Maternal bliss and bondage

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Several months ago the Twitterverse resounded with dismay when the character Lady Sybil on Downton Abbey died shortly after giving birth. The grim portrayal of eclampsia shocked many viewers, who subsequently tweeted their frustration that Sybil was not taken to the hospital when pregnancy complications arose. However, in the period of the historical drama (1912-1920), maternal mortality was much higher in hospitals than at home. Maternal mortality in the general population was low, but outbreaks of postpartum injury and infection followed doctors wherever they attended births. Maternal mortality was in fact higher among rich women who could afford an obstetrician than among poor women who gave birth with the assistance of family and/or a lay midwife.

The time period depicted in Downton Abbey also featured transformations in maternity care and medicine. Increased awareness of how infections are spread prompted physicians and other birth attendants to begin washing their hands and sterilising equipment, greatly reducing the number of deaths in maternity hospitals. However, rapid urbanisation and escalating socio-economic inequalities also put women at higher risk of difficult labours – malnutrition, corsets and limited access to fresh air and sunshine caused profound physical deformities and weaknesses.

The Victorian effect

Early 20th-century concepts of motherhood remained dominated by Victorian sensibilities. The ideal Victorian woman was domestic, focused on childrearing and subservient to gendered notions of quietude, restraint and modesty. It was considered scandalous to speak or write about the bodily experiences of sex, pregnancy, childbirth and lactation. Even Victorian- and Edwardian-era obstetricians were suspect because of their interest in these taboo subjects.

The meek and mild mother was never a stable construct – Eve, the mother of sin, always provided inspiration for labelling women as being easily corrupted in flesh, mind and soul and deserving of pain and trauma in childbearing. The ultimate perversion of the ideal Victorian mother was the woman who killed her own child – late 19th- and early 20th-century media revelled in dramatic reports of infanticide. Similarly, medical literature increasingly focused on motherhood and madness. Many studies published during this time period focused on cases of ‘insanity’ that arose during pregnancy, childbirth, the post-partum period and lactation.

While Victorians are renowned for their obsession with lunacy, childbearing women featured disproportionately in this trend – contemporary sources report that between eight and 12 percent of all patients admitted to lunatic asylums were thought to have been driven mad by childbearing. The reports of symptoms, onset and progression are strikingly consistent over many decades and institutions.

Hysteria

Most of the studies produced during this time period strongly feature standard misogynist narratives that women are weak and hysterical, that they bring their illnesses upon themselves by immoral behaviours, that their physical states are inherently pathological and so on. However, a few medical practitioners recognised patterns in the personal histories of the women suffering from childbearing ‘insanity’ and argued that this affliction may be influenced by social factors.

One of the strongest proponents of this view was Dr. Alfred Lewis Galabin (1843-1913).  He is most renowned as the author of an obstetrical textbook (modestly entitled Manual of Midwifery), published between 1886 and 1910. The textbook demonstrates a unique awareness of women’s experiences, featuring descriptions of the sounds, movements, emotions and sensations of women in childbirth. Galabin insists that the melancholic states found in pregnant women have a mental cause in ‘the fear or conviction, so commonly met with in pregnant women… that the result of the delivery will be fatal’.

This fear of death, he states, is exacerbated by exhaustion from many and closely-spaced pregnancies, poverty, extreme hard work, domestic abuse, political instability and war. He frequently emphasises that cases of violent or outrageous behaviours, such as infanticide, are the result of infections and fevers (which he insists are largely physician-caused) and suggests that these findings influence legal proceedings against women who have committed crimes during childbearing. Galabin offers an extraordinary set of recommendations for treatment, including avoidance of pregnancy, access to abortion and the complete removal of the mother from all domestic, marital and motherly duties for an extended period of time.

Motherhood

It is ironic that Victorian and Edwardian culture glorified, institutionalised and pathologised motherhood. Mothers themselves were suffering in epidemic proportions. It was rare for women to remain unmarried and most had many pregnancies and several losses as infant and child mortality remained high throughout the period. Access to birth control and pain relief were severely restricted for moral and religious reasons, while the concept of conjugal rights limited women’s ability to consent to sexual intercourse and conception. Rape and domestic violence were rarely recognised and women did not generally have access to education or gainful employment. In his Clinical Lectures on Mental Diseases(1887), TS Clouston describes the reality of life as a woman compelled to work hard while enduring the strain of poverty and childbearing: ‘The wonder is that any organism could possibly have survived in body or brain such a terrible strain and output of energy in all directions’.

