Case study E: PIH Chapter 1: “Nomads and Nationalists in the Eritrean Sahel,” by Assefaw Tekeste Ghebrekidan
9.1 9.2 ppt health care
6.2 medical humanitaianism
Exam Study Guide Topics
Understand the 10 essential services of a healthcare system
Understand the different parts of the WHO’s Health Systems Framework, including the “building blocks” and the relationship to other parts of the diagram.
Know the 3 levels of health care, and be able to identify the level given an example.
Understand the main ways that healthcare systems are organized according to financing and delivery. Given an example, be able to identify whether that is public or private (e.g. know some examples of each)
Understand the common terms used to discuss health systems, including “public,” “private,” “co-payments,” “co-insurance,” “premiums,” etc.
Know the 4 types of health care systems including:
The country known for developing it
How it is financed
Whether there is insurance. If there is insurance, describe how it works.
Impact on citizens: cost of treatment, whether everyone is insured (“Universal coverage”)
If given a description of a health care system, be able to state which of the four types of health care systems it is most like and why.
Understand the components of the US system and how it is related to the 4 “models”
Describe the political and ideological value placed on health that is associated with different types of health systems
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Bigger questions to keep in mind as you listen and read about health systems in Unit 9
To what extent do different health systems value the “right to health”?
What is the role in various health systems of individuals, as well as the public, private and nongovernmental sectors?
What is the extent to which different actors in the system are engaged in the financing and provision of health services?
How are different health systems organized and managed?
What are the key issues constraining the effectiveness and efficiency of health systems in different settings?
How can those constraints best be addressed?
2
What is a health system?
WHO definition: “All actors, institutions, and resources that undertake health actions – where a health action is one where the primary intent is to improve health.”
Similarly, “a health system in the combination of resources, organization and management that culminate in the delivery of health services to the population”
Resources: drugs, medical technologies, first aid equipment, vaccines, funding, etc.
Institutions: Clinics, hospitals, pharmacies, laboratories, agencies that set standards, fundraising institutions, etc.
Actors: Doctors, nurses, community health workers, lab technicians, pharmaceutical industry workers, health researchers, etc.
Agencies (planning, regulating)
Money
People hwo provide preventative health services
“ “ “ clinical sercies
“ “ “ specilized inputs like education, drug manufacturing, research on medical devices…
From skolnik.
3
The 10 Essential Public Health Services
Monitor health status to identify and solve community health problems
Diagnose and investigate health problems and health hazards in the community
Inform, educate, and empower people about health issues
Mobilize community partnerships to identify and solve health problems
Develop policies and plans that support individual and community health efforts
Enforce laws and regulations that protect health and ensure safety
Link people to needed personal health services and assure the provision of health care when otherwise unavailable
Assure a competent public and personal health care workforce
Evaluate effectiveness, accessibility, and quality of personal and population-based health services
Research for new insights and innovative solutions to health problems
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5
The three Levels of Care
Primary Care
First point of contact for a patient, and ongoing care over time
Primary care physician – often acts as a gatekeeper to access other levels in cases of non-emergency. Referral (to hospital) only when problems are too uncommon to maintain competence. Coordinates care when people receive services at other levels.
Secondary Care: all of the above, plus…
Specialist physicians
E.g. General hospitals
Tertiary Care: all of the above, plus…
Specialized consultative care, usu. in hospitals, on referral
Wide range of physicians (but they are specialists)
Can address a wide range of health problems
High-level diagnostics, surgeries and treatments
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Health Care Systems are Complicated!
And yes, lots of people already knew that.
Levels of care:
Primary
Secondary
Tertiary
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Classifying healthcare systems
Delivery
Public Private
Financing Public National Health Service (NHS)
National Health Insurance models
Private None Out-of-Pocket
8
Four Basic Models of Health Care Systems
British System (The Beveridge Model, aka, National Health Service)
German System (The Bismark Model)
Canadian System (The National Health Insurance Model)
Out-of-pocket System
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Beveridge Model, aka, National Health Service (NHS)
Often called “British System”
There is no insurance in this system!
