doctors had to locate and borrow epinephrine from a University of North Carolina research project in a nearby building, a process that took an hour. In the story’s headline: “No Drugs Narrowed Mutharika’s Survival.”51 The actor was “no drugs.” The absent epinephrine was at once a president’s killer and a metonym for a ravaged public hospital. Other social scientists have observed instances in which the situation is reversed: certain things or people or events are materially present, but everyone has tacitly agreed to treat them as if they are not there. I think of these as absent presences. Tara Diener, Adeola Oni-­Orisan, and Adrienne Strong all recently described the disappearance of deaths—­maternal or newborn—­in African hospitals.52 Diener noted that nurses at a large public referral hospital in Sierra Leone did not see rats on the ward, roaches in the clinic, or many of the maternal deaths at the hospital in which they worked. This unseeing was a

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part of maintaining a professional identity in which such things just could not be. Wenzel Geissler has explored how public secrets—­that is, actions and conditions that are well known but treated as if they do not exist—­made transnational collaborations possible in a large East African research station.53 Huge material disparities, both between expatriate and African-­national scientists and between researchers and the patients enrolled in their studies, threatened to undermine research success. Actions that mitigated these disparities—­such as bringing food to malnourished research participants—­were both humane and essential to maintaining successful research, but risked drawing attention to serious inequalities. These actions were rendered invisible. Some went unreported; others were recorded in field logs but cleansed from the formal data; yet others were erased through euphemisms, as when small monetary gifts were named “transport reimbursements.” You may or may not find this particular taxonomy of doubles—­unreal rou­tines, normal abnormalities, present absences, absent presences, public secrets—­to be analytically useful. Even without specific labels, however, thinking about doubling provides insight into the everyday working lives and quotidian ethical dilemmas of birth workers. Among people providing medical care, these doublings often seemed to be ways of dealing with what was but should not have been, or what wasn’t but should have been. They were not limited to contexts of poverty.54 These ghostly doubles took distinctive forms in Malawi’s health centers, hospitals, and clinics. They help us to understand people’s experiences and interpretations of maternal death.

*

Twice in later years, each time with the full-­body startle that happens when you stumble unexpectedly, I thought briefly that I saw Faith Chisoni. In 2013 she was a young woman, thin and glassy-­eyed, her head lolling against the back of a wheelchair, being pushed slowly by an older woman in a long queue of patients waiting to be seen in the “accident and emergency” department of a large hospital. In 2017 she was a young woman, delicately built, drawn and listless, walking away from a district hospital—­or, really, “walking” away, her body supported by two older women who flanked her and bore her weight. Neither young woman was really Faith Chisoni, of course. She’d have been much older by then if she had survived. And none of the older women was her mother, despite the familiar love and concern furrowing their faces. But they were very like, for a moment. Had she gotten antibiotics before surgery? Should I have tried another row of sutures? What if we’d had platelets?

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“The Windows Will Have Been Glazed” Anthropologists and historians working in places where medical technology is relatively abundant have described the immodest dreams that biomedicine can prompt. These fantasies, in their disconnection from material reality, could be considered doubles. Like absent presences and present absences, they prompted action or justified inaction. Describing American oncology, Mary-­Jo Delvecchio Good has written about what she calls a “global medical imaginary,” in which bleak realities are obscured by optimistic visions of an almost-­palpable future, always just around the corner. Medical technology and science have endless potential in this imaginary, which overlooks the financial realities in which most new ideas about cancer treatment are never funded for research, the scientific realities in which most ideas that are researched fail, and the clinical realities in which the therapies that make it through early phases of study often reveal disastrous side effects later. This medical imaginary leads cancer patients and their doctors to think of oncology experiments as cures, Good argues. Even when all concerned understand that most clinical trials do not turn out well and could prematurely kill participants, this medical imaginary perpetuates “emotional, financial, and cultural investment in experimental procedures and treatments.”55 Medical dreams could also support inaction. Among biosecurity experts, the dream that high-­tech virology could prevent serious outbreaks of zoonotic diseases justified a lack of investment in basic public health infrastructure.56 The 2014–­16 West African Ebola epidemic and, at the time of writing, the 2019–­21 COVID-­19 pandemic have exposed this dream to be an expensive fantasy that has cost hundreds of thousands of lives. Guillaume Lachenal described how this vision of science drove a team of virus hunters working in Cameroon.57 Ignoring the many actual threats to public health there, they engaged instead in a series of performances: a simulated campaign addressed a trumped-­up threat (avian influenza) that never arrived; a carefully scripted educational mobilization about the dangers of “bushmeat” never actually took place. Lachenal called this particular kind of immodest medical dream nihilistic: it legitimated public health inaction while doing nothing about real threats. In the poem that opened this chapter, Jack Mapanje describes a nihilistic medical dream. When the dictator-­doctor comes to visit at Christmas, the dream of the neat maternity ward, one patient per bed, is accomplished for a few hours by prematurely discharging patients still recovering from their surgeries, by painting over the blood on the walls and by borrowing beds from

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another hospital. Two consultants at Queens, both long gone now, espoused similar nihilistic fantasies. Each insisted at handover rounds that “you can call the consultant at any time” but neither ever actually showed up. The medical system’s terrible scarcity offered them impunity for some time: it would be difficult to justify firing a specialist when there were so few. Administrators and the consultants themselves pretended they were available. Interns and midwives left to improvise alone knew better. The modest dreams and unreal routines that Malawi’s nurse-­midwives and HSAs offered—­checking blood pressures, having reassuring chats, distributing diapers—­seemed related but not equivalent. They were far from grand. They did not ring of bravado, or conjure cutting-­edge new science. Few justified nihilism. Nurse James, for all her rushing from bed to bed “going this way and that way,” spoke kindly to young mothers even if she never rubbed their backs to relieve pain. Owen Kamfoloma worked hard and carefully, even as he imagined ways he could work better. Theirs were small dreams of caring. In part the differences might be because these were different dreamers.58 They were not international researchers flying in from abroad, university specialists, or a head of state come to the hospital for a Christmas visit. Few were the ambitious elite Malawian doctors with whom I’d previously worked. They were mostly low-­to midlevel workers on the front lines of public medical care, navigating the precariousness of their difficult workplaces as well as they could. Their dreams of medicine were much more modest than either the fantasies of last-­minute salvage through experiment in American oncology or the performances of heroic if simulated public health interventions by Cameroon’s virus hunters. These dreams were all about care. And rather than prompting action or justifying inaction, these modest dreams of care were doing something else. Maternal mortality is often produced passively: it is the product of actions not taken. The cause of death is the hospital not staffed, the safe abortion law not passed, the clinic never built, the little girl not fed much who grows to be stunted, the ambulance up on blocks not repaired or refueled, the sutures not restocked, the broken autoclave not replaced. It is the midwifery students not trained, the new graduates not posted to the districts, the consultant who doesn’t come in when called, the antibiotics not delivered to the health center. It was the methotrexate not available on wards (but used in a research project) in 2003 and the zidovudine not available in Malawi (but used in the United States) in 1990. Absences and inactions like these were unavoidable in the ordinary working lives of nurses and health surveillance assistants. Those who labor in workplaces where death has been passively enabled must find a way to live

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with their haunting by what might have been otherwise—­a way to make peace with what they might do but cannot, without giving up the possibility of doing otherwise someday. As Alice Street writes of hospital staff in Papua New Guinea, they must find a way to bear “the kinds of expertise they are not able to practice and the kind of expert person they are not able to become.”59 Imagination is doubly powerful in these circumstances. Health workers who can remember times when this kind of scarcity was not yet produced, or imagine times when it will have ended, can also imagine themselves to be a particular kind of expert person. Dreams of starter packs for which there is no money, or back rubs for which there is no time, or the careful checking of blood pressures for which there is no machine, make of the dreamer a morally exemplary clinician even when actual clinical success is sometimes elusive. But dreams are also guides to action. Mama Lillian Siska dreamed of the root she would need before the client who needed it came to her door. The doctors and nurses of Mapanje’s poem dreamed of extending the maternity wing, despite their blunt needles, lack of drugs, and small wages. And many decades after the poem, the crumbling hospital where Mapanje’s wife worked was rebuilt and expanded. The windows have been glazed now, the walls painted.60 Even if they do not prompt immediate action, dreams and fantasies keep one foot in a door that is always threatening to slam shut. Dreams can prompt advocacy and bolster enthusiasm; for example, Lachenal argues that funding for ART programs is maintained in part by dreams of a time HIV will have been defeated.61 Imagination and action are in a constantly shifting balance, James Scott points out. Dreams may go far beyond what current circumstances allow, but “as circumstances change, it may become possible to act on those dreams. The realm of consciousness gives us a kind of privileged access to lines of action that may—­just may—­become plausible at some future date.”62 The imaginations of Lucy James, Owen Kamfoloma, and Malawi’s other modest medical dreamers hold open possibilities for a time when they can act as the clinicians they know themselves to be. Island enclaves in a sea of scarcity, for all that is troubling about them, also offer dreams of care and lines of future action. Almost two decades on from the 2002 snapshot I presented earlier in this chapter, some of the research projects active then have disappeared, while others are ongoing and new ones have begun. At the time of this writing, the Malaria Research Unit is still there. It now proudly boasts Malawi’s first magnetic resonance imaging unit, used to investigate how children’s brains are affected by cerebral malaria. The Lilongwe oncology study is long over, but now patients with cancer can access chemotherapy both within Queens itself and (for those who can pay) at more than one private hospital in town.

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At this writing, there is still no radiation therapy in Malawi. Johns Hopkins maintains a substantial presence at Queens; it has moved from studies on the prevention of mother-­to-­child HIV transmission to other projects. A new building, the Mercy James Institute for Pediatric Surgery and Intensive Care, opened just next door in the summer of 2017.63 It features the only pediatric intensive care beds in the country: two for surgery patients, two for medical patients, and two for research. In 1990, Malawi offered no physician training. A child with Burkitt’s lymphoma could access effective chemotherapy only through a research project. That project laid the groundwork for a later treatment unit. By 2003, there was a pediatric oncology wing, although Catherine Gunya’s adult patient could not get chemotherapy for choriocarcinoma. A new medical school was thriving. A national antiretroviral program was gearing up. In 2011, Malawi pioneered a program in which all HIV-­positive pregnant women were offered antiretroviral drugs—­for life, not just during pregnancy. Within four years, Malawi’s approach had become standard WHO guidance, and most countries had followed its lead.64 By 2017, a specialty training program in obstetrics and gynecology flourished at Queens. As a group of energetic young trainees told me that year, not only was methotrexate available for choriocarcinoma, but so were second-­line drugs in case the methotrexate failed: “The whole package,” as one reported. “The only thing is, they tend to die of anemia because we don’t have enough blood to transfuse them.” Change, but not necessarily—­ yet—­all the development of which clinicians and patients dreamed. These projects are perhaps less like an archipelago of islands and more like a sandbar: shifting, changing shape, moving slightly, but likely to show up in the same general area.65 Seeds occasionally take root on sandbars. Life springs up there. Over time they may become earth, where a tentative permanence grows. Absences and enclaves are sometimes tragic, but they are not simple. They are bits of moral grit around which a pearl can form, or a knot of scar tissue. They are grounds for withdrawal into resentment or for determination to ex­­ pand access to care. They engender despair, and they give birth to dreams.

Rhoda Nantongwe: “By the time she comes to the hospital, it is too late.”

Each of Malawi’s twenty-­nine district health offices included a maternal-­and-­ child health (MCH) coordinator post. Like most MCH coordinators, Rhoda Nantongwe was a senior nurse who had worked her way up through the ranks. A small, stout, fast-­moving woman who always seemed to be doing three things at once, she spoke to me offhandedly while simultaneously overseeing a shipment of goods and intermittently answering her phone. To my uneducated eye, the shipment appeared complex and mysterious. Next to a stack of printer paper stood a crate of Fanta, against which rolls of black trash bags were propped. Sweating workers hustled more Fanta off of a truck onto the broad concrete veranda. Several folding wheelchairs stood by. A woman in an elegant business suit—­presumably the vendor—­grasped her shiny handbag and observed these proceedings with narrowed eyes and pursed lips. Meanwhile, Mrs. Nantongwe’s assistant checked off items against a handwritten list. The vendor scolded him: “This is carton 84! Ndibvuta ujeni. . . .” Mrs. Nantongwe leaned over her assistant to peer at his list. “Mami, just trust me!” pleaded the assistant. “Just trust! Hah!” Mrs. Nantongwe scowled. But she turned away and led me to her office to continue our conversation, one more task to squeeze into the day. The road to reducing maternal deaths was obvious, said Mrs. Nantongwe. “Transport is our major problem here.” Women faced substantial difficulties even in her largely urban district. “If a mother lives in a rural or even a semi-­ urban area and it is five or six km [kilometers] to the health center, she is going to find a TBA instead.” Mrs. Nantongwe was sympathetic to the TBAs, and sorry that formal TBA-­training programs had ended. Still, she worried about the dangers of giving birth far from medical assistance.

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Let’s say she goes to the TBA and there is a problem. So maybe the TBA even has a bicycle, a bicycle ambulance, but the relative or guardian is not well and not strong enough to push the woman all the way to the health center. So then they go to the community to find someone who can at least go to the hospital, and when they have found a strong person he goes to the district hospital and he is told, “Ah, the ambulance is out—­it is at [Mitengo]. You can just wait.”

Nurses often used faraway Mitengo Health Center as an example. It was Mitengo where the ambulance had been when the nurse-­midwife needed to transport the hemorrhaging woman from Tsoka. Years ago I had taken a pregnant woman with severe abdominal pain to Mitengo myself. It was an hour’s drive from the referral hospital under the best conditions. With traffic, or a delay at the police roadblock, or when the rains had brought mudslides or washouts to the steep winding road, it could be much longer. Mrs. Nantongwe continued her scenario. So he waits. And then the ambulance comes back, and the DHO releases the ambulance, and only then it can go back to pick [up] the woman. And then, you know, sometimes the roads, they cross small rivers, or they are very muddy. It is difficult here. So maybe by the time she comes to the hospital, it is too late.

It was very uncommon for a maternity patient at a public hospital to have access to a working car, even though car ownership (and traffic jams, accidents, and smog) had boomed in the city. Functioning ambulances were also few and far between. Some had been purchased and some had been donated, yes. But repairs, fuel, and drivers’ salaries were all obstacles to maintaining an ambulance fleet. Many “working” ambulances were unsafe at high or even moderate speed.1 Chronic petrol shortages worsened the problem. Vehicles were only one piece of the transport problem. Paved roads were often as much pothole as tarmac. Dirt roads doubled as streams in the rainy season. Both washed out entirely from time to time. With few street signs and almost no house numbers, it could be very difficult for a driver to know where to go. Dangerous roadsides, poor or no lighting, violent criminals, and witches abroad meant a breakdown at night was particularly dreadful. A marginally operable ambulance might run during the day, at the risk of breaking down, but it didn’t at night. Of course, transport wasn’t the only issue, Mrs. Nantongwe conceded; the more recent rise in maternal mortality was probably about AIDS and unsafe abortion. She mentioned a recently published paper suggesting that abortion-­ related deaths had dropped in the country. Mrs. Nantongwe didn’t believe the researchers’ numbers for a moment. “I don’t know how they are doing it, but

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these abortions are becoming very septic. When we have our maternal death audits from [the district hospital], half of them come from the gynae ward. They are septic.” She spoke from behind a desk heaped with black-­and-­white notebooks, oversize blue logbooks, and binders marked with dates and acronyms. A tea tray weighted down a stack of papers. As she described the “very septic” abortions they’d been seeing, Mrs. Nantongwe pulled a logbook from the pile on her desk to show me some recent numbers. Really, she noted, it was common sense. Women’s nutritional status was as suppressed as their immune systems were. Of course they were vulnerable to sepsis. The assistant popped his head round the open door, apparently finished with the troublesome shipment. He asked Mrs. Nantongwe when a driver should pick her up for the Saturday-­morning “community sensitization” meeting she’d scheduled with the district’s chiefs. As the two spoke, my gaze wandered for the first time to a whiteboard covering most of one office wall. It was filled with neatly written figures: district actual population; district projected population; total births; total maternal deaths; and a breakdown of the major causes of death from the district’s most recent maternal death audit.

5

Countless Accountings There is a change. Because we have the maternal deaths: one thousand one hundred what? But now the number has been decreasing. — m e l i a a s i f a , nurse-­midwife at Pamtunda Health Center, 2007

You have read many explanations given by people struggling to interpret individuals’ deaths. Another sort of story comes from epidemiologists, who assess maternal death at the level of populations—­regional, national, global. Their numbers first appear in journal articles and reports, then circulate as journalists announce them and policymakers and activists cite them. Melia Asifa’s “one thousand one hundred what” was not the only number an interviewee provided. The numbers they cited differed, as did the conclusions they drew. Mrs. Nantongwe disputed one set of metrics, on abortion-­related deaths, drew on another to support her own judgment, and helped collect the raw data for a third set. You have, no doubt, encountered population-­level assessments arranged into stories. • Maternal mortality in the United States is rising. • Black American women are almost four times as likely to die in the year following a pregnancy as are white women. • Malawi’s maternal mortality has decreased substantially. • Malawi’s maternal mortality is among the world’s worst.

Rates, counts, and ratios make these epidemiological—­and political—­stories possible. Such measures are a form of disembodied knowledge: they do not attend to the details of any particular life or death. Other accounts work at the smallest scales. These work at the largest. As a histopathologist magnifies the neoplastic cells of one piece of flesh from one specific woman, revealing the particularities of individual endothelial cells transformed by Kaposi’s sarcoma, so an epidemiologist shrinks the complex circumstances of a state, nation, or region into a number.

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This chapter describes three techniques used to produce population-­ level knowledge about maternal death in Malawi: verbal-­autopsy surveys for estimating the importance of various causes of death; the “three-­delays” framework for evaluating access to potentially lifesaving care; and a statistical model for estimating maternal mortality ratios. Mrs. Nantongwe and other district officials across Malawi were closely involved in the first two techniques. The third was developed and implemented ten thousand miles away. Each technique buttressed the efforts of policymakers and activists to interpret—­and to change—­the conditions that lead to maternal deaths. As a data geek, I enjoy working through models and equations. Not everyone shares that feeling. If you, too, are a data geek, or an actual or aspiring public health professional, you will likely want to read this chapter closely, challenging my assumptions as you go. If you’d rather just trust me, you could stop reading at “Working Through an Example” and pick up again at “A President’s Story.” Here’s the key point of what you will miss: statistical ways of knowing about death—­though often presumed to provide an objective certainty—­are more usefully considered as stories than as facts. Maternal mortality metrics conceal many uncertainties, build in many assumptions, and obscure many human decisions about what and whom to count. They are as partial as the stories told by people who interpret an individual’s death. Why Numbers Count Public health practitioners, health activists, and policymakers look for reasonably accurate maternal mortality numbers for at least three reasons. First, mortality metrics are useful to compare groups of people: younger women versus older ones, for instance, or the wealthy versus the poor. Comparisons can reveal critical problems, such as the threefold difference in the United States between black women’s and white women’s pregnancy-­related death rates. Institutions can use mortality data to redirect resources; activists can use it to identify harm and demand changes.1 Second, mortality data can provide insight into how one might best improve women’s chances of surviving pregnancy. For this purpose, numbers broken out into causes of death are especially useful. If HIV contributes to many maternal deaths, then treating HIV should be a priority. If the most frequent cause of death is hemorrhage, blood banks could make a bigger difference. A health official who has data on causes of death can direct money, staff, and training programs to those problems. Third, death rates and ratios are crucial for evaluating policy changes. Without trustworthy before-­and-­after figures, a government ministry or an

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NGO cannot know if the interventions it has implemented to make pregnancy safer—­training TBAs, banning TBAs, teaching midwives to do cesarean sections, working to reduce cesarean rates, legalizing abortion, restricting abortion—­are successful, irrelevant, or backfiring. Trustworthy maternal mortality measures are important. They are also notoriously difficult to obtain. Where diagnostic resources are limited, therapeutic options erratic, and epidemiological surveillance spotty, maternal deaths are much more likely—­and quantitative measures of maternal mortality are much less reliable. d u b i o u s n u m b e r s at q u e e n s In Blantyre, the jacaranda trees were about to bloom. A scent of smoke hung in the air—­distant smoke, from the city’s edge where people were burning fields, and nearby smoke, from the neat piles of trash and dried leaves smoldering in the brick trenches along the roadside. You could smell it in the Kamuzu College of Nursing office complex, where I met with an old colleague. But as she and I walked northward from the offices, as we passed the mortuary and the hospital laundry and got closer to the patients’ wards, the smoky scent gradually dissipated until it was entirely replaced by the bleach-­ blood-­and-­sweat aroma of Queens. As we walked, my colleague brought me up to date on recent changes. Some things on the maternity unit were better these days, she said. A more intensive focus on teaching. Good supervision of the new nurse-­midwifery students. The clinical staff remained overstretched, however, even more so in 2013 than in the years when she and I had both worked there. No matter how hard the midwives, the doctors, and the lone clinical officer worked (and while not everyone worked hard, most did), more patients needed their attention than could possibly be seen. We were midway between the mortuary and the wards when a small procession approached. First came a cloth-­draped body, on a narrow trolley pushed by two young men in pristine white uniforms. Just behind the orderlies, a middle-­aged woman keened, “My sister, my sister.” A handful of people behind sang minor-­chord responses to her plaintive tune. We paused, as is respectful, bending our heads but otherwise neither moving nor speaking as the mourners went by. When they’d passed, my colleague continued quietly: “They are saying that maternal mortality has dropped a lot, even to something like three hundred. They are saying we will meet the Millennium Development Goal. But I can’t believe it. If it’s that low, why are we still seeing this kind of thing every day? I think it has to be at least in the five hundred

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or six hundred range still. You know, there’s a lot of pressure on this goal. A lot. The president has really staked her legitimacy on improving maternal mortality.” “They are saying”: the “they” who were celebrating a dramatic drop in Malawi’s maternal mortality were the public faces of President Joyce Banda’s initiative to improve maternal health. The incumbent’s sudden death had pro­­ pelled Banda to the presidency in 2012. She was unelected, she’d begun her ten­­ ure by making several very unpopular decisions, and she was a woman. That year, in 2013, it sometimes seemed as if the only thing that was going well for her was the maternal health initiative. a p r e s i d e n c y at r i s k A few months before this conversation, one of the national newspapers reported on a presidential visit to a rural district in central Malawi: President Joyce Banda on Tuesday opened the 36-­bed Dowa Maternity Waiting Home near the district hospital with a call to all expecting mothers to report to the hospital in time for safe delivery. The maternity waiting Home has been constructed with funds from Limbe Leaf Tobbaco at the tune of K19 million [nineteen million kwacha]. .  .  . President Banda noted that the construction of Waiting Homes for expectant women will address the maternal mortality rate. She said it is not right for mothers to die while giving birth. “No woman should die while giving life to another,” charged President Banda at Dowa District Football Ground where activities marking the opening of the Waiting Home took Place. President Banda told the gathering that so far Malawi with the interventions she has put in place is doing very well though not enough. She said: “Last year in April the Maternal Mortality rate was 675 per 100,000 and right now we are at 460 per 100,000, this is quite remarkable but we can do better. My hope is to go as far as 350.”2

The reporter listed dignitaries present at the ceremony: corporate leaders, chiefs, government officials, the wife of Zambia’s vice president. Deputy Minister of Health Halima Daudi claimed that the perennial problem of maternity-­ ward drug shortages had been solved, praising the president “for your personal effort by making personal appeals to your global network to deal with this problem.” A marketing manager described Pharmanova Malawi’s donation of “over two hundred delivery kits to Dowa to help women have safe delivery.” Senior Chief Kwataine, selected by Banda to chair the Presidential

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Initiative on Maternal Health and Safe Motherhood, announced that six of thirteen planned maternity waiting homes had now been built, that two hundred girls had been enrolled in nursing colleges to become community midwives, and that “these interventions have worked.” Numbers stand out in this article: thirty-­six beds, nineteen million kwacha, six of thirteen maternity waiting homes, two hundred delivery kits, two hundred community midwifery students. Maternal mortality ratios figured prominently in President Banda’s speech. They appear again near the article’s end, where the reporter notes that “Malawi hopes to reduce the maternal mor­­ tality rate to about 350 out of 100,000 to meet the millennium development goals by 2015.”3 Banda’s safe-­maternity initiative targeted several audiences and served several agendas. The president called on Malawian women to prevent their own deaths by coming to maternity waiting homes. Describing Malawi’s progress toward the Millennium Development Goals, she was at once providing evidence to a national audience that she was a leader who could deliver, and convincing international audiences that Malawi was listening to advice—­both critical projects in 2013. Maternal mortality numbers were central to these tasks. Politicians and health planners found many uses for numbers. As a World Health Organization member state, Malawi was expected to report health indicators regularly—­including the many metrics required to assess progress toward the Millennium Development Goals.4 Among these was the goal to reduce maternal deaths by three-­quarters between 1990 and 2015. Good numbers were welcome news. Even terrible indicators, however, could be used to coax resources from donors. Metrics helped for policy decisions too. A health minister in Malawi, like her counterparts in other nations, might have to reallocate health staff and divide funds among regions. To send resources where needs were greatest, she would want numbers. working throug h an example An example from the US shows how epidemiologists prefer to calculate maternal mortality numbers, why they make certain choices, and where uncertainties and inconsistencies hide in the results. The figures in table 5.1 come from two American states with populations large enough to make mortality-­ rate calculations reasonable (although not incontrovertible, as you will read later).5 In 2017, death-­certificate data indicated 89 maternal deaths among California residents and 147 among Texas residents (line A). Public health offi­ cials can divide these deaths by each state’s population (line B) to get crude

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ta b l e 5 . 1 . Maternal deaths in two states

A. B. C. D. E. F. G. H.

2017 maternal deaths 2017 total population Crude death rate (maternal deaths / population) Women ages 15–­44 in 2017 Maternal deaths / women age 15–­44 Maternal death rate (maternal deaths / women ages 15–­44 × 100,000) Live births in 2017 Maternal mortality ratio (maternal deaths / live births × 100,000)

California

Texas

89 39,982,847 0.00000223 8,063,781 0.0000110 1.10 471,658 18.87

147 28,304,596 0.00000519 5,736,684 0.0000256 2.56 382,050 38.48

Sources: United States Centers for Disease Control and Prevention data­base, https://wonder.cdc.gov (accessed November 2019); United States Census Bureau.

death rates (line C). These rates don’t reveal much, however. Demography may differ. What if many women past their fertile years live in one state, while disproportionate numbers of young childbearing women live in the other? The state with more young women will have more deaths, even though birth is no more dangerous there. Epidemiologists prefer to divide maternal deaths by total numbers of women who might plausibly get pregnant. Typically, they simply designate an age range: a census-­bureau estimate is in line D.6 Dividing maternal deaths by this denominator gives line E. Maternal deaths are uncommon, and numbers with many zeros are hard to compare. Multiplying the whole equation by 100,000 gives line F, the maternal death rate: the number of maternal deaths (a count) per hundred thousand women of reproductive age (an estimate) within some specified period of time in some particular place. Death rates provide better understanding of how places compare. It appears that women are likelier to die of pregnancy in Texas than in California. While maternal death rates indicate that the women of Texas are at greater risk than the women of California, they don’t clarify whether Californians have better health care or Texans have more pregnancies. Being in a particular age group does not put women at risk of maternal death; pregnancy does. Perhaps pregnancy, not age range, should matter for metrics. Texas and California do not count pregnancies. Like all other US states, however, they do require birth certificates (line G). The figure in line H is the most widely used measure of maternal death, the maternal mortality ratio (MMR): the number of maternal deaths for every hundred thousand live births in a particular place within a specified period of time.7 In this case, the ratio and rate tell similar stories. Birth in Texas looks to be about twice as lethal as birth in California.

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Epidemiologists concerned with maternal health use the MMR widely, because it solves many problems. It corrects for population size, differences in age distribution, and fertility. It is still imperfect. It uses live births, not deliveries. Given that some people have twins or triplets, there may be fewer deliveries than live births. Given that some people have stillborns, there may be fewer live births than deliveries. Its denominator excludes abortions and miscarriages. It uses a place—­California, Texas, Malawi, the United Kingdom, Africa—­to stand for a population, ignoring migration in and out. New recording practices change measurements. The addition of checkboxes for pregnancy reporting on state death certificates probably contributed to rising maternal mortality numbers in the 2000s in the United States.8 And because maternal deaths are quite rare even where they are nowhere near rare enough, even a few deaths can make a huge difference in the MMR, especially in places with low rates (like Norway), small populations (like Vermont, or like the catchment area for Zingwangwa Health Center in Malawi), or both (like Iceland). For this reason, the uncertainty range surrounding the ratio is quite large. An intervention that improved or worsened maternal safety would need to have a really substantial impact before one could confidently confirm a change in the MMR.9 The MMR is far from perfect. But it is still extremely useful. If a ratio is to reflect reality faithfully, three requirements must be met: people’s births and deaths must be recorded on certificates; the information on certificates must be accurate; and the government must collect and compile certificates reliably. These three requirements are often collectively called a “complete civil registration system.” None of the three can be assumed, anywhere. Missing data is one part of the problem. Even where civil registration procedures function well, a few people slip through the bureaucratic cracks entirely at one or the other end of life, never recorded in birth or death certificates at all. Deaths and births are less likely to be recorded for people constantly on the move or trying to elude the law—­for instance, migrants without legal residence papers. Unrecorded people tend to be disproportionately vulnerable. If those who do not get birth or death certificates are sicker and have shorter lifespans than those who do, then civil registration systems will paint a falsely reassuring picture of the public’s health. In most wealthy countries, however, missing information poses less threat to reliable metrics than wrong information—­misclassified deaths. Long ago in an urban New Mexico emergency room, I remember more than once shivering my way out to the parking lot in the middle of the night to examine an elderly person, cooling rapidly in an ambulance without sirens or lights, trundled to the ER from a nursing home. Even I, newly graduated from medical

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school and sorely lacking in essential skills, could verify that he was pulseless and not breathing. Dead. Very few people (perhaps fewer than one in fifteen in the United States) now get autopsies. Instead, I would fill out the death certificate by guessing at the likely cause of death based on his medical records: whatever had come with him from the nursing home, or notes from any stays he’d had at our hospital. National measures of causes of death in the US derive from hundreds and thousands of records more or less like this—­plenty probably more accurate, some probably even less.10 Misclassification can lead to substantial underestimates of maternal mortality, for maternal deaths are especially likely to be misclassified. Suppose a woman is brought in dead after having thrown a huge clot from a vein into her pulmonary blood vessels, leaving her unable to oxygenate. Pregnancy aggravates clotting and makes death from pulmonary embolus more likely, but sometimes the person who fills out the death certificate will not have known she was recently pregnant. Surviving kin might be unaware. If the pregnancy was new, she herself might not have known. For reasons like these, and because almost everywhere some pregnancies and some causes of death have been shrouded with shame, maternal deaths have been chronically underreported and misclassified. It is standard procedure to multiply the MMR derived from civil registration systems by a number designed to compensate; for instance, the World Health Organization for many years used a multiplier of approximately 1.5 for the United States.11 Even where civil registration is considered “complete,” then, numbers derived from it are uncertain and causes of death far from obvious. (I will return to this point—­and to California and Texas—­later in the chapter.) Where human resources are stretched and bureaucratic infrastructure is less stable, the problems are magnified. How to Get Good Numbers in Malawi? Epidemiologists consider a vital registration system to be “complete”—­inclusive enough to make meaningful calculations—­if it includes over 90 percent of deaths. By 2007, an estimated three-­quarters of the world’s deaths occurred in nations that did not meet this criterion; the proportion of countries with complete registration systems had not improved for forty years.12 As I write, Malawi’s registration system is not yet complete. Only in 2009 did the legislature pass a bill requiring registration of all births and deaths.13 Several years later, the law had not yet been implemented and no legal mechanism allowed its enforcement. Even among those who knew about registration, not many could afford the time and bother.14 Singogo and colleagues

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estimated in 2013 that only about a fifth of deaths were recorded in any government records, and found that birth registrations were inconsistent.15 By 2017, doctors at Queens told me that birth registration was much improved, but no one seemed sure about death registration: “Anyway, it’s only just being implemented now.” At last estimate, about two-­thirds of births were recorded somewhere, but death records remained too incomplete to be useful. In the absence of good vital-­registration infrastructure, people used other approaches to track maternal death as a public health problem. Health officials used hospital reviews, often called audits. The noticeboard in Mrs. Nantongwe’s office, for instance, listed results of a district-­wide maternal-­death audit. Community-­linked death reviews added information from verbal autopsies. In addition to producing estimates of how many women were dying, hospital and community reviews could also be used to investigate why they were dying, often drawing on the influential three-­delays framework.16 Demographers used variations on the sisterhood method to estimate rates of maternal death. The chapter’s next section turns to these methods. All were key resources for people seeking to make births safer, but only some were useful for epidemiologists seeking to calculate death rates and ratios. d e at h au d i t s i n h o s p i ta l s and communities Policy required medical staff to review all maternal deaths that happened in health facilities, recording review conclusions on forms that were sent on to the district health officer. In theory, a national health official could simply tally all districts’ review forms to come up with a count of deaths. In practice, tallies didn’t work. They would have required (1) complete recording of deaths at every health facility, (2) reliable transfer of death records from each health facility to the District Health Office, and (3) comprehensive communication of district results to the national level. A 2010 review by Malawi’s Ministry of Health concluded that the first two steps were not happening. Fewer than a third of facilities had conducted maternal death reviews at all. In places where reviews did happen, only about a quarter of deaths were reviewed. Experienced staff who could lead reviews were lacking at many facilities. Time was inevitably pressed.17 Medical files often went missing. Health workers, worried about blame and punishment, were reluctant to conduct audits and report results. There was reason for concern about step 3 as well. I once heard a maternal health specialist from the capitol congratulate doctors in a large district for reporting no maternal deaths over a six-­month period.

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His tone dripped with sarcasm. There’d been many deaths, the staff knew—­ just no reporting. Even if these steps had all succeeded, health-­facility reviews would have missed maternal deaths. Some people never arrived at hospitals at all. Those who arrived already dead might or might not show up in health-­facility statistics. Researchers in West Africa found that staff resisted recording such deaths on hospital registries, well aware that mortality records were also used to track hospital performance.18 Enter the community-­linked maternal death review. In 2011, women’s health activists in Malawi worked with the Ministry of Health and a team of consultants to design a review process that would get communities involved in tracking deaths. Health ministries in other countries had successfully identified deaths through cemetery wardens, or emergency services workers, or religious authorities who presided over funerals. In Malawi, the people most knowledgeable about pregnancy-­related deaths in communities were often the lower layer of chiefs (village heads and group village heads) and the lower cadre of health workers (health surveillance assistants). A pilot project in one Malawi district found that chiefs and HSAs identified more than twice as many maternal deaths as hospital-­based audits alone. They even identified deaths that had occurred within the district hospital but had not been counted there.19 Community audits were labor-­and effort-­intensive. Group village heads, HSAs, and volunteers had to be trained as audit teams. When they got word of a possible maternal death, they had to track down women’s families, negotiate consent, work through a step-­by-­step structured interview, and record the results. They then organized a local community meeting, to seek additional information and ideas about preventing future deaths. The audit team was to take its findings to the health facility involved for another meeting and discussion, followed by a final meeting back in the community setting to be attended by medical staff, village heads, and anyone else who wished to participate. Collectively, these meetings were designed to produce practical intervention strategies that might lower the odds of future deaths, and to identify particular people who could be held responsible for implementing each strategy. When this multistep process worked, it could lead to real change. The activists and academics who had designed it were enthusiastic about its potential, and the pilot project succeeded well enough with health workers and community members that the Ministry of Health planned to “roll it out” to the entire country. Concerns lingered, however. In practice, deaths of women who lived outside the area were excluded. So were deaths of women whose families

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refused to participate—­refusals that seemed particularly likely in cases involving HIV or abortion. The potential for recrimination led some family members and hospital workers to avoid meetings. The commitment of the health surveillance assistant was essential to success, but HSAs already bore heavy responsibilities. It seemed likely that some deaths would continue to be missed. v e r b a l au t o p s i e s Community audit teams used a “verbal autopsy”: a standardized interview, conducted by a trained interviewer, designed to identify the cause of death. Meanwhile, an automated version was being tested for Malawi’s new civil registration system. These two forms of verbal autopsy show how key technologies could serve different purposes in accounting for deaths. The verbal-­autopsy protocol used in community-­linked death reviews posed specific questions but left room for open-­ended answers. By collecting information about the circumstances surrounding any given death—­from health workers, and from women’s families—­reviewers sought to identify common causes of death and points for possible intervention. Here, for example, is part of a verbal-­autopsy interview describing a maternal death in 2011 in Lilongwe District. The woman who’d died was forty years old and had already borne four other children. At her single antenatal visit, she’d been told she was expecting twins. She’d planned a hospital delivery. The dead woman’s mother and sister said that “she looked normal at first” on her last day of life. Towards the afternoon around 1 p.m. she started complaining that she was not well. [This phrase could refer to illness or labor.] So we got prepared to go to the hospital. We are far away. So to get a bicycle, to find someone to carry her . . . (was difficult).20

There was no car, and no ambulance. Her family realized that the woman could not manage to stay on a bicycle; she would need an ox cart. The woman’s mother went on: So we got the cart when it was late in the day, around 5 pm. So they (the deceased and her husband) went in the cart and this one (pointing to the deceased’s younger sister) went with her. On the way at Pambala, there’s a small bridge under a gum tree, that’s where she delivered. They say that’s where she delivered. It was very dark; they didn’t even have a torch [flashlight]. They had to rush to the nearby houses to borrow a torch. Then they saw that she was not well. Immediately the ox left and ran back home. So what are we going to do?

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They searched for anyone nearby who could lend them an ox. Meanwhile, someone located a TBA to remove the placenta, hoping that would stop the woman’s bleeding. “And after a little while, she died at the same spot. So they had to harness the [borrowed] ox on the cart and return home.” The dead woman’s uncle made arrangements to come the next day and pick up the woman’s body to take her to the mortuary. While death-­review verbal autopsies like these offered considerable detail, automated versions sacrificed detail for reproducibility. Interviewers using smartphone apps ran through surveys constructed of yes/no questions. When all answers had been entered, a software program assigned a single underlying cause of death, “the disease or condition that initiated the morbid chain of events leading to death.”21 Epidemiologists building population-­level metrics from verbal autopsies faced three interconnected problems: (1) the difficulties involved in assembling experts to review every death, in places where deaths were far too common and experts had far too many other demands on their time; (2) reviewers’ tendency to assign cause of death to “contributing” conditions (like transportation trouble) rather than “underlying” ones (like hemorrhage); and (3) the challenges of making comparisons across time or among nations without standardized classifications.22 Automated systems got around all three. Interviewers needed to be trained only in the technique, not in medicine. Software programs ensured that every verbal autopsy of a maternal death in any country resulted in a diagnosis drawn from the International Classification of Diseases (ICD).23 As table 5.2 shows, the ICD divides deaths in pregnancy, labor, and the first six weeks thereafter into eight underlying causes, plus a ninth set of causes that are considered coincidental. Only categories 1 through 8 were to count as maternal deaths, and they were mutually exclusive; for instance, a woman could not die of obstetric hemorrhage and a pregnancy-­related infection. In the case of the woman who died on the bridge under the gum tree at Pambala, the automated and the community death–­review versions of the verbal autopsy would have reached agreement on the “underlying cause of death”: an obstetric hemorrhage had killed her. The automated version, however, provided no place to record the obvious transport problems that played a role in her death. And the list in table 5.2 rendered many grievous problems invisible. There was nowhere to include causes like negligence, incompetence, inadequate supplies, bad roads, or a runaway ox, even if they led quite directly to a woman’s death.24 Records of deaths like the one that happened under the gum tree at Pambala were sometimes compiled to produce statistical evidence about national

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ta b l e 5 . 2 . ICD-­10 underlying causes of maternal death Category

Examples

Direct maternal death 1. Pregnancy with abortive outcome 2. H  ypertensive disorders in pregnancy, childbirth, and the puerperium (the forty-­two days after childbirth) 3. Obstetric hemorrhage 4. Pregnancy-­related infection 5. Other obstetric complications 6. Unanticipated complications of management Indirect maternal death 7. Non-­obstetric complications Unspecified 8. Unknown / undetermined causes of death Death during pregnancy, childbirth, and the puerperium—­but not maternal death 9. Coincidental causes

Septic abortion Eclampsia Placenta previa, ruptured uterus Sepsis due to chorioamnionitis (infection of the placenta and membranes) Peripartum cardiomyopathy Anesthesia complications Tuberculosis, HIV-­related disease

Herbal medicines, assault, motor vehicle accidents

Source: World Health Organization, WHO Application of ICD-­10

maternal mortality. That evidence contributed to tracking national progress toward goals, such as the fifth Millennium Development Goal (MDG-­5) or the third Sustainable Development Goal (SDG-­3). As one team of reviewers pointed out, however, the numbers often circulated to describe maternal death in Malawi were “end-­points of long, disjointed stories,” and reducing maternal deaths was not “as simple as crunching numbers and implementing biomedical interventions to prevent them.”25 For most nurse-­midwives, doctors, community leaders, and activists, precise mortality numbers and ICD-­ 10 codes were less important than expansive strategies for preventing deaths. t h e t h r e e - ­d e l a y s m o d e l In an influential 1994 article, “Too Far to Walk: Maternal Mortality in Context,” Thaddeus and Maine developed the three-­delays model of maternal death. Nurse-­midwifery students, medical students, and clinical officer students in Malawi learned this model during their training. Public health analysts drew on it.26 It also provided a framework for analysis of cases on the ward, where medical personnel used it to extract lessons about prevention. One of the obstetricians at Queens, Dr. Duncan Phiri, provided a concise, off-­the-­cuff summary of the model at handover rounds one morning in 2007.

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Two obstetricians, a handful of interns, and the nurses responsible for each ward discussed the sickest patients in the Gogo Chatinkha Banda Maternity Unit. One was a woman brought to the outpatient department after several seizures at home. Seizures complicating pregnancy-­related hypertension were not rare. It was not clear anyone in the outpatient department had noticed that the woman was very pregnant, however. Nor had anyone measured her blood pressure. They’d sent her back to her home in Pachulu, where she seized again. Since her arrival at the labor ward, she’d had six more prolonged seizures. Dr. Phiri shook his head after the intern had finished reporting on the woman’s current condition. It was dire: no one caring for her on the ward expected her to survive. This case illustrates one of the many problems in our society, something that is well known to us, called the three delays. The first delay is with the patient herself, who maybe does not think her problem is serious enough to seek assistance. The second delay is in transport, in getting to the health center or the hospital. And the third delay is the problem of logistics at the hospital itself. Sometimes these can even result in death—­it is most unfortunate.

Dr. Phiri’s succinct description implied three opportunities for intervention: improving recognition of danger signs among pregnant women; improving access to care through better transportation or closer health facilities; and speeding up care within facilities themselves. One applied the three-­delays model retroactively to any given death, imagining counterfactual situations in which timely care could have saved a woman’s life. If the patient had decided to seek care promptly, if she’d reached the hospital quickly, if staff had provided treatment rapidly, would death have been averted? In the case of the woman with seizures, there was no avoiding the truth: the critical delay had been ours. Dr. Phiri looked over his glasses at the nurses, students, and doctors. We as health care providers, we are overloaded. So there is a danger that we kind of—­brush off what is in front of us, without a proper history, without a proper exam. Let us not transfer our problems to our patients. Let us not say, oh, fifteen patients are in the queue for me but I have fifteen minutes until I want to eat lunch. If you are too tired to work, tell your boss you must have rest!

At the idea of telling a supervisor they needed rest, several interns began to murmur and shoot sidelong looks at one another. Dr. Phiri shook his head again. “Some conditions are forced on us because of the system.”