While in developed countries a majority of women can approach childbirth without such profound fear and hardship, staggering inequalities still exist. The total lifetime risk of maternal death is estimated to be one in 14,000 in Sweden, but one in 16 in Somalia (WHO, UNICEF 2010). Such statistics do not even begin to address childbirth injuries and trauma, maternal grief and exhaustion, the restriction of women’s choice in reproduction and parenting and the disproportionate suffering of women and mothers in situations of war, natural disaster and environmental degradation.

Unfortunately, recognition of the social factors involved in women’s mental and physical health is rare, both in Galabin’s time and in ours. Trends in medico-political discourse persistently construct the physiological as separate from the emotional, social and political, especially when it concerns women’s bodies and wellbeing. Taking a lesson from history, we should be asking what social inequalities are contributing to women’s and mothers’ mental, physical and psychosomatic health problems. Traumatic, stressful, debilitating childbearing should never be accepted as the status quo.

*Anija Dokter [2010] is doing a PhD at the Faculty of Music, specialising in Sound Studies. Her research examines soundscapes and embodiment in childbirth, midwifery and clinical medicine. Picture credit: Sattva and http://www.freedigitalphotos.net.

Refugees seek freedom from addiction on the Thai-Burma border

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Picture caption: As part of a camp-based mental health workshop, a student’s sketch of the drug and alcohol problems that she observes in her community of refugees at the Thai-Burma border.

Refugee camps are supposed to provide shelter from conflict and persecution, but, for Burmese refugees in Thailand, life in camp introduces a whole new set of dangers. These refugee camps have become a fertile breeding ground for drug and alcohol addiction.

I visited the Thai-Burma border camps last year as part of my work with a non-profit organisation that is dedicated to building up mental health services for refugees. I found that individuals turned to drugs and alcohol as a way to cope, however dysfunctionally, with the stress of protracted confinement in a place completely lacking in the opportunities for productive or meaningful living.

Alcohol is the most commonly abused drug in the camps. It is cheap and readily available in the form of homebrewed distilled rice liquor. These home brews can be fairly toxic with things like pesticides, fertilisers and rubber thrown in to make the concoction more potent or ferment more quickly.Research has shown that alcohol is used not only for recreation, but also as self-medication for pain and to cope with the boredom of life in camp, the depression and anxiety associated with the loss of traditional social structures and the stress of adapting to unfamiliar and austere living conditions.

In interviews with residents of the largest of the Thai camps, Mae La, some men revealed that they resort to substance abuse because they feel deprived of their typical means of livelihood. “We have only alcohol,” one man said, “It’s like being in a farm […] surrounded by a fence.” Many of these disenfranchised young men felt that they had no other avenues to express their frustration. “There is only alcohol to get release,” said one.

Male respondents lamented the loss of their normal roles as providers for the household. Female respondents described the effects of alcohol abuse as adding stress and pressure on their families. Gender-based violence, crime, the serious neglect of children and the costs of alcohol and substance use on the family’s finances all pose significant challenges to mental health. One camp resident put it this way: “The majority of addicts are men. Because of this, women are mentally ill.”

On the other hand, camp-based drug and alcohol recovery programmes gather hope from their work, seeing it as an expression of non-violent resistance against the former military dictatorship. Indeed, Burma (also known as Myanmar) stands out as a major source of methamphetamine pills and opiates in Southeast Asia today, according to a report by the United Nations Office on Drugs and Crime. Burma is the second largest opium grower in the world after Afghanistan.

Conflicts

Almost all of the opium Burma produces is grown in the eastern part of the country, in the states of the Shan and Kachin ethnic minorities. This area is also the site of long-standing conflicts between the minority groups’ armies and the central government’s military. The instability caused by these conflicts fuels the growth of opium and heroin production and is suggestive of a link between the highly profitable drug trade and the current plight of Burmese refugees.

One community-based recovery programme, DARE Network, has had remarkable success in the treatment of addicts in camp. They are a local organisation that developed in response to the urgent need to bring an end to the drug problems. DARE Network makes use of Burmese herbal medicines, acupuncture, herbal saunas, traditional massage and culturally appropriate therapies in their detoxification and rehabilitation programmes. They are guided by the belief that “recovery is a powerful weapon against those who benefit from the drug trade”. Recovery from drug and alcohol addiction returns people to their communities, and healthy communities are more resilient to manage whatever political and economic transformations are yet to come.

