Abstract and Keywords
The conclusion reflects on the main findings of this study and points to their significance beyond the specificity of both fistula and Ethiopia. It wrestles with charting a way forward and away from representations of cultural pathology. Popular portrayals of women with fistula replay well-worn tropes of a diseased Africa, steeped—as it continues to be perceived by many—in tradition and dysfunction. They have also added to impressions of distant others as irrationally bound by “culture.” What are the consequences of sustaining these kinds of representations? In part, these imaginaries continue to efface the structural dimensions that cause women to sustain fistula, as the injury comes to be seen as an instance of cultural pathology. The widespread emphasis on early marriage as a cause for fistula has meant that local and international organizations active in fistula prevention have poured money and resources into “cultural” programming, seeking to educate rural populations about the nefarious effects of their marital practices. These activities have come at the direct expense of maternal health access reforms. Yet, the conclusion also reiterates that—although indisputably distressing—women’s experiences with fistula do not estrange them from their worlds in the ways claimed by the existing publicity.
As I sit down to think about the final note for this book, my New York Times e-mail alert tells me that a new article about obstetric fistula has just come out. For a second, as I click on the link and wait for the site to load, the thought crosses my mind that maybe this time it will be something fresh, something that breaks with previous conventions. As soon as I read the byline, my optimism sinks: Nicholas Kristof has just put out another op-ed titled “The World’s Modern-Day Lepers” about women with fistula in Ethiopia, who are “poor, rural, and female, and thus voiceless and marginalized.”1 It is the “thus” that bothers me the most—the suggestion of a logical connection, a foregone conclusion that requires no explanation. On that Sunday morning, as they butter their toast and sip their coffee, millions of readers will consume the same story. Perhaps they will shake their head at so much pointless suffering in Africa; perhaps they will feel secure in their knowledge that something like this could never happen to them. It all seems so far away.
What are the consequences of sustaining these kinds of representations for women with fistula, for ourselves? Portrayals such as Kristof’s replay well-worn tropes of a diseased Africa, steeped—as it continues to be perceived by many—in tradition and dysfunction. As a discipline, anthropology has long been committed to breaking up images of “primitive” others. Yet, when it comes to combatting the logic that underwrites fundraising initiatives for global humanitarian and development projects, which—for the most part—continue to depend on depictions of unenlightened others, this task can easily seem herculean.2 The picture of the injured, abandoned, battered child bride who needs assistance from the outside—since none is forthcoming from kin—presents a formidable reason for intervention. In (p.206) an effort to “create moral categories that connect those who help the needy with those who are in need” (Bornstein 2005, 171), representational practices for fistula have added to portrayals of distant others as irrationally bound by “culture.” Crisis-ridden Africa is here, once again, pushed to the margins of the “civilized” world. In the context of a continent routinely viewed “through a series of lacks and absences, failings and problems, plagues and catastrophes” (Ferguson 2006, 2), we must scrutinize such depictions with special care.
Because obstetric fistula relates to key staples of international development—women, maternal welfare, and childbirth—it has produced an excess of meaning in the field of female reproductive politics. Journalists and NGO workers have been quick to link fistula to “harmful traditional practices” such as early marriage. Even though Kristof mentions the importance of emergency obstetric care in his latest article, other contemporary observers continue to efface the structural dimensions that cause women to sustain fistula, centering their stories on condemning what they see as instances of cultural pathology. A different New York Times journalist recently called the famous fistula documentary A Walk to Beautiful “a complex and quietly devastating indictment of chauvinist societies that see women as lovers, mothers and servants, and treat anyone who can’t fulfill those roles as a nonperson.”3
The widespread emphasis on early marriage as a cause for fistula has meant that local and international organizations active in fistula prevention have poured money and resources into “cultural” programming, seeking to educate rural populations about the nefarious effects of their marital practices. These activities have come at the direct expense of maternal health access reforms. As one British gynecologist who was being trained in Ethiopia to perform fistula surgeries in Ghana commented about the funding logic of global reproductive health reforms, “It is easier to get funding for fistula treatment than it is to raise money for more hospitals with maternity wards.” Thus, the highly stylized tragedy that surrounds the fate of fistula sufferers is fundable, while the more sobering appeal to increase access to emergency obstetric care is not.
In this book, I examined the experiences of injury and hospitalization of women with obstetric fistula in Ethiopia, both in connection to the loss-and-salvation narrative and on their own terms. I exposed some of the real-world consequences of rendering women’s experiences with fistula in this starkly dualistic way, such as when elements of the dominant narrative made their way into the hospital classroom or when they shaped (p.207) decisions about where women with chronic childbirth injuries could possibly go. But I concerned myself with this narrative and its paradoxical outcomes only to some extent. Instead, I used the example of obstetric fistula in Ethiopia to reflect more generally on individual and collective responses to bodily injury, the function and excesses of hospital treatment, and the idea of biomedicine as a modern form of salvation. I showed how dangerous the myth of the one-stop cure can be and traced women’s complicated pathways as they moved through recurring episodes of treatment.
One of the contentions of the book is that treatment for fistula in Ethiopia went beyond therapeutic practices such as surgery, demonstrating how interventions of this kind become broader social projects of subject formation. The desire to transform patients holistically—rather than on just a physical level—has been at the heart of fistula treatment in Ethiopia since the beginning and is what differentiates Hamlin fistula hospitals from others of their kind elsewhere. Treatment for fistula was entrenched in a variety of social, political, and moral agendas: urban-rural tensions reverberated through women’s hospital stays, religious convictions animated the work of healing, and the welfare of the nation became inscribed on the bodies of its women. Even the most technocratic, hygienic aspect of biomedicine—surgery—pulled in a variety of other fields of meaning and became reconfigured as something else, such as a deeply religious experience. In analyzing these dynamics and pointing to their significance, my work makes the case for the continued relevance of anthropological inquiry in assessing global biomedical interventions.
At the same time, the book reveals how an injury like fistula can cast into relief a whole realm of ideas related to bodily transgression, care, piety, shame, and belonging. Misfortunes such as fistula—and the physical and spiritual care they necessitate—can form a rich terrain for the negotiation of kin and religious relations. Although indisputably distressing, women’s experiences with fistula didn’t estrange them from their worlds in the ways claimed by the existing publicity. In fact, it was precisely those women who continued to participate in the social and religious life of their community despite their impairment who were most successful at retaining a sense of belonging. And if there is something that should be banished, I think, it is the image of the deserted girl who sits in her ramshackle hut in a pool of her own urine.
My purpose in offering a glimpse into the life of women like Yashume was to provide an account that places a woman’s affliction back into the context of her life as a whole. In some ways, Yashume is a remarkable person. (p.208) And yet, popular representations of women with fistula leave no room for people to be remarkable in any way; they don’t grant them the possibility to build lives despite their injuries or develop mastery over difficult situations. The ethnographic evidence, by contrast, suggests that the remarkable may not be so exceptional.