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Applying the three-­delays model made it harder to overlook hospital failures. The seizing woman was not an anomalous case, and Queens was not an exceptional hospital. Thorsen and colleagues analyzed thirty-­two of the fifty-­ eight maternal deaths that occurred in Lilongwe District in the first half of 2011.27 More than two-­thirds of the deaths involved delays at the hospital level that likely contributed to the fatal outcomes.28 Even when care was prompt, nearly every case involved serious systemic hospital problems: Inadequate monitoring, missed and incorrect diagnoses, delayed or incorrect treatment, delayed referrals and transfers, patients not being stabilized before referring, premature discharges, and outright negligence. . . . The findings illustrate symptoms of a weakened, under resourced healthcare system riddled with deficiencies and malfunctions.29

Lack of blood, lack of medicines, and lack of attention also contributed to these deaths, the authors noted. They concluded that “investing in family and community education, TBA role modifications and referrals, or improved transportation networks are futile when women actually reach the hospital only to die from inadequate care.”30 It was nonetheless possible—­and tempting—­for hospital workers to focus most on the delays for which they felt least responsible. The nurses and HSAs who stressed patient education on “danger signs of pregnancy” as the best way to reduce maternal death were focusing on the first delay. It was possible—­and tempting—­for policymakers to focus on delays that could be reduced at low government cost. Think back to the opening of the Dowa Maternity Waiting Home, and President Banda’s claim that building waiting homes for high-­risk women throughout Malawi would reduce the nation’s maternal mortality rate. That strategy, much cheaper than improving emergency transportation or hospital services, addressed the second delay. Had Faith Chisoni put off seeking help when she first began to bleed? Her medical team never found out whether there’d been a first delay. A second, yes: transportation from the health center to the hospital delayed treatment for her placenta previa. The terrifying long moments in which the nurse-­ midwife searched for a doctor—­any doctor—­who could perform Faith Chisoni’s emergency surgery were the third delay. goals in tension To some extent, the goals of quantifying death and explaining deaths were in tension. Hospital and community-­linked death reviews could address complex and multifactorial situations. Analysis with the three-­delays model

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pushed hospital workers to examine our own contributions to maternal death in ways that civil registration systems and automated verbal autopsies did not. But they were not very useful for estimating the scale of the problem: how many women were dying? They were also not very useful for detecting whether any given intervention was reducing maternal mortality. Much of the information needed to understand women’s deaths and to make childbirth safer had to be stripped away from processes of data collection in order to make “good numbers”: rates and ratios that could be compared with those from faraway places and charted against goals, millennial or sustainable. For Malawi’s Ministry of Health, and for the purposes of the World Health Organization and other international groups that monitored health metrics, none of the techniques described so far produced defensible statistics. The approach used to calculate maternal mortality ratios in California and Texas wouldn’t do—­deaths and births missing from registration systems would make it incomplete at best, misleading at worst. Starting in 1989, maternal mortality metrics in Malawi were extrapolated from samples instead. Epidemiologists frustrated with incomplete registration systems had developed a workaround that allowed them to estimate maternal mortality by talking with ordinary people.31 Demographers identified samples of the population.32 Field researchers tracked them down, asked them questions, and recorded their answers, initially on paper forms and later on handheld electronic devices. Supervisors “cleaned” and aggregated results. Statisticians transformed the aggregated data with various mathematical equations to produce models—­ estimates—­of death. asking the sisters Fieldworkers applying the new “sisterhood method” used checkboxes on structured questionnaires to construct for each woman her own history of childbirths (not pregnancies). They also asked women about their sisters. How many sisters born to the same mother had lived to age twelve? How many had then died, and when? Were their deaths during or shortly after pregnancy? The “maternal mortality module” used to structure these questions appears as figure 5.1. It is one page of a seventy-­four-­page women’s questionnaire.33 Fieldworkers and respondents together filled out the questionnaire over the course of an interview that could last several hours. Supervisors looked over the survey forms and took them to a field office for a thorough review. Interviewers could be sent back to fill in incomplete forms, or recheck answers that seemed unlikely.34 Clerks translated the various boxes and checkboxes into database entries. Statisticians then used the database numbers to

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f i g u r e 5.1. Maternal mortality survey module (recreated from Government of Malawi, Malawi Demographic and Health Survey, 620).

calculate general fertility and maternal mortality rates, figures that could in turn be used to generate a maternal mortality ratio. Four of the assumptions embedded in this procedure merit particular attention. First, it presumes that siblings will have known whether a sister was pregnant at the time of death. The only possible answers are “yes” or “no”;

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“don’t know” is not an option. Second, it presumes that it is a sister who is most likely to remember the pregnancy-­associated death of a sibling; brothers are not asked. Third, it presumes that family members will remember whether a given complication happened within forty-­two days of the end of a pregnancy or not.35 Fourth, it presumes that women who died are just as likely as women who survived to have living sisters to report their deaths. All four assumptions are questionable. Two appear wrong. Families with high mortality are less likely to have siblings alive to report; some epidemiologists now correct sisterhood figures for “survivor bias.”36 And brothers appear just as likely as sisters to know about a sibling’s pregnancies and deaths.37 If fieldworkers add a verbal-­autopsy questionnaire, demographers can also use the sisterhood method to produce a rough breakdown of causes of death. Some countries do.38 However, the interview is already very long. Researchers worry that interviewees will refuse to participate, quit partway through, or abbreviate their answers just to finish the thing. In the end, for demographers, there is a tradeoff between getting a fuller picture of causes and getting better samples to inform more accurate models. In Malawi, the better samples win. Two Models to Measure a Nation Statistical models building from these samples do not look like stories. The numbers they produce look like facts. Epidemiologists’ modeling equations can be understood as explanatory narratives, however, in much the same way that asing’angas’ laments about women’s willfulness or doctors’ clinical case reports can. The numbers and trends these equations generate are the morals of the stories they tell—­stories that shape politics, policies, and funding streams. In 2010, two teams of epidemiologists modeled estimates of maternal mortality ratios for the world as a whole and for every individual country. These reports told different stories, sparked widespread debates, and played out politically for years afterward. One team was an upstart group using new techniques and data sets and supported by new funders: the Institute for Health Metrics and Evaluation (IHME), supported by the Gates Foundation. The other was a long-­term collaboration based at the United Nations (the UN group). The G8 was about to meet. Global maternal health was on its agenda.39 Were maternal mortality measures worldwide improving as countries tried to meet the Millennium Development Goals? Diplomats, bureaucrats, technocrats, advocates, and politicians hungered for facts. Two months before the meeting, the new kids on the block produced numbers to satisfy that hunger.

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The IHME group concluded that maternal mortality had dropped steadily between 1980 and 2008, although the HIV/AIDS epidemic had slowed its decline. They’d modeled trends in 181 countries. Maternal mortality had worsened in some places—­notably, in three wealthy countries, including the United States, and in most of sub-­Saharan Africa. Malawi’s figures were especially dire. Its estimated maternal mortality ratio was third highest in the world, behind only the chronically war-­torn states of Afghanistan and the Democratic Republic of Congo. However, maternal mortality had fallen substantially in some regions—­notably, Eastern Europe and South and Southeast Asia. Overall, the authors saw “much greater reason for optimism than has been generally perceived,” because steep rates of improvement in several nations made clear “that substantial decreases in the MMR are possible over a fairly short time.”40 The Lancet featured the IHME article prominently. Its editor celebrated the good news: maternal mortality was on the decline—­a slow decline, yes, but a considerable one.41 A few months later, a long-­established working group released a different set of figures. Collaborators from several UN agencies, the World Bank, and the World Health Organization estimated a slightly worse global maternal mortality ratio.42 However, they also modeled a more dramatic improvement over time. The UN group’s report, like the IHME’s, included detailed methods and country-­by-­country estimates. The UN group calculated Malawi’s MMR to be less than half of that modeled by the IHME (ratios of 510 and 1140, respectively), as figure 5.2 shows. In absolute terms, the UN model would have estimated approximately three thousand maternal deaths in Malawi in 2008, while the IHME estimated nearly seven thousand.43 Far from being one of the most unsafe places to give birth in the world, as the IHME ranked it, Malawi appeared in the UN report to be in the better half of African countries, and making strong progress toward the fifth Millennium Development Goal. How did two expert groups come to such different conclusions? b u i l d i n g a n e q u at i o n — a ­ n d b r e a k i n g i t a pa rt I have written elsewhere about the UN group’s calculations.44 The IHME group used an equation with a general form that looked like this: ln(μa,i,t) = βXa,i,t + Μa,i,t + e ln = natural log μ = maternal mortality rate

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f i g u r e 5.2. Two models of maternal death in Malawi (Hogan, “Maternal Mortality for 181 Countries”; WHO, Trends in Maternal Mortality: 1990 to 2008; WHO, Trends in Maternal Mortality, 1990 to 2010).

a = age (a five-­year interval in women’s reproductive lifespans) i = place (a country) t = time (a year) β = coefficient X = stands in here for all covariates together M = unexplained component (composed of regional and national effects) e = error

People from a surprising range of disciplines use models of this basic form widely. Meteorologists, geologists, and many others develop equations like these to model explanations of all the variability seen in a measure of interest—­perhaps crop yield, or oil production capacity, or tornado frequency. In this case, that measure is a maternal death rate, μ. Such an equation is aesthetically pleasing to the mathematically inclined; the work of producing good numbers with it can be intellectually compelling. Models have practical uses too. • A model allows some kind of more or less justifiable estimate where actual measurements are lacking. What is the likely oil production capacity for war-­torn South Sudan? What was the likely maternal mortality in

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Burundi, where at the time these estimates were published in 2010 no state figures had been gathered—­ever? • Models can lead geologists, agriculturalists, global health policymakers, or others to be suspicious of certain claims that are politically convenient but far from what the model predicts—­say, grain production for North Korea. • Vital-­registration counts record the past, but models can project into possible futures: what effect is likely if key covariates change? In 2020, for instance, the IHME group modeled various scenarios of social distancing, mask use, and vaccination to estimate when COVID-­19 hospitalizations would overwhelm US state resources.45 The group’s projections guided state policymakers and underscored mask mandates. • Models can be tested against actual measurements to better understand the processes that lead to any given outcome. If meteorologists and economists worked together to model costs of hurricane damage, for instance, and tested their model against actual insurance claims from cities with reliable records, they might find that elevation above sea level matters more—­or less—­to destruction than they expected.

There are five major steps to working out a statistical explanation like the ones that the IHME and the UN group used to model maternal deaths. Each group (1) gathered all relevant measures from the places and times of interest, (2) threw out implausible outliers, (3) used the remaining numbers to develop an equation that estimated outcomes in relation to various other factors, (4) determined how to account for patterns that were consistent within countries or across regions but not globally, and (5) estimated the uncertainty around results.46 The first step was to find all data relevant to the project. The IHME team maternal-­ death ultimately used well over two thousand “observations”—­ counts or calculations derived from various sources including vital registration systems, sisterhood histories, and verbal-­autopsy studies done between 1980 and 2008. Six observations were from Malawi: one from a published article, and five from national sisterhood-­history calculations. In a second step that they described as an “expert qualitative review,” the IHME group rejected data points that were too far away from other estimates within the same country, or too dissimilar to data points from “countries with similar levels of development and health system access.”47 Reviewers clearly already had a range of outcomes and causal factors—­a rough model—­in mind. The IHME team threw out one data point for Malawi, a very low estimate of maternal mortality. Ultimately, the observations that the IHME and the UN group chose to use for Malawi were the same ones.

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Choosing Predictors At the third step, the IHME team selected factors likely to affect mortality at the population level. Predictors ultimately chosen for regression equations are called “covariates” because they vary with the indicator of interest. A potential covariate must be available in comparable units for many countries in many years in order to calculate a relationship with maternal mortality. It must be numerical to work in an equation. Because there is no widely accepted way to quantify racism or misogyny, for instance, neither can be a covariate. They disappear from the stories that equations tell. From possible numerical covariates available for many countries from 1980 to 2008, the IHME group chose several based on previously published theory; a plausible explanatory story was already in mind. They then tested to see which covariates most closely fit the many global observations of maternal mortality. For each covariate selected, modelers calculated a beta coefficient indicating the magnitude and direction of its effects. (As HIV rates rise, maternal mortality typically rises, and so the beta coefficient is a positive number; as GDP rises, maternal mortality typically falls, and so its beta coefficient is a negative number. The larger the coefficient, the greater its effect.) One obvious covariate, fertility, allows us to think through coefficient calculation. Imagine two cities—­ call them Kuchuluka and Pochepa—­ where women are equal in all respects except that Kuchuluka’s women typically have ten children during their lifespan, while women in Pochepa typically have two. Epidemiologists would expect Kuchuluka to have higher maternal death rates, because women there are exposed five times as often to circumstances in which maternal death is possible. But would Kuchuluka’s women be five times likelier to die than Pochepa’s, making the coefficient of fertility +5.0? Not if the first pregnancy is the most dangerous, as many Malawian nurse-­midwives and azamba claimed: even people who have ten pregnancies only have one first pregnancy, so the coefficient would be less than five. Or perhaps, as several asing’anga and a few hospital workers contended, cumulative wear and tear makes the later pregnancies most dangerous. Then the coefficient would be greater than five. Expecting fertility to increase maternal mortality, epidemiologists use regression to calculate the magnitude of its impact by matching every known count of maternal mortality with the fertility rate for that population at that time.48 Prediction versus Explanation In addition to practical concerns, theoretical issues affect how those who build equations select covariates. Epidemiologists want an equation that works well

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to predict mortality—­a model that produces an accurate estimate when applied anywhere in the world. They also want an equation that explains things. A good model is not just a predictive tool but also a learning tool: it helps explain what factors really matter for the outcome of concern. The need to predict and the need to explain are in tension. Maternal death varies greatly from country to country and region to region, but changes slowly across time, so one powerful predictor of a country’s maternal mortality ratio in year t is its maternal mortality ratio in year t–­5. An equation that included MMRt–­5 as a covariate would probably have excellent predictive power. But it sacrifices explanatory power: we learn nothing about why MMR in the US or Malawi is worse than that of its neighbors. Because one goal of equations like these is to explain problems in ways that can shape policy, this covariate is not a useful addition. Equations that use many covariates to produce a very accurate curve that explains little are called “overfitted.” They are aesthetically displeasing to many epidemiologists, just as tediously detailed ethnographies that make little theoretical contribution are aesthetically displeasing to many anthropologists. The tension between prediction and explanation is visible in the differences between the UN group’s equation and that of the IHME: in the selection of covariates, the two models diverged widely. The IHME group chose total fertility rates, per capita GDP, HIV seroprevalence, neonatal mortality, age-­specific female education, and “indicators for 5-­year age groups.”49 The UN group used a national measure of skilled birth attendance as a covariate, because it should matter to maternal mortality—­and when they tested it in their equation it did, although not greatly—­while the IHME group did not, because when they tested it in their equation, it did not improve predictions of maternal death. The IHME epidemiologists included neonatal mortality as a covariate, while the UN group did not: it was a powerful predictor but a poor explainer. Newborn death does not cause maternal death. It may signify a vulnerable group of mothers: malnourished, sick, stressed by poverty and marginalization. It may stem from a deeply inadequate health care system in which infants born with reversible problems are inadequately resuscitated and moderately preterm infants do not survive. It likely indicates both. Maternal vulnerability and health care inadequacy are likely to kill mothers as well as newborns. In using neonatal mortality rates and not skilled birth attendance as a covariate, the IHME probably sacrificed explanatory power for predictive accuracy. In using skilled birth attendance and not neonatal mortality rates, the UN group probably sacrificed predictive accuracy for explanatory power. Once covariates have been selected and beta coefficients calculated, the equation’s general form will be something like this:

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Maternal mortality in a given place at a given time = a constant + (first β-­ coefficient) multiplied by (first covariate at that same given place and time) + (second β-­coefficient) multiplied by (second covariate at that same given place and time) . . . plus any other covariates and their beta coefficients . . . plus a residual of unexplained variation, plus error.

To make the equation less cumbersome, “at a given place and time” becomes a subscript i,t where i indicates place and t time. Paired covariates and beta coefficients get numbered subscripts that mark them as belonging together. The constant is given as a beta coefficient with the subscript zero and no covariate.50 The IHME group and the UN group drew from different databases, chose different covariates, calculated different beta coefficients, and handled residuals differently, but both used equations that took this basic form. With the IHME’s chosen covariates included, their equation looked like this:51 ln(μi,t) = β0 + β1ln(TFR)i,t + β2ln(GDP per capita)i,t + β3(NMR)i,t + β4(education)i,t + β5HIVi,t + β6HIV2i,t + Mi,t + e ln = natural log μ = maternal mortality rate i = place (a country) t = time (a year) β = coefficient TFR = total fertility rate GDP = gross domestic product per capita NMR = neonatal mortality rate education = female education rates HIV = HIV seroprevalence M = national and regional fixed effects e = error

And here is the UN group’s model, for comparison: log(PMi,tna) = β0 + β1log(GDPi,t)+ β2log(GFRi,t) + β3SABi,t + αCj[i,t]+ αRk[i,t] + ε PMna = maternal deaths as a proportion of all non-­AIDS deaths in women ages fifteen to forty-­nine GFR = general fertility rate (live births per woman ages fifteen to forty-­nine) SAB = skilled attendant at birth (proportion of all births) αCj = fixed effect for country j αRk = fixed effect for region k ε = error

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For me, and perhaps for some people reading this book, these equations are daunting. We might be tempted to accept whatever results they produce simply because they look impressively mathematical. But once we start taking an equation apart, even without paying attention to the (significant!) methodological questions it raises, we can consider more closely the strengths and limitations of these models as explanations. Which Deaths Counted? Both modeling teams used smoothing techniques to remove what the UN called “mortality shocks” and the IHME called “fatal discontinuity” events: natural disasters, wars. The assumption embedded within these decisions was that the best explanatory line was the smoothest one, and that pregnant women were no more vulnerable than anyone else. If a typhoon made emergency obstetrical care impossible to access, or if pregnant women were especially targeted in a civil war, those hard-­to-­model excess deaths disappeared from the equations.52 Both groups’ reports highlighted the MMR, a widely recognized indicator tracked for the fifth Millennium Development Goal; but both teams actually calculated something else. The IHME group calculated maternal deaths per hundred thousand reproductive-­age women. The UN group calculated the proportion of deaths attributable to pregnancy among all deaths for women of that age group. Only later did each group convert its proportion to a maternal mortality ratio. Why use a denominator of women’s deaths, rather than directly calculating an MMR with a denominator of live births?53 Both groups expected a direct calculation to be an underestimate. Deaths of reproductive-­ age women are consistently underreported in surveys; live births are not. Dividing underreported maternal deaths by correctly reported births produces a falsely low MMR ratio. A proportion using underreported maternal deaths divided by underreported total women’s deaths will be less inaccurate. It isn’t pregnant women’s deaths that escape memories and written records. It’s women’s deaths, period. Estimates Built from Estimates Every number put into this equation—­every covariate—­is itself an estimate, not a direct measurement. Most are themselves products of multiple other estimates. The many errors and uncertainties folded into the original sources for these estimates of estimates disappear in the final estimation.

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Consider the gross domestic product, used to assess a nation’s economic well-­being—­an important covariate in both equations. To calculate a country’s GDP, economists add together all consumer spending on goods and services, all industry spending on goods and services, all government spending on goods and services, and the net value of exports.54 No country actually has this level of detail on consumption and production, however. Each component of the GDP is itself an estimate, derived from error-­and bias-­ridden source data like surveys and tax records.55 For a per-­capita GDP, divide the amalgamated number by total population. If a country has had a recent census that World Bank functionaries consider reliable, population numbers can be extrapolated from that. Otherwise these numbers come from a United Nations database of estimates. In either case, every component of the per capita GDP is an estimate. Analyzing development indicators, the economist Morten Jerven concluded that “the most basic metric of development, GDP, should not be treated as an objective number but rather as a number that is a product of a process in which a range of arbitrary and controversial assumptions are made.”56 Jerven cited Malawi’s economic indicators as particularly suspect: officials pressured the national statistical office to produce numbers favoring certain political outcomes. Policymakers should not ignore indicators, he concluded; but “the implication for our knowledge of development is that we need other skills than statistics to interpret numbers.”57 Per capita GDP—­even when calculated in good faith, without political interference, and with scrupulous attention to sources of error—­has other limitations that impair its utility as a predictor of maternal mortality. It gives little sense of people’s access to healthy food, clean water, safe health care, or other essentials for survival. It gives no estimate of inequality: if a few people are extremely rich in a nation where most people live in deep poverty, the GDP per capita will not reflect the typical experience of that nation’s citizens. GDP excludes bartered goods and services that go unreported on balance sheets. It also excludes savings. Money saved in banks is typically loaned to industry to spend on goods and services, and ends up in the equation that way; not so for money saved behind a loose mud brick in one’s house, or wrapped in a knot inside one’s chitenje. Savings and barter, excluded from the GDP, are nonetheless critical to a person’s ability to keep malnutrition at bay after a failed harvest, or to access emergency transport to a hospital for someone who is hemorrhaging. In these equations, GDP stands in for the economic well-­being of ordinary people, which no doubt contributes to maternal safety or danger. But

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economic life as lived looks different than economic life as summed up in an indicator. It’s not clear that per capita GDP is a reasonable measure of well-­ being anywhere in the world. It is also a number into which many layers of uncertainties are folded. These layers disappear when the number is inserted into the mortality modeling equation. Sometimes epidemiologists sacrifice insight to get defensible numbers, as doctors presenting case reports sometimes sacrifice detail to get a clear diagnosis. Similar exercises for each of the other covariates would show the many assumptions limiting the insights they allow.58 The covariates made aspects of demography, maternity, and economy into black boxes—­one need not look inside them (in fact, one had better not) to compare them across space or over time. The GDP was a black box in both equations. In the UN equation, the “skilled birth attendant” was a black box. She could be a physician, a nurse, or a clinical officer. He could be knife-­happy, exceptionally capable, diligent, technically on duty but mostly on the phone with patients in his private practice, or drunk. She could be burned out, inattentive, drinking tea in a break room, brilliant and compassionate, too focused on a side business selling shoes at the hospital to take a blood pressure reading. Or perhaps there was no BP machine anyway. He might speak the same language as his patients, or not. In the IHME equation, neonatal mortality was a black box. A powerful predictor of maternal death, it smuggled into the equation many important elements that remained covert. Sometimes maternal death is referred to as a puzzle with many pieces. If neonatal mortality was a single piece of the puzzle, then inadequate or unreachable emergency care, hunger, weathering, repeated bouts of infectious diseases, and other sociopolitical pathologies were likely all fragments of this single piece. What about HIV? The relationship of HIV to maternal mortality is complex. Advanced disease reduces a woman’s fertility. If a woman with significant immune compromise does conceive, however, her likelihood of a deadly complication seems to be much greater. Which such deaths should be counted as maternal, and how many are there? The UN team removed HIV-­related deaths from its core model.59 The IHME group did not. Instead, they made estimated HIV-­seropositivity rates a covariate. That covariate had such weight in eastern and southern Africa that a lead IHME epidemiologist concluded that existing safe-­motherhood approaches were wrong: “It’s not about emergency obstetric care, but about access to antiretrovirals.”60

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His conclusion made sense in the light of the story the equation wrote. HIV was an important covariate. Emergency obstetric care was not a covariate at all.61 Compare that with the story of maternal mortality written into the three-­delays model. The need for emergency obstetric care would seem obvious, since the lack of it was the third delay. HIV, on the other hand, would disappear: because it acted long term, there was no place for it in the three-­ delays model. The Rest of the Story: Effects, Errors, Uncertainties Three more pieces of these models deserve brief consideration. Two were built into the equation: in the IHME model, Mi,t + e. M included fixed effects for region and country, e was error. The third, an uncertainty range, involved a separate calculation. Effects did a great deal of heavy lifting in these equations. Modelers built the equations on the largest set of numbers deemed trustworthy from around the world. But individual countries, and particular regions of the world, consistently outperformed or underperformed the global equation for reasons unknown to modelers. Each group calculated “fixed effects,” numbers for specific nations and regions, to capture the impact of these chronic differences and improve the model’s ability to predict death. Their procedures depended on institutional histories: the UN group used WHO administrative regions; the IHME’s Mi,t used the twenty-­one regions designated by the Global Burden of Disease project.62 The error term e acknowledges that although statisticians cannot know what an equation is failing to capture, they can be confident it won’t calculate the true number of maternal deaths. Looking backward, one can calculate errors when actual death numbers are available. Looking forward, or estimating outcomes in the absence of data, error is set to zero. It is a ghost in the model. It does not change the results, but its presence serves as a haunting reminder that those results will be wrong—­slightly, or substantially. Modelers knew that many uncertainties would make their results less accurate. Each team calculated uncertainty ranges, estimating that true mortality ratios were likely to be within the dashed lines in figure 5.2. In technical reports, the IHME team spelled out its approach: of five important sources of uncertainty, two couldn’t be addressed at all. First, modelers identified no way to account for how sisterhood-­survey implementation or processing might have affected the original numbers. Second, they were well aware that fertility rates, GDP, and neonatal death rates were estimates built on other estimates, but found no way to integrate the uncertainty from these covariates into the

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f i g u r e 5.3. Maternal mortality estimates for Malawi, 1978–­2017 Sources: Original estimates made by the IHME, the UN group, and the Government of Malawi. Publication sources are Colbourn et al., “Maternal Mortality in Malawi”; Hogan, “Maternal Mortality for 181 Countries”; Kassebaum, Bertozzi-­Villa, et al., “Global, Regional, and National Levels and Causes of Maternal Mortality”; Kassebaum and GBD 2015 Maternal Mortality Collaborators, “Global, Regional, and National Levels of Maternal Mortality, 1990–­2015”; WHO Trends in Maternal Mortality: 1990 to 2008; WHO, Trends in Maternal Mortality, 1990 to 2010; and WHO, Trends in Maternal Mortality, 2000 to 2017. Note: Uncertainty bounds have been smoothed around published maximum and minimum numbers, including those applied retroactively. Uncertainty bounds provided in initial publications tended to be narrower (compare figure 5.2, for instance).

model. The group felt confident they’d made up for these concerns by overestimating other uncertainties. In retrospect, that confidence looks misplaced. Modeled estimates of Malawi’s MMR have varied widely, as figure 5.3 shows. Years later, when the IHME recalculated Malawi’s 2010 maternal mortality ratio using a much-­revised model, the results were far outside the original uncertainty ranges.63 t h e a f t e r m at h In the end, the things that differed about these equations were probably less important than the things they shared. Each model used standardized inputs

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to produce standard estimates of death that could be compared across countries and across time. Each model made a certain kind of story about maternal death and put that story out into the world for governments and advocates and others to seize upon. A growing GDP was a hero that saved women from dying; HIV and high fertility were villains that put mothers at risk. Standardized stories of national development were woven into explanations for death.64 Because these other characters continued to act out a story line, models produced numbers even with no death records or statistical samples at all. Angola—­like twenty-­six other nations—­had never provided maternal mortality metrics to the World Health Organization. Yet both the IHME and the UN calculated maternal mortality ratios for Angola, even smoothing away the “mortality shock” from the 1992–­94 escalation in its long civil war. Angola’s maternal mortality had dropped by half in a decade, the IHME estimated in 2010. After all, oil wealth had nearly doubled the GDP. Both groups circulated results to media outlets. The IHME’s report came out first. Its methods and funders were novel, its scope impressive. It provided hopeful news about a global decline in maternal death. Internationally its numbers carried considerable currency. In the United States, researchers in various American states were working out their own estimates, and debating what to do about the apparent rise in women’s risk of pregnancy-­related death. The problem of maternal mortality would not really hit the national news for several years. When it ultimately did, the IHME group’s estimates were the most widely cited. In Malawi, in contrast, it was the UN figures that circulated. The UN group had consulted with national epidemiologists. IHME researchers had not. The IHME’s very high estimates diverged from those of the national Demographic and Health Survey, a source that Malawian clinicians and academics generally knew well and considered reliable. No one who quoted figures to me used the IHME’s estimates. It was the UN numbers that made the papers, prompted consternation, and for a time supported a presidency. Numbers at Work: A President’s Story In 2012, President Joyce Banda was in a very difficult position. A businesswoman of relatively humble origins, she’d risen to become a member of Parliament, then minister for gender and community services. She had successfully championed a bill to criminalize domestic violence—­having herself fled a violent first marriage years earlier—­and had made a name for herself as a women’s rights activist. Under President Bingu wa Mutharika, she became minister for foreign affairs, then vice president in 2009. Their relationship

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deteriorated in 2010, when Banda refused to endorse Mutharika’s plans to install his brother Peter as successor. Mutharika “fired” her, handing key duties to his wife. No constitutional mechanism allowed such a dismissal, however, and Banda remained the legal vice president. The administration opened a constitutional court case to try to unseat her. Rumors circulated about a failed attempt on her life. Ostracized and harassed, by April 2012 she had not spoken to the president in more than a year. And then Mutharika suddenly collapsed, and his medical team—­working without epinephrine and other key supplies—­could not resuscitate him. The next forty-­eight hours saw a complicated political drama unfold. Officials concealed Mutharika’s death, informing reporters that he had been transported to South Africa for critical care treatment. Unnamed medics claimed otherwise: Mutharika was dead; his corpse had been flown out because the hospital’s electricity supply was too unreliable to keep it refrigerated.65 His closest advisors, soon nicknamed “the midnight six” for their feverish overnight planning, were said to be working out how they might circumvent the constitutional succession plan to ensure that Arthur Peter Mutharika, not Joyce Banda, became president. Some Malawians celebrated the rumors of Mutharika’s death. Some protested the apparent coup underway. Members of Parliament made vague statements. Many seemed to be hedging their bets, trying to take positions that would allow them to continue to work under whichever administration ultimately prevailed. Whispered truths and loud lies, outrage and faux outrage, claims and counterclaims flew. In the end, both the court and the military stood by the constitution. As Mutharika’s inner circle sought a court order to block Banda from succeeding to the presidency, the Malawi Law Society issued a statement supporting a constitutional transition of power. The leader of Malawi’s armed forces, General Henry Odillo, posted troops around Banda’s home. The “midnight six” backed off. Banda took the oath of office two days after Mutharika’s death. As if this situation were not fraught enough, Malawi was in rough economic and diplomatic shape. Mutharika, an economist by training, had started off strong as president with a robust agricultural subsidy program that many citizens credited for several years of exceptionally good harvests. In his second presidential term, however, he became more erratic, dictatorial, and combustible. He publicly allied himself with autocrats, including Sudan’s Omar al-­Bashir and Zimbabwe’s Robert Mugabe. He purchased an expensive private presidential jet; expelled a British high commissioner; tried to fire his vice president and did fire other cabinet members; appointed family members to key posts; and vowed to “smoke out” political enemies. Four major donor countries responded by withdrawing budgetary support, as did the

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World Bank, the European Union, and the African Development Bank. Foreign aid had made up at least 40 percent of the national budget. Conditions deteriorated quickly. Without the currency necessary to pay for imports, the country soon faced severe fuel shortages. Queues for petrol could last a day or more—­angering Malawians, who were already facing rising unemployment, shortages of electricity and water, and spiraling inflation. Two months before Mutharika’s death, the Guardian reported: Malawi is suffering chronic shortages of foreign currency and fuel. The latter has seen pregnant women dying after ambulances became stranded. Power cuts are frequent, the courts are shut because of a strike and people are losing their jobs. This tinderbox of frustrations may only require a spark.66

To make matters worse, drought had hit. Harvests of both the staple food, maize, and the staple export, tobacco, were far below what was necessary to support farmers and their communities. The land itself seemed to be protesting. Mutharika’s administration had dealt brutally with public unrest as the situation worsened. Officials interrogated the regime’s critics. Campus protests led to a standoff between students and police. The minister of education—­ Mutharika’s brother Peter—­closed Malawi’s two largest colleges, claiming national security concerns. Several faculty members were fired. One student activist was killed; another went missing. Protestors outside the educational system fared no better: at government orders, police quelled public rallies in the country’s north with live bullets, killing and injuring many people. Inheriting this tense situation, the new president Joyce Banda understood her most important task as repairing relations with donors. By making the nation appear attractive and compliant, she could open the tap to restore the flow of foreign aid. Banda promptly devalued Malawi’s currency, sold the presidential jet, distanced the nation from the Sudanese president Omar al-­ Bashir, and publicly vowed to overturn Malawi’s legal ban on homosexuality. These moves pleased donors but brought consternation and dismay among many Malawians.67 A cartoon in the Nation newspaper showed Banda at a podium saying, “So the donors told me to devalue the kwacha . . . so they told me to travel to build relations, . . . so they told me . . .” while members of her audience questioned whether she was actually the head of state.68 The sole initiatives with broad popular support were her efforts to keep girls in school and to reduce maternal mortality. Banda described her interventions into maternal mortality in passionate and personal language. She had herself survived a terrifying postpartum hem­orrhage, thanks to prompt treatment by Malawi’s legendary obstetrician Dr. John Chiphangwi. In interviews, she described her survival as both miracle

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and mark of privilege: few Malawian women were attended in childbirth by doctors, in hospitals with adequate blood banks. Banda often reported that she could not bear to rest while other women died. Eight months into her presidency, Banda spoke to interviewers from the US-­based Center for Strategic and International Studies (CSIS).69 Most women that die, die giving birth. And I think as a woman leader, that is not acceptable. It is not possible for me to sit back and watch 690 women die out of every 100,000 giving life. That’s not acceptable.

In a CSIS video, Banda’s voice ran through interview footage and over images from elsewhere in Malawi. What breaks my heart is the fact that when you—­if we see the women who are dying, the 690, most of them are between fifteen and nineteen. So the reason is, they are not going to secondary school. They are not going to secondary school because it’s not free. So when she cannot afford the fifty dollars, she drops out. And then the community encourages her to get married.

The video cut to a still image. Four young women lined up on a bench with their babies. One of the four looked at the camera; the others looked out through vertical bars at the sunshine beyond. In the foreground, the round dial of a scale topped out at a hundred kilograms. The imagery made the clinic seem a bit like a jail. Banda’s voice floated over the image: And because her body is not ready for childbirth, they are the ones that are dying. That’s why I’m sending 2,300 girls to school. Because I just believe that keeping a girl in school four more years is not about—­just about her future. It’s about her health.

Widespread economic precarity, the difficulties of diplomatic repair, and the evident challenges of being a woman suddenly propelled into the nation’s highest political position all made Banda’s presidency tenuous and the role of maternal-­death metrics weightier. For epidemiologists, I have suggested, the equations themselves worked as stories with key and supporting characters, plot twists, and morals. For Banda and for many who supported her, the equations seem to have been invisible. The numbers were just facts, as factual as the 2,300 girls she was sending to school. But these “factual” numbers were important actors, in their own right, in Banda’s own political story. 675, 460: numbers as characters In 2013, President Banda celebrated the improving maternal mortality metrics that my colleague doubted. Banda cited the decline from 675 to 460 per

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hundred thousand frequently in speeches at home and abroad. Her Wikipedia page repeats the same two numbers. Its sole entry under “Presidential Initiatives” reads as follows: President Banda has shown consistent commitment to maternal health and reproductive rights, specifically through her support of safe motherhood in Malawi. She showed her support through establishing the Presidential Initiative on Maternal Health and Safe Motherhood. In only two years, this Initiative showed a reduction in maternal mortality ratios from 675 deaths per 100,000 live births to 460 deaths per 100,000 live births.70

Banda often presented these numbers both as encouraging and as not good enough. Reporters who quoted her linked the numbers with deliberate efforts to improve maternal safety. In news articles and op-­eds—­unlike in the hospital—­the numbers themselves went unquestioned. To some extent, the precise figures did not even matter. One 2013 news report noted that maternal mortality had dropped “from 675 out of 100,00 [sic] to 460 out of 100,00 women dying during childbirth” and that Malawi might meet its Millennium Development Goal target.71 The denominator in this ratio was off by a factor of ten: if the reporter’s figures had been correct, Malawi’s maternal mortality would have been the worst reported anywhere ever.72 Elsewhere I have argued that numbers—­like 675 and 460 in Banda’s speeches and in the reporting about her initiatives—­can act as fetishes.73 Our belief in these inanimate things grants them a power to act that depends more on their repetition than on their precision. But perhaps it makes more sense to think of these numbers as characters in a story about Malawi’s first—­and so far only—­woman president. There is little doubt that Banda’s presidential initiative mattered for maternal safety in Malawi. Her repeated speeches on the topic brought attention to a serious problem. She spearheaded campaigns to promote birth in hospital facilities rather than at home with TBAs. She urged chiefs to innovate to improve maternal health in the districts. She coaxed funds from donors to build maternity waiting homes. Years later, Malawians in remote villages and urban centers spoke of Banda’s maternal health efforts, which undoubtedly changed the courses of many lives. The initiative could not, however, have been related to the metrics that Banda and her spokespersons repeatedly cited. The numbers came from the UN estimates plotted in figure 5.2. The MMR of 675:100,000 was the product of national sisterhood-­survey data gathered two years before Banda suddenly assumed the presidency and covering the seven years prior to that. On the graph’s x axis, the 675 was located at the midpoint of the seven years before

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2010 (2006.5). The MMR of 460:100,000—­announced in late 2012 but dated to 2010—­was a modeled extrapolation from that same point, using the regression equation to smooth and to predict what might be coming next.74 No new input data from 2012 or after was used. Neither of these numbers could have had anything to do with her interventions. The numbers 675 and 460 became supporting characters in a story about a courageous president who took up the cause of women in Malawi with interventions that had to work: secondary school for girls, maternity waiting homes, delayed marriages, facility-­birth campaigns.75 The tale that featured these numbers was in some ways not really about maternal death. It was, instead, the story of a successful initiative and a successful president. The numbers 675 and 460 seemed to validate her actions even though they were manufactured from data that preceded them. Those numbers also participated in making a political life for Banda after her presidency was over. t r u t h s , l i e s , a n d s tat i s t i c s Numbers do political work. Terrible mortality statistics and political embarrassment from missed goals and benchmarks can prompt the powerful to intervene. Malawians are not unique in using numbers to push political leaders to act, nor in interpreting numbers as signs of political failure or success.76 Competing assessments of political impact accompanied the competing global metrics released in 2010. The Lancet editor who introduced the IHME report celebrated the release of figures that offered reason for “surprise, hope, and urgent action.” Noting that poor progress on maternal mortality had caused “embarrassment to global health leaders,” he reproached activists who had urged a publication delay. The activists had worried that good news could diminish urgency among funders at the G8 and other meetings. At least one prominent women’s health advocate took a contrary view: “To us, the good news will maintain the interest of investors. If you don’t show results, that’s the worst position you can be in.”77 A few years later, maternal mortality numbers in the United States prompted shock and shame. A New York Times editorial board called maternal death metrics “unconscionable.”78 A USA Today series concluded that a decentralized health care system with little accountability or regulatory oversight added up to “Deadly Deliveries.” “The U.S. continues to watch other countries improve as it falls behind,” noted reporter Alison Young. “Today, this is the most dangerous place in the developed world to give birth.”79 An accompanying editorial put it this way: “High maternal death rate shames America among developed nations.”80

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Let’s go back to California and Texas. In 2006, epidemiologists noted that California’s maternal mortality ratio had more than doubled over seven years. Despite uncertainties about the precise numbers, the trend was clear. An innovative team of epidemiologists, sociologists, and health workers got to work. The team identified problems including widespread mismanagement of postpartum hemorrhage, overuse of certain medical interventions (such as cesarean section and labor induction), and miscommunication patterns exacerbated by workplace hierarchies. A new collaborative developed and promoted actions that hospitals could take to make birth safer. Pregnancy-­related death rates declined steadily over the next decade and more in California. Profound inequities persisted, however. Death rates among black mothers continued to be three to four times as high as those among white mothers, a ratio comparable to the national one. After signing bills to require clinician training on implicit bias, California’s governor noted in a tweet: “Our country has the worst maternal mortality rate of ALL developed countries. That’s not something we can or should ignore.”81 In Texas, a different story unfolded. Numbers were actors in this story too. In 2016, epidemiologists analyzed maternal mortality data from across the United States, noting that it was “an international embarrassment that the United States, since 2007, has not been able to provide a national maternal mortality rate to international data repositories.”82 State-­level figures showed maternal mortality to be rising substantially, the authors concluded. Much of the increase had to do with better reporting, thanks to revisions of death certificates. That simply meant, however, that maternal deaths in the past had been even more significantly underreported than previously suspected. The article singled out a steady decline in maternal mortality in California—­the only state to show improvement—­and a rise in maternal mortality in Texas so steep the authors noted it “seem[ed] unlikely.” Was that rise a measurement problem, or the result of recent changes in access to women’s health care? The authors could not be sure. As publicity about maternal death in Texas hit the news, the state’s lawmakers scrambled to address the problem—­to the extent that they could without making contraception, abortion, or insurance coverage more available for women. Legislators established a task force. (They later ignored its key recommendation.) Researchers from the Texas Department of State Health Services, which had produced the original figures, took another look at the records. If deaths had been the focus for intervention in California, rates were the focus in Texas. A labor-­intensive process of reviewing autopsy reports, interrogating people who’d filled out death records, and cross-­checking Texas

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birth registrations allowed state public health officials to revise the figures.83 Maternal mortality was no worse in Texas than in the rest of the nation, they concluded. A poorly designed electronic system for submitting death records had likely caused overreporting of maternal deaths. This design flaw was a critical finding. A close read of the article, however, shows how human choices shape statistics and the stories they tell. The researchers excluded the deaths of fifteen women whose medical records could not be found. They excluded women who died in Texas but were legal residents of neighboring states, while including Texas residents who had died out of state only if there was a Texas birth or fetal-­death certificate. Rather than evaluating pregnancy-­ related deaths (up to a year after delivery) as the CDC does, they adhered to the stricter WHO maternal-­death limit of forty-­two days.84 Each decision chipped away at the rate of maternal death in Texas without changing the number of women who died there. Problem solved! Texas’s governor weighed in with a tweet: “Turns out the critics of the Texas maternal mortality rate were just lying. It’s less than half of what the critics said. It’s about 1/10 of 1%. Still, Texas has done more than ever to reduce that rate even more.”85 Counting and Accountability Deaths related to pregnancy in California continued to fall. Deaths in Texas continued to rise, as did those in the United States overall, according to the CDC. The IHME group and the UN group continued to put out competing estimates. Epidemiologists and demographers wrote frankly—­in technical journals read by other epidemiologists and demographers—­about the limits and uncertainties of their models. Almost everyone else took the numbers those models produced as facts. In Malawi, estimates continued to differ substantially but trended downward—­or, perhaps, plateaued. Joyce Banda was president for just a little over two years, only to be defeated soundly in the May 2014 election by the man the “midnight six” had plotted to make president whether the constitution allowed it or not: Arthur Peter Mutharika. In an interview several months after her presidency ended, Banda seemed relaxed, sharing step-­parenting tips and discussing her happy marriage. When the interviewer asked about early influences, she recalled her grandmother’s explanation that she’d been named Joyce after a midwife at the rural Malawi hospital where she was born. My grandmother didn’t hesitate to give me that name because she believed I was one day going to grow up into someone like the white midwife. “Uzakhala

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ngati mzungu. [You will be like the white person].” My grandmother later told me she admired the air of authority the white midwife commanded in her white uniform and she wanted me to grow into someone like her.86

Perhaps Banda saw herself as midwife to her nation. Asked to reflect on her accomplishments as president, she had this to say: I refuse to accept that a woman should die giving life. I am proud though that due to the initiatives that we implemented in my two years, we were able to reduce maternal deaths from 675 women dying by 100 000 deaths [births] down to about 400. This achievement came about through the participation of chiefs at grassroots level and the private sector who constructed waiting shelters in hospitals. Us as Malawian women, we will forever be grateful for the support of our donors like United Nations Population Fund (UNFPA) and members of the private sector.87

Banda never seemed as popular at home as she was abroad. While I met fervent supporters in Malawi, equally fervent detractors characterized her as weak, an ignorant “market woman” controlled by international donors. People who had heard her give speeches in Chichewa said she often began with the words “azungu anatiuza”: the whites have told us. During her presidency, investigators exposed a massive looting of the public treasury. Malawians argued: was Joyce Banda a central culprit in the “Cashgate” scandal, a rare leader who had allowed effective anti-­corruption investigations, or both? She stood briefly for election in 2019, then withdrew to support another candidate. (Arthur Peter Mutharika won again, in an election where the use of the correction fluid Tipp-­Ex on vote tallies outraged many Malawians.88) Yet, among women’s rights activists and diplomats outside Malawi, Banda’s maternal health efforts brought her much acclaim. She was feted in Japan. She was included on the Forbes list of “Power Women 2014.” She was celebrated in the international news and cited for her work by both Bill and Melinda Gates. In 2017, I visited the Dowa Maternity Waiting Home that Banda had opened with fanfare in 2013. Nearby lay the hospital’s cramped and run-­down guardian shelter, filled with smoke from cooking fires. The maternity waiting home was a nice contrast: spacious, breezy, the walls open to the air from waist-­level up under a broad roof. At the end of the building, communal toilets and showers were walled off but open to the sky. A few women scrubbed clothing in the laundry sink, a step down from the bathrooms. I could not resist counting. The waiting home had thirty-­six beds: real beds, not mats on the floor as I’d seen in other waiting homes. Five were actual hospital beds, complete with cranks and trays. Only one bed was occupied, but four more had

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katundu—­luggage and zitenje and plastic dishes—­that suggested women were there too. The other thirty-­one beds seemed empty, unused. The nurse who showed me around believed hospital deliveries had increased since the waiting home had opened. When I asked how busy they were now, he knew I’d want numbers, and called up the matron. The district averaged about a hundred clients a month in the waiting home, she told him. Last month they’d had 187 deliveries. With a small smile, the nurse apologized for not having the figures at his fingertips: “We Malawians are not that big on statistics, you know.” “We Americans are obsessed with them,” I said sheepishly. His smile widened as he responded: “That’s completely obvious.” Metrics like the maternal mortality ratio provide a certain kind of testimony to statistics-­obsessed Americans and others. They are comparable, graphable, solid-­appearing. They write of death in the language of numbers, legible to investors and unencumbered by grief. The mathematical abstractions of their calculation, and their origins among interlinked groupings of international experts buttressed by acronyms, only strengthen their appearance of trustworthy objectivity.89 Even in this chapter, you may have noticed, specific people essentially disappeared from the sections describing mathe­ matical modeling. Numbers are extremely powerful and very limited, but they are not arbitrary. By dissecting the details of their production and circulation in this chapter, I do not mean to dismiss them as irrelevant to maternal health. The introduction of verbal-­autopsy techniques, sisterhood methods, and the three-­delays model all allowed for better understanding of why and where and how often women were dying. Stories of individual deaths often reveal the social, economic, moral, and biological complexity of women’s situations. In attending to them carefully, we often learn what is at stake for those who tell them, and we can sometimes hold individuals and institutions to account—­as the community death reviews showed. We learn, too, how many uncertainties are involved in any given death. Modeling equations are no less stories of causation than these individual accounts, but they tend to obscure the complexities, the uncertainties, and the stakes. Yet, these mathematical models also do something that clinical stories don’t. By allowing comparisons across countries and over decades, they hint at effects of decision-­making at larger and longer scales. Verbal autopsies, death reviews, and the three-­delays model incorporate time in hours and days—­at most, a few months. Modeling equations smuggle in much-­longer-­ term political decisions and social pressures, not evident on the surface but hidden inside bland-­looking figures like education rates and per capita GDP

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figures. It is difficult to look at these models and blame willful mothers for their own deaths; it is less difficult to blame poverty and health-­sector underinvestment. If every society has “the mortality that suits it,” as the physician-­ philosopher Georges Canguilhem has claimed, these metrics and equations go some way to showing how that mortality has been built up through the sedimentation of political and economic decisions over years and decades.90 The ambiguities that are folded within them, meanwhile, allow them to play different roles in different stories: stories of lying critics, successful presidents, international embarrassment, and hard-­won progress. Stories of what the Lancet editor Dr. Richard Horton—­memorably re-­embodying the disembodied figures that had described intractable maternal mortality—­called “one of the most deforming scars on the body of global health.” And stories, perhaps, of how those scars are at once evidence of wounding and testament to healing.