At the individual level, addiction is directly related to feelings of powerlessness. But, there is also the growing realisation that addiction plays a role in the bigger story of Burmese refugees: persecution, armed conflict, instability, a profitable drug trade and undemocratic rule. It is only by supporting those who are trying to break free from the cycles of addiction that full and inclusive participation in the creation of a free Burma for all will be possible.

*Lucinda Lai [2012] is doing an MPhil in Sociology. For more information about her work, click here.  

A looming epidemic: tackling non-infectious disease in sub-Saharan Africa

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When we think of health problems in Africa, we generally focus on infectious diseases (such as HIV and malaria), malnutrition, and maternal and childhood mortality. By contrast, non-communicable diseases (NCDs) such as obesity, heart disease and cancer are frequently referred to as ‘diseases of affluence’, and thus thought only as a problem of rich, developed countries.

However, did you know that 80% of all deaths due to NCDs actually occur in developing countries, including those in sub-Saharan Africa? Although infectious diseases are still a major problem in Africa, these countries are also battling with a substantial and rapidly growing burden of NCDs. In South Africa, for example, cardiovascular disease is the second leading cause of death after HIV, accounting for up to 40% of deaths among adults. By 2030, NCDs are projected to overtake infectious disease as the most common cause of death in Africa.

So what can be done to tackle this looming epidemic of non-infectious diseases in sub-Saharan Africa? One of the major obstacles we face in developing appropriate preventative strategies at a national level in Africa is a lack of reliable, high quality health information on NCDs. Since treatment and management for long-lasting or recurrent diseases is very expensive and requires strong and stable healthcare systems, prevention programmes may be a more cost-effective strategy for resource-poor countries. However, in order for governments to plan and implement prevention and control strategies, they need good quality data on disease burden and risk.

Uganda

In 2010, I set off to rural Uganda to work with a Ugandan project leader and team to set up and coordinate an epidemiological study on NCDs. The purpose of the study was to address this need for more information about the magnitude, distribution and determinants of these diseases in sub-Saharan Africa. The study was a collaboration between the University of Cambridge, Wellcome Trust Sanger Institute, and Medical Research Council Uganda/Uganda Virus Research Institute (MRC/UVRI). I joined as a PhD student to help coordinate the design and delivery of the project. I thus had the unique opportunity to work and live from the study field station in rural Uganda for a year, observing the project first-hand.

Piggybacking on the already well-established MRC/UVRI long-running study of HIV, we surveyed 8,000 rural Ugandans on their lifestyle (such as smoking, physical activity, and diet), physical measurements (such as obesity, blood pressure and cholesterol), and took blood samples (for tests such as for cholesterol and genetic analysis).

This was not an easy feat. Imagine trying to measure someone’s height and weight on uneven, unpaved ground, or explain to participants what you plan to do when there isn’t a local word for blood pressure. How do you ensure that adequate follow-up medical care is given to those identified with health problems in a setting where no national guidelines exist on how to treat high cholesterol and the only suitable healthcare facilities for some conditions are far away and expensive? There may be challenges to doing high quality large-scale NCD research in a low-resource setting, but it is possible! During my time in Uganda I learnt the importance of working together with collaborators, local staff, local leaders, and the community, in order to overcome such challenges together. All collaborators put a lot of emphasis on ensuring that everyone was well informed, enthusiastic, and engaged in what we were trying to achieve.

Disease risk

We successfully finished the study in 2011 and I then settled back into a slightly chillier life in Cambridge. I have since been seeing what the data has to tell us. I’m focusing on social determinants of risk factors such as smoking, obesity, blood pressure, and cholesterol, as well as evaluating how we define disease ‘risk’ for African populations. Are the tools we use to identify those at increased risk of diabetes or cardiovascular disease really internationally applicable? For example, what does it mean to be obese for Africans? Will they have the same level of risk of disease for a given amount of body fat as those of European descent? We continue to have a strong working relationship with our collaborators in Uganda (and indeed others across Africa) and research on a wide-range of topics is on-going.

I am very excited by the opportunity to work in such a new and growing area of research. This global health work has allowed me to merge my academic background in molecular medicine with my experience in international development. Ultimately I hope that this work can help to inform healthcare policy and prevention programmes, allowing Africa to achieve healthy and prosperous social and economic development.

*Georgina Murphy [2009] is a PhD student in the Genetic Epidemiology group at the Wellcome Trust Sanger Institute and the International Health Research Group at the University of Cambridge. A research paper on the project she has been working on is published in the International Journal of Epidemiology. This blog was first published on the Sanger Institute blog.