Comprehensive health services available to everyone, regardless of ability to pay
Coverage is universal; Health care is viewed as a state-supported service
Covers wide range of preventative and therapeutic services, mental health care, physical therapy, some palliative care, dental and eye care
Health care is provided and financed primarily by the government
“Single-payer system” means the government is the single payer
Countries that use the Beveridge model: Great Britain, Spain, New Zealand, Cuba, most of Scandinavia, Hong Kong
10
The Beveridge Model as it works in the UK today
Mostly public financing
75% general taxation
25% payroll tax
Minimal private funding
Copayments for outpatient (non-hospital) prescription drugs, dentistry services
11% of population also buys private voluntary health insurance
To get faster and more convenient care
For elective surgery at private hospitals
11
The Beveridge Model as it works in the UK today
Patients never get a bill from the doctor
Have some copays, but minimal
Out-of-pocket spending was 9% of total health care spending in the UK in 2012 (OECD, 2014a)
Some health care workers are public, some are private
Government pays private doctors set fees for services
All healthcare workers directly bill the government; patients don’t get bills
Single-payer system
Government decides what doctors can do
Government decides what doctors can charge
Tight government control keeps overall costs (e.g. cost per capita) low because government decides
Limits choice on what services people can get
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Variation on the NHS in Cuba
Cuba: whole system is government-operated
all clinics, hospitals, services staff
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Key components of the UK/Beveridge system (review)
The country known for developing it?
How it is funded?
If there is insurance, describe how it works
Impact on citizens: cost of treatment, whether everyone is insured?
Which part of the U.S. system is most similar to this?
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The Bismark Model (German system)
First universal system of health insurance, developed 1880s
Mandatory insurance, provided by “sickness funds”, covers 90% of population; rest have private insurance
Government regulates but does not provide health services directly
Financed by both employers’ tax, and employees through payroll deductions
Countries that use the Bismark Model: Germany, France, Belgium, the Netherlands, Japan, Switzerland and many Latin America countries
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The Bismark Model in Germany today
Insurance plans — “sickness funds”
Have to cover everyone
Must be not-for-profit (different from US system)
Participation is mandatory (like the “individual mandate” in the US Affordable Care Act)
Employers and employees split the cost of care equally (similar to employer-based insurance for the US)
The self-employed buy private insurance
Disabled and unemployed are also covered through various schemes
16
The Bismark Model in Germany today
240 sickness funds, tightly regulated by government
Multi-payer system, but tightly regulated by government to control costs
Must accept everyone, and must provide certain services mandated by the government
Can only compete by providing additional services
Health care providers and institutions are private
Payment is negotiated between the sickness funds and providers
Patients can choose their providers
17
The National Health Insurance Model: Canada
Universal coverage
Single-payer: National government-run insurance program
No profit
No need to market the plan to sell it to everyone
No financial motive to deny claims
Cheaper and simpler than private for-profit insurance (like US)
Single-payer (the government) (like Beverage)
Providers are private (like Bismark)
Countries with National Health Insurance Model: Canada, South Korea, Taiwan
This is Canada’s system
This system has elements of both Beveridge and Bismarck:
It uses private-sector providers (like Bismark) but payment comes from a government-run insurance program that every citizen pays into (like Beverage).
Canadian system – also an insurance model: government pays the providers directly through insurance,
Since there’s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance.
The single payer tends to have considerable market power to negotiate for lower prices; Canada’s system, for example, has negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated.
18
National Health Insurance Model in Canada today
Funded by taxation at the federal and provincial levels
Both personal and corporate income taxes
And some from sales tax, lottery in some provinces
Keeps costs low by limiting services and long waits for treatment
Pharmaceutical costs are so low that many Americans drive to Canada to buy medications
Although some in Canada still think they are too high
And pharmaceuticals are an out-of-pocket expense
Health care providers are largely public
National Health Insurance Model in Canada today
Covers preventive care, medical care from primary care physicians, hospitals, dental surgery and more
Some provinces require premiums for some services
But, health services cannot be denied due to financial inability to pay
Some people buy supplemental private insurance through their employer for non-covered health services
Dental services, eye care, prescription medicines
Federal system but each province gets a lot of autonomy
Differential care by province
20
The Out-of-pocket Model
The out-of-pocket model is one in which any medical care is paid for entirely by the patient
This may mean seeing a non-traditional healers
Or it may mean paying with money, food, services
Or it may mean being sick and dying young
It most likely means little to no preventative care
Many low and middle income countries have no established health care system
In many places, the rich get medical care, but not the poor
21
Out-of-pocket expenses vs. Out-of-pocket model
Most of the systems described here have some form of ‘out-of-pocket’ spending
British system: Copayments for drugs
Canadian system: Private health insurance to decrease wait times, and uncovered services
That is not the same as an ‘out-of-pocket’ model of health service
22
Is there insurance?