Dyna Ng’ong’ola and Kettie Pensulo: “Women in this community are very much concerned.”

When I met Dyna Ng’ong’ola and Kettie Pensulo in 2007, the two sisters were in their sixties. Mayi Ng’ong’ola was small, slender, wiry with muscle. Fine lines at the corners of her eyes deepened when she smiled, as she often did. Mayi Pensulo—­taller, bonier, graver—­was a few years the elder. They shared a busy practice on the outskirts of Tikhale village, a loose gathering of mud-­ and baked-­brick buildings that rambled over a broad hilltop. In this red-­ brown landscape, their sky-­blue-­and-­white clinic stood out. The four-­room structure had been built with profits from their work and with donations, they explained: cement from the DHO, paint from a nearby orphanage. A wooden sign, white letters spelling “TBA” against a black background, swung by chains over the entrance. Inside, the four-­room clinic was cool and clean. On the left side of a short central hallway were a consultation room, which doubled in a pinch as an extra delivery room, and a room set up for births. The hip-­high wooden bed featured an adjustable backrest and a washable mattress draped with a rubber sheet. Although the rest of our discussion was in Chichewa, the two women called this room, in English, their “labor ward.” On the right were a storage room and a waiting room, where a pregnant client and the woman who had accompanied her were resting on reed mats. The client was nine months along and having irregular contractions; because she lived far away, she was waiting to see if labor would begin or if the contractions would peter out. In a courtyard behind the clinic was a space for cooking, an enclosure for bathing, and a pit latrine. The TBAs’ reputation was as spotless as their building. Once a week they ran an antenatal clinic to which women came from many kilometers around Tikhale, and when a woman started into labor she knew where to go.

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From their clinic, a brisk half-­hour walk took you over hills, through valleys, and across a stream on a rickety bridge made of sticks nailed crosswise to a pair of boards, to the nearest dirt road. A small outpatient Banja La Mtsogolo family planning center stood near that intersection.1 An additional twenty minutes by minibus could get you to the nurse-­midwives at Mwenimweni Health Center. (Pamtunda Health Center was about the same distance in a different direction, but its staffing was too unreliable to make it a good option. It was near the top of a steep hill too, and often a woman in labor just didn’t have the strength to manage the climb.) It took another twenty-­five minutes—­with luck and little traffic—­to get to the nearest hospital capable of obstetric surgery. A closer option for some concerns was the sing’anga Bernard Kaseko’s place, twenty minutes’ walk down the hill from Tikhale. He had been in practice for some twenty years since the spirits called him to his work. I’d talked to him recently and knew he, too, did a brisk business with antenatal clients. “Doctor to doctor,” Bernard Kaseko said, nodding at me seriously, “if your work is good, people will flock to you.” His place was where a woman might go if she had an unnatural ailment of some sort—­say, if someone had bewitched her so that she was past ten months pregnant but her labor would not start. Some medicines he gave by mouth. Others he burned, rubbing the ash into small incisions on her back and shoulders. These remedies resolved such problems reliably. The fine dark scars they left, like tattoos, testified long afterward to women’s afflictions. Mayi Pensulo and Mayi Ng’ong’ola wanted nothing to do with that kind of work. Mankhwala achikuda was too dangerous, they said: the dosages were difficult to get right, and the medicines could be toxic. They’d seen infants born with blisters after the mothers had taken herbal remedies. The sisters had been called to their work not by the spirits but by the chief. In the late 1980s, when a call went out to Tikhale to send someone for TBA training, Mayi Pensulo—­already a respected elder in her forties—­had been selected to go. Three years later, Mayi Ng’ong’ola followed. Each completed a four-­week, nurse-­led training, graduating as “traditional birth attendants.” Each took pride in their continued close association with biomedical workers. “The medical personnel visit us,” explained Mayi Ng’ong’ola, “and we attend training sessions by doctors from Queen Elizabeth Hospital and from the DHO’s office. That is where we get medicine and equipment—­for example, malaria drugs, as well as medicine to enhance blood.” She paused. “Although sometimes, being a hospital, we go there to get medicine only to find that it is out of stock. But we do get it when stocks are there.”

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Standing in their labor ward, the sisters described ways they kept clients safe and comfortable. They felt a mother’s abdomen to estimate how far the fetal head had descended into the pelvis, assessing labor progress without the discomforts and dangers of vaginal exams. They soaked threads in surgical spirit before tying off umbilical cords. They used gloves in addition to handwashing when attending births—­for, thanks to their friendly relations with the DHO, they kept a stash of gloves at the ready. Before a client left for home, the two TBAs would explain how to wrap a newborn warmly, why the family should sleep under mosquito nets, and when the family should take the baby to the health center for vaccinations. While I did not ask, they pulled out a logbook to show me. A column on the left listed names of clients. Other columns indicated possible outcomes with drawings and Chichewa phrases: mwana alibwino with a smiling baby, mwana anamwalira with a small coffin, kuchipatala with a picture of an ambulance. The two pages they showed me covered the last month and included some thirty deliveries. All but one—­a pregnancy loss at four months—­were checked as mwana alibwino. Three additional women had been transferred in labor: one for breech, one for an antepartum hemorrhage, and one for mtsikana—­she was a too-­young girl. The two TBAs agreed that their most serious problem was the distance to reliable biomedical help. If a woman presented in advanced labor with a previous scar, for instance, the sisters would call Mwenimweni Health Center, and the nurses at Mwenimweni would call the referral hospital to get an ambulance dispatched. An ambulance could not traverse the way I’d come. While a longer way round was manageable with skill and difficulty, it “takes forever to get here. Sometimes it does not even get here in time and we end up handling a complicated case ourselves before the ambulance arrives.” Women could deliver “but maybe lose a lot of blood in the process,” for instance. “We still send them to the hospital upon arrival of the ambulance.” The sisters were vigilant, referring clients when they anticipated trouble. But women didn’t always want to go. The youngest and oldest were particularly resistant. “We have problems with women who have many children who are not supposed to come here for assistance,” Mayi Ng’ong’ola commented. “They are supposed to go to a central hospital, but they have their delaying tactics so that when they arrive here, labor is already advanced.” Young women in their first pregnancies were also supposed to deliver at health centers, but they, too, often had other ideas. “They come here when they are in labor and almost force us not to send them to the hospital,” explained Mayi Pensulo. “Sometimes they come here at night and claim that they cannot make it to the hospital as it is dark, so we keep them overnight on the

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understanding that we will send them to the hospital the following morning. Usually the baby comes in the night before we can send them to the hospital!” Fortunately, these women and their newborns usually did well. A health surveillance assistant had previously come from Mwenimweni to give vaccinations at their clinic—­a great help to women who otherwise had to walk a long distance with little ones. In recent years the HSA’s vaccination rounds had stopped, “due to pressure of work,” Mayi Pensulo explained. Nonetheless, continued good relations with the clinic made birth much safer than it had been years ago, before the two had set up their practice. “There is a remarkable difference,” she said. Things are better now. In the past, things were okay, but the hospital dealt with a lot of complications. Problems diminish when people help one another. Now when we say we have failed to solve a complicated case, people around here appreciate it, because if we refer a case to the hospital, we hear that the woman either delivered through a cesarean or vacuum. Things are much better now.

Ten years on, the picture was not so clear and not so positive. From the outside, Dyna Ng’ong’ola and Kettie Pensulo’s little clinic looked much the same in 2017 as it had in 2007. Its tidy black sign, “TBA,” still swung above the front door; the blue-­and-­white paint was still fresh and clean. But one only needed to step through the front door to realize that much had changed. Only the consultation room was neat and spare. The others, including the former labor ward, were filled with stacks of paper, empty maize sacks, trash swept into corners, and cardboard cartons. A wooden table and chair sat in what had once been the waiting room, now commandeered by workers to register villagers for the new national ID card. The local HSA used it too, once again offering occasional under-­five vaccination clinics there. Mayi Ng’ong’ola and Mayi Pensulo were on cordial terms with these workers, they commented, and they were glad their little chipatala was being put to use, for it was no longer a center for birth. TBA deliveries had been banned. Radio campaigns instructed women to go to the hospital to deliver. Fines for women who sought care with TBAs were broadly publicized. (There were no fines for women who consulted asing’anga, but Bernard Kaseko was dead and no one had taken his place locally. The nearest was Bonnex Kaunda, considerably farther away, down near the minibus stop.) For a while, the two women explained, they had continued to run their clinic. In Tikhale, the chief—­an elderly woman—­did not fine women who delivered outside the health facilities. Her nephew, next in line to take up chiefly duties and already doing much of the day-­to-­day work, seemed sympathetic to women’s plights too. Mayi Ng’ong’ola and Mayi Pensulo judged that he would also be unlikely to impose fines: “He understands.”

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Perhaps a jealous neighbor reported them. They were not sure, or perhaps they were not going to voice their suspicions to me. One night, the police came and threatened to take them to jail: “What you are doing is against the policy.” Afraid of imprisonment, they finally stopped. Mayi Ng’ong’ola and Mayi Pensulo, now both in their seventies, made a little money when they could from ganyu—­farm work in other people’s fields. They’d assisted in a road-­building project, too, one in which the government provided food for labor. That had helped for a while. Women in Tikhale were expected to find their way to the hospital when labor began. But “women in this community are very much concerned,” said Kettie Pensulo, “because this place is very far from any clinic.” The bridge was more solid; the tarmac extended farther than it had in 2007, thanks in part to the road-­building project the sisters had worked on. But it was still a half-­ hour’s walk to the road, and any hospital was still a long minibus ride from there. After sunset when the minibuses stopped running, women had few options. “Of course, at night it’s too dangerous to be out there, because of armed robbers and thieves.” Kettie Pensulo and Dyna Ng’ong’ola did, reluctantly, assist women who came to them in situations like these. “Some women even still come here, although we discourage them and when they come we are afraid.” It happened once, maybe twice, a month. But the sisters asked women’s parents and husbands to attend as well. These witnesses could testify—­if the police were to return—­that they’d given the azamba no choice. Mayi Ng’ong’ola and Mayi Pensulo observed that more women in the community had delivered on the road, with no care at all. That, too, happened a couple of times a month. Mayi Pensulo shook her head. “This policy has not assisted women, not at all. It has caused a lot of trouble for people in the rural areas especially. A lot of trouble. The government really rushed. It would have been better if they built new clinics first in the rural areas, with doctors and nurses. Then they could stop the TBAs, but not before there was somewhere else for the women to get help.” Mayi Pensulo fell silent. Mayi Ng’ong’ola picked up where her sister had left off: “Those people could have referred to our records and said, ‘These people may practice and those people must stop.’ We all had to keep records. They could have looked.” Mayi Pensulo’s daughter, a quiet woman who had been the sisters’ apprentice, now spoke up for the first time: “But the government should know, the TBAs are still assisting women.” Women came with their worries. “If they are not sure how many months pregnant they are they come to us, and we measure them and tell them.” Couples with marital problems sought good advice. “We are still a part of the community. The women still come.”

6

Fragile Authority

In proposing remedies for the crisis of maternal death, experts often shored up one kind of authority at the expense of another. Rivals made competing claims about the lethal dangers of particular places (inside or outside health facilities), people (such as doctors or TBAs), and therapeutic technologies (among others, cesarean and mwanamphepo). Dyna Ng’ong’ola and Kettie Pensulo contrasted their own careful work with Bernard Kaseko’s herbal treatments, which they saw as reckless. Meanwhile, health officials characterized the two women’s own practice as unsafe, eventually using their authority to enforce a preference for biomedical alternatives by shutting the TBAs’ clinic down. The first half of this chapter shows how competing claims about safety could contribute to danger. The second half turns to two policy changes intended to improve women’s safety: a moratorium on out-­of-­hospital birth and the people who once attended it, and the promotion of male involvement in antenatal care. Each of these policies was justified by narratives about maternal death. Each was sustained by a moral vision of good—­and inexpensive—­care. These policies may have reduced maternal death rates, although that is not clear. It is clear that they increased burdens for women and their families. They also extended patriarchal control over a domain that had once belonged to women. Birth as a Domain of Struggle All new humans come into the world through pregnancy and birth: one person becomes two during a struggle that is typically bloody and painful. Childbirth is socially essential. Often, it is profoundly joyful. Always, it is haunted by the specter of catastrophe. As Joyce Banda put it, “I have grown up in a society where, when a woman is pregnant, the whole village is anxious.”1

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Given the stakes, it’s no wonder that this process is a critical realm for contests over authority—­within and beyond Malawi.2 Medical anthropologists use “reproductive governance” as a shorthand to encompass the ways powerful institutions such as states, transnational nongovernmental bodies, or religious institutions achieve broader aims through the control of reproduction. Control over childbirth is particularly fraught. Contradictory judgments proliferate. Is birth a natural process or a medical emergency? Spiritually, is it the unfolding of a sacred mystery, a potential source of power, or a time of pollution? Is it properly supervised by women or by men? Do those who attend it possess mysterious arts, or hold dirty secrets? Who may take part? Who should address problems? Who must stay away? In Malawi, the answers to these questions—­and the maternity-­care alternatives for both pregnant women and policymakers—­took root in a ground of therapeutic pluralism and grew within the economic constraints of family and national budgets. Scarcity limited the reach of reproductive governance, dictating that interventions should be inexpensive—­better yet, free. Scarcity turned up the heat under a simmering sense of crisis, especially as the 2015 deadline for the Millennium Development Goals came near. Arguments over whose care was dangerous, whose care legitimate, what care was possible, and who was responsible spilled over into policy prescriptions and reconfigured control over birth. From the early 2000s on, policymakers’ interventions often entailed efforts to move births away from homes or the village sikelo run by azamba, and into the hospitals and health centers where skilled birth attendants worked. Radio campaigns and billboards, newspaper articles and village safe-­motherhood committees all joined the push for “facility birth.”3 (It was not called “hospital birth”; not all health facilities were hospitals.) Maternal deaths justified these campaigns. Exhortations to choose facility birth with skilled birth attendants, and warnings about the deadly dangers of traditional birth attendants, presumed these categories to be distinct and internally homogenous. There were real differences between so-­called SBAs and so-­called TBAs, but there were huge variations within each group and areas of overlap between them. Paths to Legitimacy In the cities, Malawians with reproductive-­health concerns had ready access to consultation with many different kinds of experts: nurses, asing’anga, herbalists, clinical officers, and others.4 It usually took more money to consult a doctor, but that was possible too. Even in rural Malawi, there were typically several different people from whom one might seek help with a pregnancy problem.

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Sources of legitimacy—­dreams, afflictions, family tradition, formal trainwere as plural as healing techniques. Professional ing, apprenticeships—­ titles did not always predict the origin stories people would tell when describing their careers. Some nurse-­midwives, while trained and licensed and possessed of the appropriate certificates, had been called to their profession in dreams. Some doctors were guided by God through serious illnesses of their own. Herbalists often began identifying medicinal roots through mystical revelations, but some had purchased therapeutic secrets or had learned through apprenticeships. A successful parent or grandparent might eventually share a small chipa­ tala and the necessary equipment, and hand it over entirely in time. Mayi Idah Mongolo had learned a few plant medicines from her grandmother: Me, in my work, I prepare trees. My practice is that of an herbalist doctor, not a dreamer or spirit medium—­because others in my field have dream revelations, but not I. And there are healers, too, that throw bones and burp to do a diagnostic reading. But I do not work like that; mine I just learned from my granny.

Mayi Mongolo knew only six trees, she said. But they were good ones, able to cure antepartum bleeding, threatened miscarriages, and other pregnancy problems in addition to the asthma treatments for which she was known best: “I am good at what I do, and if I put my mind to helping someone with these trees, they really get cured.” Others, especially asing’anga, gained their expertise through visions that accompanied personal suffering. Monetary and mystical routes to a healing career were not mutually exclusive. Doctor J. Makhukwa, for instance, had fallen ill, been treated by a Mozambican healer, learned his trade during a seven-­year apprenticeship, and at the end of it paid the healer a substantial sum to learn the final secrets of the oracle. Doctor Wasema had been healed of fits and paralysis by foreign spirits. While she treated pregnant women for various maladies, she did not attend births: “I do not allow expectant mothers to deliver their babies at my clinic, because I get my instructions from my ancestors, who dictate what I must do. At the moment, I am not allowed to deal with delivering babies.” That, she thought, might come in time. a z a m b a t o o k m a n y pat h s Paths to becoming a mzamba were equally variable. Consider Janet Rose Saikonde, Getrude Gwalangwa, and Abigail Daudi.5 I first spoke with each of them in 2007, a few months before their work was suddenly declared illegal.

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Janet Rose Saikonde’s calling had found her early. She was a girl in primary school when the fits and fainting began. When her seizures became too disruptive, she was forced to drop out of school midway through standard 3.6 Not long after, she said, “I kind of lost my mind, like madness. After that I underwent the traditional chanting ceremony where they sang and chanted for me, then I started going into the mountains, where I got my initiation and equipment for this trade. I started seriously practicing in 1993.” At age twenty-­one, “I got the full revelation regarding which trees to use, and I started also getting visions in dreams.” Doctor Saikonde attended only a few births a month. Her specialty was a treatment to turn a child in the womb to an optimal position for birth. When treatment worked, the pregnant woman would be expected to call her to attend the delivery. When it failed—­which was rare—­Doctor Saikonde would see the persistent malposition in her dreams and refer the mother to a hospital. Getrude Gwalangwa had been born in South Africa, where her mother was a birth attendant with a midwifery clinic in their house. “After I had two children of my own, then I developed an interest in this job,” she explained, “and I used to help my mother around the clinic at home to the extent that I used to deliver babies in my mother’s absence.” When Mayi Gwalangwa came to Malawi, she advertised her experience with childbirth and set up a small clinic of her own. By the time I met her, she had been practicing a few miles from the city center for nearly thirty-­five years. Mayi Daudi learned her job from her husband. “He was a traditional healer, so he knew a lot of herbal medicines—­whether for medicinal incisions, whether you have been magically hit with a hammer on the forehead, or for other things.” Her husband had attended some births, but thought a woman would be more suitable for the job. “So at one time he said to me, ‘Come, I will train you to be a traditional birth attendant.’ ” Mayi Daudi’s clientele was broad. She was especially well known in the neighborhood for reversing witchcraft. If a woman’s pregnancy, by some other people’s magic, remains undelivered up to, say, eleven months, they do come to me. They tell me that the pregnancy is stuck. So, I fetch some traditional medicines and make them drink it. Almost immediately, labor pains begin and she will go to hospital for delivery. Within three days, she will safely deliver, and no operation.

Some clients did not want hospital deliveries, however. Mayi Daudi was ready to help them too. When labor advanced without a problem, she said, “then we receive the child.” A few azamba moved between informal and formal sectors. Ganet Banthu, who had attended births around Pamtunda village for decades, told me she’d

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learned her skills as a young woman, when she’d worked “for several months as a nurse” at the mission hospital in Mfundo.7 In another village, a nurse-­midwife built a shelter and began delivering babies there after retiring from the nearby district hospital. This hospital-­trained and -­certified midwife became known locally as a TBA; eventually, over the course of several years, she trained a daughter without hospital experience or credentials to take her place. These women all shared the label TBA, but they brought very different experiences to birth work. When officials tallied health indicators, however, all of them—­in addition to Dyna Ng’ong’ola and Kettie Pensulo—­counted as TBAs.8 The bureaucratic label congealed an extremely heterogeneous group into a category. In the process, it also rendered stable the category to which the TBA was defined as “other”—­the skilled birth attendant (SBA). sbas were heterogeneous too Official definitions of “skilled birth attendants” stressed particular skills and knowledge, to be used within an environment enabling competent, high-­ quality care.9 In theory, this definition made sense. In practice, when officials wrote policies or assessed SBA coverage, occupational categories stood in.10 Policy stipulated that district hospital labor wards were to be staffed with nurse-­midwives, clinical officers, and doctors. Referral hospitals were also to have obstetricians. At health centers, the “skilled birth attendant” category stretched to cover medical assistants and enrolled nurse-midwives; each group had completed two to three years of postsecondary medical training, including some specific training in obstetric care. Protocol, however, was not practice. Poor staffing, minimal budgets, and high demand for hospital care led to considerable “task shifting.”11 One nurse-­ midwife I interviewed, technically in charge of the maternity ward, spent most working hours as the chief psychiatric provider at her small hospital. Several others ran outpatient clinics designated for clinical officers whose posts were unfilled—­or who were on the roster but away at trainings, or ill, or working in private practices. Laboring women on the maternity ward were left to HSAs or ward attendants for hours at a time. Sister K. J. Nyirenda, a nurse-­midwife, described the staffing at her busy urban health center: kj n : We have three registered nurses. We have five community health nurses, one psychiatric nurse. And, I think, five nurse-­midwives. In total we are almost thirteen. cw: Wow, that’s a lot.

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kjn: But one is sick and she’s always on-­off, on-­off. One is on maternity leave. The other is on leave; she went to another health center for relief duties. One has gone back to school for midwifery. She had only nursing, so she has gone back for one year for midwifery. And the other one, she’s not a midwife, she’s just a new nurse; she usually works in the dispensary. So she is out—­she has gone out for a training, too, in midwifery. cw: So in theory you have thirteen, but really there are eight. kjn: Yeah. But currently working, the number who are working is only three. In circumstances like these, with thirteen positions “filled” but only three people actually working, any employee who could cover a labor ward was considered better than no one. I spoke with several health surveillance assistants who had been pressed into attending births, despite no formal training in maternity care. Some described these experiences as troubling. Others, like the HSA Alex Kadzombe, were proud to contribute to a team effort: We do have the shortages with health personnel, so you can’t expect only the one who deals with midwifery to deal with the pregnant woman. Then that one cannot be assisted fully! We have to work hand in hand. . . . Lots and lots of people want to be assisted at a time, but the one to assist them? I mean, the ones to assist them, they are insufficient.

Nurse Lea Chabwera, who worked at the same busy health center as Alex Kadzombe, confirmed that people even less prepared than he—­cleaning staff, or ward attendants—­sometimes delivered babies there.12 The problem was especially acute at night, with one nurse on duty. I thought I’d misheard: one nurse for the whole health center? Yes! Who is supposed maybe to deliver eight to ten or twelve patients during the night?! There is only one qualified nurse, and there is a ward attendant. And sometimes three or four deliveries can happen at the same time. You find that maybe, heh, the unqualified one is delivering the patient. Because one nurse cannot manage three or four deliveries at one time. So I think it is difficult. And I think pregnancy is dangerous in Malawi.

Women might or might not know the qualifications of the staff who’d attended their births. Because SBA rates came from women recalling their own reproductive histories, hospital employees were likely to be tallied in official statistics as “skilled birth attendants,” whether or not they fit the technical definition. A ward attendant or cleaner who attended a birth in a hospital could be counted with SBAs. A nurse-­midwife who attended births in the com­

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munity could count as a TBA. Like TBAs, then, SBAs were heterogeneous in training, experience, skills, and even credentials. Whether they’d been credentialed by the government or called by God or both, guided by dreams or by granny’s knowledge or both, people who treated pregnant women frequently expressed confidence in their own techniques and denigrated the safety of others’ efforts. Claims of effectiveness could pit a single healer against another. One herbalist would boast that his medicines were stronger than a competitor’s, while another warned that a competitor’s medicines were too strong to be safe. More often, claims of effectiveness and safety pitted one category of expert against another. Herbalists claimed that their treatments, unlike mankhwala achizungu, always worked. Nurses contrasted their own safe care with the dangers of TBAs. In one case that I recorded, the mere involvement of a TBA was enough to close discussion on the cause of a woman’s death. Esme Lifa’s Story Esme Lifa’s life lasted twenty years. Her death took two days. She had come to the outpatient department of a teaching hospital complaining of pain and fever. Her last menstrual period, she said, had been about five months earlier. The intern’s very short admitting note listed only a tentative diagnosis: “? malaria ? septic abortion.” Neither a temperature nor a pelvic examination was recorded. Probably they had been done, but no one remembered by the time of the case discussion. The rushed intern ordered no medications. Perhaps he’d hoped that his patient would be evaluated more thoroughly when she arrived at the gynecology ward. That happened sometimes, but not for Esme Lifa: the only action the on-­duty nurse took was to find her a bed. A day and a half later, a different intern, Dr. Makano, did gynecology ward rounds.13 Esme Lifa worried him: her abdomen was rigid and her skin burning. This was no case of malaria. When ward rounds were done, the conscientious Dr. Makano loaded Esme Lifa onto a trolley and wheeled her down the hall to the operating theater. There he dosed her with anesthetic, dilated her cervix, and curetted her uterus. Her cervix appeared torn. The material he scraped out smelled foul. Both findings added support to his suspicion that her condition resulted from an attempted abortion. The antibiotics he started were too late. Not long after Esme Lifa was wheeled back to the gynecology ward, she died. Teams reviewing a case sometimes struggled to reach a consensus about a woman’s cause of death. Not so this time. True, Esme Lifa had received almost

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none of the tests a doctor might want. She never got an ultrasound. No blood cultures or wound cultures specified the infectious organism and assessed whether it had reached her bloodstream; no white blood cell count measured her immune response. The material Dr. Makano scraped from her uterus was not inspected under a microscope by a pathologist. She’d had neither a pregnancy test nor an HIV test. Still, the assembled clinicians agreed quickly that she had died from septic shock due to an unsafe abortion. Suddenly, one of the obstetricians began to laugh. “Isn’t this the one who came with a love note from the TBA?” The intern paged through the short file and pulled out a torn scrap of paper. He read aloud the words a traditional birth attendant had written in labored English: “I send Miss [Lifa] to hospital. She is five months. Look like she damaged her pregnancy. She need treatment.” A few people chuckled. Others stared stonily at the floor. The specialist laughed again. “A love note! We got a referral from the TBA!”14 Another obstetrician broke in coldly: “You may laugh, but it looks to me like the TBA made the right diagnosis and we did not.” The chuckling died away, but the case was closed. The involvement of a TBA was, for one obstetrician at least, the end of the story. The box for “TBA” was checked on the death-­review form, and the box for “use of traditional medicine / practices.” These check marks implied culpability—­even in this case, when a TBA had provided more careful care than we had. Crisis and Blame The discussion of Esme Lifa’s death was an extreme example, in which simply invoking the TBA seemed to one doctor to let the hospital off the hook. That degree of dismissal was rare. Workers inside and outside hospitals often chastised one another for unsafe practices, however. Birth attendants invoked not just the dangers of pregnancy and birth but the dangers of care. Some dangers threatened attendants themselves. In much of Central Africa, exposure to the blood of childbirth has been said to “kill the eyes.” The anthropologist Nancy Hunt heard this explanation frequently in Congo.15 Many years later I heard it from three women in Malawi. Wezie Njerengo, an initiation counselor who had attended a few births, regarded the idea as old-­fashioned: “There is a common belief that after I have helped a woman deliver a baby I must wash my face in medicine, but these days we do not follow that custom anymore.” Two azamba in other regions, however, did follow the custom, explaining that they still used protective mankhwala on their brows after a birth to prevent blindness resulting from the power of blood.16 Blood endangered workers in an additional way: exposure to HIV. Azamba and asing’anga had altered their practices in response to the epidemic. Asing’anga

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commonly cut small incisions into which they would rub medications; now they were careful to use new razor blades to cut these mphini. Many azamba stressed their need for gloves, perhaps hoping that I might supply some. Two only accepted clients who brought evidence of negative HIV tests. Inadequate supplies meant that hospital workers also had many exposures to infected blood. Scalpel handles were scarce; midwives typically cut episiotomies with small bare blades that kept one’s fingers uncomfortably close to the sharp edge. Curved surgical needles, difficult to grip with worn-­down needle holders, “danced” unpredictably toward the hands of surgeons and theater nurses. Antiretroviral drugs that could limit the risk of contracting HIV from a blood splash or needle stick were unavailable for years, and cumbersome to access for years after that. Most clinicians did the work that needed doing, either seeming resigned to their occupational hazards or making occasional bitter comments about the risks they were expected to take.17 Occasionally a doctor or midwife let fear overtake good clinical judgment. One doctor I worked with often canceled surgeries for women he suspected to be “chronically ill,” even if no one else was available to do necessary operations. Perhaps the dangers to clinicians exacerbated a sense of crisis that swirled around childbirth. The same obstetrician who canceled essential surgeries once declaimed to a group of students and interns that “women in Malawi should be counseled that to become pregnant is to sign their death warrant!” Experts based in health facilities and those working in neighborhoods often depicted unsafe motherhood as a political, moral, or public health crisis. “Older women are advising these young women that nowadays pregnancy is a [more] dangerous thing than before,” said Sister K. J. Nyirenda. “Because there are so many maternal deaths nowadays. And there are so many, you know, injuries during birth, or after delivery. . . . The women may be disabled.” Betty Dzimbiri, an elderly initiation counselor who described birth as “very dangerous,” elaborated: “During our time we used to deliver our babies at home—­in my case I delivered all six children at home, no complications—­but these days you cannot do that. Most pregnancies result in operations. Yes, to give birth is to be in danger here.” Betty Dzimbiri’s comment was not unique in conflating danger with surgery. The initiation counselor Amos Jere said flatly that pregnancy and birth in Malawi were perilous: “Especially when it is young girls involved. Early pregnancies are dangerous, as they result in cesarean operations to deliver the babies, as their bodies are not mature and ready for the task of pregnancy.” Not everyone saw maternity as crisis, or surgery as saving. Mayi Abigail Daudi, the mzamba trained by her husband, scoffed at doctors’ quick recourse to scalpels. Yes, she said, sometimes women were small, babies were

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large, and the path for birth did not open wide enough at first. At the hospital, yes, an operation might be advised. But that was a dangerous course. “Here in the villages,” she explained, “we have medicine. We sprinkle it on her according to our knowledge. And some she drinks. That’s all. The way widens up adequately for the child without trouble.” Contrast two assessments of pregnancy’s dangers, from two people in the same neighborhood. The mzamba Ruth Welemu had been practicing for many years. Even when talking to a mzungu doctor, she was quick to disparage hospital care. The most dangerous mistake a pregnant woman could make, she said, was to fill her mind with fear and rush to the chipatala. There one would find trouble—­and unnecessary cutting. Not far away, at the neighborhood health center, the HSA Owen Kamfoloma urged women to steer clear of the TBAs: “Their baby can easily die, even the mother due to bleeding. Even there are also traditional birth attendants who are not well trained. So if [mothers] go there, they don’t give enough care to them: the baby can die, and also the mother.” Part of the cultural work that talk of maternal death accomplished was to mark certain kinds of care as dangerous. What kind of care was too much, or not enough? What kind of people were best suited to mitigate danger? These questions were not unique to Malawi. Worldwide, contestation over birth has very often involved attempts by medical people to remove it from the hands of women depicted as old, unclean, backward, or witch-­like. Worldwide, it is often very difficult to disentangle medical opposition to out-­of-­hospital birth from patriarchy and from profit-­seeking. The depiction of a repulsive and dangerous female “other” contrasts with a biomedicine deemed new, clean, modern, rational—­and masculine.18 Worldwide, although a biomedical approach to pregnancy and birth has become dominant, challenges to medical authority over birth persist. Outsiders claim that medical institutions are neither safe nor benevolent, and that medical control of birth can cause serious harm to women even as it can also save lives. In Malawi, under intense scrutiny over the nation’s poor track record in maternal health, maternity workers blamed one another for dangerous actions—­or unsafe inaction. A few senior nurse-­midwives considered TBAs to be essential to rural maternity care. Most clinicians who spoke to me about out-­of-­hospital birth, however, saw it as unacceptably hazardous. Several characterized the practitioners who worked in that context as dangerous or backward.19 The azamba I interviewed could be just as critical of medical personnel. While some allied themselves closely with the hospitals, proudly recounting earlier training or friendly relations with local health care workers as testament to their own legitimacy, others denigrated the quality,

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respectfulness, and safety of in-­hospital care. TBAs reported that women languished in clinics waiting in vain for assistance, or were treated rudely, or were sent away if they’d failed to bring along a clean razor blade to cut the umbilical cord or a cloth in which to wrap the newborn.20 As Kettie Pensulo noted, “Some women even eloped from the hospital to come give birth here because the nurses were very harsh with them. No. You must welcome her.” From the perspective of workers outside the formal sector, the dangers of the hospital included risky surgeries.21 Stories circulated about sterilizations done without consent at a woman’s second or third cesarean, once an unwritten rule among surgeons in Malawian hospitals.22 Dangerous surgeries also included unnecessary cesarean sections—­which several informal-­sector practitioners reported were especially common among the youngest pregnant women—­and episiotomies. Herbalists, counselors, and TBAs often reported that they had to teach women who’d had episiotomies or cesareans to apply mankhwala to avoid scarring. Some boasted of remedies that could help a woman avoid unnecessary and dangerous operations altogether. Mama Thokozire, an elderly mzamba who’d given birth to sixteen children of her own, used a poultice of cooked wild fruit to open the path for birth when labor grew difficult. Janet Rose Saikonde used the more widely known mwanam­ phepo to get labor going when it wasn’t happening on its own. She had other medicines that could turn a breech baby or a baby that couldn’t “find the birth canal,” two scenarios that in hospitals often led to surgery. She did not attend many births, she said, but once she got a labor started, her treatments never failed. Techniques like Janet Rose Saikonde’s were controversial: was mwanam­ phepo the solution to the dangers of labor, or a danger in its own right? Like every other clinician I’ve asked in Malawi, I have seen women hospitalized with extremely strong contractions, fetal distress, and even uterine rupture related to the use of herbs for labor induction. Just as azamba sometimes saw both neglect and excessive intervention as dangers of the hospital, medical personnel charged TBAs with both inaction and overzealous action. One common complaint was that TBAs caused obstructed labor by failing to intervene when women labored for days with in­­ effective contractions. Another concern was that they administered man­ khwala in unregulated dosages that were often far too powerful. Some herbalists scoffed at this perception—­or blamed clients for incorrect dosing. Mafumu, for instance, explained that “every time that I am administering medicine, I taste it myself, just to have an idea of the effect of the medicine. We just don’t give medicine any which way. . . . I stress on the dosage as well. If they follow what I tell them, then it’s fine, but if they mix wrongly, then it becomes

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poisonous.” A few TBAs, including Kettie Pensulo and Dyna Ng’ong’ola, distanced themselves from those who gave such medicines. What was a pregnant woman to do, when claims of superior efficacy and claims of serious danger both circulated in her community? Where should she seek assistance, and from whom? Women often faced hard choices, their difficulties magnified by the blame that hovered and the scarcity they were likely to encounter with either form of care. Many voted with their feet: they absconded from hospitals to consult TBAs, left care with TBAs to attend at health centers, or even (for those with resources) sought out private care. In the high-­risk antenatal clinic at Queens one day in 2007, I spoke with a twenty-­three-­year-­old woman late in her third pregnancy. Christina Chilundu had been a teenager in Zimbabwe when she got pregnant the first time. Perhaps it is not surprising that a teenage primigravida got a cesarean section for cephalopelvic disproportion, given the many stories about young girls unable to give birth “naturally.” When she moved to Malawi and became pregnant again, the obstetrician who saw her at Queens considered her to be an excellent candidate for a vaginal birth. She wasn’t particularly small, and her fetus didn’t seem particularly large. She’d have a good chance at a normal birth, the obstetrician told her, as long as she went into labor in a place she could be monitored closely. Queens, however, turned out not to be such a place. Christina Chilundu went into labor on the antenatal ward and ruptured her uterus while waiting for a doctor’s evaluation. Taken for a repeat cesarean section, she had a “fresh SB,” the abbreviation used to indicate a fetal death (stillbirth) in labor. I’d been working at Queens at the time she ruptured on the ward, but didn’t remember the story, which wasn’t all that uncommon. A year after her uterine rupture and the intrapartum death of her second child, Christina Chilundu’s first child died. Now she was pregnant again, nearing her due date, with no living children and a badly scarred uterus. I explained that because she’d had two cesarean sections and a uterine rupture, it was dangerous to try for a vaginal delivery: her weakened uterine wall could rupture again easily. She should be admitted to the antenatal ward—­the same ward where she’d ruptured her uterus four years ago—­and I would schedule her for a repeat cesarean section as soon as we could be confident that the fetus was really at full term. I thought I was convincing, even though the long lines of women waiting in the high-­risk clinic meant I did not take as much time to talk it over as would have been ideal. I thought she had agreed to my sensible plan. Christina Chilundu headed off toward the antenatal ward, clutching her health passport in her hand. But when I went to find her, that day, and the next day, and again the next week, the nurses told me she had never shown up. Long

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after her due date had come and gone, no one with her name was admitted to our unit. I have no idea what happened to her. Maybe she scraped together funds to go to a private chipatala. Maybe she found a TBA like Mayi Daudi who was unafraid of a woman with scars. Maybe she simply labored and gave birth at home, probably uneventfully, perhaps catastrophically. Mercy Kumwenda’s Story Catastrophes did happen. When I first heard about Mayi Mercy Kumwenda, she was already dead. Mayi Kumwenda had come to the hospital in active labor, but after some hours her contractions subsided into almost nothing. One might, in such a circumstance, simply wait: usually labor will pick up again, although not at the pace the partograph and the crowded labor ward demand. One might instead suggest oxytocin, a synthetic version of a hormone involved in labor and birth. Given intravenously, it can stimulate contractions. The dosing is tricky, however. Too little and nothing happens. Too much and contractions can be so overwhelmingly strong that a fetus becomes distressed or a woman’s uterus ruptures—­more likely when a woman has had many previous births or a previous uterine surgery such as a cesarean. Everywhere I’d worked in the US, oxytocin was given through automated pumps that meted out the drug meticulously. Malawi’s public-­sector hospitals did not have pumps: the only way to dose a finicky drug was to calculate the rate at which fluid dripped through the IV, using a small roller to pinch the IV and slow the flow or open the IV and speed the flow. It’s a relatively crude method, and labor intensive, but it works—­at least, as long as nobody miscalculates the rate, or bumps the roller, and as long as the laboring woman doesn’t move her arm in such a way that the IV needle changes position. Given the dangers of the drug and the imprecisions of its dosing, oxytocin was restricted in Malawi. Hospital policy stipulated that it should never be given to women with a prior cesarean section, nor to a woman with more than five previous births. Mercy Kumwenda was on her ninth. Instead of oxytocin, the clinician on call recommended a cesarean section. I don’t know whether that conversation seemed as reasonable and clear and convincing as I thought mine with Christina Chilundu had been, or whether it was rough and peremptory. Nurses said later that the clinical officer had presented the cesarean as a command: no alternative. I don’t know whether Mayi Kumwenda was afraid of surgery or whether she simply thought it unnecessary. I only know that when the nurses came to get her to take her to the operating theater, she had disappeared.

