Sai Hankuri

The Race to the Bottom and the Superlative Sufferer

 In a recent CNN article ominously (and sensationally) titled “A fate worse than death”, reporter Morgan Windsor describes obstetric fistula as a horrifying condition whereby a sufferer will be “rejected by her husband and shunned by her village because of her foul smell and inability to bear more children”.   Windsor presents fistula to a Western audience who might never have heard of the condition, forwarding a fairly monolithic archetype of the fistula suffer: young, powerless, and pitiable.  Still, the article wraps-up with a dash of hope – Windsor introduces us to a woman from Washington who was moved to act after reading a book about a woman’s experience with fistula.  This Washingtonian began a fundraiser (through which participants practice yoga for seven days, ostensibly for the pledges of supporters) in order to collect money for repair surgeries.  Windsor reports that the fundraiser has accrued enough money for two to five surgeries (depending on where you get your estimates).

I don’t usually respond to these sorts of articles.  I read articles about Africa, about African women, and particularly about women who are victims of being African and I quietly shake my head and mumble under my breath.  But this time it’s personal. I have been conducting fieldwork for my doctoral dissertation in anthropology in Niger, focusing on the experiences of women with fistula.  Two weeks ago Morgan Windsor interviewed me for over two hours for this article.

Let me preface what comes next – I’m not writing this to criticize Morgan Windsor, CNN, Olivia Bowen, or anyone who is moved to act, to get involved, to try to make a difference. Apathy is far too common and standing up for the disempowered is entirely laudable. But, I write this to encourage a different and hopefully a more constructive approach.

I accepted the request for an interview with some trepidation, knowing that in the West fistula has gained a recent notoriety – attracting the attention of donors, humanitarians, and nonprofit organizations, but often doing so with stories that overlook women’s real and complicated experiences.  In the world of foreign aid and nonprofit fundraising, organizations are all too often engaged in a race-to-the-bottom of suffering, fighting tooth and nail for a limited pot of money.  Good-hearted donors want their money to go the furthest, to make the most difference.  So, organizations championing fistula, cleft palette, leprosy, AIDS, domestic abuse, malnutrition (the list goes on) engage in a battle of the superlative pitiable – all making one claim: Our victims are the most deserving; Our victims suffer the most.  And anyone with any basic understanding of economics could guess what happens next, organizations compete for donors, reporters compete for readers, and victims become more and more pitiable.  A hungry child will no longer do – now the child must be on the verge of death.  An abused woman no longer merits attention – now she must be the victim of savage, rifle gang rape.

Much like female genital cutting (or “mutilation”) a decade ago, fistula seems to be pulling ahead in this race to the bottom.  You see, fistula is at the confluence of several factors: young girls and forced marriage (read: innocent and virginal and totally non-culpable), “backwards” cultural practices encouraging birthing alone and at home, victimization by African (and better yet, Muslim) men, and – to top it off – it’s about genitals.  Fistula becomes symbolic of the physical consequences of harmful culture on the quintessentially innocent.

There’s only one problem.  A problem that when I began my conversation with CNN’s Morgan Windsor, I tried to be explicit about.  The problem is that while young girls who suffer dramatic consequences of fistula, including abandonment and total social isolation, exist, they aren’t typical – they aren’t even the majority.  Indeed, there is no “typical” sufferer of fistula.  Although it is compelling to think so, and certainly helps forward the race to the bottom of suffering, fistula isn’t caused by early marriage.  Approximately 15% of women  (all women, placing your mother, sister, wife, a stranger in Tegucigalpa or Timbuktu equally at risk) will experience complications during labor.  There are very few and very inaccurate methods for guessing who these women will be.  They aren’t necessarily young.  They aren’t necessarily African.  These women are 15, these women are 45; it is their first pregnancy and it is their twelfth; these women are rural and urban; they’ve fastidiously followed pre-natal care and they’ve never seen a doctor; they are educated and they are not; they live in mansions and they barely get by. What differentiates a woman experiencing obstetric complications in New York from a woman in rural Niger is her access to care to emergency obstetric care.  In the United States less than 1% of women birth at home and 33% of women undergo cesarean sections.  In Niger, those numbers are over 80% and less than 1% respectively.  As I tried to explain to Ms. Windsor, we like to situate fistula as the consequence of culture, oppressive patriarchy, neglectful families, and easily rightable wrongs.  But in reality, fistula (and many sicknesses) is more a result of poverty, of legacies of colonization and post colonization, of geopolitical priorities, of structural adjustment policies and structural violence. But those are problems too big and too systemic for any yoga-a-thon to address.