Who runs the insurance system?
Yes
No
Canadian System
German System
Public/Government
Private
companies
Who pays at point of service? (Who gets the doctor’s bill?)
British System
Out of pocket System
The government
The patient
Distinguishing between the models based on insurance
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Distinguishing the models based on delivery and financing
Delivery
Public Private
Financing Public National Health Service
(UK, Cuba, Spain)
National Health Insurance
(Canada, South Korea, Thailand, New Zealand)
Private None Out-of-Pocket
(most countries until the 19th or 20th c.)
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Pluralistic Models
Combination of private, public, and not-for-profit sectors playing important roles in health care services
Health care is not considered a human right, but rather a personal good that is commodified
Countries that have ‘pluralistic’ models health systems
India
Nigeria
United States
25
The US system is pluralistic
“Health care in the United States is currently a unique hybrid, multiple-payer system, but with elements of single payer (i.e., Medicare, although beneficiaries also contribute through premiums), publicly subsidized private payers (e.g., employer-sponsored health insurance), socialized medicine (e.g., Department of Veterans Affairs, in which government is both the payer and the employer), and self-pay (i.e., out of pocket).”
Donnelly, Peter D., Paul C. Erwin, Daniel M. Fox, and Colleen Grogan. 2019. “Single-Payer, Multiple-Payer, and State-Based Financing of Health Care: Introduction to the Special Section.” American Journal of Public Health 109 (11): 1482–83. https://doi.org/10.2105/AJPH.2019.305353.
26
Which parts of the US health system are like these health models?
German system – employer-provided insurance
Difference being that in Germany, these are all non-profit insurance organizations, whereas most insurance plans in the US are for profit
Canadian system – Medicare and Medicaid
Government-run insurance plans that pay private doctors for certain sets of treatments
British system – Veteran’s health plans
Government run hospital system, public health providers
Out-of-pocket system – population with no health insurance
They can get care if they can pay for it
27
Health system: 1. Private 2. Pluralistic 3. National Health Insurance 4. National Health Service (NHS) 5. Socialized Health Service
Prototype: Most countries until the 19th or 20th century United States, Peru, Nigeria, India Canada, Germany, France, Belgium, Netherlands, Taiwan, Japan, Costa Rica, Latin American countries United Kingdom, Italy, Sweden Cuba, Soviet Union
Political and ideological values:
Health care as an item of personal consumption Health care as primarily a consumer good Health care as an insured, guaranteed service Health care as a state-supported service Health case as a right and a state-provided public service
Position of the physician: Solo entrepreneur Solo entrepreneur and member of practitioner group Private solo or group practice and/or employed by hospitals Private solo or group practice and/or employed by hospitals State employee
Ownership of facilities: Private Private, not-for-profit, and public Not-for-profit and public, some private Mostly public Entirely public
Source of financing: Private out-of-pocket payments Mix of private out-of-pocket and public Primarily public single-payer Public monopsony (only 1 buyer) Public monopsony (only 1 buyer)
Administration and regulation Market Market, some government Government, some market Government Government
Adapted from: Birn, A, Y, Pillay, and T. H. Holtz. 2017.
Textbook of Global Health. Oxford University Press. Page 481.
The spectrum of health systems
28
Part III of your country papers: Health System
Organization: Is it a coordinated system run by the Ministry or Department of Health or is it more fragmented and relies primarily on market forces or NGOs? Is there a linked system of primary care, hospital care, and tertiary care?
Financing: This will vary widely by country, but some guiding questions: Is the system publicly funded, privately funded, supported by foreign donors, or a mix? If it is a mix, which kind of financing is dominant? Is the funding level sufficient to meet the needs of the population? If it has public funding, is it from taxes (if so, what kind of taxes?) or insurance premiums? What percent of healthcare costs are paid by the government (versus individuals)?
Coverage: Is there insurance? How does insurance work (who pays for it, what % of people are insured)? What costs are incurred by citizens (insurance premiums/cost of care)? Any recent significant changes in the system?
Key sector issues… next lecture.
Describe the overall health system (including organization, financing, coverage and model). After you’ve given an overview, then you’ll analyze the key sector issues. You’ll need to be concise as you will only have about a paragraph or less for each of the key sector issues.