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The next time anyone in the hospital saw her, she was dead. Her distraught husband had brought her in on a minibus. She’d gone to the TBA, he said, to drink medicine that would bring her labor contractions on again. The concoction worked, as Mafumu and Janet Rose Saikonde and others said it always did. Her contractions overpowered her. The TBA called Mr. Kumwenda to come take his wife to the hospital, but it was too late. Mercy Kumwenda’s death became a morality tale at the hospital. For some, the moral was “See what happens when you use a TBA?” For others, it was “See what happens when a woman has no choice?” Perhaps in a hospital with intravenous pumps, she could have received a small dose of oxytocin instead of a large dose of mwanamphepo. Perhaps in a hospital with better staffing, the clinician could have spent enough time with her to assess her concerns carefully. Perhaps with a less crushing patient load, her autonomy would have outweighed the need to keep labor moving in accordance with the lines on a sheet of paper. Perhaps a city with a robust ambulance system could have gotten her to the hospital in time. Perhaps, had supervisory visits for TBAs persisted, the TBA would have been more circumspect about administering mwanamphepo. Perhaps none of these things would have mattered—­but they might have. Christina Chilundu’s case ended, for me, with a question mark. Mercy Kumwenda’s ended with a series of questions about what could have been different in a system where women had choices other than to disappear, a system with enough time and staff for careful care, a system less polarized between in-­ hospital and out-­of-­hospital treatment. The Rise and Fall of TBAs A public health sector characterized by scarcity justified extensive task shifting and made both hasty care and outright neglect inevitable. Inadequate staff, tight budgets, and overwhelming patient loads smoothed the paths to Esme Lifa’s death from neglect, to Christina Chilundu’s ruptured uterus in her second pregnancy, and to Mercy Kumwenda’s flight from callous care to lethal treatment. Not long ago, the same concerns drove the medical creation and support of traditional birth attendants—­the very TBAs who later became medicine’s enemies in the fight for safe motherhood. a who invention Public health consultants had mentioned people called “traditional birth attendants” as early as the 1950s.23 In the 1970s, World Health Organization

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personnel codified the category, advocated for its potential utility, and provided the acronym TBA as a bureaucratic shorthand. The TBA, an influential WHO document specified, was typically a respected older woman, nearly always past menopause, who had herself borne children: She lives in the community in which she practices. She operates in a relatively restricted zone, limited to her own village and sometimes those immediately adjacent. Her role includes everything connected with the conduct of childbirth and this is the sphere in which she holds most power and authority.24

WHO’s planners saw the TBA as a partial solution to a number of vexing problems, particularly in Asia and Africa: weak maternal-­child-­health infrastructure; poor transport from rural and remote homes; health care personnel inadequate in number and reluctant to work in rural areas; lack of community participation in health programs; the often-­poor fit between biomedical routines and customary childbirth practices; and—­perhaps most of all—­little money for health services. If health ministries could train TBAs in the rudiments of safe maternity care, WHO planners argued, these programs could allow “the extension of health care coverage through optimal utilization of local resources” while blending the biomedical and the traditional in a way that communities would accept.25 The concept of “the TBA” simplified a complicated reality. For one thing, not all birth attendants were women. Like Mayi Abigail Daudi’s husband, some men attended births in a range of African communities; in a pilot program in Senegal in the 1970s, more than 40 percent of the birth attendants identified were men.26 Also, people attending village births brought widely variable experiences, skills, and sources of legitimacy to the task. Of the azamba I’ve described, Dyna Ng’ong’ola and Kettie Pensulo were probably the closest fit to the WHO’s imagined TBA. In Malawi and areas nearby, a “luck mother”—­that is, a mother who has fortunately achieved her wish for a pregnancy—­should deliver with the person who made her pregnancy possible by reversing witchcraft-­ related reproductive evil or administering herbal treatments. These specialists were people like Mayi Daudi, who used herbal treatments to reverse magical impediments to delivery, or Janet Rose Saikonde, who diagnosed breech pregnancies in her dreams. They were not at all the biomedical health extension agents that the WHO’s planners envisioned, and they might attend only a few births per year. Experts like Getrude Gwalangwa had attended hundreds of births over the course of many years.27 Many “TBAs” selected by chiefs for training, however, had been present only at one or two births among kinswomen. Many clinicians and some policymakers knew how heterogeneous the people newly called TBAs were. Concerns about how their differences might

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play out in practice, however, did not diminish widespread enthusiasm for their potential to extend basic primary care to the poor. A 1973 WHO conference laid out key principles that should be taught to TBAs. Model plans for their training and supervision were distributed to regional offices by 1975.28 In 1979, Malawi became the first African nation to implement plans to train every TBA. In 2007, Malawi became a pioneer again by imposing a legal moratorium on TBA practice, in some cases instituting fines for women who sought to deliver with TBAs. The specifics of this history altered many women’s births, lives, and livelihoods. The rise and fall of traditional birth attendants in Malawi and elsewhere also serves as a cautionary tale. Some global health schemes today invest high hopes in community health workers, imagined to extend appropriate, sensitive, and inexpensive care to people in remote low-­income communities beyond the reach of doctors and nurses.29 These hopes echo the aspirations for TBA training programs decades ago. b e g i n n i n g s : t b a p r o g r a m s i n m a l aw i The Scottish obstetrician-­gynecologist Colin Bullough, working within Malawi’s Ministry of Health, devised a training program built on the WHO model. Bullough described TBA training as “a good example of the new concept of primary health care, the aim of which is to improve the standard of rural health by recruiting ordinary villagers as health workers, thus bringing the health services within the reach of everyone.”30 The curriculum he wrote was to solve the problem of rural maternity care in Malawi by making village women into maternal health extension agents. As an incentive, each TBA who completed the program was to be given a delivery kit. The graduates were neither to be paid nor to be compelled to compile “oppressive paperwork and reports,” a plan intended to “preserve their dignity” (nearly all would have been illiterate) and to keep costs down.31 In each district, one senior nurse-­midwife was to coordinate trainings and supervision. Refresher courses were to be offered on a regular basis. Ongoing supervision would ensure that TBAs maintained their skills and used their training wisely. Faced with severely limited budgets and ever more women seeking care, policymakers saw TBAs as “an important link in the chain of health personnel providing primary health care in Malawi.”32 Ten-­year health plans and strategy papers depicted them as integral to Malawi’s maternal and neonatal health policy. For some twenty-­five years, TBAs were registered (although never entirely), trained (although never at a grand scale, despite the best-­laid plans of the Ministry of Health), and supervised (although never consistently).33

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i n s ta b i l i t i e s In fact, almost no element of this training and supervision program stayed stable over time or place, and almost no element worked out on the ground the way it had been designed to on paper. These instabilities had everything to do with the problems for which TBA training had been intended as a solution. Limited budgets, long distances, and lack of health care personnel ensured that the referral systems on which TBAs were to depend remained nonfunctional, and undermined TBA training and support.34 By 1987, the standard training program had shrunk in both duration and content. It prioritized lectures on hygiene, normal and abnormal labor, and identification of concerns that would mark a woman as “high risk”—­and therefore better off delivering at a hospital. This didactic training was poorly suited to people accustomed to learning by doing: no lab, apprenticeship, or simulation component allowed trainees to practice their skills. Lectures were to be followed by a period of observation in a health center or district hospital, but the observation period was inevitably brief, and sometimes limited to a tour. At four weeks, this curriculum was already short. It was often cut even further for lack of funds, or lack of clinical staff to lead it—­especially after structural adjustment curtailed staffing. In practice, “trainers” were often inexperienced. The original plan specified that senior nurse-­midwives or community health nurses should train TBAs. But remember K. J. Nyirenda’s clinic, with three nurses doing the work of thirteen, and imagine where TBA training would fit into a list of urgent needs. Training programs inevitably got pushed down the medical hierarchy, often at the last minute. Trainers had little or no pedagogical preparation. In many cases, they were health surveillance assistants who’d themselves had minimal maternal-­child health education and might never have seen a birth. Supplies and equipment given to TBA training–­program graduates were donor dependent and therefore unpredictable. Bullough had intended each kit to include a plastic apron, a plastic sheet, a pair of scissors, a metal basin and two stainless steel bowls, clamps that could be used to sterilize instruments by holding them in boiling water, a scrub brush, gauze, soap, cotton wool, and antimicrobial eyedrops for newborns. Some TBAs actually did get these, in packets donated from UNICEF. Some were even supplemented with useful tools like kerosene lamps. Kits depended entirely on what donors would provide, however. One I saw included only the two stainless steel bowls and some packets of gauze. On the other hand, TBAs were not to get medicines, but many did. Several of the TBAs I spoke with reported

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that health surveillance assistants in their areas brought them iron tablets or malaria treatments to give to clients, in some cases even years after the legal moratorium on TBA care. Supervision ranged from limited to negligible. The planned on-­site supervision of TBAs rarely happened in practice. Nurse-­midwives to supervise were scarce, fuel and vehicles to get to remote locations even scarcer. When rural TBAs did get a visit, it was almost always by a health surveillance assistant: TBAs who spoke with me about health workers’ visits consistently mentioned HSAs, not nurses. If these visitors were not the birth experts envisioned by Dr. Bullough, however, they were often community experts. In some cases, TBAs and HSAs developed cordial and collegial relationships—­ like that between Mama Lillian Siska and Mr. Pious Muleko—­and in some cases, these relationships persisted long after the formal ban on out-­of-­facility birth. As the new relationships between TBAs and HSAs indicate, even in their truncated forms, TBA training programs had social side effects. Programs often created social relationships between the trainers and the trained. TBAs I spoke with who had been through trainings considered these relationships to be the most valuable aspect of the programs. After trainings, they could ask advice from someone who knew them by name and reputation. Some former trainers agreed: after trainings, they knew who was reliable in a community and how to reach women there.35 Dr. Bullough had hoped that the training program he’d designed would improve TBAs’ success and influence. It probably did. A surge of construction followed the first course arranged by the Ministry of Health, as TBAs erected, extended, and improved clinics. Some built labor beds like the one Dyna Ng’ong’ola and Kettie Pensulo used—­although trainers had not suggested doing so.36 Throughout the decades of training, national rates of TBA-­attended births rose, while births attended solely by kinfolk dropped.37 As it did in Nepal and elsewhere, training in Malawi created a new category of specialist. The plan had been to draw from a pool of older azamba imagined as already there, already experienced with birth, already respected members of the communities to which they would return. Some new TBAs did fit this description. Bureaucratic and pedagogical considerations ensured that many did not. Each district, no matter its size, was encouraged to train ten TBAs per year. Not all districts had enough women known as azamba to maintain that pace. Besides, elderly women who had attended many births were not always receptive to trainers’ instructions. Younger women with more enthusiasm than experience were often selected to become TBAs, the training their legitimation to start a new career.

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did it make a difference? Malawi’s TBA training program, for all its instability and corner-­cutting, lasted for a quarter century. Concerns about its efficacy never went away, however: did it actually make pregnancy and birth safer? When skepticism about the beneficial impact of TBA trainings increased among international policymakers, those concerns prompted action. An ever-­greater emphasis on “evidence-­based” practice shaped health interventions internationally by the late 1990s. Only certain kinds of evidence could support policy recommendations. Evidence had to be quantitative, amenable to statistical analysis, and large scale. Randomized controlled trials played central parts; qualitative studies, if they appeared at all, were bit players; historical and ethnographic evidence was offstage entirely. TBA programs were extremely difficult to evaluate on these terms. A systematic compilation of research covering three decades of training programs provided little evidence that they improved maternal or newborn health, or even survival.38 Faith in training programs faltered, as did faith in TBAs as inexpensive agents of safe motherhood. By the mid-­2000s, the WHO deemed TBA training a dis­­ appointing failure, and most donors withdrew funding.39 In Malawi, the already struggling programs for training, supervision, and support withered as donor funds evaporated. The Ministry of Health stopped supporting TBA programs, although some district health offices continued to make them a priority. Simultaneously, another pressure was at work. As the countdown to the 2015 Millennium Development Goals got underway, international and national news sources drew attention to Malawi’s terrible maternal mortality statistics. Political leaders needed to do something about the problem of maternal death. a m o r at o r i u m a n d i t s a f t e r m at h That something took the shape of a ban: an edict issued suddenly in late 2007 prohibited TBAs from attending any births at all.40 Community leaders—­ the various village heads, group village heads, and “traditional authorities” collectively known as chiefs—­were to enforce the moratorium. Chiefs instituted bylaws and levied fines—­sometimes for any TBA found attending to a woman in labor, sometimes also for women who gave birth with TBAs, and sometimes for anyone reporting a maternal death outside a health facility. The fines, often in cash or livestock, could be substantial. The nationwide ban did not last long. In 2010, with little evidence that maternal health had improved or deteriorated in the intervening time, President

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Bingu wa Mutharika proclaimed that the ban was over—­without consulting the Ministry of Health. Some TBAs returned to health centers and district hospitals asking for assistance, gloves, and medicines. But doors generally remained shut. Some nurse-­midwives and doctors experienced the legal moratorium as a relief. It had allowed them to stop supervising, registering, or training traditional birth attendants—­liaison services they saw as legitimizing dangerous practices. One physician and one nurse-­midwife also noted that TBA trainings had allowed the government to be “doing something” about maternity care at very little expense and without training badly needed additional biomedical personnel. Since the ban, links between the formal health sector and TBAs, never especially strong, had broken entirely. With rare exceptions, clinicians and administrators working at district health offices and hospitals had little will, no money, and no mandate for continued support of TBAs after the moratorium ended. TBAs’ legal and social positions became even more precarious in 2012 when Joyce Banda assumed Malawi’s presidency. As described in the previous chapter, Banda fought hard for safe motherhood. She delegated much responsibility to chiefs, publicly celebrating those who tried new approaches—­such as, for instance, developing bicycle ambulance systems in their communities. This strategy was a clever one. Granting power to the chiefs ensured that a range of approaches to improving maternal health could be tried out, rather than committing fully to any one strategy that might fail. It also bolstered Banda’s support among the nation’s “traditional” patriarchy, some of them ill disposed toward a woman president. Traditional authorities were ready to demonstrate that their leadership was essential to the public good. In the southern district of Phalombe, for instance, Traditional Authority Mkhumba was quoted in the weekly newspaper as saying, “Our women are dying, and we as chiefs have a responsibility to protect our people.”41 Banda’s vocal support for institutional delivery effectively reinstated the TBA ban. For many chiefs, the TBA was an obvious target for local bylaws. Like other “harmful traditional practices,” birth with a TBA was a backward custom from which women should be freed.42 Bylaws banning birth outside medical facilities could be enacted immediately and did not cost chiefs any money. They could even bring in money. Once again, TBAs and their clients were publicly vilified. Once again, they were fined. And once again, some TBAs simply stopped working while others continued secretively. lessons learned From the moment of its invention, “the TBA” was always a category simultaneously enticing and threatening. Positioned on the edge between voluntary

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and paid labor, TBAs were enticing to health planners looking for a cheap way to extend care to the poor: families, not the government, paid them. They were threatening lest they demand state compensation.43 Their presumed closeness to the people they were to serve was enticing in its promise of culturally sensitive care. It also threatened to open doors to practices thought of as superstitious, ignorant, or harmful. TBA support was an enticing yet threatening performance of a certain kind of health care system. Trained TBAs initially symbolized the promise of state scale-­up, including Africanization of the health workforce. As the decades passed, they became excuses: they allowed governments and multinational organizations to “do something” without doing something expensive. Ultimately, they came to be embarrassing testaments to state failure. TBAs were enticing and threatening to ordinary villagers who might seek them out for care too: accessible, welcoming, not too expensive, and unlikely to propose frightening and unwanted surgical interventions—­but also old-­ fashioned, sometimes thought of as backward, and sometimes suspected of witchcraft. After the legal moratorium went into effect, they became threatening in a whole new way: one could be fined simply for seeking them out. Policy reports often include descriptions of “lessons learned.” One lesson learned from the rise and fall of “the TBA” in Malawi is that the category itself held contradictions in tension. Those contradictions probably made the hopes invested in TBAs possible, and their disappointment inevitable. Trained TBAs were not just at an imagined boundary between traditional and biomedical. The whole category was a product of bureaucratic boundary-­ drawing that never matched up with what was actually happening in practice. Social Iatrogenesis and Male Involvement Policies that legitimated certain kinds of expertise and depicted others as dangerous fractured relations between people working inside and outside of hospitals. Those fractures could harm individual women, as the first part of this chapter described. The next section turns to harm at the social level. We could think of it as social iatrogenesis: policies intended to improve medical well-­being—­the ban on TBAs, the turn to “male involvement,” and the reinvention of the community midwife—­enacted gendered social harms. Decisions about birth in Malawi’s rural landscape, once under the control of older women, were increasingly laid in the hands of men. One morning in 2007, the busy maternity ward where I was working faced an unexpected demand: a father insisted on being present for the delivery of his child. It was not long after I’d first met Dyna Ng’ong’ola and Kettie Pensulo,

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and only months before the surprise announcement of the TBA ban. Until then, I’d never even seen a man accompany his partner to the antenatal clinic. The exclusion of men from spaces where pregnancy care happened was so routine it drew no notice. Husbands were not allowed in the labor ward at Queens; nor was any other family member or friend.44 Women labored and birthed without anyone they really knew, accompanied by a trained midwife or a half-­trained medical or nursing student or an untrained ward attendant, or—­all too often, especially at night when the staffing was thinnest—­ completely alone. Curtains on the labor ward’s cubicles were rarely drawn, leaving fourteen women at a time more or less exposed to the view of staff and one another. A husband’s presence there was out of the question. But this man’s wife needed a cesarean section, which happened in a separate operating room. He had confidently asserted his right to be present, video camera and all. Whether it was the magic of his polished English or his necktie or his mention of fathers’ rights in South Africa or his general aura of privilege, he had prevailed. So there he was, over by the anesthetist, filming as I pulled his newborn out of the mother and as the nurse examined and wrapped the baby. Among the staff, his presence elicited consternation. Why would a man want to be there, and with a camera? And yet . . . he seemed so up-­and-­coming. “The new Malawian man,” the anesthetist said. I could not tell if the comment was ironic or admiring. Ten years after this encounter, in 2017, I arrived at Zayamba Health Center on antenatal clinic day. A pregnant woman waited in the consultation room, another in the examination room. Next to each sat a man. Neither man wore a tie, spoke English, or held a video camera. Neither appeared up-­and-­coming, privileged, or even particularly comfortable. Like most people in rural central Malawi, they were farmers. Sister Delhia Msukwa, the small facility’s nurse-­ midwife, explained that the government had been pushing for “male involvement.” The major purpose was to encourage HIV testing, she said. It also allowed her to convince men to arrange transport. Women might have to travel a long way to deliver at the health center, which was required now. The TBAs had been banned from practicing, and the chief in Zayamba had imposed heavy fines on anyone who delivered outside a health facility. In the decade between these two moments, maternal health policy had changed dramatically. The TBAs once held up as the solution to a vexing problem had become a vexing problem to be solved. Male partners, meanwhile, had gone from irrelevant curiosities to essential maternal health “champions.” A man who accompanied his partner to the clinic or cared for an infant might still elicit remarks in tones of congratulation sharpened by an edge of derision: “Ah, but you are doing jenda [gender].” Yet such actions

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seemed also more and more common, and less and less likely to draw comment. They were even enforced. Sister Msukwa explained that midwives in health centers had been told that women who brought husbands along should be seen “fast and first,” while other women were pushed to the back of the queue. This strategy was both an incentive for male participation and an acknowledgment that men had many other demands on their time. Sister Msukwa enforced the policy strictly. She also chastised women who came for routine visits—­or who presented in labor—­without a husband. These changes and enforcement strategies were not unique to Malawi. Similar policies elsewhere were built on a WHO push for “male involvement in reproductive care,” which in turn arose from a resolution at the 1994 Cairo conference on population and development. One might be tempted to characterize Malawi’s male-­involvement policy as a set of moral norms about good fathers and partners that traveled from north to south in the briefcases of global health experts. That conclusion would be hasty. The Cairo resolution itself was in part a backlash, led by feminists from the Global South and allies from the North, against a long history of efforts that barely hid population control agendas under the cloak of reproductive health.45 The push for male involvement was homegrown in many ways, promoted by leaders in Malawi’s powerful and exceptionally well-­educated nursing profession.46 Privately, nurses sometimes spoke of male involvement as a path to equitable gender relations. In public venues, however, they typically argued for the policies’ potential to reduce both HIV transmission and maternal mortality. Clinicians who worked directly with pregnant women knew that HIV testing was a common reason for avoiding antenatal care: many women dreaded bringing a bad diagnosis home to a partner.47 In theory, a couple who attended the first antenatal visit could get counseled together, tested together, and counseled again. Research in other countries had suggested that this strategy might reduce mother-­to-­child transmission of HIV. Men could support women’s adherence to medication regimens and infant-feeding choices, fending off challenges by in-­laws. Advocates for male involvement hoped that women could secure the infant-­health benefits of testing while avoiding the marital downside. In the late 2000s, the push for male involvement began. As with the TBA ban, much of the implementation was left to chiefs, sometimes working with health administrators in their districts and sometimes at the side of NGOs with reproductive health interests. For instance, UNICEF sponsored a competition in one district in 2008: which community could get the most men into the clinic with their spouses? Men’s participation increased dramatically. People’s likelihood of agreeing to HIV testing improved too—­although it was

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also a time during which antiretroviral therapy for HIV was rapidly expanding in the district, and more people get tested when they can get treatment. Lucy Kululanga and colleagues, investigating the implementation, raised concerns. During the UNICEF competition, chiefs vying for the prize outdid one another with fines and bylaws.48 These coercive actions seem to have been the key to male involvement in many communities in which people complied without enthusiasm or commitment. Ordinary men and women in Mwanza’s villages and towns described the male involvement push as one more new government law—­probably one instigated by foreigners. Women who spoke to the researchers expressed disapproval about men’s intrusion in an arena formerly under women’s control. As one said, “Remember that there are some things for women only. Our tradition is that men should not witness childbirth. Do not bring foreign ideas into our culture.”49 m a k i n g a pat r i a r c h a l b a r g a i n The male involvement policy, like the ban on TBAs, cannot justly be called a foreign idea. Neither arrived from outside somewhere in a visitor’s briefcase or flash drive. Both sets of ideas moved across national borders. Malawi’s policies inspired similar policies elsewhere, and were inspired by resolutions, proposals, and conversations beyond Malawi’s borders. Neither came to an empty landscape. Both policies drew from changing and circulating imaginations about what it meant to be moral, equitable, modern—­what it would take to move from a problematic past to a good future. Both policies took root in a moral landscape already shaped by the circulation and exchange of ideas about what healthy communities and safe motherhood were, and what it took to make them happen. Some of these ideas had been taught with the “life skills” curriculum in Malawi’s primary and secondary schools. Some came with David Livingstone’s bundle of surgical tools and his Bible two hundred years ago. Some were considerably older. Connections between the moral health of the body politic and the bodily health of mothers and infants were as old as the wâkongwe figure, described in chapter 1, who taught boys their responsibility for safe reproduction within their families and their communities. Both the push for male involvement and the ban on traditional birth attendants were moral responses to the moral crisis of unsafe motherhood and newborn death. They were intended to make birth safer for women and the first weeks of life safer for their newborns. They may well have done so, although it is difficult to be certain. They were also struggles over authority, waged in the public domain. Women lost. Together, these policies exerted a sub­­

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tle shift, increasingly taking the control of birth out of the hands of women and placing it into those of men. The geographer Mark Hunter has used the term patriarchal bargain, in a very different context, to describe effects of migrant labor on domestic gender roles in South Africa.50 I borrow his term here because I think it encapsulates how some architects of these policies gathered support and mobilized implementation. In a bid for safer motherhood and a better society, these policies underwrote male power—­in particular, the power of Malawi’s traditional chiefs. Not all chiefs were male, of course, but all the traditional authorities who took central roles in safe-­motherhood efforts were. Every reference to a chief who enforced bylaws against home births, both in conversations during my fieldwork and in journalism I’ve found on the topic, was about a male chief. In contrast, in two of the three districts where azamba told me chiefs turned a blind eye to their continued practice after the ban, the chiefs were women. Male traditional authorities did not resist the enhancement of their own power when the chance came to extend it into the realm of birth, a realm formerly overseen by female elders.51 Joyce Banda’s move to improve maternal health through alliances with both international safe-­motherhood NGOs and powerful male Malawian traditional authorities can also be seen as a patriarchal bargain. Augmenting male power served other interests. Getting the chiefs behind her was necessary if she was to survive the presidency at all; making her name in the global-health world ensured her a legacy and opportunities even after her short presidency was over. She elevated Chief Kwataine of Ntcheu to the position of senior traditional authority and put him in charge of the nation’s safe-­ motherhood efforts. In this capacity, he encouraged other chiefs to improve maternity care. Like Banda, he, too, gained a national and international profile. Appearing on the newspapers’ front page, at ceremonies and meetings, and in New York at the side of Oprah Winfrey, he was a tireless advocate for safe motherhood who cut a powerful figure. I do not mean to suggest that these bargains for legitimacy were cynical or opportunistic. There is every reason to think that maternal health was a genuine commitment for Banda and for Kwataine. In each case, the commitment was rooted in painful experience. As a young mother, Banda had suffered a hemorrhage in one of her own pregnancies that could have been fatal without prompt medical care. As a young man, Kwataine had helped carry a bleeding postpartum woman to get help; the woman had died along the way. Each told these stories repeatedly in interviews and speeches. Accounts of death, and of near death, justified their interventions and spoke to the righteousness of their shared cause.

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From the vantage points of Safe Motherhood, the White Ribbon Alliance, and other such groups, Banda was a moral president leading the people of her country to a better future. From the vantage points of many chiefs, she was a president with the confidence and vision to empower Malawi’s traditional moral leaders. Kwataine too was heralded as a visionary, a reminder that chiefs mattered as much as other political leaders and held the keys to changing social norms and keeping women safe. Some journalistic profiles celebrated him specifically for being male and for caring about women’s health.52 Narratives of maternal deaths cemented particular people’s authority; safe-­motherhood campaigns accomplished many aims. an uneven landscape A decade after the national moratorium had been lifted, the legal status of the people once designated as TBAs varied among districts and even villages. In theory, TBAs had been reinvented as unpaid community health workers, charged with monitoring women known to be pregnant and encouraging them to attend hospital. Some TBAs were to follow up with women in the postpartum period. A few districts even experimented with paying them small sums to deliver new health services, such as medications intended to prevent transmission of HIV from mothers to infants. In those rare locales where chiefs took little interest in policing births, TBAs attended deliveries more or less openly. Mama Lillian Siska, who attended the occasional birth in her rural home in Kwinakwake, was one such woman. What else was one to do? Kwinakwake was an hour by car from the nearest hospital, a small mission facility. And cars were scarce. In some of the places where chiefs imposed fines, TBAs attended births rarely and reluctantly, when a woman in active labor simply could not get to a health center in time. Nurses, HSAs, and TBAs reported that some women deliberately put off journeys to the hospital in the hope of being “forced” into a TBA-­attended delivery that they could justify to chiefs and safe-­motherhood committees. A successful justification could mean a lighter fine, or one that was announced but never collected. In some areas, however, TBAs seemed to have ceased work entirely. Chief Kwataine’s district was one such place. In the early 2010s, Ntcheu District became famous for its chief ’s vigorous and enthusiastic work promoting facility birth—­and for its strict ban on attendance at birth outside a health facility. Rural TBAs in Ntcheu District reported to an interviewer that they turned clients away even in active labor because they feared fines or impris-

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onment, only to have the women deliver unattended on the road. “We have thrown away childbirth,” one said bitterly.53 Nurse-­midwives agreed that in-­ hospital births now included many more late arrivals, unattended hospital births, and “floor births” that happened because all delivery beds or tables were already in use.54 Overcrowding was not limited to Ntcheu; nurse-­ midwives I spoke with at four health centers, two district hospitals, and two mission hospitals in other districts in 2014, 2015, and 2017 also described late arrivals, floor births, and an increase in “BBAs”—­babies born before arrival. Nationally, the facility birth rate was said to have risen dramatically. One Ministry of Health official with whom I spoke believed that radio campaigns encouraging women to deliver with skilled birth attendants had been even more effective than fines in driving up hospital deliveries. On the other hand, both radio campaigns and fines increased the stigma of a TBA-­attended delivery; it would not be surprising if part of the apparent reduction in out-­of-­ hospital birth reflected underreporting. The effects on maternal and newborn health were also unclear. In the aftermath of the moratorium, those azamba whose legitimacy came from the spirits or from their parents were less likely to see a government ban as relevant. Many were indifferent to state prescriptions and proscriptions. Why should an earthly power take precedence for someone called by a supernatural one? TBAs who were created, trained, licensed, and registered by a government that proclaimed them an essential link in the chain of maternal-­ child health, on the other hand, were likely to be visible to that government when it turned to stamp them out. Those azamba who were most likely to have some knowledge of basic biomedical obstetrical care, and most likely to have working relationships with facility-­based medical personnel, seemed also most likely to stop assisting rural women. With supply sources cut off, the TBAs who continued working could no longer protect themselves or the mothers they delivered by wearing gloves. All but two I spoke with reported either going bare-­handed or covering their hands during births with the thin blue plastic “jumbo” bags in which sugar and other goods are sold. TBAs in most locations were no longer able to consult with health providers, or to refer complicated clients openly. They could not arrange transport from the shelters in which they delivered women, lest a driver report them to the authorities. It seems plausible—­indeed, likely—­that some women and newborns suffered greatly from these changes, even as more women were shunted to health facilities.

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all of this has happened before The moratorium on birth with TBAs did not resolve problems with rural care. Nor did the promotion of male involvement. No proliferation of hospitals or health centers accompanied the end of the TBA. Nurses continued to plead for budgetary support for midwifery training programs, which continued to graduate nowhere near the numbers needed.55 Despite impressive efforts in many communities, transport remained a huge problem. Rural women often found it difficult to make it to health facilities in time to deliver, even during the daytime and in the dry season. During the rainy season, many roads and paths became impassible to cars or bicycle ambulances. In any season, transportation at night—­when both the spiritual dangers of witchcraft and the secular dangers of assault and robbery were at their height—­was extremely limited. To solve the dilemmas of rural maternity care in the aftermath of the TBA, politicians touted two interventions: maternity waiting homes and community midwives. Each of these strategies had long precedent. One might think that their advocates were reinventing the wheel. Given the well-­ documented failures of prior attempts, however, it might be more honest to describe them as reinventing the flat tire. One solution to the problem of rural obstetrics and poor transport was to build more “maternity waiting homes” in which pregnant women could come to stay near the hospital. Many such waiting homes, built with volunteered local labor using materials donated by local companies or provided by government grants, were opened to great celebration. In 2017, three that I visited were mostly empty; a fourth served as an overflow guardians’ shelter for a busy and cramped district hospital. Women could not easily relocate. There were children to care for, fields to tend, small enterprises to run. A second solution was the invention of a new category of birth workers called community midwives or community midwifery assistants. These women, to be selected by their villages, were to undertake a short training course in biomedical obstetrics—­no primary care, just maternity care—­and then return to the village to attend births. This proposal might seem quite similar to the 1979 TBA training plan, but differences in both the training and the candidates were substantial. Training was to be eighteen months long, to be conducted in English, and to include a practical component. Candidates had to have a Malawi School Certificate of Education, available only after one has finished four years of secondary school. In practical terms, these requirements made former TBAs ineligible.56 Some newly trained community midwifery assistants were to work at rural health centers under direct supervision. Others, returned to home villages

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without health centers, were to take over the clinics formerly used by TBAs. No incentives were offered to TBAs to give up their clinics—­which, in many cases, were also their homes. No mechanisms ensured that community midwives would have steady supplies of essential tools and medications. No improvements in transportation ensured that patients who developed emergencies under the care of the community midwives could get to a hospital. No plans for better training in basic primary care were implemented, even though the presence of a health worker in the village would predictably draw people seeking help for conditions other than pregnancy. No backup system would relieve the new community midwives from a 24/7/365 schedule. Even if these potential obstacles had been overcome, the new community midwives often felt little commitment to rural practice. Smart town girls who had completed secondary school saw the push for community midwives as a rare opportunity to establish a foothold in the civil service. Many of these women were ill prepared for and uninterested in rural life. Marriage was a particular concern. Few were well disposed to rural farmers as good marriage prospects. If unmarried, the community midwives were not considered culturally adult and were looked at askance by community members. Married midwives mostly had husbands with jobs in town. They sought transfers to more urban facilities. These social complications were unsurprising: experienced Malawian clinicians predicted them, and they’d been documented for similar interventions elsewhere.57 By 2017, disgruntled nurse-­midwives told me that the community midwives were filling posts for which they were inadequately trained in hospitals and health centers and that—­still—­large rural stretches of the country had no maternity care available at all. fa m i ly b u r d e n s Families had already borne many burdens and responsibilities even before these policy changes. The edict banning TBAs had proclaimed that village heads and HSAs were to be responsible for identifying high-­risk women and transporting them to hospitals, but no assistance had been given to them, nor was there any reduction of the many other burdens they juggled. Realistically, everyone knew that transport was for families to arrange. Supplies and medications often were too; some women continued to secretly seek TBAs because they could not afford the supplies that hospitals expected.58 When health centers and hospitals were out of stock, families would be sent to buy necessary medications or bandages out-­of-­pocket at private pharmacies. Inside health facilities, families provided most (in some facilities, all) food: I once found a pregnant diabetic patient in a hypoglycemic

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coma on an antenatal ward because her family hadn’t appeared for days to feed her. One reason that Faith Chisoni’s mother was at her side through her three-­ week hospital ordeal was that family members did a great deal of essential nursing care. Nurses were scarce. Guardians bathed bodies, washed linens, supplied bandages and medicines, cooked meals, fed patients, encouraged spirits. Like Faith Chisoni’s mother, they helped, decided, listened, and advocated. They were critical not just to recovery but often to survival, inside and outside the hospital. The TBA ban and the male involvement policy added to family responsibilities. Fines were one burden. Because of the fines, Sister Delhia Msukwa explained, no more TBAs worked near Zayamba. Men were more likely to attend antenatal care and to have transport set up. The chief kept track of all the pregnant women in a logbook. He knew whether they were attending antenatal care, and “if there was a home birth, that would be a real problem.” The woman, the TBA, even the village head all knew they would owe a fine to the senior chief. In Zayamba, the mere threat of the fine worked to keep everyone in line. In other communities, fines on families were collected enthusiastically. A news article about Chikhala village, for instance, celebrated the “magic of safe motherhood committees.” Any woman in the area who discovered she was pregnant was required to report her pregnancy to the committee. The chairperson of Chikhala’s safe-­motherhood committee, Fiziwell Mbetayasamba, told the journalist about a schoolgirl who delivered at home, having hidden her pregnancy from neighbors with her family’s aid. “We summoned the family and fined it five goats for the offence of concealing the girl’s pregnancy,” Mr. Mbetayasamba explained.59 Two goats went to Senior Chief Nthondo, who put the bylaws in place and appointed the committee, and the other three went to the committee itself. The male-­involvement policy wasn’t completely successful, or fully enforced. As several health workers explained in 2017, medical staff weren’t sure what to do with the men during the antenatal visits. Clinic routines hadn’t been restructured. There was no educational curriculum for men once they’d been given HIV tests and exhorted to arrange transport. Were they supposed to sit alongside women in the waiting room, singing songs about pregnancy danger signs? That seemed inappropriate to everyone involved. And men couldn’t really be present at births, or during the period of postpartum bonding. Midwives in both rural and urban health centers showed me small labor and postpartum areas when I asked about the male involvement policy. In each, there was no privacy at all: women delivered, recovered, and nursed their infants in close proximity to one another. One nurse-­midwife simply

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said, “For a man to see another man’s wife like this? Not possible.” Some health centers had quietly stopped enforcing the policy. Others continued to demand men’s presence at antenatal visits and in waiting rooms, while turning them away from births. Where it was enforced, male involvement placed additional burdens on women. Enforcement worked mostly through policies that a woman would not be seen—­or would be seen last—­at her antenatal clinic if she arrived without a husband. A woman who was divorced, whose husband was in another country working, or who had no one who would admit responsibility for the pregnancy had to get a letter from the chief indicating that health workers could see her without a husband in tow.60 Two markets had sprung up from this policy: a market in “letters from the chief ” written by educated villagers who could produce a convincingly chiefly missive, and a market in “husbands” who could be rented to come to the first antenatal visit, get HIV counseling and testing, and go on their way. The researcher Elizabeth Mkandawire learned about such rental husbands in Ntcheu District;61 in 2017 I heard about them from a health center nurse-­midwife two hundred miles away in another district. And yet, partner involvement also seemed to have increased.62 Men took roles beyond arranging transport to support women in other ways. In 2001, I’d not seen men carrying children; by 2007 it happened occasionally and by 2017 it was no longer unusual. Health workers often described these changes as positive and overdue. Several who were fathers spoke about their fears for their wives’ wellbeing, or their respect for the power of women. One nurse-­ midwife noted that colleagues at his district hospital disliked the male involvement policy. They claimed they had no time to teach the men, who just sat there uncomfortably on the clinic’s wooden benches listening to women’s joking and singing. His own experience with the policy had been different, however. If you brought men into the consultation room, explained what you were doing and why, the visits went well. Change, he thought, would be slow—­but he hoped someday his open-­ward hospital could be rebuilt in such a way that men could be present for the actual births. Families would be smaller if men saw what women went through. Husbands would be more respectful. The new Malawian man indeed. The journalist who wrote on safe-­motherhood committees and their magic also interviewed another member of the Chikhala committee, Jelmos Wisiki, a father of four. “I grew up thinking maternal issues were for women only. I even refused to escort my wife to a clinic for fear of being laughed at by fellow men,” says Wisiki.

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But the coming of the safe motherhood committees has changed his mindset that now he is one of the committee members. “I am at the forefront spreading messages encouraging male participation in maternal issues,” he says adding that men are now rising up to take their roles in these matters.63

The push for male involvement was intended to bring about social change. Perhaps it did—­as did the increased exposure to images and stories from outside the country, the terrible depredations of HIV that reconfigured families, and the widespread circulation of safe-­motherhood messages that constantly reminded people how dangerous motherhood could be. Moral Visions and Changing Patterns of Control Joyce Banda lost to the unpopular brother of her dead predecessor in the 2014 election, one that many Malawians suspected was rigged. Not long after, she fled the country. Although Banda re-­established a political profile in Malawi, rumors that she was considering a run for the 2019 presidential elections petered out; all contenders were men. At the time of this writing, well after the end of her presidency, she has maintained a significant profile in safe motherhood. Chief Kwataine continued efforts in Ntcheu District to ensure safe motherhood. At the time of this writing, male “champions” are still celebrated there. When a man has come to the antenatal clinic four times with a woman, he is thanked publicly in a ceremony. Women are not thanked in ceremonies for attending antenatal care. Chief Kwataine’s profile seems somewhat lower than it was during Banda’s rule. The last time I saw him in the news, the chief was promoting medical male circumcision. In this chapter, I have considered how narratives about maternal death and about dangerous care drove policy. An effort to reduce maternal deaths justified shifts in authority—­authority over birth, and authority over other people—­as various policy interventions circulated through national and transnational circuits. Policy shifts altered families’ burdens and shaped women’s choices. In a context of rival therapeutic traditions, in which pregnant women weighed cost, accessibility, safety, and quality of care, policy put a finger on the scale. That scale once tipped toward trained TBAs and away from the formal health sector; now it tips in the opposite direction. In each case, policymakers justified their interventions with explanations of danger and safety in childbirth. Some patterns of change in authority seem to repeat over time and among spaces that are in other ways dissimilar. In many parts of the world, in the twentieth and twenty-­first centuries, the goal of reducing maternal death legit­

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imized biomedical control of birth. As in Malawi, in the United States and in the United Kingdom and elsewhere, this biomedical control often involved removing birth from homes and placing it in hospitals. It often also involved removing power from the hands of women and putting it in the hands of men. In the US, as the sociologist Alicia Bonaparte has shown, physicians positioned themselves as expert in part by linking black granny midwives to maternal death, while making racialized and gendered critiques of “backwards” black communities.64 Forced into hospitals, black women often en­­ countered—­and continue to encounter—­disrespectful, coercive, or neglectful treatment.65 In Malawi, many different interests converged on the TBA ban: chiefs seeking a way to take responsibility for maternal health; government officials needing to do something without doing something expensive; nurse-­ midwives and doctors tired of TBA training serving as an excuse for inaction in other respects; activists inside and outside the country ready to see “harmful traditional practices” as responsible for maternal mortality. Think back to the “global medical imaginary” that Good described, discussed in chapter 4. In this vision, medical science and technology have endless potential, to be realized any moment—­except the moment now. The manifold harms, side effects, and failures of medicine recede into the shadows.66 A comparable global policy imaginary may overlook the long history of failed interventions and harmful side effects. In this imaginary, the promise of safe, compassionate, and accessible care is always right around the corner. Malawi was one of many nations left in the wake of colonialism with limited infrastructure and not nearly enough trained clinicians to provide biomedical care to its people. Many essentials of biomedical maternity care were scarce. Money to train nurse-­midwives and doctors. Salaries to keep them in the public sector. Funds to build, plumb, and wire health facilities, and then to keep the electricity and water bills paid. Schools to train auxiliary staff like radiology technicians and HSAs. Teachers to teach them. Vehicles to bring sick people to where they could be assisted. Fuel, spare tires, and mechanics for those vehicles. Medical equipment, reagents, and blood supplies in hospitals to which the ambulances came. Not one of these necessities had been in satisfactory supply in Malawi, ever. Ambitious plans to develop a strong primary care network, scuttled by structural adjustment, were replaced by a minimalist policy imaginary. There was no money to get skilled attendance to everyone.67 A way to make do with something cheap was necessary. Like the medical imaginary that sustains experimental oncology, the policy imaginary that sustained decades of TBA training survived because the alternative was unbearable.

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The minimalist imaginary centered not on high-­tech, high-­cost, cutting-­ edge interventions, but on low-­tech, low-­cost people. These people were the human version of the “appropriate technologies” discussed in chapter 3, imagined as more or less effective stand-­ins for other, more expensive providers. TBAs were invented because they were needed. A whole cadre of people were imagined as already there in poor communities, ready to work at little or no cost to government and ready to provide good care with just a little training and supervision. This imaginary, too, tended to overlook the political realities in which most ideas fail, the financial realities in which they are never (or never adequately) funded, and the clinical realities of disastrous side effects. It prompted action: to identify TBAs even if that actually meant creating them. For some decades and in some places, it also legitimated inaction. The imagination that trained TBAs could provide safe rural biomedical obstetrical care allowed policymakers to put off the painful and expensive work of making both real biomedical emergency obstetric care and careful and sensitive childbirth attendance available. It did, however, at least contain an element of commitment to national development, and to welcoming, woman-­centered care even in the most remote parts of the nation. Now, in the aftermath, cheapness still matters. But in a neoliberal era, when the hallmark of “good government” is its tiny footprint, the locus of responsibility has shifted from the nation to the village and the family. And now a different kind of intervention ascends: a moral vision of a new Malawian man who is the champion of his family and makes all the necessary arrangements to buy access to safe birth; a moral vision of a chief who takes responsibility for his village or district through surveillance and punishment. Bylaws became one more way to reinforce patriarchal power. They made men central in childbirth—­once a domain of women’s expertise and authority. It is plausible that maternal mortality has declined in Malawi with the surge in facility-­based birth, and that male support for women as they labor and birth has saved lives. It seems likely too that trouble persists in the cracks, the crevices, and the aftermath. Moral visions underwrote policy in maternity care. These moral visions projected imagined futures from reimagined pasts. Backward elderly women were to be replaced with educated young nurses. Irresponsible husbands were to grow up, rise up, and take on roles protecting their families. These hopeful imaginations collided in Malawi’s efforts to reduce maternal mortality, producing results both unexpected and predictable. Narratives of crisis legitimated actions that subtly shifted the social ground. New policies built on bargains that in most cases stabilized the power of the already powerful and undermined those who were already on the margins.

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Women were left in a position even shakier than that they had earlier occupied. The women of Tikhale and other rural villages risked long walks at night and the possibility of delivering unattended along the way. Dyna Ng’ong’ola and Kettie Pensulo, who had once “welcomed women nicely,” risked poverty, the loss of their place in the community, and arrest. Mercy Kumwenda died not just for want of an IV pump, but for want of any way to exert authority over her own body within the confines of the hospital. Esme Lifa died because she couldn’t get a safe abortion or a prompt evaluation. The woman who cared for her in the community, who made the right diagnosis long before we doctors did, and who wrote us a “love note” full of concern, couldn’t even get heard.

Conclusion

23 G3P1 29 wks previa, abruption clinical DIC emergent C/S undiagnosed twins 1600g male 1/4 1200g female 2/5

Faith Chisoni was gravely ill. The anesthetist had watched her carefully, in the hallway that served as recovery room, until she was stable enough to transfer. The head postpartum-­ ward nurse had assigned her a bed near the nurses’ station, where she could be observed more closely than the stable patients in the far reaches of the ward. Her mother had stayed by her side whenever guardians were allowed in the ward, tending to her: feeding, bathing, worrying, watching, encouraging. For a while she had seemed to rally. Her bleeding had stopped. The transfusion had helped. But she was pale and lethargic despite two units of blood. When we tried to get more blood, the blood bank staff resisted. The obstetrics units got too much of their limited stock, they said. They had a point. Birth is bloody, and a labor ward can use up a great deal of blood. A week out, Faith Chisoni spiked a high fever. The only surprise was that it had taken that long. The postoperative infection rate after cesarean section at Queens was high. Her surgery had been an emergency—­always a greater risk. Her severe anemia meant her healing tissues were receiving little oxygen, making infection yet more likely. We guessed about other contributing factors. Had her bleeding resumed after I’d held pressure against her uterine wound and called her hemostatic? Probably. Was there a clotted pool of blood

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sitting in her abdomen, a perfect site for bacterial growth? Probably. Had she had an emergency dose of antibiotics before she went to the operating theater, a dose that was sometimes available but often not? Probably not. My notes are scanty after that initial week. The first newborn, the boy, died in a few days. The girl held on longer. After both twins had died, Faith Chisoni stared at the wall and said nothing. Skin hot to the touch, eyes glassy. On antibiotics now—­whichever we had then, likely crystal penicillin and chloramphenicol. No doubt somebody wondered about malaria. Probably somebody else recommended an HIV test. Her mother helped her up to the bathroom, tried to keep her comfortable on the narrow cot, tried to get her to eat something. Much later, the midwife still remembered the mother’s worried face. So did I. My notes record, and I remember (or I remember because my notes record) that eventually, when the antibiotics failed and Faith Chisoni became delirious with fever, the team on call took her back to the operating theater. They’d hoped for infected tissue to cut away, or an abscess to open and drain. Nothing. Just a little pus in her abdomen. They washed her out, closed her up, and took her back to the ward. The delirium ebbed. She resumed staring sadly at the wall, pulse racing, respiration fast and shallow. I’d seen this scenario before. When I was still in training in New Mexico, a teenage girl was transferred to our university hospital from a rural part of the state. She’d had a baby the week before and developed a low-­grade fever afterward. Sent home on a course of oral antibiotics, she came back raving with a high temperature. Her doctor took one look and knew she was going to need an intensive care unit. She was critically ill when she arrived at the university hospital. With the on-­call faculty obstetrician, I took her to the operating room and opened her up. We found pus, but no obvious source of infection. We washed her abdomen out with saline and took her back to intensive care, where she continued to deteriorate despite all the blood products, all the antibiotics, and all the specialized nursing care one could ever wish to have. Some twenty-­four hours later, the new on-­call team took her back to the operating room for a hysterectomy, hoping against hope that removing the likely source of infection could make a difference. They thought we’d been foolish not to remove her uterus right away. We thought they were foolish to put her body through the stress of another major surgery without a clear indication. Whether anyone was foolish or wise or whether we were all just spitting in the wind, we would never know. She died the following day of overwhelming sepsis. That is what I expected for Faith Chisoni too, and that is probably what happened. Probably, but not quite certainly. One early morning, a week after her second operation and three weeks after her cesarean, I came in to Queens to find that Faith Chisoni was gone.