That said; I get it.  It is hard to know where to start or how to help.  And the promise that for what you might spend on a plane ticket to visit your aunt in El Paso you could save a woman from the depths of suffering – well, that’s compelling.  That opens wallets and hearts in a way that talk of policies set in place before most of us were born and decisions made by the World Bank two decades ago simply doesn’t.

So, what’s the harm of exaggerating a little if the result brings in money to help these women who certainly are suffering?

“A fate worse than death” made the answer to that question quite clear to me.  After reading CNN’s article on fistula, many readers were moved to comment.  One reader says: “Interference is needed for sure. This isn’t a different ‘culture’ this is an unpoliced society living an adolescent fantasy. It’s hard to believe that there is any way we all came out of Africa. These folks still don’t have any basic respect for human rights”, later adding “Can we just wipe these places off the map already? The suffering is heartbreaking and there’s no end in sight.”  Another reader opines: “We can’t fix a broken and uncivilized culture. We will not drag them kicking and screaming into their own enlightenment, they’re going to have to do it on their own. And until they do, we should leave them to wallow in their own misery and ignorance.”  And another: “This is horrible, Africa is a beautiful place, but it’s [sic] people are Neanderthals. At some point, they have to realize their condition and rise up. Black people are always crying to go back to Africa…,not me!!!”.

Indeed, not being specific, accurate, and honest can promote xenophobic, hateful, misled, and counterproductive impressions while, admittedly, at the same time galvanizing readers to donate a few bucks to the cause.

So what is the reality of obstetric fistula?  Yes, for some, fistula results in divorce or abandonment, mistreatment by neighbors or even family, diminished marriage prospects, and social abandonment.  But, no, the vast majority of these women are not abandoned by their families.  Most continue to have fulfilling friendships and many (although admittedly fewer) of these women continue to receive the support of their committed husbands (contrary to what seems to be popular belief, African men are not unloving fiends).  Many of these women continue to have satisfying sexual relationships with their husbands, continue to have pregnancies, continue to work, continue with life.  Few women report outward mistreatment.  Many attempt to manage relatively normal lives for decades while living with fistula.

Still, imagine for a minute that you were chronically incontinent.  Now imagine that you didn’t have access to adult diapers or sanitary napkins.  Imagine that you were too poor to buy extra fabric and spent much of your day washing the few soiled cloths you owned.  Imagine how the acidity of the unremitting flow of urine burned away at your thighs, cracking your skin and leaving you vulnerable to painful infections.  Imagine the shame you’d feel – a grown adult incapable of avoiding the small pool of urine you’d leave behind on a friend’s chair after a visit, or the highly visible wetness on your backside.

For most women, their stories lack the dramatics of those highlighted by fistula campaigns or articles.  And yet, life with fistula is difficult.  It is physically uncomfortable and emotionally taxing. For many it is a condition that complicates lives, reduces wellbeing, causes social anxiety and results in many women trying to manage their shame by staying home, limiting the time they spend with friends or neighbors, concealing their condition, regularly reducing the amount they eat or drink, and practicing various other forms of strict self-management.  Isn’t that enough?  Why doesn’t that motivate us to act?  Why do we need the superlative of suffering?  Why must we highlight the extreme cases when the norm is bad enough?

I am asking for two things.  Reporters: take a stand and present stories with more nuance.  Your articles might not get shared as much on Facebook.  But they will be more honest and they will encourage a more in-depth comprehension of a problem where the victims and the villains are less clear.  The result of such a strategy is that options for intervention become less obvious, but it will curb the backlash to these race-to-the-bottom tactics – disgust, ethnocentrism, othering, and hate.   Readers: when you read about Africa keep in mind that in this economy you have a role in driving content – don’t participate in the sensational, and don’t assume that some cultures are less evolved or sophisticated, or inherently more nefarious than the one you come from. Because those assumptions bring us back to a time of dangerous ignorance and insidious racism.  If you have questions about cultural norms surrounding marriage, birth, or other social practices, investigate; ask yourself what kind of political, historical, and economic factors might have created an environment where certain practices prevail.

In the end, places like Niger do need help, and fistula is a human rights issue.  There are so many real heroes in the battle to increase maternal health – African surgeons who are underpaid and overworked, local village chiefs who are working to encourage hospital births by making funds available for emergency hospital evacuations, women with fistula themselves who heroically speak with other women in neighboring communities to raise awareness.  And while her efforts do deserve acclaim, an American woman who might never have been to Africa but raises money through down-dogs probably shouldn’t rise to the top of the list.