The mysterious lives of globetrotting birds

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Migratory birds make seemingly impossible journeys thousands of kilometres long. They cross oceans, high mountains and barren deserts to exploit the northern summer bounty and raise their hungry chicks. The most extreme traveller, the Eastern Bar-tailed Godwit, covers 17,000 km in 14 days of flight: eight days non-stop from New Zealand to China where they briefly rest and refuel, and another five-day flight to reach their Alaskan breeding grounds. These travels make even our most feared ultra-marathons look rather unimpressive: to equal the Godwits’ feat, a human would have to run at over 70 km/hr for two weeks.

Sadly, these long distance specialists are in a state of serious population decline. For example, in the European-African migratory system most long distance migratory bird species, from songbirds to shorebirds, have declined rapidly and consistently since the 1960s. The Wood Warbler has declined by 60% in the UK just since 1995. In contrast, resident species, which brave the cold European winters, have had stable populations over the same time period. But what’s most troubling is that the reasons for these declines are largely unknown. And because long distance migrants occupy such diverse parts of the globe, we don’t know where the source of these declines might be: are they in Europe, during migration, or on the wintering grounds in Africa?

Breeding success

One reason for this gap in our knowledge is the difficulty of tracking migrants year round. Of course, we’ve come a long way since Aristotle’s time when Barn Swallows were thought to bury themselves in the mud at the bottom of ponds during the winter. Yet it is easy to imagine the logistic hurdles of tracking an eight-gram Willow Warbler as it migrates south across the Sahara desert. As a result, the overwhelming majority of our knowledge comes from studies on the northern hemisphere breeding grounds, when nests can be found and breeding success measured by counting successfully reared chicks. While this information is hugely important for understanding population dynamics, the fact is that long distance migrants spend over 60% of the year thousands of kilometres away from Europe, either on migration or in Africa.

Widespread population declines in trans-Saharan migrants have been a call to action for understanding the factors at work in Africa. The problems faced by migratory birds in Europe are relatively well known, but for many species factors during the breeding season (such as habitat destruction) don’t fully explain the observed population declines. A number of recent initiatives are now focussing on the lives of long-distance migrants outside Europe. The British Trust for Ornithology has begun a satellite tracking project of European cuckoos, made possible by the recent development of five gram solar powered satellite transmitters which are light enough for cuckoos to carry on their journeys. Cuckoos in England have declined by over half in the last 25 years meaning the beloved “coo-coo” call is disappearing from the landscape. This project is an effort to understand their migration routes and where in Africa they spend the winter. Each tracked cuckoo has a blog where daily updates on their progress are posted.

Willow Warblers

Similarly, a joint Royal Society for the Protection of Birds (RSPB) and BTO project in Burkina Faso and Ghana aims to advance our knowledge of how, when, and where birds are using their African wintering grounds. My own work is based in Zambia, where I study wintering Great Reed and Willow Warblers. I use radio telemetry, stable isotope analysis and physiological measures of condition to determine how movement, habitat quality, and behaviour contribute to individual over winter success in Africa. In practice this means I divide my time between untangling bird nets from thickets of African thorn trees and measuring out tiny aliquots of hormones in collaborators’ labs in several European countries.

The quest to understand the double lives of long distance migrants is still very much in its early days. But the various initiatives beginning now will no doubt result in a better understanding of the challenges many familiar European birds face during their fascinating other lives in Africa.

And for these astounding globetrotting birds, any information that can help focus conservation resources can’t come too soon.

 *Marjorie Sorensen [2010] is doing a PhD in Zoology.

The International Criminal Court and the Kenyan election

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The March 4th 2013 election was a defining moment in Kenya’s post-independence history. This election was significant for several reasons. It was the first election under a progressive constitution which proposed a devolved system, an increase in the number of posts being elected and the strengthening of institutions which caused the undermining of the results of the 2007 elections, such as the judiciary and the electoral commission.

In addition to a progressive constitution, another outcome of the contested 2007 elections was the Kofi Annan mediation process in February 2008, which introduced reforms aimed at addressing the root causes of the 2007 post election violence (PEV). These included land reform, security sector reform, addressing historical injustices and ending a culture of impunity through transitional justice mechanisms such as the International Criminal Court (ICC). The then ICC prosecutor Luis Moreno Ocampo also started to investigate those who bore the greatest responsibility for crimes against humanity during the PEV.