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Her mother had taken her home the evening before. She almost certainly died there, and very soon too, perhaps even on the way home. Almost certainly, the womenfolk in her family prepared her body and lamented, while the men pooled funds to get her a casket and then dug a grave. Given her condition, these things almost certainly happened. But in fact I don’t know. Faith Chisoni disappeared into the city, a city where there were probably a few thousand young women of her age and economic status, and a dozen or more with her name. Is there a remote chance that a healer with more powerful skills than ours had something to give her, some effective mankhwala old or new? Perhaps her mother and other kin found a sing’anga who threw bones and identified the root of the problem, or a self-­appointed bishop of his own church who cast out the demons giving her fever. Is it self-­indulgence to speculate on a possibility so improbable, or hubris to believe I know what must have happened? Perhaps her ancestors came to her in dreams and told her what to do. Perhaps, with no one’s help, she just got better. It happens. I’ve seen it. Perhaps after her dreadful and tragic journey through the valley of the shadow of death Faith Chisoni became a healer in her own right. I so want to make a story for Faith Chisoni. I want to cheat death in the story, make for her the lucky escape that she almost without a doubt didn’t have. Almost. But this is not a work of fiction. And at this point in her life the facts and Faith Chisoni escape from my story

Many pages in this book are covered with ink, arranged into ideas of my choosing. One is blank. The blank page is a reminder, if an inadequate one, that even a very long book is a woefully incomplete story of births, deaths, and explanations. It is an acknowledgment that the experiences of maternal death most central of all—­those of the women themselves, and of the people to whom they are beloved—­are entirely absent here. It is a reminder of how easily women’s voices disappear under the layers of stories told by experts, even those working hard to keep them safe and improve their care. Expert narratives illuminate but cannot explain the fate of Faith Chisoni, who ends this book, any more than they explain that of the woman in Saginaw who began it. Who Should Tell These Stories? Who should write about these things—­about a mother with her face turned to the wall, her own mother caring for her as she burned and dwindled, thousands of miles away from the country where I am a citizen? About the doctors who operated on her and on many other women, or chose not to operate? About asing’anga who divined the nature of danger by traveling into nonhuman worlds in their dreams, and azamba who tried to keep birth safe while working in secret? About nurse-­midwives who handled complex births with enormous skill, or drank tea in the break room while women delivered unattended? About a president and chiefs and epidemiologists who took their interpretations of what had gone wrong and wrought policy from them? About elders who blamed democracy for death? About the inseparability of healing and harming?

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Faith Chisoni’s blood touched the hands of many people. (Touched? Marked, bathed, anointed, stained.) The anesthetist, the midwife, and I were among them. One pair of hands sutured the wound that my scalpel had made. Two pairs of hands held sterile surgical cloths against the wound while we counted time on the operating-­room clock. Three pairs of hands on her body, we told ourselves diagnostic stories and acted in response. My stories looked inward. I imagined platelets rushing to the wound edge, coagulation factors at work, fibrin strands forming the first fragile beginnings of a clot. Were the others oriented outward as well as inward? Did the midwife pray for hemostasis? Did the anesthetist? Did anyone call on the ancestors? Our interventions may have extended Faith Chisoni’s life for a few weeks. Under our hands, the fast violence of surgery also brought her to the brink of death. The slow violence of racialized and gendered capitalism brought her to the brink of death too. She might have recovered readily, as other women do—­not always, but almost always—­in hospitals with adequate blood banks, well-­stocked pharmacies, nurse-­to-­patient ratios better than one to fifty, low thresholds for intensive care support and the clinicians and tools needed to make “intensive care” both intensive and caring. Her babies, early and tiny as they were, would have had a chance in a hospital with a well-­equipped newborn intensive care unit and the staff to run it. Among the many reasons that none of these conditions existed in Malawi, two were central: a very long history of extraction, and a very long history of stories about it that justified the consequences for people who were black, female, or both. In the 1890s, it seemed reasonable to powerful slave traders that fines could be paid with a daughter, who would bear children in a strange household, only to be traded away again. In the 1920s, it seemed appropriate to powerful colonial administrators that women—­African women, at least—­could be kept captive as fines for nonpayment of taxes. In the 1940s and ’50s, it seemed prudent to mine and plantation owners to keep healthy black African laborers’ wages low and to send sick men home, to be tended by—­and to spread disease to—­their families. In the 1960s, it seemed right to a newly minted Malawian president for life to prioritize tobacco plantations over basic medical care. In the 1980s, it seemed best to economists to gut public-­sector health and education services in poor nations, and in poor communities within rich ones. In 1998, it seemed appropriate to an American president to insist that patent protections for pharmaceuticals be put ahead of African lives. These injuries, stacked atop one another, were inflicted in the interests of profit. They were justified with stories that did not look much like stories, written as they were in the mathematical entries of balance sheets and the bloodless language of bureaucratic inevitability. But the decisions justified were never

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bloodless. They injured and killed many people, and they continue to do so. In this respect, Faith Chisoni’s blood is on many more hands. In this respect, many of us bear a responsibility to consider her story with care. Which stories should be told, by whom and for whom? These are central questions in anthropology; less often asked in medicine, they are pertinent there too.1 Anthropologists seek to make the world more hospitable to a variety of narratives. As you have seen, each narrative reveals something and obscures something else. The material presented here gives only one particular slice of the complex problem of maternal death, one that hews most closely to the perspectives of people who gather to care for these women and work to make sense of their fates—­and one that is inevitably shaped by their choices to tell particular stories to a particular interviewer.2 I hope readers who are Malawian nurse-­midwives and doctors, policymakers and feminists and activists, mothers and daughters and fathers and sons will challenge this account and write their own. I hope that you, my reader, whoever you are, will tell your own story of people’s lives and the threats to them, and that collectively we will try out many possible endings. Why Are These Stories Important? Midwives, politicians, azamba, epidemiologists, doctors, and counselors (among the many, many others who try to keep birth safe) must work despite imperfect and incomplete knowledge. They must be able to act, in the full awareness that a scalpel or a cup of mwanamphepo or a policy may also harm, and with the awareness that the knowledge on which they act may change at another time, or in another place. They—­or rather, we—­cannot wait for a morally pure position or a technically perfect intervention. As a sociologist reminded me, “All of our models are wrong; some of them are useful.”3 Stories about maternal death function as models. They are wrong for the same reason that they are useful. They select out evidence that will be seen against a background that will remain unseen, shaping any understanding of how maternal death happens, and why. The interventions people consider grow up from this ground. • If, as Chief Wyson Matengo held, maternal death is a product of democracy, the solution is a return to autocratic rule. • If, as Nurse Meria Gomani claimed, maternal death results from ignorance, from “traditional” behaviors like food taboos and the practices of azamba and asing’anga, one solution is biomedical education—­a form of scientific evangelism, perhaps.

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• If maternal death is a product of society-­wide moral decline, as many older men and a few older women suggested, it will not improve until the community of Malawians (and most especially the fraction of the community made up of fertile women) mends its ways. As the sing’anga Mayi Lemani exhorted, “Those with ears, take my advice.” • If, as epidemiologists’ models predict, maternal death results from a low GDP, a high fertility rate, and a low fraction of births attended by those people designated as “skilled,” the solution is likely to entail economic growth (no matter how unequally distributed), modern contraceptives (no matter how coercive), and forced institutionalization of birth (no matter how harmful). • If, as Dr. Duncan Phiri and many others concluded, danger springs from “the three delays” in getting pregnant women to skilled care, then to address it requires convincing women that institutional birth is best, ensuring ready access to it, and providing prompt care once a woman is inside the institution. • If danger is actually located within medical institutions, as the mzamba Ruth Welemu and others believed, if “we have thrown away birth” by letting women get cut for every little thing, then hospital birth is itself better avoided. • If danger resides in the body of the pregnant woman, as many doctors presume, the solution may be to examine what goes into that body and what comes out of it; to monitor her weight; to draw her blood and test a host of possible markers that might predict certain frightening outcomes; to scan her and supervise her at every opportunity. The turn among United States obstetricians to labeling black women as “high risk” results from this conceptual model, and fits within a long history of policing black bodies.

All these conceptual models about death and danger—­and many others—­ can be applied in good faith, by well-­intentioned people who very much want to improve maternal health. Many of them can also be used, through conscious or unconscious opportunism, as routes to some other end. World Bank economists could draw on the epidemiological models that linked GDP with maternal survival when they called for “investing in African health” by reducing trade barriers and privatizing state services. This same economic prescription was (and is) a panacea, recommended by mainstream economists for every social ill from youth unemployment to political paralysis to widespread tax evasion to maternal mortality. Various ways of explaining maternal death support various prescriptions, some of which also shore up the authority of elders, the power of medical

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professionals, the status of men or chiefs. Many of these prescriptions presume that some people can and should control the bodies of others. That presumption has long been racialized and gendered. It is no surprise that explanations for maternal death so often undermine the authority and autonomy of black women. The many explanations for maternal death that people provided to me over the years, and the observations I’ve made in two countries, do support a few broad conclusions. The very complexity of maternal mortality means there are many points of possible intervention to improve women’s chances of surviving and thriving. Some of the strategies likely to have the largest impact are those that will take effect most slowly. Magic bullets aren’t magical, although sometimes they will make a difference. Demanding accountability (whether from pregnant women, from nurse-­midwives, from informal-­sector healers, or from male partners) without providing practical support—­in material ways like extra hands and reliable supplies—­is unlikely to end well. Misogyny kills, as does racism, as does disrespectful care. Something can be worse than nothing. It is unwise to presume that a preferred method of knowing—­whether that be a randomized controlled trial, a demographic and health survey, or a folktale—­ delimits what is important to know, about maternal death or about anything else. No society is static, but neither does the past really go away entirely; current interventions, descriptions, and prescriptions are layered over older ones, and a good knowledge of the past can help people to avoid mistakes that others have already made. Unintended effects can sometimes be anticipated. New technologies inevitably have social effects, for instance. New policies frequently reshape authority; new exercises of power often restrain women’s autonomy. Collectively, these stories also prompt wariness about the depiction of maternal mortality as a crisis. Lauren Berlant, in an essay on “slow death,” has warned that crisis rhetoric misdirects our attention.4 By relabeling the slow and unremarkable as fast and dramatic, it hides long histories. Crises tempt people to look for scapegoats, and talk of crisis allows premature death to be recast as a problem that belongs to particular self-­destructive people. As chapter 1 showed, experts often blamed women themselves for maternal death. In the United States, that blame often had to do with age, obesity, and addiction.5 In Malawi, it was often about having sex too soon or too late or with the wrong person. The default intervention in each case was to empower (or educate, or exhort) these pregnant social liabilities to make more healthy (or modern, or moral) choices. The representation of maternal death as crisis can be politically vital. It can prompt action—­funds, training, legislation—­and it can focus attention. But there are ways, I think, in which understanding maternal death as crisis

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discourages attention to the long histories that underlie it: the slow cumulative injuries to bodies, the slow accretions of disrespectful care, and the slow erosions of autonomy and dignity that hurt people seeking care as well as people trying to provide it. The stories presented here show that slow death may begin even before one is born. Ambivalent technologies, abundant scarcity, partial stories and mortal embodiment are not unique to Malawi. Acknowledged or not, they shape healing practices and explanations for suffering and death everywhere. It is my hope that the distinctive forms they take in Malawi’s pluralistic medical world help illuminate the power and fallibility of all expert narratives, and help readers think critically about interventions into mortal bodies—­whoever makes these interventions, and wherever they are made. What Do These Stories Leave Out? The accounts of maternal death given in this book are true and incomplete. They are partial. The most important omission, as the incomplete story of Faith Chisoni drives home, has to do with the experiences of the women who are becoming pregnant, delivering, surviving into parenthood—­or not. But there is another vital omission. Cumulatively, the stories presented here risk creating a false picture of birth as inherently dangerous, and of Malawi as a nation in perpetual crisis.6 And they risk leaving out a joyfulness in life that is intimately connected to its dangers. An old saying has it that life itself is a sexually transmitted, universally fatal condition. Sex, pregnancy, and childbirth are far more than things that kill us. Sex and procreation are keys to the good life in Malawi, as they are elsewhere. Sex can be a sensory and social pleasure, a way to engage with others, feel good, nourish relationships, build space and comfort even in lives that have little of either.7 Birth is how we make life. Having a baby is an awe-­ inspiring act of creation. In Malawi, it makes a person a full adult and thus ushers parents into a new social world. Sometimes birth is grievous, but almost always—­including for people who live quite difficult lives—­it is an occasion for celebration and for pride. The emphasis in this book on birth’s dangers and the griefs that surround them tells a remarkably partial story. Most births happen smoothly: again and again, in Malawi, in the United States, everywhere in the world. Many are joyful. All are profound. They are the fundamental acts of incarnation without which none of us—­as individuals, cultures, a species—­exist. They happen at home, in hospital, in a TBA’s shelter, on the way to get help. They are the way we all come into this world, and a testament to women’s power.

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*

One last story. Tall and heavy double wooden doors made an imposing entrance to the maternity unit at Queens, even if they were nearly always kept locked in favor of a more modest utilitarian entry on the side. Years ago, my partner and I were leaving at the end of a long day. Just outside the big locked doors, on the sidewalk, we encountered an improvised wall of bright cloth: a ring of seven or eight women, each of whom had partially unwrapped the colorful chitenje worn around her waist and held its end out against her neighbor’s hip. From within the circle came a quiet voice and a suppressed grunt. My partner, a midwife, walked over to the circle. Inside it a young woman had just given birth to her baby. A nurse in white uniform knelt beside her murmuring encouragement. Cradling the baby’s head, the nurse looked up just long enough to smile and say, “It is fine, sister.” It was fine. A smiling nurse and a sturdy surround of women’s support made it so. There was no need for either of us, and we walked away.

Glossary of Chichewa Terms

Many of these words have variable spellings or regionally specific alternatives, ignored here to avoid confusion. Words used only once and translated in the text are not listed here. alangizi. Plural of mlangizi, advisor. anamkhungwi. Plural of namkhungwi, initiation counselor. asing’anga. Plural of sing’anga, spirit healer, commonly glossed as “African doctor.” azamba. Plural of mzamba, traditional birth attendant. chidyerano. Customary food sharing. chinamwali. Girls’ initiation. chipatala. Clinic or hospital. chitambalala. One who has died in pregnancy. chitenje. Cloth wrap commonly used as a skirt. ganyu. Informal labor for hire. gule wamkulu. The masked dance of the Nyau secret society. kachasu. Distilled maize liquor. kanyera. A wasting disease caused by violating abstinence guidelines. katundu. Baggage; all the stuff a person carries with her. kuchipatala. To the hospital. kwacha. Malawian unit of currency. kwabasi. Very. malungo. Malaria. mankhwala. Medicine or treatment. mankhwala achikuda. Medicine of the Africans. mankhwala achizungu. Medicine of the Europeans. matenda. Illness. matenda wa masiku ano. Modern diseases. Mayi. Title of respect given an adult woman. mbumba. Women’s dance-­and-­praise-­song group.

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g l o s s a r y o f c h i c h e wa t e r m s

mlangizi. Advisor. moyo. Life. mphini. Incision(s) used in healing practices, or scar(s) left by these incisions. mtsikana. Girl. mwambo. Custom. mwana. Child. mwana alibwino. The child is well. mwana anamwalira. The child died. mwanamphepo. Herbal treatment given to induce or augment labor. mzamba. Traditional birth attendant. mzungu. White, European, or (sometimes) rich person. namkhungwi. Initiation counselor. nansula. An herbal fertility treatment. ndiwo. Meat or vegetable “relish” to be served with nsima or rice. nsinjiro. Groundnut (peanut) flour. nsima. Stiff maize porridge, the staple food in most of Malawi. nyumba. Home, dwelling. sikelo. Clinic (literally, “scale”). sing’anga. Spirit healer, used interchangeably with “African doctor” in Malawi. ubuntu, umunthu. Communal solidarity, in two common spellings. ufiti. Witchcraft. ufulu. Freedom or rights. vimbuza. A healing dance used in northern Malawi. zipatala. Plural of chipatala, clinic or hospital. zitenje. Plural of chitenje, cloth wrap or skirt.

Approximate pronunciations: • Vowels are mostly pronounced as follows: a = ah (as in wall), e = eh (as in thread), i = ee (as in dream), o = oh (as in old), u = oo (as in tool). • Ch and sh are pronounced as they are in English, as in chip or ship. • Kh, ph, and th are pronounced like the k, p, and t in key, purpose, and tell. • When an n or m precedes another consonant, it is barely voiced. Novice Chichewa speakers can usually be understood even if they omit the m or n. For example, Banja La Mtsogolo will be readily comprehensible without the m sound that begins the final word.

Key People and Places

During the years of this research, most Malawians sought biomedical services in the public sector. Mission hospitals provided about a third of reproductive health services in Malawi, especially in rural areas without government facilities. Some biomedical services were available privately. People often consulted other kinds of healers for afflictions related to fertility and pregnancy; I have listed these here as belonging to the “informal sector.” People in the Informal Sector counselor. A mlangizi and/or namkhungwi (below). herbalist. Healer who works with plants; some who specialized in medicinal baths referred to themselves as yazitsamba. mlangizi (pl. alangizi). Elder who may be consulted for advice about sex, pregnancy, and childbirth; the term is also used for various extension workers. mzamba (pl. azamba). Traditional birth attendant. namkhungwi (pl. anamkhungwi). Elder who counsels initiates about sex, pregnancy, and childbirth. sing’anga (pl. asing’anga). Traditional healer, also often called “African doctor.” traditional birth attendant (TBA). See mzamba; see also chapter 6.

Overlap among these categories can be confusing. Most people said that TBAs and azamba are English and Chichewa words for the same person, for instance—­but a few interviewees reserved “TBA” for people who had taken a training course. In general, I’ve followed the terms people used for themselves. People in the Formal Sector obstetrician-­gynecologist. Completed medical school, internship, and multiyear specialty training. doctor. Five years’ medical training plus eighteen-­month internship.

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key people and pl aces

clinical officer. Three years’ training plus eighteen-­month internship. registered nurse-­midwife. Equal to SRNM, state-­registered nurse-­midwife; four years’ training, university degree. enrolled nurse-­midwife. Equal to NMT, nurse-­midwife technician; three years’ training, no degree. medical assistant. Two to three years’ training. community midwifery assistant. Two years’ training. health surveillance assistant. Ten weeks’ training in community health.

These workers are listed roughly according to years of training, from most to least. I have used the word surgeon to cover anyone who does surgery, anesthetist to include anyone who administers anesthesia, nurse-­midwife to include both SRNMs and NMTs, and clinician to include anyone responsible for diagnosis and treatment in a medical setting. The term skilled birth attendant always applies to the first four categories on the list, through “registered nurse-­midwife,” usually also the next two, through “medical assistant,” and occasionally—­in practice—­to all these people and then some. See chapter 6.

Abbreviations

a r t   antiretroviral therapy at p   adenosine triphosphate b b a   baby born before arrival b p   blood pressure c d 4  an immune-­system cell counted to assess severity of HIV infection c d c   United States Centers for Disease Control and Prevention c p d   cephalopelvic disproportion d h o   district health officer f s b   fresh stillbirth g 8  Group of 8 g d p   gross domestic product h b  hemoglobin h i v / a i d s   human immunodeficiency virus / acquired immune deficiency syndrome h s a   health surveillance assistant i c d -­10  International Classification of Diseases, 10th ed. i h m e   Institute for Health Metrics and Evaluation m d g   Millennium Development Goal m m r   maternal mortality ratio n g o   nongovernmental organization o p d   outpatient department s b  stillbirth s b a   skilled birth attendant s d g   Sustainable Development Goal t b a   traditional birth attendant u n   United Nations u n a i d s   Joint United Nations Program on HIV and AIDS

286

u n f pa   United Nations Population Fund u n i c e f   United Nations Children’s Fund u s   United States v s i   Venture Strategies Innovations w h o   World Health Organization

a bbr ev i ations

Acknowledgments

Early one morning in December 2020, as a global pandemic ground on, I logged on to a web platform to serve as examiner for a dissertation defense taking place ten thousand miles away. Or, I tried to. My laptop chose a bad moment to die. On an old computer, in the dark kitchen, the internet con­ nection came and went. Once finally—­if fitfully—­connected, I could see col­ leagues surrounding a gleaming conference table at the University of Ma­ lawi’s College of Medicine. Their technology was flawless, their organization of the process seamless, the intellectual exchange at the defense exciting. We chatted briefly afterward. I congratulated them on Malawi’s extraor­ dinary 2020 election, inspiring to activists around the world and soon be rec­ ognized with The Economist’s “country of the year” designation. We didn’t talk about the disputed American election. They asked about COVID. Was it true what they were hearing, that people were fighting about having to wear masks, that the country’s public health response was in disarray, that case­ loads in Wisconsin were sky-­high? (Yes.) Was I all right? (Yes.) Did I know how well they’d kept the virus at bay in Malawi? (Hooray! Yes.) It felt as if a geopolitical wheel had turned. It also felt like a good time to finish a book about competing explanations for death. Like most people, I’d been hearing many attributions of blame for America’s extraordinary rates of death: China, the WHO, deforestation, care­ less college students, wet markets, Big Pharma, Trump, 5G, and on and on. Expert explanations for death proliferated, as did expert proposals to mini­ mize it. Some powerful actors dismissed as “fake news” any explanations that didn’t serve them, while others spoke of “the science” as if it were a singular and omniscient divine entity. Choosing among epidemiological models was no theoretical exercise: models guided life-­or-­death decisions, in hospitals

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and in government buildings. I’d seen some of this before, and had long been thinking and writing about it. It was simply much closer to home now. This book has gestated for a long time. Along the way I have benefited from the generosity of many fellow thinkers—­far too many to list. In Malawi, guidelines about confidentiality prevent me from naming many of the peo­ ple who provided time, insights, good conversation, roasted groundnuts, or shared bowls of nsima and ndiwo, and help finding my way in and out of their neighborhoods. It was my honor to hear their stories and watch them at work; I only hope that this work reflects their ideas and experiences as truthfully as possible. Some people I can name: discussions with Chiwoza Bandawe, Ur­ sula and George Kafulafula, Bonus Makanani, Frank Taulo, and Terrie Taylor were always stimulating. I was fortunate to learn from conversations with Lucy Kululanga, Davison Mchika, and Chisomo Kalinga. In this project and others, I have benefited from working alongside Stella Asani, Tracy Chasima, Chimwemwe Kambuzi, Zikani Kaunda, Patrick Makhuva, Martha Mpunga, Max Nthenda, Catherine Nyirenda, and the excellent research team at the Invest in Knowledge initiative. Early stages of research were made possible by generous funding support from the Wenner-­Gren Foundation for Anthropological Research and from the University of Wisconsin–­Madison, including the Institute for Research in the Humanities, the Center for Research on Gender and Women, and the Graduate School. A fellowship from the American Council of Learned So­ cieties and a residential writing fellowship at the Notre Dame Institute for Advanced Study made it possible to finish the manuscript. At Notre Dame, Chloe Hemm, Symone Johnson, Yixuan Mao, and Vania Smith-­Oka all provided particularly generative and careful feedback. My fel­ low NDIAS fellows were delightful and challenging interlocutors, and Faisal Husain was in addition the best Michiana exploration companion I could have wanted. Archivists and librarians at the World Health Organization, the National Archives in Kew, the University of Edinburgh, the Wellcome Collection, the National Library of Scotland, Oxford’s Rhodes House, and the Malawiana collection at Chancellor College Library were all gracious in helping a non­ historian find her way. Warm thanks to the University of Wisconsin’s Tom Durkin, anthropology librarian extraordinaire. At the University of Wisconsin, I am especially indebted to colleagues in anthropology, history, and African Studies. Monica Grant deserves special thanks: her patience with nondemographers and her broad intellectual curi­ osity inspire me. Maria Lepowsky gave important early encouragement and guidance, as did Susan Friedman. Emily Callaci, Jérome Camal, Christina

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Cappy, Finn Enke, Nan Enstad, Pablo Gomez, Rachel Goodman, Ellen Heb­ den, Judy Houck, Christine Jeske, Nancy Kendall, Neil Kodesh, Vijayanka Nair, Rachel Silver, Taryn Valley, and Will Voinot-­Baron have all provided lively intellectual community. Their ideas have improved this book—­whether they knew it or not—­and their good company has made my working life a pleasure. I would be remiss not to thank other scholars at other institutions for inci­ sive comments, thoughtful engagement, and their generous gifts of time and close attention. I learned from presenting early versions of several chapters at Carleton and Dartmouth Colleges; at the Universities of Bergen, Cambridge, Florida, North Carolina, Notre Dame, Tennessee, and Washington; at Case Western Reserve, Duke, Michigan State, Rice, Stanford, and Yale Universi­ ties; at Washington University in St. Louis, the University of California at San Francisco, and at the University of Malawi College of Medicine. Thank you especially to Cal Biruk, Howard Brody, Brenda Chalfin, Susan Erikson, Steve Feierman, Wenzel Geissler, Ilana Gershon, Jean Hunleth, Nancy Hunt, Stacey Langwick, Julie Livingston, Lucy Mkandawire-­Valhmu, Ruth Prince, Peter Redfield, Harris Solomon, Adrienne Strong, Noelle Sullivan, and Me­ gan Vaughan, among others. Some of you also wrote letters for me; I owe you. I’m a good baker . . . just a thought. Several people at the University of Chicago Press have strengthened this manuscript. Thank you to Priya Nelson for taking it on, Karen Merikangas Darling for picking it up, and Johanna Rosenbohm for making it better with careful and sensitive copyediting. Two anonymous peer reviewers pushed me to make a stronger, more focused, less unwieldy book: thank you. Mary Moore and Kathy Wendland each read every page of the manuscript and provided wise advice—­some of which I took. Neither they nor anyone else listed here should be held responsible for mistakes, misinterpretations, infelicities, or half-­baked ideas. Those are all mine. My writing buddy Judy Houck kept me focused and, when necessary, off the impostor-­syndrome ledge. And as I have for more than two decades now, I owe the most of all to Mary Moore: stalwart partner, exceptional bullshit detector, fierce feminist, best reader, and heart’s home.

Notes

Introduction 1. Cited in L. L. Wall, “Dead Mothers and Injured Wives.” 2. In Chichewa: Mimba njosadzitamira. See chapter 1 for other reasons not to boast about pregnancy. 3. Comaroff, “Medicine: Symbol and Ideology,” 53. 4. See Kaunitz et al., “Perinatal and Maternal Mortality in a Religious Group.” 5. WHO, Trends in Maternal Mortality, 2000 to 2017. 6. The CDC website provides a wealth of United States data to anyone with sufficient patience to work through the search function. Even there, however, metrics for maternal death are difficult to access. It is much easier to find information on childhood cancers, on alcohol abuse, on infant mortality, and on tobacco. The only major killer more difficult to get data on than pregnancy is guns. It’s as if we don’t want to know. 7. For international statistics released in 2019, see https://data.unicef.org/topic/maternal-health /maternal-mortality/. 8. Of the five women’s deaths that opened this chapter, only those related to postoperative hematoma and tetanus would have counted at the time as maternal deaths. Homicides did not count, although homicide rates are higher during pregnancy—­see Cliffe, Miele, and Reid, “Homicide in Pregnant and Postpartum Women Worldwide.” Deaths from HIV did not count either, although pregnancy exacerbates some HIV complications. 9. Iatrogenesis refers to harm caused by medical treatment. 10. The study of expert explanations for maternal death was approved by the University of Malawi College of Medicine Research Ethics Committee and by the University of Wisconsin–­ Madison Social and Behavioral Science Institutional Review Board. Some observations come from an earlier study of medical trainees, approved by the University of Malawi College of Med­ icine Research Ethics Committee. Quotations from interviews in more recent years are drawn from team ethnography projects, each separately approved by the relevant oversight committees. Many serious questions, including those about the politics of representation and about who may tell what stories, were not part of these formal ethical reviews at all. My aim throughout has been to tell the truth, and to do so respectfully and generously. 11. Except when drawn from published materials, and except for one interviewee who requested that I use his real name, all names (and initials) have been changed. Most hospital,

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health center, and neighborhood names are pseudonyms. Other potentially identifying information has been omitted. In several cases I have left out the year of a death; in many I have left unnamed the people involved in discussions or the hospitals in which those discussions took place. No case, and no person, is a composite. 12. For southeastern Africa, see, for example, Banda, “Stakeholders’ Perceptions of Traditional Birth Attendants”; Chapman, Family Secrets; and Strong, Documenting Death. 13. All figures derived from Hogan et al., “Maternal Mortality for 181 Countries.” Chapter 5 explores these calculations; it is unwise to consider them simple statements of fact. 14. Livingstone cited in Iliffe, Africans: History of a Continent, 188, and many other places, often with minor variations. 15. He continued: “But if the world as a community focused on it, we could heal it. And if we don’t, it will become deeper and angrier” (Blair, “Full Text: Tony Blair’s Speech”). 16. See Adichie, “The Danger of a Single Story.” 17. For a critical discussion of spectacular black suffering and white violence, see Hartman, Scenes of Subjection. On the spectacle of African death, see Kalusa and Vaughan, Death, Belief and Politics, xi. 18. For example, Kalusa and Vaughan, Death, Belief and Politics. 19. For example, Chapman, Family Secrets; and Banda, “Stakeholders’ Perceptions of Traditional Birth Attendants.” 20. For example, S. L. M. Davis, The Uncounted. 21. For example, Strong, Documenting Death. 22. For example, Langwick, Bodies, Politics, and African Healing. 23. For example, Suh, Dying to Count. 24. Not everyone who carries and gives birth to a child identifies as a woman. Many writers choose terms that describe parents rather than mothers, childbearing people rather than women, they rather than she. As important as I believe it is to use language respectful of all people who do the work of birth, I refer mostly to women, for two reasons. First, I have encountered no version of this particular discussion in Malawi. Second, pregnant and childbearing women have experienced much harm, historically and today, related specifically to their gendering as female. To erase their gender would perpetuate the invisibility of misogyny. Bonnex Kaunda: “There are too many goings-­on these days.” 1. Most asing’anga with whom I spoke introduced themselves with the English word doctor, as Bonnex Kaunda did. Signs advertising their workplaces and classified ads promoting their services often also used this word, even when the rest was in Chichewa. I have used the title Doctor when they did, reserving the abbreviation Dr. for physicians. More generally, titles throughout the book reflect the forms of address that interviewees used. 2. At the time, two hundred kwacha was equivalent to about fifty US cents. Chapter 1 1. These arteries supply the placenta with a half liter of blood per minute (Cunningham et al., Williams Obstetrics, 108). Research in rats, sheep, dogs, and monkeys has generated most medical knowledge about utero-­placental function. The shape and number of spiral arteries, however, comes from a plaster-­and-­glue model based on a human specimen (Brosens and Dixon, “Anatomy of the Maternal Side of the Placenta”).

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2. In an assessment of personnel providing emergency obstetrical care, registered nurse-­ midwives averaged a 4.5/10 score on questions regarding management of retained placenta, the highest of any group surveyed. That year, 68 percent of health centers and 24 percent of hospitals were assessed as unable to manage retained placentas (Ministry of Health, Malawi Emergency Obstetric and Neonatal Care Needs Assessment, 28, 108). 3. Midwives and doctors are taught that structures at the brain’s base regulate functions essential to life. The intracranial swelling that accompanies eclamptic seizures can force (“herniate”) these structures into a woman’s spinal canal, our textbooks warn. The compression that results disrupts cardiac and pulmonary function, often lethally. 4. Ashforth, Trials of Mrs. K., shows how these plots played out when a district-­hospital nurse in central Malawi was accused of being a witch. 5. The emphasis was Chief Matengo’s. Repetition also adds emphasis in many Malawian languages, including English. 6. At the time of this interview, two thousand kwacha was roughly equivalent to five US dollars. This fine was more than a week’s wages—­at the minimum wage, then 317 kwacha daily. Wages were often below minimum, especially for ganyu (ad hoc labor for hire). 7. Sister Kunjirima’s account was optimistic. In general, operating theaters were poorly staffed, queues for surgery long, and procedures for putting emergency cases first ineffective. Many a cord-­prolapse case ended with both a “fresh stillbirth” and a fresh uterine scar, making the mother’s subsequent pregnancies more dangerous. 8. This brief history neglects important moments and permits overbroad generalizations. For a fuller picture, consult McCracken, History of Malawi, for a politically focused history; Lwanda, Politics, Culture and Medicine in Malawi, for a medical one; or Morris, An Environmental History of Southern Malawi, for an environmental one. The material that follows draws heavily on all three, with additional sources cited. 9. This focus is an analytical choice, not an emic interpretation. When older people described a better past, the inflection points they typically mentioned were not the cash economy, labor migration, or structural adjustment, but instead multiparty democracy and “this new disease” of HIV/AIDS. 10. I follow Steven Feierman, among the first to describe how economic changes affected health and disease in southern Africa and how healing practices responded to these changes; see Feierman, “Struggles for Control.” 11. Mlendo ndiye ayenda ndi kaluma kakuthwa. 12. Schoenbrun, “Conjuring the Modern in Africa,” 1438. 13. Janzen, Quest for Therapy, notes that competing explanations for complex afflictions made the work of these “therapy management groups” essential—­and difficult. 14. Sing’anga is the Chichewa word. In northern Malawi’s Tumbuka-­speaking communities, separate specialists typically undertook divination and treatment (Wendroff, “Trouble-­Shooters and Trouble-­Makers”). Details of terminology and practice are beyond this book’s scope. 15. To use language from older anthropological scholarship, an afflicted supplicant might join a healing cult and eventually become a priestess herself. This language seems needlessly exoticizing—­or, perhaps, the language used to describe similar patterns in other places is needlessly flattening. Imagine an American who joins a yoga group, experiences a health improvement, and ultimately becomes a yoga instructor: is she a priestess in a yoga cult? 16. Much—­not all—­of what is now Malawi traced kin through matrilines. It was not a matriarchy, and certain patriarchal practices were widespread.

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17. Boucher, When Animals Sing and Spirits Dance. Girls were warned to be careful about their own sexual activity, lest they hurt the chief. 18. Stannus and Davey, “Initiation Ceremony for Boys among the Yao.” See also Sanderson, “Inyago.” 19. Vaughan, “Maternal Mortality in Malawi,” 297. 20. Schoffeleers, Religion and the Dramatisation of Life, 41–­44, probably referring to events in the mid-­twentieth century. 21. Boucher, When Animals Sing and Spirits Dance, 114, recounting what people described as customary practice. 22. Kaspin, “A Chewa Cosmology of the Body,” 561, describing events in the 1980s. 23. See Kaspin, “Chewa Visions and Revisions of Power”; and Kaspin, “A Chewa Cosmology of the Body.” 24. See Vail and White, “Possession of the Dispossessed.” Wright, Strategies of Slaves & Women, analyzes enslaved women’s oral histories from this region. 25. Wright, Strategies of Slaves & Women. 26. Vergès, Le Ventre Des Femmes, ch. 3; David Brion Davis, Inhuman Bondage. 27. The Mpemba cult, for instance, was established by a healer based in what is now Congo-­ Brazzaville. Treatment centers flourished far afield, drawing women seeking reproductive help (Janzen, “Ideologies and Institutions”). 28. Contemporaneous accounts suggest that Europeans were disturbed both by powerful and by powerless African women. Missionaries and colonial officials preferred situations in which women, while not actually enslaved, were under male control. 29. Webb and Giles-­Vernick, introduction to Global Health in Africa. 30. Missionaries, traders, plantation owners, and (later) colonial officials were not mutually exclusive categories: Europeans moved among them. Some came to Nyasaland as missionaries only to become plantation owners, for instance. 31. Leys included this example in a long unsolicited letter to Britain’s secretary of state for the colonies, written after colonial officials had crushed a Nyasaland rebellion and executed its leader, John Chilembwe. Future uprisings were inevitable, Leys warned; they should be understood as insurrection against unjust rule, not dismissed as “tribal” disputes. Only land tenure reform, equality under the law, basic health care, and public education could preserve Britain’s African colonies (Leys, “Typescript Copy of a Letter, 1918”). 32. Alexander, The New Jim Crow; see also Bailey, Feldman, and Bassett, “How Structural Racism Works.” 33. Rotberg, Rise of Nationalism in Central Africa; McCracken, History of Malawi, ch. 3. 34. Numbers were higher in some areas. Lovett, “From Sisters to Wives and ‘Slaves,’ ” has estimated that by the 1950s, 60 percent of men from Nyasaland’s Tonga-­speaking region were working outside the area. Women had to assume their husbands’ workloads, while also lacking their brothers’ support and protection. 35. Packard, “Invention of the ‘Tropical Worker.’ ” 36. Leys, “Typescript Copy of a Letter, 1918.” 37. Eventually these infections became deadlier. Many of South Africa’s migrant workers, including Malawians, infected partners with HIV on returning home (Barnett and Whiteside, “Why Africa?”). 38. See, for example, Vaughan’s analysis in “ ‘Divine Kings’ ” of a maternal death and its after­­ math, drawn from the unpublished 1930s field notes of the anthropologist Audrey Richards.

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39. Kaspin (“A Chewa Cosmology of the Body”) learned about this option in the 1980s; it likely dates from decades earlier. 40. Some hospital workers blamed overlong abstinence periods for male infidelity and its dangers. 41. Chanock, “Ambiguities in the Malawian Political Tradition.” 42. Henderson and Gilman, “Women as Religious and Political Praise Singers.” 43. Vaughan, Curing Their Ills, 67. 44. Chanock, Law, Custom and Social Order; see also Wright, Strategies of Slaves & Women. Indirect rule was common throughout British colonies. 45. The legal situation was quite complex, as Chanock, Law, Custom and Social Order, points out. Missionaries clearly sympathized with male African elders who complained about moral breakdowns. Colonial records suggest that government perspectives were more mixed. British bureaucrats, European missionaries, and African elders did not always agree on how marital disputes should be adjudicated, or who had jurisdiction. 46. British colonial administrators often distinguished between “witchcraft” they took to be occult and “native medicine” they imagined as herbal (Langwick, Bodies, Politics, and African Healing, ch. 2). Most informal-­sector practitioners who spoke with me, however—­even those who at first claimed to use only “roots” or only divination—­eventually referred to practices that blurred such distinctions. 47. Anti-­witchcraft movements troubled colonial bureaucrats more than witchcraft did. Administrators banned divination practices intended to uncover the origins of malign forces. They did not—­or felt they could not—­believe witchcraft itself existed, and did not ban witches. These actions were widely interpreted as unjust: why would government weigh in on the witches’ side, against those who kept the community safe from them? 48. Interviewees might have spoken differently about witchcraft with another interviewer, of course. 49. Mandala, The End of Chidyerano; cf. Moore and Vaughan, Cutting Down Trees. 50. Mandala, End of Chidyerano, 46. 51. Marshall, “Reminiscences of Medical Work” (unpaginated). 52. Vaughan, “Famine Analysis and Family Relations.” 53. Capitalism and colonial conquest took root just before a time of rapid change in biomedicine; see Vaughan, Curing Their Ills, ch. 3; Comaroff and Comaroff, Of Revelation and Revolution, Volume 1; and Hokkanen, Quests for Health in Colonial Society. Mission records from the 1880s demonstrate that germ theory was not yet established, surgical techniques were limited, and much depended on prayer. Life-­threatening complications of childbirth afflicted missionary families as well as their prospective converts. In one week during June 1884, for instance, Dr. William Scott noted: “Mrs Moir has got [delivered] a daughter but has been most seriously ill,” and “I was called to see a case of retained placenta, but the woman was dead before I arrived” (W. Scott, “Private Journal”). 54. See McCracken, History of Malawi, 116–­21. The term medical auxiliaries referred to various workers without broadly recognized credentials. The rate of training at many Nyasaland facilities was slow, the caliber uneven. In 1939, Nyasaland’s director of medical services noted that there was not one trained nurse or midwife in government service (de Boer, “[Nyasaland] Medical and Health Services Report”). 55. The physician J. B. Davey, who’d worked in Nyasaland from 1902 to 1919, called it “the Cinderella of the Protectorates. Certainly no country could have been run so economically—­

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parsimoniously, in fact. To obtain a 5 note for urgently needed repairs to house or hospital was a serious undertaking” (Davey, “Nyasaland,” unpaginated). 56. Leys, “Typescript Copy of a Letter, 1918,” 36. 57. Nurses saw some African patients at a hospital in the colonial capitol by 1925, when a maternal death attributed to “delayed labor” was recorded there (Nyasaland Protectorate, “Annual Medical Report”). 58. See Colonial Office, “Proposals for the Development of Medical and Sanitary Services.” 59. Cooper, “Modernizing Bureaucrats, Backward Africans.” 60. Chirwa died in prison in 1992 after Banda, under domestic and international pressure, commuted his sentence to life imprisonment (Carver, Where Silence Rules). 61. He turned against it when the great masked Nyau dance, the gule wamkulu, incorporated critical references to his government (Boucher, When Animals Sing and Spirits Dance; Forster, “Culture, Nationalism and the Invention of Tradition in Malawi”; Kaspin, “A Chewa Cosmology of the Body”). 62. For this episode and the longer history of  health care funding, see Messac, No More to Spend. 63. Bierdrager et al., “National Health Planning, Malawi,” 134. 64. See Packard, History of Global Health, ch. 10; and Murphy, Economization of Life. 65. WHO, “Inter-­agency Co-­ordination—­Family Planning—­Malawi.” 66. Chapter 6 describes TBAs and the government training courses that some undertook. 67. See Colbourn et al., “Maternal Mortality in Malawi”; cf. Hogan et al., “Maternal Mortality for 181 Countries.” 68. Draw your own contemporary parallels. 69. For more on Bretton Woods, see Helleiner, “From Bretton Woods to Global Finance”; for its human and environmental consequences, see Philipsen, Little Big Number. Late in the Cold War, both lenders changed missions to promote recipients’ participation in international marketplaces. In theory, the free flow of money would encourage the free flow of democratic ideas. In practice, it opened opportunities for international investors. 70. See Berg, Accelerated Development in Sub-­Saharan Africa. Loan conditions applied to sovereign governments are called “conditionalities,” perhaps because that makes them sound more like technical processes and less like demands. 71. The word neoliberalism has been applied elastically (Bell and Green, “On the Perils of Invoking Neoliberalism”). Here I use it specifically to indicate this set of macroeconomic poli­­ cies—­often called, aptly or not, the “Washington Consensus.” All six principles work to privatize profit and to socialize risk. Limitations on collective bargaining and other worker-­protection measures are frequently included. The liberal in neoliberal does not indicate a left-­leaning ideology, but rather one that conflates unregulated markets with personal liberty. 72. Kate Bridges and Woolcock, How (Not) to Fix Problems That Matter. 73. WHO, “Co-­ordination with UNDP—­Country Programme—­Malawi [1986],” 11. 74. William Peters, British high commissioner from 1980 to 1983, recalled an IMF team sent to Malawi to recommend loan conditions: “For anyone cognisant of the prevailing economic and political circumstances, it was abundantly clear that these recommendations were going to spell misery and acute hardship for the greater part of the population” (quoted in Dent and Peters, “Malawi Debt,” 13). Later, the IMF leadership denied any institutional responsibility for structural adjustment’s harms. Dent and Peters saw in this denial “hauteur of a staggering size, fit, one is tempted to say, only for the High Priests of a new religion of financial management” dedicated to enriching the already rich (ibid., 16).

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75. Anthropologists have thoroughly documented structural adjustment’s immiserating effects, which worsened health and hastened death for people in Africa and elsewhere (Pfeiffer and Chapman, “Anthropological Perspectives”). 76. WHO, “Co-­ordination with UNDP—­Country Programme—­Malawi [1991].” 77. Chapter 2 describes mechanisms by which health-­sector deterioration worsened the HIV epidemic. 78. Bassett, Bijlmakers, and Sanders, “Experiencing Structural Adjustment in Zimbabwe”; Bryceson, “Ganyu Casual Labour, Famine and HIV/AIDS in Rural Malawi”; Dent and Peters, “Malawi Debt.” The “gig economy” is not new; its spread to middle-­class people in the Global North is. Like the “informal economy,” it allows the privileged to celebrate as initiative what might otherwise be understood as misery. 79. Mandala, End of Chidyerano. 80. WHO, “Emergency Relief and Assistance to Refugees—­Malawi.” 81. Namangale, “People Facing Hunger Increase.” 82. Cited in Dent and Peters, “Malawi Debt.” 83. Wolf, “AIDS und Kanyera in Malawi”; cf. P. E. Peters, Kambewa, and Walker, “Contestations over ‘Tradition.’ ” 84. WHO, World Health Report 2002. Expanded access to antiretroviral treatment, especially after 2007, made an enormous difference. It could not heal the wounds to families and friendship networks, nor did it repair the damage done to institutional memory and function. 85. See Dilger, Leben Mit AIDS. 86. The pattern of confusion and denial followed by victim-­blaming is common in epidemics. As Malawians blamed witchcraft and then promiscuous women, so Americans—­including medical scientists—­blamed party-­drug use and then gay men. The COVID-­19 pandemic provides additional examples. 87. Women’s literacy and employment rates lagged behind men’s, but the gap has narrowed; see World Bank Development Indicators, https://databank.worldbank.org/reports.aspx?source =world-development-indicators (accessed December 29, 2019). 88. On Malawian youths’ experiences with the informal economy, see Hajdu et al., “Income-­ Generating Activities for Young People.” 89. See Verheijen, “Balancing Men, Morals and Money”; and Kaler, “ ‘When They See Money.’ ” 90. Bridewealth payments were also common in parts of the country, as were “virgin seduction fees” men paid to a girl’s parents. For Mozambique, see Chapman, Family Secrets. 91. For more on these relationships and the tales told about them, see Silver, “Sex, Schooling, and Moral Triage,” ch. 6; for Mozambique, cf. Chapman, Family Secrets; and Manjate, Chapman, and Cliff, “Lovers, Hookers, and Wives.” 92. For recent figures, see Government of Malawi, Malawi Demographic and Health Survey. 93. Zeleza, “Politics of Research in Africa.” 94. For an examination of these concerns in Mozambique, see Chapman, “Endangering Safe Motherhood in Mozambique”; and Chapman, Family Secrets. 95. Many health care workers grumbled about women who initiated prenatal care in the last trimester of pregnancy, but none initially volunteered fears of witchcraft as a reason; instead they blamed willfulness, transportation difficulties, or ignorance. Only when I asked whether concerns about jealousy were a factor (thus acknowledging, without using the word, that I already knew about witchcraft) did some interviewees fill in those blanks.

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96. See, for example, Lyons, The Colonial Disease; Vaughan, Curing Their Ills; and Greene et al., “Colonial Medicine and Its Legacies.” 97. Douglas, Risk and Blame. 98. To “tell it to them like it is” in Chichewa is the sonically pleasing kuwauza tchutchutchu. It’s worth sounding out aloud. 99. People in this region often attributed prolonged labors to women’s infidelity. Interviewees may have been hinting at a connection between Western contraceptives and sexual immorality. No one stated as much explicitly, but Chichewa is rich in euphemisms, and I may have missed some. 100. Initiation ceremonies persisted among most ethnic groups (Munthali and Zulu, “The Timing and Role of Initiation Rites”). A separate, later initiation taught young women about birth and motherhood. 101. It’s not clear that teen pregnancy has increased in Malawi. Some of this disapproval may reflect a sexually conservative form of Christianity that has become widespread. 102. Kaler, “Many Divorces and Many Spinsters”; Kaler, “ ‘When They See Money’ ”; see also Vail and White, “Possession of the Dispossessed.” Divorce rates had not risen appreciably in six decades. Interviews did illuminate social change: in the 1940s, elders often attributed marital fragility to tensions over money and goods brought back by migrant laborers. In the 1990s, they blamed changing sexual norms and the rise of commodified sexuality. 103. It’s possible, too, that the context of an interview with me made particular morals and stories feel more important to tell. Agnesi Kunjirima: “You can make your pregnancy safe.” 1. The conditions mentioned in this sentence of English, medical slang, and Chichewa include pregnancy-­induced hypertension (PIH), ordinary hypertension (named in both English and Chichewa), malaria, and anemia. People occasionally mingled languages this way. Knowing Sister Kunjirima, I suspect she was testing my Chichewa. Chapter 2 1. M&M meetings are intended to produce knowledge and ideas for new training policies or other systemic changes. Disciplinary actions seldom result. Patients’ family members do not attend, nor are they informed of conclusions. 2. Hospital discussions, like community discussions of deaths, are sensitive. In accordance with ethical guidelines and guided by Shellhaas et al., “Examination of a Death,” I have worked to keep cases untraceable. At several points in this book I have omitted a meeting location, making clear only whether it was in Malawi or the US. I’ve given as “diagnosis” the cause of death assigned at the meeting. When records were compiled, analysts recoded to conform with standard WHO nomenclature. 3. The priorities are reversed in many US teaching hospitals, where interns learn that “if it isn’t in the chart, it didn’t happen.” Sometimes, in both locations, what is in the chart also didn’t happen. 4. See WHO, “Integrated Management of Adolescent and Adult Illness.” 5. Spontaneous abortions and stillbirths are more frequent with some serious illnesses, possibly an evolutionary adaptation to preserve scarce maternal resources (Rutherford, “Womb to Womb”).

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6. In Blantyre’s public-­sector clinics, midwives made these routine measurements with their hands, measuring tapes, and sturdy metal or plastic tubes (Pinard horns) through which they listened to fetal heartbeats. Elsewhere, clinicians often made the same measurements with ultrasound machines (see, for example, Gammeltoft, “Sonography and Sociality,” for Hanoi; and Erten, “At Least Three Children,” for Istanbul). 7. Eclampsia and cerebral malaria are not the only plausible biomedical explanations, although they may be the likeliest in a Malawian teenager. A review article on neurological emergencies in pregnancy mentions eleven causes for seizure—­malaria not included; see Edlow et al., “Diagnosis of Acute Neurological Emergencies.” Researchers in Mozambique, comparing maternal death-­review diagnoses to autopsy findings, concluded that reviewers overdiagnosed eclampsia and underdiagnosed infection. About half the deaths attributed to eclampsia by obstetricians looked like meningitis, sepsis, or other infections to pathologists (Ordi et al., “Clinico-­pathological Discrepancies in the Diagnosis of Causes of Maternal Death”). 8. The WHO estimates that one in two hundred illegal abortions in sub-­Saharan Africa ends in a mother’s death, a rate double that of “all developing regions” (WHO, Safe Abortion, 21). 9. Health centers were consistently testing for HIV by this time, but TBAs—­who lacked lab access—­were not. A few TBAs said they urged clients to get tested. Two reported that they accepted only those clients who produced evidence of negative tests. 10. Morning handover rounds allowed the newly arrived team to learn about patients of concern from the team going off call. They were critically important. Because staffing was so limited, however, attendance at rounds sometimes left few or no midwives to handle unexpected emergencies. 11. The term is intended only for deaths before birth, the stillbirths for which “SB” is shorthand. Hospital staff occasionally applied it to early postnatal deaths, especially unobserved ones, as a way of sidestepping accountability (cf. Strong, Documenting Death, ch. 5). 12. Laboratory technicians calculate hematocrits as percentages: what percentage of a person’s blood, when spun down in a centrifuge, consists of the red blood cells that carry oxygen, as opposed to other cellular material and the plasma in which those cells float? People with lower hematocrits may have fewer red blood cells, smaller ones, or both. 13. Standard Ministry of Health treatment guidelines recommended transfusion with a hemoglobin less than seven grams per deciliter of blood at any time in pregnancy. That figure was roughly equivalent to a hematocrit of 21 percent (Ministry of Health, Republic of Malawi, Malawi Standard Treatment Guidelines). 14. Frusemide is the Malawian (and British) English spelling of the drug Americans know as furosemide, or Lasix. The intern’s dilemma was a common one. A recent review on pneumonia on the African continent notes that fluid management is “fraught with uncertainty,” especially in cases of sepsis (Aston and Rylance, “Community-­Acquired Pneumonia in Sub-­Saharan Africa,” 860). 15. People with early symptoms of HIV often have generalized skin rashes (Eddleston, Oxford Handbook of Tropical Medicine). 16. Specifically, this section draws heavily on Cronjé and Grobler, Obstetrics in Southern Africa, and on Kumar et al., Robbins & Cotran Pathologic Basis of Disease. The medical library contained several well-­thumbed and underlined copies of each. 17. Mitochondria are organelles, a word from the Latin for “little tool.” The evolutionary biologist Lynn Margulis proposed in 1967 that mitochondria began as free-­living cells, incorporated into animals in a process of symbiosis (Sagan, “On the Origin of Mitosing Cells”): a “little

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tool” that could produce energy with such efficiency would have been advantageous. Over three decades this theory went from radical fringe to orthodoxy. 18. This process, like all others that use oxygen and release carbon dioxide while making energy from nutrients, is called respiration. 19. A typical erythrocyte lasts about four months, going through this cycle many hundreds of times before the spleen breaks it down into component parts for recycling. Cells with unusual shapes, such as sickles or spheres, get broken down much faster, as do erythrocytes distorted by malaria parasites. New erythrocyte production cannot always keep up. 20. Among patients in the Queens ICU, anemia was strongly associated with death from pneumonia (see Hartung et al., “Etiology of Suspected Pneumonia in Adults”). 21. Kumar et al., Robbins & Cotran Pathologic Basis of Disease, 52. 22. Using other creatures as models for humans, the pathology text notes that “elevated body temperature has been shown to help amphibians ward off microbial infection, and it is assumed that fever does the same for mammals, although the mechanism is unknown” (Kumar et al., 74). 23. Untreated HIV alters nearly every aspect of these processes. Immunologists conclude that the virus decreases total numbers of immune cells, delays recognition of problematic microbes, and diminishes activity of phagocytes and related cells. Most of the time, pneumonia in people with HIV is caused by garden-­variety pathogens that hit more often and more severely when immunity is compromised; sometimes it results from “opportunistic” microbes that rarely affect those with robust immune function (Hartung et al., “Etiology of Suspected Pneumonia in Adults”). Typical radiographic changes that doctors look for depend on typical immune-­system responses, and so X-­ray diagnoses are also less reliable for people infected with HIV (Aston and Rylance, “Community-­Acquired Pneumonia in Sub-­Saharan Africa”). 24. Most sepsis originates in the lungs. Immune compromise caused by untreated HIV infection increases the likelihood of pneumonia, its severity, and the odds that it will progress to sepsis (Aston and Rylance). 25. Much of what public health specialists know about maternal death in each place comes from these forms, a point discussed in chapter 5. 26. Roberts, Fatal Invention. 27. I borrow here not only from the Chichewa proverb—­which is very much intended to apply to people—­but also from the gardener’s metaphor developed by Dr. Camara Phyllis Jones in “Levels of Racism” to teach about how structural racism hurts people. 28. They fit well, too, with a drive to develop consumer markets for individualized injury prevention: consider bone-­density scans and bone-­building pharmaceuticals for the elderly. 29. Fassin, When Bodies Remember. For a fuller and more complicated story about tuberculosis, see Packard, White Plague, Black Labor. 30. Katoto et al., “Ambient Air Pollution and Health.” While my focus here is on pulmonary damage, polluted air also contributes to cardiovascular disease and death. 31. Hotez and Whitham, “Helminth Infections.” Parker and Allen, “De-­politicizing Parasites,” notes that “neglected tropical diseases” mostly afflict neglected people; treatment and prevention are inherently political matters. 32. Stauffer and Madsen, “A One Health Approach to Schistosomiasis.” 33. Bailey, Feldman, and Bassett, “How Structural Racism Works.” 34. I will not discuss malaria here. For an overview of its impacts on pregnancy, see D’Alessandro et al., “Treatment of Uncomplicated and Severe Malaria.”

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35. Medical personnel also linked malnutrition with maternal danger when it caused short stature, a causal narrative discussed in chapter 3. The obstetrics textbook warns that severe anemia could cause cardiac failure, exacerbate infection, and prevent women from recovering from obstetric hemorrhage. “All of these will delay general physical recovery, especially after caesarean section, where maternal death may be the ultimate outcome” (Cronjé and Grobler, Obstetrics in Southern Africa, 543). Anemia probably contributed to three of the deaths described at the beginning of this chapter. 36. See, for example, the UN World Food Program, https://www.wfp.org/countries/malawi (accessed December 29, 2020). 37. Mandala, End of Chidyerano, 221–­25. 38. Clinicians and epidemiologists distinguish between two forms of hunger: in one, lack of dietary protein is more severe; the other involves a general lack of calories. Pathologists note that both forms suppress bone marrow and contribute to anemia (Kumar et al., Robbins & Cotran Pathologic Basis of Disease, 428). 39. Schumacher and Messmer, “Malnutrition and Micronutrient Deficiencies,” 141. 40. Unless, perhaps, Schumacher and Messmer meant counseling and educating trade-­ policy architects and corporate titans. 41. For the estimates provided in this section, see Government of Malawi, Malawi Demographic and Health Survey. For a public health perspective on fertility, see Menken and Rahman, “Reproductive Health.” Johnson-­Hanks, “When the Future Decides,” provides a study combining anthropological and demographic approaches to fertility. 42. In 2017, I took a minibus trip of 130 kilometers (eighty-­one miles) that began at eight in the morning and reached my destination seven hours later—­even without mechanical breakdowns or police stops. 43. Calculated from Ministry of Health, Malawi 2010 EmONC Needs Assessment Final Report. Overall, 33 percent of positions for doctors, clinical officers, and nurse-­midwives were filled, ranging from 50 percent in central hospitals to 14 percent in health centers. A 2015 update showed little change. 44. UNAIDS, Global AIDS Update; see also Government of Malawi, Malawi Demographic and Health Survey, ch. 11. 45. Three-­quarters of adolescents infected are girls, a disparity attributed to age-­disparate sexual relationships. Routine screening in antenatal clinics means women are also more likely to be diagnosed. 46. Epidemiologists see the relationship between HIV and maternal death (discussed briefly in chapter 5) as complex. HIV prevalence in Malawi has been relatively stable for years. Illness patterns have changed, however. Early on, few people had yet lived with the virus long enough to show symptoms. The overall epidemiological picture became bleaker as more and more people with the virus began to develop the cancers and infections that are a hallmark of untreated HIV. Beginning around 2005 to 2007, treatment reduced illness severity. 47. Colbourn and colleagues, in “Maternal Mortality in Malawi,” reached a similar conclu­ sion. Several of the article’s authors had decades of experience—­far more extensive than mine—­ on obstetrics wards in Malawi. See also Kanyighe et al., “Determinants of Post-­partum Maternal Mortality.” 48. See, for example, Thomas and Cole, “Thinking through Love in Africa.” Mkandawire-­ Valhmu and colleagues, in “Marriage as a Risk Factor for HIV,” observe that Malawian women, unlike public health researchers, often see marriage as their most significant risk for HIV.

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49. This correlation may be why the Malawian English word movious describes someone who has many sexual partners. 50. See, for example, K. M. Wall et al., “Schistosomiasis Is Associated with Incident HIV.” 51. Gisselquist and colleagues, in “Let It Be Sexual,” argue that researchers have strategically underestimated iatrogenic spread of HIV, to avoid frightening people away from medical help or distracting from public health messages about safe sex. 52. People described this practice in Malawi; I have not observed it. For Uganda, see Birungi, “Injections and Self-­Help.” 53. Ofri, in “Medical Errors during the Coronavirus Crisis,” describes similar consequences when the first wave of COVID-­19 hospitalizations crashed on ill-­prepared hospitals in New York City. 54. See Bicego, Boerma, and Ronsmans, “The Effect of AIDS on Maternal Mortality”; and McCoy et al., Going from Bad to Worse. The gap may reflect higher urban HIV prevalence, unsafe medical care, or both. 55. See Peabody, “Economic Reform and Health Sector Policy”; Pandolfelli, Shandra, and Tyagi, “The International Monetary Fund, Structural Adjustment, and Women’s Health”; and Pfeiffer and Chapman, “Anthropological Perspectives.” Prince, “Situating Health and the Public in Africa,” usefully situates the public health impact of structural adjustment in a much longer history. 56. For a rare study assessing HIV risks at individual and neighborhood levels, see Feldacker, Ennett, and Speizer, “It’s Not Just Who You Are.” Distinctions between levels, although analytically useful, are often difficult. Many a pregnant woman living near Lake Malawi has contracted Schistosoma haematobium, a waterborne parasite that causes chronic blood loss, while doing the family laundry in polluted streams and lakes. What is the most important scale? The family that designates women as the ones to wash clothes? The community with inadequate sewer infrastructure? The nation that has not controlled the parasite’s spread despite decades of public health efforts, and that does not include schistosomiasis screening in antenatal care protocols? The transnational economy that has extracted wealth and undermined responsible governance for centuries, ensuring that public health infrastructure projects remain inadequate? These scales are not fully separable. Together they ensure that Malawian women are far likelier to suffer from schistosomiasis than are people elsewhere who do laundry in machines connected to relatively clean water systems. 57. Biruk, Cooking Data. 58. See Nixon, Slow Violence and the Environmentalism of the Poor. 59. Messac, No More to Spend. 60. Geronimus et al., “ ‘Weathering’ and Age Patterns of Allostatic Load Scores.” For consideration of weathering and epigenetic change, see Geronimus, “Deep Integration.” 61. See also Bledsoe and Banja, Contingent Lives. 62. Probably not—­see Pollak et al., “Exogenously Applied Muscle Metabolites.” 63. See Mberu et al., “Health and Health-­Related Indicators.” 64. An enormous body of work has built up knowledge about scientific knowledge. For a useful overview of twentieth-­century scholarship, see Martin, “Anthropology and the Cultural Study of Science.” I find the works Haraway, Modest_Witness@Second_Millenium; Fullwiley, Enculturated Gene; and Mol, Body Multiple to be helpful entry points for thinking about biological science, public health knowledge, and medical diagnosis, respectively. No doctor or medical stu­­ dent who studies Mol’s work on atherosclerosis will understand medical knowledge the same way again.

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65. Dreams, too, can be ways of knowing, as chapter 4 will describe. 66. Wilson did not think much of the nearby health center, where such tears were too common. She offered medicinal baths that expedited healing. 67. See Lampiao et al., “Preliminary Investigation of Labour Inducing Plant.” The assumption is that effects on rats will illuminate effects on people. Researchers also assume that the plant itself—­not the words said as it is given, or the relationship between giver and recipient—­ produces the treatment’s effects (cf. Feierman, “Explaining Uncertainty in the Medical World of Ghaambo”). 68. Krebs, “The Citric Acid Cycle and the Szent-­Györgyi Cycle.” 69. Other animals can be metaphors too, as in Declercq and Shah’s “Maternal Deaths Represent the Canary in the Coal Mine,” about women’s health in the United States. Deaths specifically related to pregnancy (like those from obstetric hemorrhage) have fallen, they note. But maternal deaths related to chronic poor health and chronic social problems—­such as abusive relationships and unstable housing—­have risen substantially. 70. Like Chewa elders, evolutionary biologists look beyond individual species to consider relationships among organisms—­for instance, the coevolution of microbes and animals thought to have given us mitochondria. 71. Rutherford, “Womb to Womb.” 72. For an influential discussion of how factory metaphors shape medical ideas about women’s reproduction, see E. Martin, The Woman in the Body. 73. Rensberger, Life Itself, 76. 74. Krieger, “Epidemiology and the Web of Causation.” 75. Fassin, “Exclusion, Underclass, Marginalidad.” 76. That was the point of my earlier book, Wendland, A Heart for the Work. You may have noticed this point in the conversation among three doctors recounted in chapter 1, and you will encounter it again in chapters to come. 77. These tools for building mortality statistics will be described in chapter 5. 78. Nancy Krieger developed an ecosocial model to help epidemiologists analyze how the physical and social environment become embodied over the life cycles of people who occupy different social positions. See Krieger, “Embodiment: A Conceptual Glossary”; see also Krieger and Smith, “ ‘Bodies Count,’ and Body Counts.” She urges epidemiologists to “avoid the trap of conflating scientific assumptions with reality” (Krieger, “Epidemiology and the Web of Causation,” 898). 79. Malnutrition takes months to weaken immune responses, years to stunt bodies. HIV has a latency period from the time the virus enters someone’s body to the time it turns her immune system to its own purposes. Only after that immune assault does she fall victim to opportunistic pathogens. This latency period is typically five or more years; it ranges from a few months to over a decade. 80. As Gil-­González, Carrasco-­Portiño, and Ruiz have pointed out in “Knowledge Gaps in Scientific Literature.” 81. Krieger, “Epidemiology and the Web of Causation.” Lillian Siska: “I help them right here at home.” 1. Mostly, “roots” were actual roots from medicinal forest gardens. Sometimes the term was a shorthand that included bark, twigs, or leaves.

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2. Biomedically inclined readers might think of vimbuza spirits as a sort of spiritual immune system: in balance, they protect one from injury; out of balance, they cause serious harm. See Friedson, Dancing Prophets. Chapter 3 1. My distinction is intended as pragmatic, not definitive; it rides roughshod over a substantial literature on technology; see, for example, Sismondo, Intro to Science and Tech Studies, ch. 9. 2. See fig. 13.24 from King and Mola, Guide to Safe Motherhood in Developing Countries, a reference text used in several of Malawi’s district hospitals. 3. See Mol’s study of atherosclerosis, Body Multiple; see also Mol and Law, “Regions, Networks and Fluids,” a work on the diagnosis of anemia. 4. Stacey Langwick argues that dividing a healer’s techniques into diagnostic and therapeutic measures “smuggles in a narrow conception of etiology” that prioritizes the material (Langwick, Bodies, Politics, and African Healing, 203). I am steeped in medical taxonomies and rarely avoid this danger. Langwick’s warning is useful. Many maladies, especially those without visibly material etiologies, resist reductionist diagnosis. And sometimes—­as in both vimbuza trance healing and psychotherapy—­diagnosis is therapy. 5. Clinicians worry most about head size in relation to the maternal pelvis because the head is usually the largest part of a fetus’s body. In exceptional cases, the fetal shoulders are larger. Obstructed labor does not always result from CPD. Rare fetal malformations or tumors can cause it, as can some malpresentations (such as a fetus presenting shoulder first). 6. Maharaj, “Assessing Cephalopelvic Disproportion,” 387. 7. Maharaj, 387. 8. The assumption that efficient walking requires a narrow pelvis has not held up to testing, and pelvic shape seems to be relatively unimportant for smooth childbirth; see Dunsworth, “There Is No ‘Obstetrical Dilemma.’ ” Stone, “Biocultural Perspectives on Maternal Mortality,” argues that the Darwinian narrative was a misinterpretation of poor obstetrical outcomes that actually resulted from corset-­wearing, lack of exercise and sunshine, and medicalization of birth among white, middle-­class Victorians. These misinterpretations were used to pathologize women as inherently fragile and in need of medical assistance. 9. Epidemiologists, clinicians, and activists understand obstructed labor to be by far the most common cause of fistula. Pressure-­caused tissue necrosis most commonly creates openings between a woman’s bladder and her vagina, but fistulas can also involve the rectum, uterus, cervix, or ureters. See L. L. Wall, “Dead Mothers and Injured Wives”; Arrowsmith, Hamlin, and Wall, “Obstructed Labor Injury Complex”; and WHO, “Obstetric Fistula.” 10. See Ratsma et al., “Why More Mothers Die”; and Rosato et al., “MaiMwana Women’s Groups.” 11. Medically trained birth attendants measure cervical dilation with two fingers. On many labor wards, trainees practice measurements on boards with cutout circles of various sizes. You must learn what degree of finger separation compares to each increment between zero and ten centimeters, and train yourself to remember how that separation feels. Doctors also learn to do rough-­and-­ready assessments of patients’ peripheral vision and hearing by comparing them to our own. Smith-­Oka and Marshalla, in “Crossing Bodily, Social, and Intimate Boundaries,” 114, aptly call these processes “somatic translation.” 12. Maharaj, “Assessing Cephalopelvic Disproportion,” 367.

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13. Stricter referral indications may backfire. The architect of TBA training in Malawi struggled with this dilemma: too high a cutoff “might have meant that TBAs would be expected to refer such a large number of their patients that they would have been discouraged and have been likely to ignore the instructions” altogether (Bullough, “Traditional Birth Attendants in Malawi,” 105). 14. Government of Malawi, Malawi Demographic and Health Survey, table 11.1. For historical data, see World Bank Development Indicators for Malawi at https://data.worldbank.org /indicator. 15. Brabin, Verhoeff, and Brabin, “Maternal Height, Birthweight and Cephalo Pelvic Disproportion.” 16. Chronic diarrhea and chronic parasitic infections reduce nutrient absorption, threatening growth of bone and muscle and brain. Nutritional deprivation also damages immune function: undernourished children are vulnerable to further infection. 17. Roberts, in Fatal Invention, and Gravlee, in “How Race Becomes Biology,” describe how deprivation and discrimination are frequently misread as racial difference. 18. Obstetricians often express particular concern for young first-­time mothers scarred by various techniques of genital cutting, a practice very rare in Malawi. The alarms sounded by the World Health Organization about obstetrical consequences of genital cutting are not supported by compelling evidence, as Hodžić, “Ascertaining Deadly Harms,” has shown. 19. This policy change was part of an international shift from the ineffective “risk approach,” in which peripheral facilities were to screen for risk factors and refer high-­risk women to better-­ staffed and -­supplied centers (AbouZahr, “Safe Motherhood”). 20. See, for example, Maharaj, “Assessing Cephalopelvic Disproportion.” 21. Some physiologists believe that a hormone called relaxin, secreted by the placenta and other pregnancy-­related tissues, has cartilage-­softening actions that are responsible. 22. Anthropologists connect this complex series of movements with the shift to bipedalism. Rosenberg and Trevathan, in “Birth, Obstetrics and Human Evolution,” have argued that the utility of assistance during this stage, as the fetal shoulders move through a mother’s pelvis, makes humans more dependent on skilled companionship at birth than any other primates. 23. Rates of CPD diagnoses can be highly variable among practitioners and hospitals. Professional organizations often urge clinicians to avoid the diagnosis of cephalopelvic disproportion entirely, instead advocating narrower labels (such as “arrest of descent”) with clearer definitions. 24. In the obstetrical literature, this tool is often called a partogram; in Malawi, it was a partograph. 25. In Tanzania, Strong (Documenting Death) noted that midwives and supervisors used partographs less to prevent obstructed labor and more to enforce—­or evade—­accountability. Melberg and colleagues (“Policy, Paperwork and ‘Postographs,’ ”) found that Burkinabe health workers sometimes called them “postographs”: they were filled in after the fact to satisfy supervisors’ demands for the “right” results. 26. Khonje, “Use and Documentation of Partograph in Urban Hospitals.” 27. I have not confirmed that this form exists. 28. With these muscles and those that run alongside the spine, Malawian women keep their bodies erect and loads balanced while carrying firewood, buckets of water, sacks of charcoal, or other burdens atop their heads. These muscles form the “six-­packs” admired among muscular men. 29. Several techniques are used for cesarean section; this description details the approach I usually saw in Malawi. Some surgeons cut skin and fat in a vertical line from a woman’s umbilicus toward her pubic bone, while others used an arcing line between the hip bones.

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30. This ripping and stretching sounds brutal. In a linguistic mitigation of its violence, surgeons call it “blunt dissection.” Bluntly dissected tissues heal better and bleed less than tissues sliced with a scalpel or cut with scissors. 31. Catgut is made from tendons or guts, but not those of cats. 32. DIC can also result from sepsis, as chapter 2 described. 33. Complications in later pregnancies include abnormal adherence of the placenta to the uterus, abnormal location of the placenta over the opening of the cervix (placenta previa), and a doubled risk of stillbirth (Clark and Silver, “Long-­Term Maternal Morbidity Associated with Repeat Cesarean Delivery”). Cesarean section also raises risks for later conditions—­such as bowel obstruction related to internal scarring—­that may require surgery. 34. Murphy, Economization of Life. For the US, see, among others, Roberts, Killing the Black Body; and Lawrence, “The Indian Health Service and the Sterilization of  Native American Women.” 35. WHO, Managing Complications in Pregnancy and Childbirth, P-­53. 36. Cronjé and Grobler, Obstetrics in Southern Africa, 349. 37. Other destructive techniques are used for other causes of obstructed labor; see King and Mola, Guide to Safe Motherhood in Developing Countries, sec. 24.8. 38. Cronjé and Grobler, Obstetrics in Southern Africa, 350. 39. Cronjé and Grobler, 350. 40. When a fetal head enlarged by hydrocephalus caused obstructed labor, craniotomy could be the only way to get the fetus out at all. 41. Verkuyl, “Think Globally Act Locally.” Nonmortal consequences did not factor into this equation. 42. Chilopora et al., “Postoperative Outcome of Caesarean Sections”; Mputsoe, “Incidence and Risk Factors for Post-­caesarean Wound Infection.” 43. See, for example, Davis-­Floyd and Cheyney, Birth in Eight Cultures. 44. For example, many Chichewa speakers used sikelo to indicate both an antenatal clinic and the scale used to weigh patients there. The association between scales and antenatal care was so strong that the word was used even for clinics—­like those held by an HSA in an empty church, or by a mzamba in a shelter behind her house—­where there had never been scales. 45. Hunt, Colonial Lexicon of Birth Ritual, 234–­35. 46. This paragraph refers to the West, the North, and Africa as if the meanings of these terms were uncomplicated. They are not. Customs for naming parts of the world have shifted over time; they vary, too, among communities of speakers. In this book I generally use North and South to describe flows of medicines, technologies, and policies. These terms are good reminders that Malawi’s major historical, intellectual, and economic connections lie more on north-­to-­south than on east-­to-­west axes. Malawians usually used developed, underdeveloped, and developing to describe economic differences; to avoid the evolutionary implication embedded in those terms, I typically use poorer and wealthier instead. I follow my interviewees in using Western and African to describe groups of people. Malawians also used Western and African when discussing cultural issues such as music, fashion, and behavior—­as in chapter 1, in which many people connected bad behavior with Western values. See the longer discussion in Wendland, A Heart for the Work, 245–­46n1. 47. Mwanamphepo is probably a generic term covering several different plant-­based treatments. Early in pregnancy, mwanamphepo could cause abortion. 48. See International Federation of Gynecology and Obstetrics, “Misoprostol Dosage Chart (2017),” https://www.figo.org/news/misoprostol-dosage-chart-2017; see also Raymond, Har-

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rison, and Mark Weaver, “Efficacy of Misoprostol Alone”; and Moseson et al., “Self-­Managed Abortion.” 49. Misoprostol inhibits glandular cells from producing hydrochloric acid. When maverick researchers discovered that stomach acid was not the cause of most ulcers—­it was a bacterium, Helicobacter pylori—­it became clear why misoprostol was not very effective. It is still used for prevention, for people rendered vulnerable to ulcers not by H. pylori but by nonsteroidal anti-­ inflammatory drugs (NSAIDs). NSAIDS, like misoprostol, are medicine and poison. They reduce inflammation and pain. In the process, they can produce ulcers, gastrointestinal bleeding, and heart disease. 50. Wendland, A Heart for the Work, 135–­36. 51. Livingston, Improvising Medicine, 62, 66–­69. 52. The concept of “side” effects, notes Emily Martin in “The Pharmaceutical Person,” is one way that medicines are split into good and bad parts, and the bad parts displaced. 53. One can inject oxytocin into a large muscle, but the effects are more unpredictable. Ergometrine is used for hemorrhage but not labor induction. Given orally, it is slow to take effect. Given intramuscularly or through an IV, it constricts blood vessels—­a particular problem if a woman’s blood pressure is already elevated. Ergometrine must be kept cool and dark to maintain efficacy, and oxytocin must be kept cool; misoprostol is not finicky about storage conditions. 54. Ministry of Health, Malawi 2010 EmONC Needs Assessment Final Report, 92. 55. See Women on Waves, “Safe Abortion Hotlines.” 56. During the years of VSI’s efforts, many African states—­including Malawi—­had legally banned out-­of-­hospital birth attendants; see chapter 6. 57. See Bixby Center for Population, Health & Sustainability, https://bixby.berkeley.edu/vsi/. 58. Ultimately, the “wonder drug” was revealed as one more case in which mothers were to be sacrificed to the public health priority for infants. For some, nevirapine became a symbol of government cruelty (Fassin, “Adventures of African Nevirapine”). On postabortion care, see Suh, Dying to Count, an excellent example of convergence. 59. Malawi’s health sector had no real capacity to monitor adverse drug reactions either. 60. The hospital where I did specialty training used a similar tactic for surgical abortions. By more than doubling the price of the procedure, administrators could “offer complete reproductive services” and “support women’s autonomy” while ensuring that anyone actually seeking an abortion would go to Planned Parenthood instead. Religious protestors stopped swarming the hospital entrance; conscientious objectors among the OR staff had no more cause for objection. Problem solved. 61. Moran-­Thomas, “How a Popular Medical Device Encodes Racial Bias.” 62. Erikson, “Global Health Indicators and Maternal Health Futures.” Impaired fetal growth raises concerns about insufficient placental transfer of blood and nutrients, and is a risk factor for stillbirth. 63. See, for example, Harries, Schouten, and Libamba, “Scaling Up Antiretroviral Treatment.” 64. Farmer, Infections and Inequalities, 21. “Shit for the poor” can be literal. Flush toilets connected to municipal water and sewer systems are gold-­standard sanitation technologies for wealthy and middle-­class people. “Improved pit latrines”—­built with their intended users’ donated labor—­are sanitation technologies prescribed for poor rural people. Tax-­supported water and sewer infrastructure whisks away the shit of the rich, while the shit of the poor collects in holes dug by the poor. 65. Feierman, “When Physicians Meet,” 172.

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66. Sandall et al., “Midwife-­Led Continuity Models.” 67. The Society of Gynecologic Surgeons describes rapid adoption of robot-­assisted hysterectomy as “a prime example of the powerful effect that marketing can have on the use of new technology,” especially when marketing entails “confusion and misinformation” (Moen and Harmanli “Considerations to Improve Hysterectomy,” 587). 68. Conde-­Agudelo and Diaz-­Rossello, “Kangaroo Mother Care.” 69. On reverse innovations for maternity care, see Vanderbilt, “ ‘Reverse Innovation’ Could Save Lives.” 70. Hiatt, Kenney, and Rosenberg, “Global Health at Home,” 49. 71. Harries, Ford, et al., “Act Local, Think Global.” Chimwemwe Bruce: “Changes, yes, but no development.” 1. Jik is a brand of liquid bleach. HTH is calcium hypochlorite, granular chlorine that is mixed to make a sanitizing solution. Chapter 4 1. This note continues: “That’s not counting the things that don’t close the theatre: no iodine, no chlorhexidine, no spirit; no consultants; no phones.” The first three are antiseptics, used to prepare a patient’s skin before surgery to reduce infection risk. 2. Mapanje was married to a nurse-­midwife who worked at Zomba Central Hospital. This poem, like his others, was well rooted in Malawi’s material and political world. It has been published in various versions; for an earlier one, see Vaughan, Curing Their Ills, vi. 3. See Government of Malawi, Malawi Demographic and Health Survey, ch. 2: almost half of rural households got water from a site at least half an hour away; 15 percent used “unimproved” (readily contaminated) water sources. 4. In 2016, the going rate for water at these kiosks was twenty-­five kwacha (then about two US cents) for a forty-­liter bucket. For a short interview with a water seller and a description of how the kiosks work, see http://ndirande.com/, select “visit the English website,” and click on “Selling Water.” 5. Water for irrigating crops or supplying livestock, while vital to most households, is beyond my scope here. 6. See Ferguson, Global Shadows. 7. Burawoy, Colour of Class on the Copper Mines; see also Ferguson, Expectations of Modernity. 8. Ferguson, Global Shadows, 208–­9. 9. Rob Nixon characterizes the chronic poisoning and abandonment of the delta villagers as acts of ecological dispossession, or slow violence. He memorably describes “those Niger Delta villages where children for decades had no access to electricity for studying at night, while above their communities Shell’s gas flares created toxic nocturnal illumination. Too dark for education, too bright for sleep: modernity’s false dawn” (Nixon, Slow Violence and the Environmentalism of the Poor, 42). 10. Some automotive plants went to Mexico, where minimum wages were lower. Some went to Canada, where state-­managed health care minimized financial and bureaucratic burdens for employers. 11. For more on this story, see Hanna-­Attisha, What the Eyes Don’t See.

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12. Organ transplantation, considered the gold standard for end-­stage renal failure, was not available in Malawi anywhere at the time of writing. A kidney transplant required travel to India, South Africa, or elsewhere; patients also needed steady access to expensive immunosuppressive drugs forever after. Does the availability of a dialysis unit somewhere reduce the constituency of those agitating for better renal failure care everywhere? Or does its visibility enhance advocacy? This is an empirical question to which I do not have an answer. 13. Malawi’s neighbors Tanzania (see Strong, Documenting Death) and Mozambique (see McKay, Medicine in the Meantime) had each treated primary health care as a crucial element of socialist national development. Both developed more robust networks of rural clinics and health workers than the Malawian government ever managed. 14. A model called “selective primary health care” replaced “Health for All.” It focused on cheap prevention strategies: growth monitoring, oral rehydration for diarrheal disease, breastfeeding, and vaccination. 15. See Redfield, Life in Crisis. MSF ran two prototype treatment enclaves in Malawi. 16. Some people feared that irregular adherence to therapeutic regimens would encourage medication-­resistant mutation while decreasing treatment efficacy. Racist imaginaries of Africans who could not tell time or follow instructions magnified these fears (Crane, Scrambling for Africa; Benton et al., “Temporality and Positive Living”). 17. See Bemelmans et al., “Providing Universal Access to Antiretroviral Therapy,” which gives no hint that public-­sector nurses and doctors saw MSF as a separate and parallel struc­ ture.  See also an external evaluation solicited by MSF and posted at https://norad.no/global assets/import-2162015–80434-am/www.norad.no-ny/filarkiv/ngo-evaluations/a-study-of -stakeholders-perception-of-medecins-sans-frontieres-support-to-thyolo-district-in-malawi.pdf (accessed June 11, 2020). 18. In a sharp analysis of white supremacy in West Africa, Jemima Pierre calls such folk “development whites”; see Pierre, Predicament of Blackness, 18. See also Pandolfi, “ ‘Moral Entrepreneurs,’ Souverainetés Mouvantes et Barbelés.” 19. See, for example, Redfield, “The Unbearable Lightness of Ex-­pats.” On the many dysfunctions that resulted from NGO health care structures and practices in Mozambique, see Pfeiffer, “International NGOs and Primary Health Care,” 734. 20. MSF’s Thyolo project, for instance, was both humanitarian intervention and research endeavor. 21. Meinert and Whyte, in “Epidemic Projectification,” refer to this complex landscape as “projectification” of care. For a study of the constraints and opportunities posed—­for patients and providers—­by widespread projectification in Mozambique, see McKay, Medicine in the Meantime. 22. Ooms and colleagues warn against disease-­specific funding in global health, lest it create “islands of excellence in a sea of under-­provision” (Ooms et al., “The ‘Diagonal’ Approach to Global Fund Financing,” 6). Johanna Tayloe Crane, writing on controversies over research in Africa, quotes a senior Ugandan obstetrician who resisted pressure for research that might be “an island of excellent investigation where that’s not your standard of care” (Crane, “Adverse Events and Placebo Effects,” 856). 23. Ferguson, Global Shadows, 14. 24. Sullivan, “Mediating Abundance and Scarcity.” 25. Moral distress, a term used widely in the nursing literature, describes the emotional consequences of knowing the right thing to do but being prevented by institutional constraints from

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doing it. A related term is moral injury, the result of perpetrating actions one feels to be morally wrong. Both terms have been used to analyze the phenomenon more commonly known as burnout. To reframe burnout as moral distress or injury is to prioritize collective solutions—­like reorientation of medical care away from profit and toward patient well-­being—­over individualizing strategies like mindfulness training. 26. This phrase is often a euphemism for a patient’s death. 27. Maluwa, “Moral Distress in Nursing Practice,” 27. 28. Nearly all women whose cancers do not resolve with methotrexate can be treated successfully with another set of chemotherapy agents (Brown et al., “15 Years of Progress in Gestational Trophoblastic Disease”). Choriocarcinoma treatment is one of the most remarkable success stories of biomedicine. 29. Some twenty-­eight thousand women were tested in these two countries in the course of recruitment for the zidovudine trial (Nguyen, “Trial Communities”). 30. See Peterson et al., “Saying ‘No’ to PrEP Research in Malawi.” 31. Interested readers can find more information in many other sources, including Wiktor, Ekpini, and Karon, “Short-­Course Oral Zidovudine”; and Wendland, “Research, Therapy, and Bioethical Hegemony.” I have suspected for years that my own article missed a key point about this controversy: why the placebo was so troubling to many non-­African commentators, while the subsequent lack of treatment for mothers and infants was not. 32. These committees operate under intense pressures. International projects provide most if not all funding for research at many African universities and medical schools. Research, as this chapter has made clear, is also a significant source of health care. Leaders in countries highly dependent on donor aid are loath to antagonize powerful outside institutions. For research ethics controversies in Malawi and Uganda, respectively, see Peterson et al., “Saying ‘No’ to PrEP Research in Malawi”; and Crane, “Adverse Events and Placebo Effects.” As Crane notes, debates over research ethics are not solely about what’s right and what’s wrong; they are also about whose work constitutes good science, and what scientists’ roles should be in a world of terrible inequality. 33. Street, Biomedicine in an Unstable Place. 34. Geissler, “Archipelago of Public Health.” 35. Several colleagues at Notre Dame’s Institute for Advanced Studies found this comparison unfair—­to the theologians. 36. On informed consent, see, for example, Kaufert and O’Neil, “Biomedical Rituals and Informed Consent”; and Riessman, “Exporting Ethics.” On recruitment, see Elliott, White Coat, Black Hat. On research as therapy, see Petryna, “Ethical Variability: Drug Development”; Petryna, When Experiments Travel; Nyambedha, “Ethical Dilemmas of Social Science Research”; and Geissler, Kelly, et al., “ ‘He Is Now Like a Brother.’ ” 37. See, for example, Azetsop, “New Directions in African Bioethics.” 38. Kingori, “Experiencing Everyday Ethics in Context”; cf. Graboyes, The Experiment Must Continue. 39. Peterson et al., “Saying ‘No’ to PrEP Research in Malawi.” 40. See Eyakuze et al., “From PMTCT to a More Comprehensive AIDS Response.” Effects of ARV treatment have been politically and socially important, and medically complex; see Fowler, Qin, and Fiscus, “Benefits and Risks of Antiretroviral Therapy.” 41. Mama, “Is It Ethical to Study Africa?,” 23. 42. Berliner and Kenworthy, “Producing a Worthy Illness.”

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43. Mulemi, “Technologies of Hope.” 44. See Wendland, “Moral Maps and Medical Imaginaries”; and Wendland, “Opening Up the Black Box.” 45. UNFPA, “Healthy Baby Girl Born in a Refugee Camp!” See the campaign archive at https://web.archive.org/web/20201125052953/www.mhtf.org/2012/09/28/new-campaign-safe -birth-even-here/. 46. Expulsion from school was not a policy, but it was an almost ubiquitous practice (Silver, “Sex, Schooling, and Moral Triage”). 47. Neuroscientists who study the brain’s electrophysiological processes in waking and dreaming, explains Oliver Sacks, “postulate a single fundamental mechanism for both—­a ceaseless interplay of image and feeling, irrespective of whether there is sensory input or not. When there is sensory input, this interplay integrates it to generate waking consciousness, but in the absence of sensory input it continues to generate brain states, those brain states we call fantasy, hallucination, or dreams. Thus waking consciousness is dreaming—­but dreaming constrained by external reality” (Sacks, Anthropologist on Mars, 57). 48. Readers may think of other kinds of doubles. Historians and ethnographers, for instance, have analyzed past futures: once-­potent dreams of powerful public-­sector medicine or nationalist science, mourned although they never came to be. See, for example, Geissler, Lachenal, et al., Traces of the Future. 49. Mbanda’s references to normal abnormality echo older discourses. The early twentieth-­ century “race science” of some British colonial psychiatrists characterized African brains and African sexualities as normally abnormal (Keller, “Madness and Colonization”; Tilley, Africa as a Living Laboratory; Vaughan, Curing Their Ills, ch. 5). Decades later, Barnett and Whiteside, in “Why Africa?,” analyzed the explosive growth of HIV on the African continent in light of other illnesses spread by massive migration under duress—­from the slave trade, to colonial military conscription and forced labor, to ongoing migrations prompted by poverty and civil conflict. These huge population movements were a form of normal abnormality, they concluded. 50. Other absences mattered for healing. Family members who stayed absent from treatments that were intended to cure a relative could weaken the power of medicines (as Steven Feierman described in an exploration of healing in Tanzania; see “Explaining Uncertainty in the Medical World of Ghaambo”). So could attenuated or absent relationships between healers and supplicants. 51. See “Doctors: No Drugs Narrowed Mutharika’s Survival.” After a fruitless resuscitation, Mutharika was flown lifeless to South Africa in a complicated political drama that ended—­after two tense days in which it appeared that a judicial coup might be in the making—­with the succession of Vice President Joyce Banda to the presidency. Chapter 5 describes the consequences of this crisis for maternal health. 52. See Tara Diener, “Embodied Practice and Place”; Adeola Oni-­Orisan, “The Obligation to Count”; and Adrienne Strong, Documenting Death. 53. Wenzel Geissler, “Public Secrets in Public Health.” 54. American hospitals commonly obscure from clinicians uncomfortable reminders that the care we provide can bankrupt our patients. We are shielded through architectural practices that separate billing areas from clinical ones, and institutional practices like outsourcing the most brutal forms of extraction to collection agencies. The costs borne by our patients, like the rats on the ward in Sierra Leone, become absent presences. 55. Good, “Medical Imaginary and the Biotechnical Embrace,” 276.