Coincidentally, the winner of presidential election Uhuru Kenyatta and his deputy William Ruto are the ICC’s main suspects and their win came as a surprise when it was announced on March 10th 2013 by the Independent Elections and Boundaries and Commission (IEBC) and was later confirmed by the Supreme Court. The ICC investigation of the 2007 elections continues to provoke discussions and debate that are not only relevant to Kenya but also peace-building institutions and supporters of the ICC, such as western countries and the United Nations. The ICC has had several unintended consequences on the Kenyan elections:

First, I contend that the ICC contributed considerably to the Uhuru Kenyatta-led Jubilee coalition win. The two popular coalitions, Raila Odinga’s Coalition for Democracy (CORD) and Kenyatta’s Jubilee party drew largely on ethnicity issues and elite support for the dismissal of the ICC to mobilise voters. I believe the Uhuru and Ruto partnership was first a ‘marriage of convenience’ due to both being suspects of the ICC and a protest union  to save themselves from the ICC.

Constant reminders from Kofi Annan, United States African envoy Johnnie Carson and some European countries against electing Uhuru and Ruto went unheeded as the duo’s popularity grew with every intervention, judging from the popularity polls conducted at that time. The duo managed to craft a narrative around their role as revolutionaries, defying western imperialists who seek to undermine Kenya’s sovereignty. Using propaganda, they also asked voters to reject Odinga’s CORD coalition since it was part of the imperialist agenda and working in cahoots with the ICC. They thus completely flipped the national consensus against the ICC to suit their ends and it worked. Sadly, though, this Uhuru-Ruto win, as one Kenyan political analyst has observed, has shifted the ICC debate from the powerless victims who suffered displacement and sexual violence to the powerful accused who are now in power. This may render the victims even more vulnerable and in need of support.

The second unintended consequence of the ICC in Kenya is temporary or ‘negative peace’ in the Rift Valley province to use Johann Galtung’s term. According to Galtung, societies should aspire for positive peace which is the peace that comes when the root causes of violence are addressed as opposed to negative peace which is the peace arising from the absence of overt violent conflict like in the Kenyan case. Since the advent of multiparty democracy, the Rift Valley province has seen ethnic violence instigated by the ruling elite in every election apart from 2002 when they united to get rid of the former dictator Daniel Arap Moi.

In the 1992, 1997 and 2007, the Rift Valley elite instigated violence around contested land issues between Ruto’s Kalenjin people and Kenyatta’s Kikuyu people, who are viewed as outsiders. These definitions are based on historical injustices and settlements which date back to the acquisition of fertile highlands by British colonial settlers. Since the land question is still to be resolved in the Rift Valley and William Ruto and Uhuru Kenyatta’s families are beneficiaries to unequal land distribution in Kenya, it is doubtful that peace will prevail in the long-term unless they are genuinely committed to addressing the land question in Kenya.

The third positive unintended consequence of the ICC is the emergence of issue-based politicians at the national and county level outside the three leading coalitions led by Uhuru Kenyatta, Raila Odinga and Musalia Mudavadi. These three coalitions were largely supported by their ethnic groups, although the voting cannot be neatly defined as purely ethnic. We need to appreciate the nuances in voting patterns, for instance, issue-based voting is emerging in cosmopolitan counties like Nairobi and there is a probability that some voters voted based on rational self interest which coincided with a politician from their ethnic group. Outside the leading coalitions, five issue-based candidates with varying track records in the private sector and government emerged, giving Kenyans an alternative issue-based leadership. One of the most consistent candidates was the only female candidate, former Justice Minister Hon. Martha Karua who, despite the lack of significant votes, consistently campaigned on issues such as integrity, refusing to join hasty coalitions which were based on increasing numbers as opposed to a similarity in political ideology. Reminding Kenyans about the victims of the post election violence in 2007, she urged the electorate to end impunity by voting for leaders with integrity.

Finally, the ICC was a deterrent to violence in the 2013 elections. Many politicians, citizens and members of the media acted more responsibly in both public and private spheres by avoiding hate speech and any actions that could be construed to cause tension in a country that is deeply divided along ethnic lines – largely due to the fear of being investigated by the ICC.

*Njoki Wamai [2012] is a Gates Cambridge Scholar from Kenya in Politics and IR.  She was a human rights worker during the Kenyan Post Election Violence in 2007/08, focusing on women’s experience of the mediation process that followed. Her current research is on the impact of the external intervention processes, such as mediation and the International Criminal Court, on local politics and peace-building. Picture credit: Nuur Khamis.