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56. Zoonotic infections are those—­such as Ebola virus, West Nile virus, or the three recent coronaviruses causing COVID-­19, SARS, and MERS—­that “emerge” from an animal host to infect humans. Those most worrisome for public health become transmissible human-­to-­human. 57. Guillaume Lachenal, “Lessons in Medical Nihilism.” 58. Nguyen, in “Trial Communities,” describes modest dreams of caring among the mutual-­ aid groups that grew out of perinatal zidovudine trials in Burkina Faso and Côte d’Ivoire. Women in these groups, given what was then a death sentence, struggled together to identify ways to live out their remaining time well. The absence of treatment and the scarcity of state support prompted collective dreaming about making a good life. 59. Street, Biomedicine in an Unstable Place, 166. 60. Needles are occasionally—­and drugs are often—­still problems. 61. Lachenal, “Le Stade Dubaï de la Santé Publique.” 62. J. C. Scott, Weapons of the Weak, 38. 63. The hospital, funded by the American pop star Madonna, was named for the daughter she adopted from Malawi. 64. See Harries, Ford, et al., “Act Local, Think Global.” 65. Thanks to Peter Redfield and the University of North Carolina’s Moral Economies of Medicine group for imaginatively extending this metaphor. Rhoda Nantongwe: “By the time she comes to the hospital, it is too late.” 1. A news report of a fatal collision between an ambulance and a minibus elicited outraged comments about both ambulances and minibuses, among them this one: “Malawi ambulances are the most unsafe. . . . They are locally serviced by unregistered mechanics (no dealer service), they are fitted with substandard spare parts, they are way past their due dates for service, they drive with worn out tyres, and most times the drivers are drunk” (BTN, April 19, 2018, comment on “Patient Dies in Ambulance Accident,” Nyasa Times, https://www.nyasatimes.com/patient -dies-in-ambulance-accident/#comments). Chapter 5 1. See, for example, the Black Mamas Matter Alliance, http://blackmamasmatter.org, which uses metrics to advocate for reproductive justice and black maternal health in the US; or the court case in Uganda in which activists used indicators alongside two women’s deaths to hold government accountable for maternal health (Okiror, “Uganda Court Rules”). 2. “JB Opens Maternity Home in Dowa.” Spelling, capitalization, and punctuation reproduced from the original. 3. “JB Opens Maternity Home in Dowa.” 4. Malawi was one of 194 member nations; US membership was contentious at the time of writing. 5. The numbers originate from a death-­certificate section that asks specifically about a woman’s pregnancy status, and a set of codes indicating whether her death was directly or indirectly related to that pregnancy. Aggregating numbers and cleaning up anomalies takes some time; these figures were the latest available at the time of writing. To check the math, make his­ torical comparisons, or calculate metrics for other states, consult https://wonder.cdc.gov, a freely available database of United States health statistics, from which I obtained these figures in No-

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vember 2019. Unlike the WHO, the CDC includes deaths more than forty-­two days but less than one year after pregnancy in the category “maternal death,” as have I. 6. The CDC uses a “reproductive age” range of 15 to 44; Malawi follows the WHO in using 15 to 49 as the denominator. Many small differences like this one make numbers difficult to compare between countries. 7. Typically, rates and ratios are given for a year. 8. See, for example, MacDorman et al., “Recent Increases in the U.S. Maternal Mortality Rate”; the consensus is both that actual deaths have increased and that maternal deaths were underreported before checkboxes were introduced. 9. Adams and colleagues were warned that “not enough women die” in Tibet to show that their proposed intervention would help. Adams, “Saving Tibet?,” 76. 10. See Schulz, “Final Forms.” 11. See, for example, WHO, Trends in Maternal Mortality: 1990 to 2008, 34. 12. Boerma and Stansfield, in “Health Statistics Now,” point out that assessing a system for completeness is itself beset with uncertainties. Vital registration systems are now a major focus of global health activity. 13. The pre-­2009 law, dating to 1904, reflected the colonial legal system’s priorities. Birth registration was mandated only “if one or both parents are of European, American or Asiatic race or origin or in the case of an illegitimate child not recognized by its father, the mother is of European, American or Asiatic origin” (McGregor, “Health Legislation in Malawi”). Death registration requirements were similar. 14. As of 2019, birth registration entailed no fees, but birth certificates did. 15. Singogo et al., “Village Registers for Vital Registration.” 16. Periodically a “confidential enquiry into maternal deaths” followed: experts compiled and reviewed all audits, if necessary studying patient records and interviewing people who were involved with each case, to identify patterns of problems and avenues for improvement. I have drawn on confidential enquiries (for example, Mataya and Malawi National Confidential Committee, Report on Maternal Deaths in Malawi) but have not analyzed them in this chapter. 17. See Bayley et al., “CLMDR to Measure and Prevent Maternal Mortality”; cf. Strong, Documenting Death. 18. Diener, “Embodied Practice and Place”; Oni-­Orisan, “The Obligation to Count.” 19. For more on the community-­linked death review process, see Bayley et al., “CLMDR to Measure and Prevent Maternal Mortality.” 20. This case is described in Thorsen, Sundby, and Malata, “Piecing Together the Maternal Death Puzzle,” 5. Parentheses appear in the original source; square brackets enclose my additions. 21. WHO, The WHO Application of ICD‐10, 7. 22. Mgawadere, Unkels, and van den Broek, “Assigning Cause of Maternal Death”; Owolabi et al., “Establishing Cause of Maternal Death in Malawi.” 23. These complex codes were initially designed to organize public health data and thus evaluate how lives might be saved. In the mid-­twentieth century, they expanded to manage billing. Insurance-­company concerns began to take precedence over public health priorities, explaining some peculiarities of the coding system. Since 2012, review forms and verbal autopsies have drawn on the tenth revision of the ICD, https://icd.who.int/browse10/2010/en. ICD 11 is scheduled to take effect in 2022. 24. Category 6, “Unanticipated complications of management,” looks as if it would encompass many health-­system factors. In fact, however, this code applies solely to anesthesia

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complications. For readability, the table’s examples use plain language rather than the formal language of the ICD, in which “septic abortion,” for instance, is “O07.0 failed medical abortion complicated by genital tract and pelvic infection.” 25. Thorsen, Sundby, and Malata, “Piecing Together the Maternal Death Puzzle,” 1. 26. See, for example, Thorsen, Sundby, and Malata; Vink et al., “Maternal Death Reviews at a Rural Hospital”; cf. Allen, Managing Motherhood, Managing Risk, a critique of the three-­delays model as used in Tanzania. 27. Thorsen, Sundby, and Malata, “Piecing Together the Maternal Death Puzzle.” Nineteen women were ineligible for review because they’d lived outside the district; patient records for seven others were missing. 28. A third of the women had delayed seeking hospital aid. One-­fifth had transportation problems. The context of this study probably kept these proportions low. As the nation’s capital and home to many NGO and government offices, Lilongwe District is relatively urban. It has more health facilities, more transport options, and better roads than most of Malawi. It is also home to a famously dysfunctional public hospital (Meguid and Mwenyekonde, Department of Obstetrics & Gynaecology). 29. Thorsen, Sundby, and Malata, “Piecing Together the Maternal Death Puzzle,” 10. 30. Thorsen, Sundby, and Malata, 11. 31. Graham, Brass, and Snow, “Estimating Maternal Mortality.” Demographers in Malawi later used a variant (Rutenberg and Sullivan, “Direct and Indirect Estimates of Maternal Mortality”). 32. The researchers selected sample “households,” not specific people. Fieldworkers tried to interview any woman age 15 to 49 who either lived in a sample household or had stayed there the previous night. For details on sampling and survey methods, see Government of Malawi, Malawi Demographic and Health Survey, ch. 1. 33. The “women’s questionnaire” plus the twenty-­three-­page “household questionnaire” made the survey nearly a hundred pages long. Men were surveyed too, but only a third as many, using a questionnaire less than one-­third the length. 34. Biruk, Cooking Data, 145. 35. This WHO-­derived customary date seemed so arbitrary that interviewers in Malawi until recently asked instead about complications that had happened within two months of the end of pregnancy—­as line 1212 in figure 5.1 indicates. 36. Gakidou and King, “Death by Survey.” 37. Merdad, Hill, and Graham, “Improving the Measurement of Maternal Mortality.” 38. See, for example, Kassebaum and GBD 2015 Maternal Mortality Collaborators, “Global, Regional, and National Levels of Maternal Mortality, 1990–­2015.” 39. The “Group of Eight” (G8) included leaders of eight wealthy nations and the European Commission’s president. In 2008 the G8 had pledged material assistance for improving maternal health, as many African nations struggled to achieve Millennium Development Goal 5. Then came a global economic downturn. The 2010 meeting included an “Africa outreach” session with seven African leaders, Malawi’s Bingu wa Mutharika among them. On the agenda was aid reduction. 40. Hogan et al., “Maternal Mortality for 181 Countries,” 1619; see their web appendix for methodological and country details. 41. Horton, “Maternal Mortality.” 42. WHO, Trends in Maternal Mortality: 1990 to 2008. Technical advisors from the University of California at Berkeley also assisted.

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43. Hogan et al., “Maternal Mortality for 181 Countries,” web appendix, 9, gives 6,800 as the modeled annual number of maternal deaths in Malawi; multiplying 6,800 by a ratio of 510/1,140 yields a UN annual maternal-­death estimate of 3,042. 44. See Wendland, “Estimating Death.” 45. See Institute for Health Metrics and Evaluation, “COVID-­19 Resources,” http://www .healthdata.org/covid (accessed December 22, 2020). 46. For brevity’s sake, I have left out the extensive testing of both the equation and the uncertainty intervals. The IHME team provided detailed explanations of these processes; see Hogan et al., “Maternal Mortality for 181 Countries.” 47. Hogan et al., 1611. 48. Of course, it is never the case that two groups are equal in all respects except fertility. What if women in Pochepa also have much better health care? Or what if health care quality is great in Kuchuluka but roads are so terrible that women have difficulty accessing it? 49. The IHME group, unlike the UN group, modeled death rates for women in five-­year age cohorts, using proprietary estimates it did not share with other researchers. For clarity’s sake, I have ignored the effects of these age groups on the calculation process and (from this point on) removed the subscript a marking them. 50. β0 looks like a coefficient but functions as a constant. If one graphs ln(μi,t) in the IHME equation or log(PMina) in the UN equation against time, β0 marks the point where they cross the intercept line. One could think of it as a sort of global baseline of maternal mortality, when all covariates are set to zero. It is neither predicted by covariates nor altered by regional and national fixed effects. 51. Replacing each beta with its actual coefficient gives ln(μi,t) = 5.107 + 1.884ln(TFR)i,t − 0.536ln(GDP per capita)i,t + 13.994(NMR)i,t − 0.101educationi,t + 0.119HIVi,t − 0.002HIV2i,t + Mi,t + e. ­ 52. Both equations also used logarithms, which make the mathematics of the equation easier by converting certain curved distributions into linear ones, and smooth results by reducing the effects of highly variable inputs. The IHME equation treated the dependent variable (the maternal mortality rate μ) and two covariates (GDP and TFR) logarithmically. The modelers decided that HIV rates, education rates, and neonatal mortality rates were better treated as linear. Each was expressed as a fraction somewhere between zero (for instance, no one in the population has HIV) and one (everyone has HIV). 53. MMR can be calculated directly from sisterhood surveys, which both models used as source data. 54. The usual equation is as follows: GDP = C + I + G + NX, where C = personal consumption, I = investment (the name given to industry consumption), G = government spending, and NX = net exports. NX = X –­M, where X = exports and M = imports. 55. See Fixler, Greenaway-­McGrevy, and Grimm, Revisions to GDP, GDI, and Their Major Components. 56. Jerven, Poor Numbers, 121. 57. Jerven, 121. 58. I will not try your patience exploring additional uncertainties here. Interested readers may dive down these covariate rabbit holes on their own. 59. Their equation gives the dependent variable as PMina, the proportion of maternal among non-­AIDS deaths in women ages fifteen to forty-­nine. A later step added a separate estimate of HIV-­related deaths. See discussion in Wendland, “Estimating Death.”

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60. Christopher Murray, quoted in Grady, “Maternal Deaths in Sharp Decline.” In later years, these modelers came to see their approach to HIV as a source of error. Subsequent publications, which took a substantially different approach to the model in general and to HIV in particular, revised earlier figures for Malawi downward (see Kassebaum, Bertozzi-­Villa, et al., “Global, Regional, and National Levels and Causes of Maternal Mortality”). 61. Neonatal mortality rates were likely indirect measures of emergency obstetric care. 62. M looks simple, but its calculation is complex (if regrettably beyond my scope). It involves several assumptions; see the web appendix section on spatial-­temporal local regression in Hogan et al., “Maternal Mortality for 181 Countries,” 2. The IHME group did not publish numbers for these fixed effects. The UN group’s regional effect for sub-­Saharan Africa moved MMR estimates substantially upward. 63. In 2010, the IHME estimated Malawi’s 2008 MMR at 1,140, with the uncertainty interval between 675 and 1,813. A 2015 model re-­estimates the 2008 MMR at about 310, with an uncertainty interval between 195 and 465. See Kassebaum and GBD 2015 Maternal Mortality Collaborators, “Global, Regional, and National Levels of Maternal Mortality, 1990–­2015,” supplement, 408. 64. Standard stories about development are also woven into many other “population” statistics (Murphy, Economization of Life). 65. Mapondera and Smith, “Malawi Faces Power Struggle.” 66. Smith, “Malawi: Africa’s ‘Warm Heart’ Feels Chill.” 67. The sale of the presidential jet was not terribly controversial at the time, but Banda never accounted for the sale’s proceeds to the satisfaction of critics. 68. The 2012 cartoon is reproduced in Chikaipa, “Caring Mother or Weak Politician?,” 10. 69. See Fleischman and Nagel, “President Joyce Banda: New Focus.” The transcription is mine, from an interview previously linked via Fleischman and Nagel; see CSIS Smart Global Health, “President Joyce Banda on Women’s Health.” 70. Wikipedia, s.v. “Joyce Banda,” accessed October 7, 2019, https://en.wikipedia.org/wiki /Joyce_Banda. 71. Mbewe, “Malawi Maternal Mortality Reduced.” 72. It also referred to women delivering rather than babies born, a subtler alteration. 73. See Wendland, “Estimating Death,” 75. 74. Carla AbouZahr specifically warns against using modeled maternal mortality ratios in the way Banda and her supporters used them. Such numbers “should not be used for monitoring progress towards agreed targets and for an assessment of what is effective and what is not,” she notes. Decision-­makers need “data that are accurate, frequent and rapidly available at national and sub-­national levels. . . . Estimates based on statistical models do not answer these needs” (AbouZahr, “New Estimates of Maternal Mortality,” 123). 75. Review the chapter, and you may note that the same numbers were used to explain that girls were having babies instead of staying in secondary school, and that rural women were delivering far from assistance. They were used to applaud the generosity of funders, the participation of chiefs, the mobilization of communities, the education of a new cadre of “community midwives,” the donation of drugs, and the involvement of the private sector. 76. As I write today in September 2020, the United States has just passed two hundred thousand deaths from COVID-­19; epidemiologists calculate that we have 20 percent of the world’s COVID-­19 deaths with 4 percent of its population. These numbers are important and contested political actors. 77. Flavia Bustreo, then director of the Partnership for Maternal, Newborn and Child Health, quoted in Grady, “Maternal Deaths in Sharp Decline.”

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78. New York Times Editorial Board, “America’s Shocking Maternal Deaths.” 79. Young, “Hospitals Know How to Protect Mothers.” 80. USA Today Editorial Board, “High Maternal Death Rate Shames America.” 81. Gavin Newsom, @GavinNewsom, “Our country has the worst maternal mortality rate of ALL developed countries. That’s not something we can or should ignore,” Twitter, October 9, 2019, 1:17 p.m., https://twitter.com/gavinnewsom/status/1181997107999207424?lang=en. 82. MacDorman et al., “Recent Increases in the U.S. Maternal Mortality Rate,” 454. 83. Baeva et al., “Identifying Maternal Deaths in Texas.” 84. Definitions do explain some differences in published metrics, although I have generally avoided them here (see, for example, WHO, Trends in Maternal Mortality, 2000 to 2017; see also examples in table 5.2). 85. Greg Abbott, @GregAbbott_TX, “Turns out the critics of the Texas maternal mortality rate were just lying.  .  .  . Facts matter,” Twitter, June 9, 2019, 11:07 a.m., https://twitter.com /gregabbott_tx/status/1137753213619318786?lang=en. 86. See Khunga, “EW’s Big Interview.” 87. Khunga. 88. A remarkable story of democratic activism followed: after a year of mass protests, the courts not only nullified his election, but made changes to election rules that would allow more representative governance. Malawians voted in new leadership in 2020. 89. An updated IHME publication listed 347 individual authors (Kassebaum, Bertozzi-­Villa, et many many al., “Global, Regional, and National Levels and Causes of Maternal Mortality”). 90. Canguilhem, The Normal and the Pathological, 161. Dyna Ng’ong’ola and Kettie Pensulo: “Women in this community are very much concerned.” 1. The donor-­supported Banja La Mtsogolo (Family of the Future) clinics provided more than half of all contraceptives dispensed in Malawi. Chapter 6 1. My transcription, from CSIS Smart Global Health, “President Joyce Banda on Women’s Health,” 1:01. See also Fleischman and Nagel, “President Joyce Banda: New Focus.” 2. Contestation over childbirth is very old and very widespread; see, among many others, Giladi, “Liminal Craft, Exceptional Law”; and Jordan, Birth in Four Cultures. On reproductive governance, see Morgan and Roberts, “Reproductive Governance in Latin America,” 243. 3. See, for example, Zamawe et al., “Impact of a Community Driven Mass Media Campaign.” 4. People I spoke with in Malawi, unlike those Chapman (Family Secrets) spoke with in Mozambique, did not include church leaders among those from whom they sought reproductive health care. 5. All three, along with Dyna Ng’ong’ola and Kettie Pensulo, have appeared briefly in earlier chapters. 6. Standard 3 is roughly equivalent to third grade, but age and school year are not tightly linked in Malawi. She was in her middle teens when the spirits began to call her. 7. While I cannot be completely certain about her training, I suspect from her description of this time that she was actually employed as a patient attendant rather than as a nurse. Nursing training typically followed secondary school. Ganet Banthu was one of the two azamba I met

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who had completed standard 8 (roughly equivalent to eighth grade), but she had not gone on to secondary school. 8. See Langwick, Bodies, Politics, and African Healing, ch. 5. Following Pigg, “Acronyms and Effacement” and “ ‘Found in Most Traditional Societies,’ ” Langwick explains how TBAs are made up through bureaucratic practices of counting and labeling. 9. See, for example, WHO, Definition of Skilled Health Personnel, 2. 10. Credentials are much easier to assess. A section on skilled birth attendance in the WHO “Global Health Observatory,” for instance, does not mention the official definition. Instead, it conflates title with skill: “Most obstetric complications could be prevented or managed if women had access to a skilled birth attendant—­doctor, nurse, midwife—­during childbirth” (WHO, “Maternal and Reproductive Health”). 11. See chapter 3. Task shifting entails shuffling medical work to personnel with less training. It can be used strategically to extend access while minimizing costs (WHO, Task Shifting). Ad hoc task shifting is common in understaffed and overstretched clinical contexts. 12. A ward attendant or patient attendant is responsible for cleaning the ward and handing out any food that the hospital provides. The TBA Ganet Banthu, described above, had probably begun her career as a ward attendant. The position requires no medical training, although one group of researchers has pioneered training ward attendants to draw blood—­a task-­shift intended to free up nurses’ time (Walker et al., “Phlebotomy Training for Patient Attendants”). 13. In theory, each patient gets evaluated at ward rounds. In practice, clinicians do not see patients who are not in bed. If you’ve gone off to get an X-­ray, or stepped out to the street vendors to buy a couple of bananas or airtime for your phone, you miss your chance at a medic’s visit. 14. Written referrals from TBAs were quite rare. Most were not literate in Chichewa or En­ glish. The ambiguous legal status of out-­of-­hospital birth likely made paper referrals feel perilous even to those who could write them. 15. Hunt, Colonial Lexicon of Birth Ritual, 110, 204, 316. 16. Mama Lillian Siska claimed that it wasn’t blood that endangered one’s eyes, but looking at another person’s private parts. Both explanations are consistent with proverbs and folklore. 17. For more on this topic, see Wendland, A Heart for the Work, ch. 5. 18. An extensive literature documents how widespread this pattern is; see, for example, Berry, Unsafe Motherhood; Guerra-­Reyes, Changing Birth in the Andes; Pinto, Where There Is No Midwife; and contributions to Davis-­Floyd and Cheyney, Birth in Eight Cultures. 19. These complaints made for a striking contrast with my previous research, in which neg­ ative comments about traditional practitioners were extremely rare. At least four factors may contribute to the difference. First, it is possible that more experience leads to a more negative view of traditional birth attendants; most interviewees in the earlier project were medical trainees at early stages of their careers. Second, the current project primarily involved frontline staff at health centers and district hospitals: nurse-­midwives, community health nurses, and health surveillance assistants. They may have felt a stronger need to differentiate themselves from informal-­sector workers than did high-­status doctors at referral centers. Third, this research began at a time when an intense national focus on maternal mortality put birth workers under scrutiny. Deflecting blame was tempting. Finally, it is possible that people spoke more negatively about traditional practitioners to me because they expected a foreign doctor to seek “harmful cultural practices.” In another recent project, many nurse-­midwives who spoke with Evelyn Chitsa Banda described the work the traditional birth attendants had once done in positive terms; see Banda, “Stakeholders’ Perceptions of Traditional Birth Attendants.”

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20. Kumbani and colleagues found that stories of mistreatment by nurses circulated widely in rural Malawi. Women who had attended antenatal care at a clinic but delivered with a TBA cited numerous reports of health center mistreatment: cruelty, inattention, rough exams, shouting, even slapping. In almost all cases, women reported that they had heard about such care from others but not experienced it themselves. The stories were enough to keep them away from health facilities (Kumbani et al., “Why Some Women Fail to Give Birth at Health Facilities”; compare de Kok, “Between Orchestrated and Organic”). 21. TBAs interviewed by Banda also critiqued unnecessary surgeries. When God could reveal through dreams a treatment that would allow easy delivery, “why should we say that [for] each pregnancy complication the answer is operation?” a mzamba asked Banda. “Should all of us be scarred? We feel sad about it” (Banda, “Stakeholders’ Perceptions of Traditional Birth Attendants,” 126). 22. See chapter 3. Allen (Managing Motherhood, Managing Risk), working in Tanzania, noted that programs designed to reduce threats of motherhood often ignored threats to motherhood. Unwanted sterilization is one such threat. 23. See, for example, WHO, “Review of Maternal and Child Health Activities.” Earlier reports usually used “village midwives.” 24. Verderese and Turnbull, “Traditional Birth Attendant: Guide to Her Training,” 1. 25. Verderese and Turnbull, 1. 26. See Bannerman, “Field Visit Report: African Region.” Many people in southeast Africa claim that “it is impossible to have a man attend birth” in a community setting. The person who keeps listening, however, may learn of exceptions to this rule. I have spoken with two men without biomedical training who regularly attended community births in Malawi—­in addition to male clinical officers, medical assistants, and doctors who attended facility births. Noelle Sullivan (pers. comm.) has encountered a highly respected male birth attendant in Tanzania, as has Rachel Chapman (Family Secrets) in Mozambique. The culturally “impossible” is uncommon, but it exists. 27. Pigg, in “Acronyms and Effacement,” found that TBA training programs in Nepal gave birth to the very category they presumed already existed: villagers were frequently unable to identify a single midwife until after training programs had created them. Langwick (Bodies, Politics, and African Healing, ch. 5) has made a similar argument for parts of rural Tanzania. 28. Verderese and Turnbull, “Traditional Birth Attendant: Guide to Her Training,” 38–­69. 29. For introductions to this literature from an anthropological perspective, see Maes, “Community Health Workers and Social Change”; and Maes, Closser, and Kalofonos, “Listening to Community Health Workers.” 30. Bullough, “Traditional Birth Attendants in Malawi,” 12. 31. Smit, “Traditional Birth Attendants in Malawi,” 26. 32. Smit, 25. 33. Bisika, in “Effectiveness of the TBA Program,” estimated that about 40 percent of Malawi’s TBAs were trained by the time programs ended circa 2005. How he derived the denominator for this estimate is unclear. 34. Material in this section comes from field notes and interviews, as well as Bicego, Boerma, and Ronsmans, “Effect of AIDS on Maternal Mortality”; Smit, “Traditional Birth Attendants in Malawi”; and Banda, “Stakeholders’ Perceptions of Traditional Birth Attendants,” ch. 5. 35. Mrs. Nantongwe had been one such supervisor. She was concerned, however, that “these TBAs we trained, most of them now are getting older, and they are training their daughters

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to take over.” Key points were not reaching this next generation. Reaching into a cabinet, she pulled out a dilapidated logbook filled with records of supervisory visits from years past. Notes included “facility very dirty, not well cared for,” “shelter roof collapsed in rainy season; she is now rebuilding,” and “deceased—­daughter now using shelter.” 36. Smit, “Traditional Birth Attendants in Malawi,” 26. 37. Colbourn et al., “Maternal Mortality in Malawi,” table 3. 38. See Sibley, Sipe, and Barry, “Traditional Birth Attendant Training.” The meta-­analysis as a whole first appeared in an influential database of systematic reviews in 2007. Several pieces had been published separately in 2004; the study’s findings circulated, and began to influence funders and policymakers, even before that. 39. For more on the struggle over the legitimacy of TBAs and why it led to increased interest in a magic-­bullet drug, see MacDonald, “Misoprostol.” 40. The policy’s official title was “The Guidelines for Community Initiatives for Reproductive Health.” Bureaucrats sometimes called it “the community policy.” Azamba, nurse-­midwives, and others who worked directly with pregnant women mostly called it “the TBA ban.” The “rapid assessment” on which the moratorium was ostensibly based showed strong community support for TBAs and was inconclusive about their efficacy. As nurse-­midwife Evelyn Chitsa Banda logically concluded, “the assessment was made not necessarily to inform the policymakers on what to do with the TBAs but as a means to ratify a decision already made” (Banda, “Stakeholders’ Perceptions of Traditional Birth Attendants,” 39). 41. See “Phalombe Chiefs Ban Traditional Birth Attendants.” 42. The phrase “harmful traditional practices,” a category that also included various initiation rituals and marriage customs, originated in 1990s HIV-­education campaigns. How much harm these practices actually caused remains unclear (Biruk, Cooking Data; Swidler and Watkins, Fraught Embrace). Denouncing them was an effective way to signal one’s modernity. 43. R. W. Peters, “When the Medical Is Political,” documents such concerns in Angola. For a parallel dilemma involving community health workers in South Africa, see Colvin, “Extension Agents or Agents of Change?” 44. The word husband should not necessarily conjure up wedding ceremonies and legal certificates. For most Malawians, marriage was more process than event. A ceremony might or might not happen. Processes varied. Most involved discussions with guardians, and the birth of a child or children. Some began with a virgin-­seduction payment followed by bridewealth or bride service, often provided over years. The word husband was applied flexibly at many points along this course. 45. See Murphy, Economization of Life, for a brilliant examination of these agendas—­by no means past. Activists sought a reorientation to community flourishing, women’s rights, redress of inequities in wealth and power, and reproductive justice. 46. Several of these nurse educators earned doctoral degrees in European nations that promoted gender equity through parental leave and other policies. 47. See Njunga and Blystad, “ ‘The Divorce Program.’ ” 48. Kululanga et al., “Striving to Promote Male Involvement.” 49. Kululanga et al., “Male Involvement in Maternity Health Care,” 151. 50. Hunter, Love in the Time of AIDS, 62. 51. This gendered power shift had historical precedent. In the 1930s, chiefs in Nyasaland made registration of marriages mandatory and divorce more difficult, at the urging of missionaries and with the blessing of the government. This move consolidated chiefly power—­for chiefs

n o t e s t o pa g e s 2 5 8 – 2 7 5

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registered marriages and adjudicated divorces—­in the name of custom. The historian Martin Chanock has argued convincingly that “customary law” on marriage, inheritance, and other aspects of family life was not a survival of older precolonial ways of life. It was a creation of colonialism, “a weapon within African communities which were undergoing basic economic changes, many of which were interpreted and fought over by those involved in moral terms.” The missionaries’ prescriptions and the chiefs’ interests turned a flexible set of social practices into a rigid set of moralized legalisms. Women found their ability to rid themselves of unsatisfactory husbands much reduced (Chanock, Law, Custom and Social Order, 4; see also 149–­52). Even earlier, Marcia Wright has argued, “customary law” had narrowed women’s room to maneuver. Writing of court cases over enslavement of women between 1900 and 1910, she concludes that Western ideologies about “the approved form of control over women” were apparent: “A hardening of ‘tradition’ and a strong disposition to enforce patriarchies were discernible among the main outlines of a settled colonial situation” (Wright, Strategies of Slaves & Women, 12). 52. See, for example, Khazan, “Africa’s New Agents of Progress.” 53. Banda, “Stakeholders’ Perceptions of Traditional Birth Attendants,” 133. 54. Banda, 133. 55. Lennie Kamwendo, then chair of Malawi’s White Ribbon Alliance, petitioned the minister of health to “sav[e] the lives of women and infants,” blaming poor government funding of midwifery training for “increasing deaths of women in pregnancy and child birth” (“Government of Malawi Petitioned”). 56. Of the azamba who spoke with me, none had attended secondary school, although two had completed primary school. None was comfortable in English. 57. See, for example, Justice, “Neglect of Cultural Knowledge in Health Planning.” Imagine Tikhale, where a girl with a school certificate and less than two years’ training would have substituted for a pair of women with thirty years of experience. The plan seemed to reflect a powerful faith in book learning over practical experience. 58. Uny, de Kok, and Fustukian, “Weighing the Options for Delivery Care.” 59. Quoted in Kasondo, “The Magic of Safe Motherhood Committees.” 60. Kululanga et al., “Striving to Promote Male Involvement.” 61. Mkandawire and Hendriks, “Qualitative Analysis of Men’s Involvement.” 62. Kululanga et al., “Male Involvement in Maternity Health Care.” For a related photo essay, see Parrott et al., “Portraying Fathers: Reproductive Journeys in Malawi.” 63. Kasondo, “The Magic of Safe Motherhood Committees.” 64. Bonaparte, “Regulating Childbirth.” 65. See Roberts, Killing the Black Body; Dána-­Ain Davis, Reproductive Injustice; and Khiara Bridges, Reproducing Race. For a global overview of disrespectful and abusive care, see Bohren et al., “Mistreatment of Women during Childbirth.” 66. Good, “Medical Imaginary and the Biotechnical Embrace,” 276. 67. Graham, Brass, and Snow, in “Estimating Maternal Mortality,” argue that “skilled attendance” must include both skilled people and an enabling environment. Conclusion 1. The writing I’ve found helpful in anthropology includes Das, Critical Events; Fassin, “That Obscure Object of Global Health”; Mattingly, “Toward a Vulnerable Ethics”; Visweswaran, Fictions of Feminist Ethnography; Estroff, “Whose Story Is It Anyway?”; Riessman, “Exporting

322

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Ethics”; and Mkhwanazi, “Medical Anthropology in Africa.” See also Frank, Letting Stories Breathe. 2. Other slices have been described by people working from other perspectives. Many of the works cited earlier provide very different perspectives for Malawi. For the United States, good starting points are Amnesty International, Deadly Delivery; Roberts, Killing the Black Body; and N. Martin and Montagne, “Nothing Protects Black Women from Dying.” 3. Thanks to Sarah Mustillo for these words of wisdom. 4. Berlant’s essay “Slow Death” addresses the so-­called obesity epidemic in America. Advance readers of this book questioned the essay’s relevance and prevailed on me to keep it out of the main text. I’ve found it exceptionally useful to think with, however, and recommend it with enthusiasm. 5. See McLemore, “How to Reduce Maternal Mortality.” 6. To some extent, this emphasis is an obstetrician’s perspective. I returned to the United States from Malawi with a sharpened sense of birth’s dangers. Other people could and did come away with a renewed respect for the incredible robustness of birth and of women’s bodies. After all, most births—­even in difficult circumstances, even among sick women—­went well. 7. Here too I draw on Berlant, “Slow Death,” which makes the argument for food and eating that I am making for sex and procreation.

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Index

Page numbers in italics refer to figures. Abbot, Greg, 224, 317n85 abortion: Esme Lifa’s, 239–­40, 267; incomplete, 71, 123; law, 100, 182, 223; and maternal death, 68, 186–­87; misoprostol for, 137–­39; and mwanamphepo, 306n47; pricing, 307n60; septic 72–­73, 186–­87, 200, 239–­40; in teenagers, 20; unsafe, 72–­73, 139, 140, 186–­87, 299n8. See also miscarriage; postabortion care AbouZahr, Carla, 316n74 absence: of family, 39–­40, 261–­62, 311n50; and haunting, 17, 215; placebo as, 171–­72; present, 178–­81; of tools and technologies, 152–­55, 179, 184 abstinence: and disease, 53; postpartum, 40–­41, 47, 59–­60, 295n40; ritual, 21, 32, 36, 40. See also cycle regulation Adams, Vincanne, 313n9 adenosine triphosphate (ATP), 77, 99, 100 Adichie, Chimamanda Ngozi, 13 African Development Bank, 219 alcoholism, 106 Allen, Denise Roth, 314n26, 319n22 Allen, Tim, 300n31 Alma-­Ata Declaration, 160 ambulances: bicycle, 230, 252, 260; scarce, 23, 86, 186, 198, 219, 230, 265; unsafe, 186, 312n1 (Rhoda Nantongwe). See also transportation anamkhungwi, 3, 8, 34–­35, 37 ancestors: and affliction, 56, 179; in dreams 179, 235; time of, 30, 32 anemia, 66, 78–­79, 85–­86, 87, 146; and choriocarcinoma, 184; complications, 301n35; D. A.’s, 74, 75, 76, 77, 79, 94, 98, 109; diagnosis, 24, 109–­11, 142, 304n3; enactment, 110; Faith Chisoni’s, 50,

165, 269; and HIV, 94; and hookworm, 85, 94; and hunger, 87, 301n38; and pneumonia, 94, 300n20; R. C.’s, 71; and sepsis, 81; and transfusion, 20, 61, 74, 299n13 Angola, 217, 320n43 animal models, 99–­100, 292n1, 303n69–­70 antenatal care, 65–­66, 85, 306n44; delayed, 297n95; at health centers, 72; HIV testing, 255; and jealousy, 56; male involvement, 233, 255, 262, 264; midwife led, 143; mistreatment, 319n20; obstetrician led, 143; risk screening, 302n56 antibiotics, 66, 126; Faith Chisoni’s, 126, 180, 270; preoperative, 126, 154, 270; R.C.’s, 70–­7 1; scarcity, 148, 153, 154, 179, 182 antiretroviral therapy, 54, 71, 92, 183, 214–­15; aftermath, 310n40; delayed in Africa, 309n16; and gold standards, 142–­43; MSF demonstration project, 161; as post-­exposure prophylaxis, 241; in research enclaves, 163; roll-­out in Ma­ lawi, 6, 142–­43, 144, 172, 184, 297n84; stock-­ outs, 148 Apgar scores, 17, 125 appropriate technologies, 15, 112, 132, 141–­44; defined, 111; TBAs as, 266 Asifa, Melia (pseudonym), 188 asing’anga, 8, 292n1 (Bonnex Kaunda); becoming, 19, 33; consultation with, 33, 42, 56–­57, 229; dreams, 99; use of mphini incisions 92, 108, 229, 240–­41. See also names of specific individuals asthma, 82; herbal treatment, 45, 52, 106, 135 ATP (adenosine triphosphate), 77, 99, 100 audits. See maternal death audits Aunty Jane hotline, 139 austerity. See structural adjustment

346 authority: and dangerous care, 15, 233–­34, 239, 240–­44, 264; of chiefs and elders, 34–­36, 41–­42, 252, 255–­56, 266, 320n51. See also patriarchy autonomy: constrained, 102, 246, 277–­78; bioethical concept of, 131; reproductive, 139, 141, 307n60 autopsy, 195, 223, 229n7. See also verbal autopsy azamba. See traditional birth attendants Banda, Evelyn Chitsa, 292n12, 292n19, 318n19, 319n21, 319n34, 320n40 Banda, Hastings, 44–­45, 46, 52, 55, 96, 296n60–­61; as “Father Christmas” 150, 170, 181–­82 Banda, Joyce: alliance with chiefs, 252, 257–­58, 264; presidency, 15, 217–­20, 225, 264, 316n67–­68; at Dowa, 191–­92, 202; safe-­motherhood initiative, 191–­92, 219–­22, 224–­25, 252, 316n69–­72; succession to presidency, 191, 217–­18, 311n51 Banja La Mtsogolo, 229, 317n1 (Dyna Ng’ong’ola and Kettie Pensulo) Banthu, Ganet (pseudonym), 59, 135, 236–­37, 317n7, 318n12 Barnett, Tony, 294n37, 311n49 Bashir, Omar al-­, 218, 219 Berlant, Lauren, 277, 322n4, 322n7 best practices, 14, 15, 143, 176–­77 beta coefficients, 207, 209, 211, 315n50–­51 bioethics, 15, 162, 168–­73, 310n36; African 172–­73; “global,” 168–­69, review committees, 310n32 bipedalism, 112, 304n8, 305n22 Bisika, Thomas, 319n33 Bixby, Fred, 139 Blair, Tony, 12, 292n15 blame: and audits 196–­98; and crisis, 241–­44; in epidemics, 297n86; and risk, 59; of health workers, 196–­98 Blantyre, 1–­2, 68, 190; infrastructure, 156; neighborhoods, 83, 94; private medicine, 160 Blantyre Malaria Project, 162–­63 bleach, 65, 146–­47, 148, 308n1 (Chimwemwe Bruce); smell of, 53, 190 blood: circulation, 77–­78; dangerous, 240; Faith Chisoni’s, 98, 129, 274–­75; “kills the eyes,” 240, 318n16; menstrual, 40; postpartum, 40, 53; products, 165, 270. See also red blood cells; transfusion blood pressure: broken machines, 15, 65, 72, 152, 154; and eclampsia, 72, 201; “new disease,” 53; on the partograph, 120; pregnancy screening, 7, 65–­66, 108, 154, 176; and sepsis 81; and shock, 74 Boerma, J. Ties, 313n12 Bonaparte, Alicia, 265 Bretton Woods, 47–­48, 296n69 Bruce, Chimwemwe (pseudonym), 85–­86, 145–­49, 152–­53, 154, 164 Bullough, Colin, 248–­49, 250, 305n13

index Bungalo, Lydia (pseudonym), 61 Burkina Faso, 168, 305n25, 312n58 Burkitt’s lymphoma, 2, 163, 184 Bwanali, Gray (pseudonym), 28, 126, 133–­34, 145 Bwanikwa, 37, 62 bylaws, 26–­27, 251–­52, 267. See also fines Cairo resolution, 255 California, 6, 192–­95, 223, 224 Cameroon, 181, 182 cancer: Burkitt’s lymphoma, 2, 163, 184; cervical, 161–­62, 179; chemotherapy, 2, 163, 166, 183–­84, 310n28; choriocarcinoma, 166, 170–­7 1, 310n28; Kaposi’s sarcoma, 2, 170, 188; and medical dreams, 181–­82; pediatric, 163 Canguilhem, George, 227 capitalism, 2, 38, 41, 274–­75, 295n53; and medicine, 300n28. See also flexible accumulation; racial capitalism care: dangerous, 15, 233–­34, 239, 240–­44, 264; disrespectful and abusive, 319n20, 321n65 care, family: activating medicines, 311n50; for Agnesi Kunjirima’s daughter, 67; as durable pattern, 32–­33; for Faith Chisoni, 33, 50–­51, 69, 126, 180, 262, 269–­73; guardians, 146, 163, 174, 186; for returned migrants, 39, 274 care, medical 61, 89–­90, 91–­93, 94–­95; justified by maternal death, 264–­65; in missions, 11, 43–­44, 49, 295n55; on plantations, 43–­44; private, 49, 149, 244, 245; public, 43–­44, 46, 49, 89–­90; urban bias, 89 case reports, 69–­75, format 75–­76, thinking with 75–­76, 102 cash, 21, 38–­39, 42–­43, 55, 293n9; debt service, 50, 170; women’s access to, 55, 91. See also fines; taxation cash crops, 43, 50, 96 Cashgate, 225 CD4 lymphocyte counts, 142–­43, 144 Center for Strategic and International Studies, 220 Centers for Disease Control and Prevention (CDC), 6, 224, 291n6, 312n5, 313n6 Central Medical Stores, 90, 139, 140 cephalopelvic disproportion, 111–­13, 244; diagnosis, 119–­23; and human evolution, 112; prediction, 113–­19 cervical cancer, 161–­62, 179 cesarean section, 125–­31, 244; as alternative to de­ structive delivery, 133; as ambivalent technol­ ogy, 15, 141, 233, 293n7; complications of, 2, 269–­70, 306n33; for CPD, 120; and intensive care, 124; marker of danger, 231, 241; overuse, 5, 240–­41, 243, 319n21; and partograph, 121, 245–­ 46; for primigravidas, 119; technique, 126–­28, 145, 305n29, 306n30

index Chabwera, Lea (pseudonym), 56, 238 Chaluwa, Catherine (pseudonym), 60 Chancellor College, University of Malawi, 11 change: cyclical, 32; ecological, 45–­46, 52, 96–­97; linear, 32 Chanock, Martin, 295n45, 320n51 Chapman, Rachel, 297n90–­91, 297n94, 317n4, 319n26 Chichewa language, 3, 8, 11, 99, 298n98–­99. See also under proverbs chiefs: authority, 34–­36, 252, 255–­56, 266; and customary law, 41–­42, 320n51; and death audits, 197; and Joyce Banda, 252, 257–­58, 264; and safe-­motherhood initiatives, 221, 231, 251–­52, 256, 257; and TBA ban, 251–­52 Chikhala village, 262, 263–­64 Chikumbutso, Immaculate (pseudonym), 29, 30, 53–­54 chikuta, 47 child spacing, 46, 88–­89, 150. See also contraception; fertility Chilembwe, John, 294n31 Chilundu, Christina (pseudonym), 244–­45, 246 chinamwali, 34 Ching’amba, Zebron (pseudonym), 178 Chiphangwi, John, 219 Chirwa, Orton, 44–­45, 296n60 Chisoni, Faith (pseudonym), 17–­18, 33, 50–­51, 69, 98, 116–­17, 125–­27, 128–­30, 165, 180, 202, 262, 269–­75; mother of, 33, 50–­51, 69, 126, 180, 262, 269–­73 cholera, 85 choriocarcinoma, 166, 170–­7 1, 184, 310n28 Christianity, 38, 44, 298n101; and gender roles, 41. See also missionaries cilwa, 34, 35 circumcision, 97, 264 civil registration, 192, 194–­95, 208, 312n5; completeness, 194–­95, 313n12; in Malawi, 195–­96, 313n13–­14 clinical officers, 8 College of Medicine, University of Malawi, 3, 7, 78, 99, 132, 170, 184; political diagnosis at, 303n76; Research Ethics Committee, 168, 291n10 colonialism: and anthropology, 13; British, 31–­32, 37–­44, 320n51; opposition to, 44 Colvin, Christopher, 320n43 Comaroff, Jean, 3 commodified reproduction: in Malawi, 55, 59, 64, 298n102; in Mozambique, 297n90–­91 community health workers, 248, 258, 319n29, 320n43. See also health surveillance assistants community midwifery assistants, 192, 260–­61, 321n57 confidential enquiries, 313n16

347 Congo, 135, 158, 206, 240, 294n27 contraception, 46, 60, 148, 276, 298n99 copper mining, 157 cord prolapse, 29–­30, 293n7 Côte d’Ivoire, 168, 312n58 counting. See numbers; metrics covariates, 209–­11; as estimates, 212–­14 COVID-­19, 140, 181, 208, 297n86, 302n53 CPD. See cephalopelvic disproportion Crane, Johanna Tayloe, 309n16, 309n22, 310n32 craniotomy, 133–­35, 141, 306n40. See also destructive delivery crisis: and blame, 241–­44, 277; as legitimation, 266; rhetoric, 277–­78; routine, 175, 178 Cronjé, H. S., 133, 299n16, 301n35 currency devaluation, 48, 219 custom. See mwambo customary law, 41–­42, 320n51 cycle regulation: agricultural, 11, 34–­36, 39, 41; maternal death and, 41, 59; sexual and reproductive, 11, 33, 34–­36, 40–­41 cycles: agricultural, 34–­36, 39, 41; ecological, 97; fiscal, 97; generational, 97. See also under time D. A. (pseudonym), 73–­75, 76–­81, 83–­87, 89, 92, 94, 97, 98, 101, 102 D. V. (pseudonym), 71–­72 dangerous care: and authority, 15, 234, 239, 264; Esme Lifa’s case, 239–­40; and maternal death, 233, 239, 242–­43; Mercy Kumwenda’s case, 245–­ 46; and policy, 264; and surgery, 243 Daudi, Abigail (pseudonym), 56, 124–­25, 235–­36, 241–­42, 245, 247 Daudi, Halima, 191 death certificates, 192, 194–­95, 312n5 debt, 39, 158, 296n74. See also structural adjustment delivery kits: for TBAs, 108, 248, 249; for women to bring, 175 democracy, 14, 26, 27, 55, 72, 293n9; in Flint, 159; in Malawi, 317n88 Demographic and Health Survey, 203–­5, 204, 217 destructive deliveries, 132–­35 dextrose, 121, 135 diabetes, 53, 261–­62 diagnosis: of anemia, 24, 109–­11, 142; clinical, 98, 109–­10; of CPD, 119–­23; with dreams, 105–­6, 111, 235, 236, 273; political 303n76; and “somatic translation,” 304n9; and therapy, 304n4; with vimbuza, 99, 106, 304n4 dialysis, 160, 309n12 Diener, Tara, 179 displaced knowledge, 170 dispossession, 38 disseminated intravascular coagulopathy (DIC): and Faith Chisoni, 129, 165; and sepsis, 306n32 divorce, 32, 42, 43, 62–­63, 298n102

348 donors, 191, 228; and health policy, 161, 251; influence of, 218–­19, 225 doubling, 62, 175–­80, 181; as taxonomy, 180, 311n48 Douglas, Mary, 59 Dowa Maternity Waiting Home, 191–­92, 202, 225–­26 dreams, 15, 105–­6, 179, 181–­84; as call to healing career, 235; diagnostic 105–­6, 111, 235, 236, 273, 319n21; neuroscience of, 311n47; as ways of knowing, 303n65 drought, 43, 51, 219; and climate change, 52, 96, 97 Dzimbiri, Betty (pseudonym), 241 Ebola, 181, 312n56 eclampsia. See seizures education, 44; among interviewees, 9, 321n56; moral, 26; as solution to maternal mortality, 62, 202, 220, 275, 277; for women, 55, 210–­11. See also initiation electricity: at hospitals, 86, 90, 109, 218; infrastructure, 178, 219; in the Niger Delta, 308n9 electronic medical records, 147–­48 Elias, Bertha (pseudonym), 78, 86 Elijah, Liness (pseudonym), 45 embodiment, 14, 98, 303n78; and porousness, 101–­2; and stature, 116–­18 emplaced knowledge, 170 enactment: of anemia, 110; of atherosclerosis, 110; of CPD, 111–­12, 120 enclaves, 155, 157–­73; defined, 154; and dreams, 183–­84; ethical, 165, 170–­72; medical, 159–­65; and “projectification,” 309n21; research, 161–­64, 167–­72; as seeds, 183–­84; and structural adjustment, 154; and vertical funding, 309n22 enslavement, 36–­38, 55, 274; and colonialism, 38, 320n51; and migration, 311n49; and missionaries, 12, 37, 294n28; oral histories, 37, 294n24 epidemiology, 188, 192–­95, 199 epinephrine, 179 episiotomy, 243 epistemic communities, 16 equations: explanatory, 209–­10, 217; IHME, 206–­ 17; predictive, 209–­10; UN group, 206–­17. See also models equipment and supplies, 4–­5, 108–­12, 229; inade­ quate, 49, 74, 89–­90, 91–­92, 96–­97, 148–­49, 150, 153–­4, 179, 239–­40; and doubling, 176–­78; and HIV risk, 241; and maternal death, 24, 26, 29, 30, 49–­50, 57, 65–­66, 71, 81, 111, 142–­43, 144, 201; and newborn death, 152; as family responsibilities, 261; for TBAs, 249–­50. See also absence; enclaves; delivery kits ergometrine, 138, 307n53 Erikson, Susan, 141, 307n62 error (in models), 215 erythrocytes. See red blood cells

index European Union, 219 evolution, human, 112, 298n5, 303n70, 304n8 facility birth, 26–­27, 46, 66, 90, 148–­9, 221, 231, 266; avoidance strategies, 230–­31; as lifesaving, 146, 234, 276; and prior cesarean, 131; rates, 259 famine, 43, 51–­52. See also hunger false pregnancy, 56 Farmer, Paul, 143 Fassin, Didier, 300n29, 307n58 fear (as risk), 29 Feierman, Steven, 143, 293n10, 303n67, 311n50 female genital cutting, 305n18 Ferguson, James, 157–­59, 161, 164 fertility, 34–­36, 46, 300n41; control of, 131; as covariate in MMR models, 315n48; and mater­ nal death, 87, 88–­89, 209, 217, 276; unwanted, 25. See also child spacing; contraception; sterilization fines: as family burden, 262; for maternal death, 37, 251; for out-­of-­facility birth, 231, 251–­52, 258–­59; as solution for maternal mortality, 26–­ 27, 252; for TBAs, 251–­52; women as, 37, 39 fistula, obstetric, 97, 112, 161, 304n9 fixed effects, 215, 315n50, 316n62 flexible accumulation, 158, 308n10. See also capitalism; neoliberalism Flint, 159 food insecurity. See hunger food taboos, 52, 58 Frank, Lazarus (pseudonym), 59–­60, 88 ganyu (piecework), 156, 157, 232, 293n6, 297n78 gardener’s metaphor, 82, 88, 104, 300n27 Gates, Bill and Melinda, 225 Gates Foundation, 205 Geissler, Wenzel, 180, 311n48 gender roles, 33–­34, 37, 39, 41–­42, 89, 254–­55; and birth attendance, 19, 236, 256, 257; and HIV/ AIDS, 54; and missions, 41, 294n28, 295n45; and obstructed labor, 304n8 General Motors, 159 gloves: in delivery kits 175; inadequate, 57; plastic bags as 107, 259; reused, 49; for TBAs 107, 230, 241, 252 “gold standards”: 142, 144, 307n64; organ transplantation as, 309n12; and doubles 177–­78 golden-­age stories, 14, 20, 28, 30, 59, 62–­63, 241 Gomani, Meria (pseudonym), 58, 61, 117, 119, 275 Gondwe, Thomas (pseudonym), 108, 113 Good, Mary-­Jo Delvecchio, 181, 265 Goodwell, Bernard (pseudonym), 57–­58, 121, 137, 138 Graham, Wendy, 314n31, 321n67 Gravlee, Clarence, 305n17 Grobler, C. J. F., 133, 299n16, 301n35

index Gross Domestic Product (GDP): as “black box,” 214; covariate in maternal mortality models, 209, 210–­11, 217, 276; estimation, 213–­14, 315n54; as hero, 217; Malawi’s, 213 Group of 8 (G8), 205, 222, 314n39 guardians. See under care, family guns, 1–­2, 36–­37, 291n6 Gunya, Catherine (pseudonym), 166, 170–­7 1, 184 Gwalangwa, Getrude (pseudonym), 30, 235–­36, 247 “harmful traditional practices”: 252, 265, 318n19, 320n42 haunting: and doubles, 175–­76, 177, 178–­80, 183; error term in MMR model, 215 health surveillance assistants (HSAs), 8, 142, 151–­52, 177; and antiretroviral rollout, 144; attending births, 238; relationships with TBAs, 105, 250; role in death audits, 197–­98, as TBA trainers, 249; vaccination rounds, 231 heat and cold regulation practices, 36, 40 height. See stature; stunting hematocrit, 24, 109, 299n12–­13; as delaying technology, 123 hemoglobin, 78–­79, 86; color scale, 109, testing, 71 hemorrhage, 1, 2, 23–­24, 27–­28, 62, 71, 74, 103, 126, 145; antepartum, 130; at cesarean, 127; miso­ prostol for, 137, 145; postpartum, 2, 146, 165, 199, 219, 257 hemostasis, 128, 130, 269, 274 herbalism, 235, 239, 243, 295n46; changes in, 45–­ 46, 58, 96; Lillian Siska’s, 105–­7; roots for, 303n1. See also mankhwala hidden pregnancy, 56 histopathology, 138, 167, 174 HIV: latency period 303n79; prevention of mother-­to-­child transmission (PMTCT), 140, 163, 167–­68, 172, 255, 258; vaccine research, 163–­ 64. See also antiretroviral therapy; HIV/AIDS; HIV seroprevalence; HIV testing HIV seroprevalence: effects on maternal mortality, 206, 209, 217, 301n46, 302n54; in MMR models, 316n60; in teen girls, 301n45; as villain, 217 HIV testing, 95, 163, 255; and male-­involvement policy, 254, 255–­56, 263; and TBA care, 241, 299n9 HIV/AIDS, 2, 6, 7, 20, 42, 49, 52–­54, 90–­93, 94, 293n9; in case reports, 75; as cause of mater­ nal deaths, 57, 61, 73, 146, 186–­87, 214–­15; as “chronic illness,” 7, 167; and D. A., 74, 98; and hunger, 51; iatrogenic, 302n51; and Lillian Siska, 105; and maternal mortality, 206, 209, 217, 301n46, 302n54; as occupational hazard, 240–­41; and R. C., 70–­7 1; and structural adjustment, 90–­93

349 Hodžić, Saida, 305n18 homicide, 1, 291n8 homosexuality, 219 hookworm, 85, 87, 94 Horton, Richard, 12–­13, 222, 227 hospitality, 84 housing, 83–­84, 107 humanitarian aid, 49, 160–­61, 162, 175 hunger and malnutrition, 21, 42–­43, 50–­52, 87–­88, 146; cyclical, 51; and ecological change, 96; and gender, 51; and HIV/AIDS, 51, 73; and immune function, 305n16; and stunting, 117–­18, 301n35, 303n79 Hunt, Nancy Rose, 135, 240 Hunter, Mark, 257 hydrocephalus, 120, 306n40 hypertension, 53. See also preeclampsia hysterectomy, 270; robot-­assisted 143–­44, 308n67 iatrogenesis, 5, 7; and COVID-­19, 302n53; and HIV, 92, 302n51; social, 253 ICD. See International Classification of Diseases ignorance (as cause of maternal death), 57–­59, 61–­62 illiteracy, 57, 146, 297n87, 318n14 imaginary: medical, 181, 265; minimalist, 265–­66 immune response, 79–­80, 81, 85, 300n22; and HIV, 300n23 improvisation, 138, 152, 154, 173–­74, 182 incubators, neonatal, 144 inequality, 2, 213 infection. See pneumonia; sepsis; sexually transmitted infections; and names of specific diseases infection, postoperative, 7, 122, 130, 269–­70; Faith Chisoni’s, 50, 126, 269–­70 infection prevention, 53, 90, 126, 143; and delivery kits, 147, 175. See also bleach infertility, 20, 37, 88; herbal treatment, 20, 88, 106 infrastructure, 85, 86–­87, 265; and enclaves, 157; and maternal death, 143; sewer, 307n64; water, 143, 151, 153, 155–­57, 219, 265, 307n64 initiation, 32, 34–­35, 41, 45, 59, 60, 298n100; Christianized, 60 Institute for Health Metrics and Evaluation (IHME): and COVID, 315n45; fixed effects calculations, 215, 316n62; global MMR estimates, 205–­6, 222, 224; HIV calculations, 214–­15, 316n60; Malawi MMR estimates, 206, 216, 217, 316n63; MMR model development, 206–­14, 217, 315n46–­47, 315n49–­52 intensive care, 274, 300n20; and cesarean, 124; for D.A., 74, 77; pediatric, 184; in US, 270 International Classification of Diseases (ICD), 199–­200, 200t, 313n23–­24 International Monetary Fund (IMF), 48, 170, 296n69, 296n74

350 intravenous fluid, 24, 70, 138; perils of, 74 iron tablets, 66 (as ferrous sulfate), 102, 154, 176, 229, 250 James, Lucy (pseudonym), 176, 178, 182, 183 jealousy, 33, 40, 42, 297n95 Jere, Amos (pseudonym), 241 Jere, Ian (pseudonym), 28 Jerven, Morten, 213 Jimu, Ulemu (pseudonym), 56 Johns Hopkins University, 163, 184 Jones, Camara Phyllis, 300n27 Kadzombe, Alex (pseudonym), 61, 238 Kaler, Amy, 62–­63, 298n102 Kalimira, Takhala (pseudonym), 29 Kalusa, Walima, 292n17–­18 Kamfoloma, Owen, 177–­78, 182, 183, 242 Kamowa, Mercy (pseudonym), 53 Kamudzi Health Center (pseudonym), 71–­72 Kamuzu College of Nursing, University of Malawi, 190 Kamwendo, Lennie, 321n55 kangaroo care, 144 kanyera, 53 Kaposi’s sarcoma, 2, 167, 170, 188 Kaseko, Bernard (pseudonym), 42, 52, 53, 229, 231, 233 Kasongo, Bernadette (pseudonym), 119 Katembo, Doriss (pseudonym), 30–­31 Kaunda, Bonnex (pseudonym), 16, 19–­21, 26, 31, 39, 42, 61, 63, 231 Knight, Solomon (pseudonym), 54 knowledge: clinical, 98–­99, 109–­10, 230; displaced, 170; embodied, 98, 113; emplaced, 170; epistemic communities of, 100; medical, 14, 97–­101, 302n64; outsider, 32; sensorial, 98–­99, 109–­10, 304n11 Krebs, Hans, 99 Krieger, Nancy, 101, 103, 303n78 Kululanga, Lucy, 256 Kumanja Health Center (pseudonym), 121, 137 Kumbani, Lily, 319n20 Kumwenda, Mercy (pseudonym), 245–­46, 267 Kunjirima, Agnesi (pseudonym), 29, 65–­67, 68, 74, 102, 293n7, 298n1 Kwataine, Chief, 191, 257–­58, 264 Kwinakwake village (pseudonym), 105, 142, 258 labor: forced, 38–­39; migration, 38–­40, 257, 294n34, 294n37, 298n102 Lachenal, Guillaume, 181, 183, 311n48 lactate, 76–­77, 97, 302n62 The Lancet, 206, 222, 227 land theft, 38 Langwick, Stacey, 295n46, 304n4, 318n8, 319n27

index Lemani, Mayi (pseudonym), 40–­41, 116, 118, 276 Leys, Norman, 38, 39, 294n31 Lifa, Esme (pseudonym), 239–­40, 246, 267 Lilongwe: fistula ward, 112; hospitals, 163, 179, 198; maternal death review, 198–­99, 202, 314n28; neighborhoods, 94 Livingston, Julie, 138 Livingstone, David, 12, 256 Liwanda, Charity (pseudonym), 154 logbooks, 108, 187, 230, 262, 319n35 Macheso, Phillipina (pseudonym), 99, 153 madness, 42, 311n49 Mafumu (pseudonym), 243–­44, 246 magic bullets, 14, 15, 136, 137–­41, 143, 277; misoprostol as, 320n39; and policy, 102 magnesium sulfate, 145, 148 Makano, Dr. (pseudonym), 239–­40 Makhukwa, J. (pseudonym), 235 malaria, 66, 70, 72, 146, 162–­63, 176, 183, 299n7; in pregnancy, 300n34; treatments, 229, 250 Malawi Congress Party, 45 Malawi Law Society, 218 male involvement policy, 233, 253–­57, 262–­63; enforcement, 254–­55, 256, 263; and HIV testing, 254; and social change, 263–­64; as social iatrogenesis, 253, 263 malnutrition. See hunger and malnutrition malposition, fetal, 107, 236, 243 Maluwa, Veronica, 164–­65 Mama, Amina, 172–­73 Mambosasa, Alick (pseudonym), 88 Mandala, Elias, 51 Mandawala, Loveness (pseudonym), 9 mankhwala: achikuda and achizungu, 136; for alcoholism, 106; for asthma, 45, 52, 106, 135; dosing, 243–­44; for childbirth, 242, 243; for infertility and reproductive misfortune, 37, 56, 229; for postpartum care 58, 243, 303n66; for prolonged labor, 135–­36; protective 40, 240; revealed in dreams, 179, 183. See also medicines; mwanamphepo Manyunga, Annettie (pseudonym), 28, 51 Mapanje, Jack, 150, 153, 155, 170, 181, 183, 308n2 marriage, 32, 295n45, 298n102; changes, 62–­63, 320n51; as HIV risk, 48; as process, 320n44 Martin, Emily, 302n64, 303n72, 307n52 Matengo, Wyson (pseudonym), 26–­27, 31, 41, 55, 58, 275, 293n5 maternal death audits, 187, 196–­98, 313n16; and blame, 196–­98; community-­linked, 197–­98, 202–­3 maternal death rate, defined, 193 maternal death review forms, 75, 87, 102, 240, 300n25

index maternal death reviews. See maternal death audits; maternal death review forms; morbidity and mortality meetings maternal morbidity, 5, 241, 306n41. See also fistula; symphysiotomy maternal mortality: and women’s well-­being, 5; as crisis, 233, 234, 241, 256, 266, 277–­78; and health-­care function, 4–­5, and HIV, 206, 209, 217, 301n46, 302n54; as marker of inequity, 5. See also maternal mortality in Malawi; mater­ nal mortality in United States; maternal mortality metrics; maternal mortality ratios maternal mortality in Malawi, 10; as political problem, 4; trends, 6, 188, 190–­91, 206, 207, 216 maternal mortality in United States: black women’s 5, 6, 188, 189, 223, 276, 322n2; in California, 223, 224; overall, 5, 6, 188, 189, 192–­95, 222–­24, 291n6, 312n5, 317n81 322n2; in Texas, 223–­24, 317n85; trends, 6, 188, 222, 313n8 maternal mortality metrics, 14, 15, 188; global, 222; and policy, 189; uses of, 189–­90, 192, 312n1, 316n75–­76 maternal mortality ratios (MMRs), 3, 10, 47, 193–­4; calculating, 6–­7, 192–­95, 193; defined, 193; modeling, 15, 189, 203, 205–­17, 315n45–­53, 315n59; without medical care, 5 maternity waiting homes, 191–­92, 221, 222, 225–­26, 260 matriliny, 34, 37, 39, 293n16 Mbanda, Paul (pseudonym), 28, 49, 63, 133, 178, 311n49 Mbetayasamba, Fiziwell, 262 Mbewe, Grace (pseudonym), 151–­53, 154, 164, 176, 178, 179 mbumba, 41, 45 measurement: of cervix, 304n11; as control 115; of pelvis, 113–­15, 114, 120; prenatal, 299n6; of stature, 115–­16, 123; versus modeling, 207–­8 medicines: ambivalent, 135–­36, 141, 307n49, 307n52; counterfeit, 140; herbal, 135, 146, 229; stocking of, 140, 229. See also mankhwala; names of specific medicines Médicins Sans Frontières (MSF), 160–­61, 164, 309n15, 309n17, 309n20 Meinert, Lotte, 309n21 Melberg, Andrea, 305n25 menses, 21, 36, 41 Messmer, Sarah, 88, 301n39–­40 methotrexate, 166, 171, 182, 184, 310n28 metrics. See maternal mortality metrics; maternal mortality ratios; numbers Michelangelo, 97–­98 Michigan State University, 162 migration: and HIV, 311n49; labor, 38–­40, 257, 294n34, 294n37, 298n102; urban, 94, 96

351 Millennium Development Goals, 4, 192, 205, 234, 251; fifth (MDG-­5), 4, 190, 192, 200, 206, 212, 314n39 minibuses, 89, 156, 301n42, 312n1 (Rhoda Nantongwe); and D. A., 86–­87; as medical transport, 23, 154, 229, 232; and Mercy Kumwenda, 246 mining, 39, 40, 157–­58, 159 Ministry of Health, Malawi, 118, 124, 137, 191; clin­ ical guidelines, 299n13; and maternal death au­ dits, 197; and metrics, 203; study of EmONC 138–­39, 196, 197, 301n43; and TBA policy, 250, 251–­52 miscarriage, 21, 123, 298n5; and choriocarcinoma, 166; maternal death from 27–­28, 63; in MMR calculation, 194; and misoprostol, 138, 141; prevention, 66, 235; R. C.’s, 71, 99; recurrent, 33, 42, 62 misclassification (of maternal deaths), 195 misogyny, 12, 81, 209, 277, 292n24 misoprostol, 15, 136–­41, 307n49, 307n53; and TBAs, 320n39; unavailable, 137, 145 missionaries, 37, 41, 294n28, 294n30; and patriarchal bargains, 320n51 Mitengo Health Center (pseudonym), 23, 186 mitochondria, 77, 100, 299n17, 303n70 Mkandawire-­Valhmu, Lucy, 301n48 Mkandawire, Elizabeth, 263 Mkhumba, T. A., 252 models: animals as, 300n22, 303n66, 303n69; of COVID-­19, 208; machines as, 100, 303n72; of maternal mortality, 15, 189, 203, 205–­17, 207; as stories, 15, 205, 217, 220; uses of maternal mortality models, 207–­8, 226–­27 modernity, 14; inadequate as cause of maternal death, 14, 57–­59; signaling, 320n42; wrong as cause of maternal death, 14, 59–­62 Mol, Annemarie, 110, 302n64, 304n3 Mongolo, Idah (pseudonym), 45, 52, 63, 235 moral distress, 309n25 moral injury, 309n25 Moran-­Thomas, Amy, 141 morbidity and mortality (M&M) reviews, 7, 68–­ 76, 79, 100, 298nn1–­2 Mozambique: antenatal care, 297n94; autopsy study, 299n7; birth attendants, 319n26; civil war, 160; commodified reproduction, 297n90–­ 91; health care, 46, 309n13, 317n4; misoprostol in, 139; NGOs in, 309n17; projectification in, 309n21 Mpemba healing cult, 294n27 Mphande, Chrissy (pseudonym), 46–­47, 59 Mphatso, Doctor (pseudonym), 33 Msukwa, Delhia (pseudonym), 52, 254, 255, 262 Mugabe, Robert, 218 Muleko, Pious (pseudonym), 105, 106, 142, 250 Mulemi, Benson, 173

352 Murphy, Michelle, 316n64, 320n45 Murray, Christopher, 214, 316n60 Mustillo, Sarah, 322n3 Mutharika, Arthur Peter, 218, 219, 224, 225, 264, 317n88 Mutharika, Bingu wa, 179, 217–­19; and G8, 314n39; death and political crisis, 218, 311n51; and TBA ban, 251–­52 Mwaiwathu Hospital, 160 mwambo, 36, 40, 41, 56. See also abstinence; food taboos; initiation mwanamphepo, 135–­36, 146, 233, 243; and abortion, 306n47; as ambivalent technology, 243; and ruptured uterus, 246; study in rats, 99, 100–­101, 303n66 Mwanza, 2, 256 Mwaseko, Martha (pseudonym), 117 Mwenimweni H. C. (pseudonym), 86, 151–­53, 229, 230, 231 Nairobi, 173 nansula, 20, 88 Nantongwe, Rhoda (pseudonym), 73, 185–­87, 188, 189, 196, 319n35 narratives. See stories National Aids Control Programme, 161 Ndhlovu, Martin (pseudonym), 118 Ndirande, 156, 308n4 Nduyo, Temwanani (pseudonym), 55–­56 negligence, medical, 71, 75, 93, 182, 201–­2, 239–­ 40, 241; as cause of maternal death, 201–­2, 239–­40 neoliberalism: and family burdens, 266; and flexible accumulation, 158; history, 47, 48; and maternal death, 12; as panacea, 276; and primary care, 160; principles, 48, 296n71. See also structural adjustment neonatal mortality (as MMR model covariate), 210, 214, 316n61. See also newborn death nevirapine, 140, 307n58 newborn death, 29, 30, 242, 270. See also neonatal mortality Newsom, Gavin, 223, 317n81 Ng’ong’ola, Dyna (pseudonym), 88, 108, 113, 228–­ 32, 233, 237, 244, 247, 250, 267 Nguyen, Vinh-­Kim, 310n29, 312n58 Niger Delta, 158, 159, 308n9 Nixon, Rob, 96, 308n9 njala. See hunger Njamba, 156 Njerengo, Wezi (pseudonym), 60, 240 Nkhoma, Evelyn (pseudonym), 57 normal abnormality, 28, 117, 311n49 Ntcheu District, 257, 258–­59, 263, 264 Nthondo, Chief, 262 numbers, 192, 225–­26

index nurse-­midwives: at district hospitals, 237; and emergency obstetric care, 293n2; at health centers, 72; inadequate numbers, 151, 171, 301n43, 321n55; and postabortion care, 137; task shifting, 237; training, 265, 295n54, 317n7, 321n55 Nyasaland: colonial rule, 37–­44; “customary law” 320n51; indirect rule, 320n51; health-­worker training, 43, 295n54; medical care, 43–­44, 295n55, 296n57 Nyau secret society, 45, 296n61 Nyirenda, K. J. (pseudonym), 53, 237–­38, 241, 249 obstructed labor: and CPD, 15, 111–­13, 125, 243; and fistula, 304n9; and maternal death, 111, 112, 296n57; prevention with partograph, 121; unrelated to CPD, 304n5 Odillo, Henry, 218 Oni-­Orisan, Adeola, 179 Ooms, Gorik, 309n22 operative vaginal delivery, 122, 124–­25, 132, 134, 231 organ transplantation, 309n12 oxygen, 74, 76–­78, 80, 81, 300n18; for choriocarcinoma, 166; concentrators, 74; and ischemic necrosis, 76–­77 oxytocin, 121, 135, 138, 245, 307n53; policy on use, 245–­46 Pachulu village (pseudonym), 201 Packard, Randall, 300n29 Pamtunda Health Center (pseudonym), 188, 229 Pamtunda village (pseudonym), 236 Pankhuyu Health Center (pseudonym), 108, 113 Papua New Guinea, 169–­70, 183 parasitic infections, 85, 117, 300n31, 305n16. See also hookworm; malaria; schistosomiasis Parker, Melissa, 300n31 partograph, 15, 120–­23, 121, 141, 245–­46, 305n25 patriarchal bargain, 252, 256–­58 patriarchy, 15, 277; and control of childbirth, 233, 242, 256–­58, 266–­67; and indirect rule, 41–­42, 320n51; misread as female pathology, 304n8. See also patriarchal bargain pelvimetry: clinical, 113–­15, 114, 171; x-­ray, 115 Pensulo, Kettie (pseudonym), 108, 113, 228–­32, 233, 237, 243, 244, 247, 250, 267, 317n5 Peters, Rebecca Warne, 320n43 Peters, William, 296n74 Peterson, Kristin, 310n30, 310n32 petrol, 86, 186, 219 Phambala, Cecilia (pseudonym), 29, 58 pharmaceutical companies, 191 Phiri, Duncan (pseudonym), 200–­201, 276 Pierre, Jemima, 309n18 Pigg, Stacy, 318n8, 319n27 PIH (pregnancy-­induced hypertension). See preeclampsia

index placebo, 168–­69, 171–­72, 310n31 placenta: animal model, 292n1; previa 125–­26, 306n33; retained, 23, 24, 107, 138, 199, 293n2, 295n53 pluralism, medical, 234–­35, 264 pneumonia, 39, 67, 70–­7 1, 74, 79–­80, 94, 98, 101; and anemia, 300 n20; and fluid management, 299n14; and HIV, 300n23–­24 poison, 57; mankhwala as, 243–­44; medicines as, 125, 135, 141, 307n49 police: delaying transport, 186, 301n42; enforcing labor, 39; enforcing TBA ban, 232; quelling protests, 219; transporting blood, 165 policies, 14, 15; changing, 118–­19, 148, 232, 251, 305n19; circulating, 256; evidence-­based, 251, 320n38; and magic bullets, 10; and metrics, 192; on misoprostol, 140; on oxytocin, 245–­46. See also male involvement policy; TBA ban polio, 115 pollution, 158–­59; air, 82, 84–­85, 300n30; soil, 85–­8; water, 85–­86, 302n56 Pondani, Hannifa (pseudonym), 30 population control, 46, 53, 139–­40, 141, 255, 320n44 postabortion care, 307n58 postdates pregnancy, 25, 236 poverty, 21, 62; and racism, 1, 2; as cause of maternal death, 57; embodied, 116–­18 preeclampsia, 25, 66, 72, 201 pregnancy and birth: as dangerous, 20, 28–­31, 53–­54, 57–­62, 233, 241–­42, 276; as joyous 233, 278; proverbs about, 3, 291n2; as robust, 241–­42, 278–­79, 322n6; as unpredictable, 3 primary health care, 309n14; political commitment to, 160, 309n13; TBAs as, 248, 320n39 primigravidas: and cesarean, 119; consoling, 176; dangerous, 118–­19, 209; transfer policy, 118–­19 “projectification,” 309n21. See also enclaves protest, political, 44, 159, 219, 307n60, 317n88 proverbs: on bodies and land, 11; Chichewa, 3, 16, 54, 99, 104, 293n11, 300n27; Hausa, 3 pseudocyesis, 56 Queen Elizabeth Central Hospital (Queens), 7, 89–­90, 93, 166–­67; changes at, 95–­96, 156, 162–­64, 170–­7 1, 183–­84, 190, 196; as teaching hospital, 170–­7 1; ICU, 124, 300n20; research enclaves in 162–­64, 183–­84; three doctors describe, 27–­28 R. C. (pseudonym), 69–­7 1, 99, 123 racial capitalism, 31, 38, 48, 274–­75 racialization: and structural violence, 103, 274–­75, 305n17; of austerity, 274; in case reports, 75; in death reviews, 81; in public health, 101, 103; in risk assessment, 7, 276

353 racism, 12, 82, 209; and antiretroviral delay, 309n16; and employment, 157, 159; and maternal death, 222, 277; and medical control of childbirth, 265, 276–­77; misread as pathology, 82; in obstetric care, 321n65; scientific, 311n49; structural, 159, 294n32, 300n27; and weathering, 97. See also racial capitalism; racialization; structural violence red blood cells, 24, 78, 79: analyzers, 109, 110; destruction, 85, 300n19; measurement, 109, 110–­11, 299n12; production, 94 Redfield, Peter, 309n15, 309n19, 312n65 relaxin, 305n21 reproductive governance, 15, 234, 317n2 reproductive misfortune, 33, 42. See also infertility; miscarriage; stillbirth research methods, 7–­10, 291n10, 291n11, 297n95 resilience and vulnerability, 14, 82, 101 resourcing. See improvisation rickets, 115 risk approach to safe motherhood, 249, 276, 305n19 Roberts, Dorothy, 82, 305n17, 306n34 roots. See herbalism; mankhwala Rosenberg, Karen, 305n22 ruptured uterus, 90, 112, 153; and cesarean section, 127, 130–­31, 132, 134, 244; Christina Chilundu’s 244, 246; Mercy Kumwenda’s 245–­46; and misoprostol, 136, 137; and mwanamphepo, 136, 243, 246; and oxytocin, 136, 245; in rats, 100 Rutherford, Julienne, 99, 298n5 Sacks, Oliver, 311n47 Safe Motherhood International, 258 safe motherhood committees, 258, 262, 263–­64 Saginaw, 1–­2, 6, 159, 273 Saikonde, Janet Rose (pseudonym), 235–­36, 243, 246, 247 Sambani, Jackson (pseudonym), 53 scales: and fractals, 94; spatial and temporal, 2, 14, 76, 82, 87–­88, 94–­97, 98, 100–­104; thinking across, 101–­4, 302n56; for weight, 306n44 scarcity, 15, 28, 49, 150, 153–­55, 171, 265; and maternal death, 57; and policy, 234, 246; and triage, 24. See also absence; equipment and supplies scars, 12–­13, 184, 227; cesarean, 130, 293n7; treatment with mankhwala, 243 schistosomiasis, 85, 87, 92, 302n56 Schoenbrun, David, 32, 293n12 Schumacher, Sandra, 88, 301n39–­40 Scott, James, 183 Scott, William, 295n53 secrets, public, 180 seizures, eclamptic, 71–­72, 145, 146, 201, 292n3, 299n7 Senegal, 247

354 sepsis, 74–­75, 80–­81, 103, 270, 299n7, 299n14; pulmonary origin 300n24. See also under abortion sexism. See gender roles; misogyny; patriarchy sexual behavior, 34, 39–­40, 54–­55, 294n17; commodified, 297n90, 298n102; and dangerous pregnancy, 54, 59–­50; and maternal death, 16, 26, 61; social control of, 61; and structural adjustment, 91. See also commodified reproduction sexual violence, 37, 39 sexually transmitted infection, 20, 66, 94; life as, 278; and social upheaval, 37, 40; untreated, 92 shock (medical diagnosis), 24, 74–­75, 240 Sierra Leone, 158, 179, 311n54 sing’anga. See asing’anga Singano, Eliza (pseudonym), 122, 123, 124 Singogo, E., 195–­96, 313n15 Siska, Lillian (pseudonym), 105–­7, 109, 183, 250, 258, 318n16 sisterhood surveys, 203–­5, 208, 226, 314n32–­33, 315n53; in Malawi, 204, 314n35 skilled birth attendance: as covariate in MMR model, 210–­11; definition, 318n10, 321n67 skilled birth attendants: as black boxes, 214; heterogeneity, 237–­39 slave trade. See enslavement slow violence, 96–­97, 274, 277–­78, 308n9 smoke, 84–­85, 147, 190, 225; from cookstoves, 84–­85 social and moral decline, 295n45; as cause of maternal death, 59–­61, 276 South Africa, 140; Agnesi Kunjirima’s daughter, 66–­67; community health workers, 320n43; fathers’ rights, 254; Getrude Gwalangwa in, 236; health care destination, 218, 309n12, 311n51; labor migration, 38, 84, 257, 294n37; Orton Chirwa in, 44 Stansfield, Sally, 313n12 starter packs, 177 stature, 115–­18, 305n13; and cesarean section, 115; clinical assessment, 115; measurement, 115–­16; shoe size as proxy, 116. See also stunting sterilization (of women), 131, 243, 306n34 stigmatizing technologies, 131–­35 stillbirth, 65, 74, 306n33; “fresh,” 74, 122, 244, 293n7, 299n11; risk factors, 307n62 stories, 3–­4; construction of, 3; about development, 217, 316n64; epidemiological, 188; eth­ nographic, 10; “golden-­age,” 14, 20, 28, 30, 59, 62–­63, 241; in medicine, 12; partial, 13–­14, 271–­ 73, 278; single, 13, 278; statistical models as, 12, 205, 217, 220–­22, 226–­27; what they do, 3–­4, 12, 275–­76; who should tell them, 273–­75, 291n10, 321n1 Street, Alice, 169–­70, 183 string. See thread

index Strong, Adrienne, 179, 292n12, 292n21, 299n11, 305n25, 309n13 structural adjustment, 47–­50, 55, 158, 265, 296n74, 297n75, 297n78; and medical enclaves, 154; principles of, 48; public health impact 302n55 structural violence, 93–­94, 103–­4; defined, 93 stunting, 117–­18, 301n35, 303n79 Suh, Siri, 292n23, 307n58 Sullivan, Noelle, 164, 319n26 surgery: as ambivalent technology, 274; as lifesaving, 23, 29, 146, 179, 270. See also cesarean section; craniotomy; hysterectomy; sterilization; symphysiotomy; suture Sustainable Development Goals, 200, 203 suture, 128, 130, 153, 306n31 symphysiotomy, 132, 134–­35, 141 Tamayenda, Salome (pseudonym), 30, 60 Tanzania, 311n50, 314n26, 319n22; enclaves in, 164; misoprostol in, 139; partograph in, 305n25; primary care in, 46, 309; TBAs in, 319n26–­27 task shifting, 142, 152, 237–­38, 246, 318n11–­12 taxation, 38–­39, 43, 48, 50, 55 TBA. See TBA ban, TBA training, traditional birth attendant TBA ban, 3, 258–­60, 151; aftermath, 254, 258–­60, 318n14; converging interests, 265; Kettie Pen­ sulo and Dyna Ng’ong’ola, 231–­32, 233; legal, 248, 251–­52, 307n56, 320n40; and secret work, 273 TBA training: beginnings of, 248–­51, 305n13; end of, 185; extent of, 319n33; Kettie Pensulo and Dyna Ng’ong’ola, 108, 229; as minimalist strategy, 252, 265 technological imperative, 135 technologies: ambivalent, 15, 136–­41; as assemblages, 123; defined, 108, 304n1; delaying, 123; justifying action, 123; stigmatizing, 131–­35 teen pregnancy, 20, 53, 61, 72, 241–­42, 262, 298n101; and CPD, 117–­19; and maternal death, 220; and school expulsion, 311n46 Tembo, Dr. (pseudonym), 23–­25, 110 tetanus, 2, 107, 291n8 Texas, 139, 192–­94, 195, 223–­24, 317n85 The Lancet, 12–­13, 206, 222, 227 “therapeutic misconception,” 162, 172 therapy management groups, 33, 293n13 Thokozire, Mama (pseudonym), 57, 243 Thorsen, Viva Combs, 202, 313n20, 314n26–­27 thread, 142, 152–­53, 175, 179, 230 three-­delays framework, 15, 189, 200–­203, 215, 276; critiques, 226, 314n26; at death audits, 196, 201–­3, 314n28 Thyolo, 160–­61, 164, 309n17, 309n20 Tikhale village (pseudonym), 19, 228–­32, 267, 321n57

index time: cyclical, 14, 96–­97; ethnographic present, 101; linear, 14, 96–­97; pathologic present, 101; punctuated, 95–­96 tools: defined, 108; justifying action, 123. See also equipment and supplies tradition, as dangerous: 14, 58, 275. See also “harmful traditional practices”; mwambo traditional authority, 41–­42, 45, 252; and land allocation, 83. See also chiefs traditional birth attendant (TBA), 8, 46, 106–­7, 185–­86, 199, 228–­32, 246–­53; as ambivalent technology, 252–­53; as bureaucratic label, 237, 247; as dangerous, 147; gender of, 236, 247, 319n26; heterogeneity, 235–­37, 247–­48, 259; invention, 246–­47, 253, 318n8, 319n26; legitimacy, 235–­37, 250; and maternal death, 58, 234, 239–­40, 242; as primary care, 247; relationships with HSAs, 250; supervision of, 151, 248, 250, 319n35. See also TBA ban; TBA training transfer (between health facilities), 73–­74, 113; for short stature, 115; justified by partograph, 122, justified by technologies, 124 “transactional sex,” 91 transfusion, 20, 24, 27–­28, 62, 66, 71, 74, 137, 165, 299n13; for choriocarcinoma, 184; and Faith Chisoni, 129–­30, 165, 269; as technology, 108, 111 transplantation, organ, 309n12 transportation difficulties, 22–­23, 72, 86–­87, 89, 229, 230, 260; of blood, 165; and male involvement policy, 254, 261, 262; and maternal death, 185–­86, 198–­99, 202, 219; night-­time, 232; and TBA ban, 259 Trevathan, Wenda, 305n22 Tsoka, the woman from 22–­25, 50; alternative pasts, 63; anemia diagnosis, 24, 110; madness vs. witchcraft, 25, 26, 42, 56 Tsoka Health Center (pseudonym), 23, 24, 138 tuberculosis, 39, 56, 84, 148; and mining, 300n29; pelvic, 174 Twalibu, Rosena (pseudonym), 117 twin pregnancy, 73–­74, 194, 198; Faith Chisoni’s, 17, 128–­30, 270 ubuntu, 26 ufulu, 26 ultrasound, 58, 299n6; diagnostic, 56, 123; delaying intervention, 123; justifying intervention, 141 uncertainty (in MMR estimates): ranges, 193, 316n63; sources of 207, 215–­16, 216 underreporting (of maternal deaths), 212, 223, 313n8 understaffing, 49, 89–­90, 151–­52, 190, 237–­38, 299n10, 301n43; and task shifting, 318n11 UNFPA, 46, 175, 225 UNICEF, 249, 255–­56 United Kingdom, 12, 265

355 United Nations Maternal Mortality Estimation Interagency Group (“UN group”), 205–­6, 208, 210–­12, 214–­16, 221 unruly women, 21, 27, 54, 55–­56, 58, 59–­60, 61–­62 unruly people, 59 unseeing, 179–­80, See also doubling urbanization, 83–­85, 97, 314n28 uterine rupture. See ruptured uterus uterotonics, 136. See also ergometrine; mwanamphepo; misoprostol; oxytocin Vaughan, Megan, 34, 292n17–­18, 294n38 Venture Strategies Innovations (VSI), 139–­40, 307n56–­57 verbal autopsy, 15, 189, 208, 226; and community-­ linked death reviews, 196, 198–­99; as DHS module, 205; automated, 102, 199, 203 vimbuza, 99, 106, 304n2 (MLS), 304n4 virus hunters, 181–­82 visions. See dreams vital registration. See civil registration vulnerability and resilience, 14, 82, 101 wa Mutharika, Bingu. See Mutharika, Bingu wa wâkongwe, 34, 60, 62, 256 Wasema, Doctor (pseudonym), 56, 235 Washington Consensus, 93, 296n71 water: infrastructure, 143, 151, 153, 155–­57, 219, 265, 307n64; polluted, 159, 302n56; sacred, 105; for sterilization, 156, 249 weathering, 97, 103, 214, 302n60 web of causation, 101, 103 Welemu, Ruth (pseudonym), 29, 242, 276 Wellcome Trust, 162 white privilege, 11–­12, 162 White Ribbon Alliance, 258, 321n55 white saviors, 13 white supremacy, 38, 277, 309n18. See also racial capitalism; racialization; racism Whiteside, Alan, 294n37, 311n49 Whyte, Susan Reynolds, 309n21 William, Chifundo (pseudonym), 118, 124 Wilson, Mayi (pseudonym), 41, 98, 303n66 Winfrey, Oprah, 257 Wisiki, Jelmos, 263–­64 witchcraft, 21, 25–­26, 33, 42, 55–­57; and AIDS, 53, 297n86; and colonial administration, 295n46–­ 47; diagnosis, 106; and Hastings Banda, 45; and inequality, 33, 42, 55–­56; and reproductive misfortune, 32–­33; and research methods, 295n48, 297n95; reversal, 42, 236, 247 Women on Waves, 139 World Bank, 48, 206, 213, 219, 276, 296n69 World Health Organization, 47, 51, 70, 76, 95, 192; archives, 11; clinical guidelines, 132; Essential Medicines List, 166; on genital cutting,

356 World Health Organization (cont.) 305n18; hemoglobin color scale, 109; and male-­involvement policies, 255; and maternal-­ mortality metrics, 203, 206, 224; membership, 312n14; partograph, 121; on skilled birth attendance, 318n10; and structural adjustment, 49; and TBAs, 246–­47, 251. See also United Nations Maternal Mortality Estimation Interagency Group Worldwide Governance Indicators, 48 wounded healers, 33, 235, 271, 293n15 Wright, Marcia, 320n51

index Zambia, 46, 191; border with Malawi, 31, 139; mining 157, 159 Zayamba Health Center (pseudonym), 254, 262 Zayamba village (pseudonym), 254, 262 Zibwalo Health Center (pseudonym), 145–­49, 154 zidovudine (AZT): in the United States, 167, 182; perinatal trials of, 167–­72, 310n29, 310n31, 312n58 Zimbabwe, 116, 218, 244 Zomba Central Hospital, 308n2 zoonotic infections, 181, 312n56