29
Exam Study Guide Topics
Know what each of the 7 health sector issues means, plus:
A specific example
A strategy to address issues related to that Key Sector Issue
Use this understanding to do research for part III of your country papers
Before next slide: what would a demographic change be? Epidemiologic change?
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Definition Examples Strategies to address concerns
Changes in the population or changes in the patterns of disease. A health system needs to be able to respond to these. Longer life expectancy or immigration, the increase in non-communicable diseases or the emergence of a new disease like HIV or Zika. A health system needs to be able to respond to these issues. If non-communicable disease are on the rise, then need initiatives to address lack of physical activity, cigarette usage, etc. If HIV is on rise, need effective treatment and prevention. If population is aging, need to address NCDs such as CVD, dementia, and if the country can financially support aging population.
1. Demographic & Epidemiologic Change
2
Definition Examples Strategies to address concerns
Quality of governance—is it open/transparent? Clear rules/
regulations? Are rules enforced?
Staff hired because of connections rather than skill. New staff may have to pay off hiring managers. Staff high absenteeism without losing job. Buying products without best prices because of corruption. Staff getting kickbacks.
This happens because of lack of governance—not just individual choice. Nat’l anticorruption campaigns with strong political will. Reforming supply procurement systems & making transparent. Auditing health system & enforcing penalties.
2. Stewardship and governance
3
Definition Examples Strategies to address concerns
Issues related to health system staff members (includes having sufficient staff, well-trained staff, distributed throughout country where needed, salaries to keep people, high quality work conditions, not losing top skilled workers to other countries/settings). Shortages of docs, nurses, lab techs, unqualified managers. Deficient skills due to poor training. More staff in cities; more shortages rural areas. Public sector salaries < private sector.
Lack financial incentive to do quality work. Poor working conditions prompt them to leave country. Countries & their dev’ment partners more support for education, training, plans for retention. Wealthy countries more shared global responsibility so workers won’t leave resource poor areas.
3. Human Resources
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Human Resources Sector issue example
2003 survey of over 1400 public health centers across India
Surveyors verified the attendance of providers during unannounced visits
nearly 40% of doctors and medical service providers are absent from work on a typical day.
the absence problem is quite widely distributed and not concentrated among a few doctors.
“Doctors posted at remote facilities and at facilities with poor infrastructure and equipment were absent at significantly higher rates, as were those with longer commutes.”
Muralidharan, Karthik, Nazmul Chaudhury, Jeffrey Hammer, Michael Kremer, and Halsey Rogers. 2011. “Is There a Doctor in the House? Medical Worker Absence in India”. (working paper, Harvard University)
5
Definition Examples Strategies to address concerns
Safe, effective, patient-centered, timely, efficient, equitable Not using evidence-based guidelines. Don’t know correct diagnosis or treatment for a disease. Inappropriate use of antibiotics, fluids, feeding, oxygen. [Note: High quality can be achieved in low-resource settings.] Need assessments to identify quality gaps. Better oversight & training. Use clear guidelines & algorithms. Link payments to NGOs with performance.
4. Quality of care
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7
Definition Examples Strategies to address concerns
How to fund sufficiently, how to find funding to cover more or to keep covering what system is supposed to cover with changing costs (new tech, drugs, aging pop increase costs) New technologies drive up cost of care, how to fund to reduce wait times, govt not funding health system enough to ensure decent care regardless of ability to pay. Shift some $ from another part of economy to health. Shift to most cost effective interventions. Gather data, monitor outcomes. Increase efficiency.
5. Financing of Health System
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Definition Examples Strategies to address concerns
Financing the system without denying healthcare coverage to poor & without making people go bankrupt. Goal: universal coverage for basic package of health services In India spending $ on health is a primary reason why families fall below poverty line & cause of family selling assets. People use less health care (ie hospital deliveries of babies) when charged. Raising $ for health, improving efficiency, less out-of-pocket. Providing universal health ins. Targeting free basic package of services to those most in need
6. Financial Protection & the Provision of Universal Coverage
More example of solutions: Allocate more proportionately to basic packages to people & places with most need. Subsidize care for poor. govts encourage NGOs to provide services to poor.
Before next slide: what’s access and equity?
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Definition Examples Strategies to address concerns
Any disparities by sex, age, ethnicity, income, education, location? Lack of coverage in areas where poor, rural & minorities live. Fewer trained people, equipment & drugs in those areas. Services like vaccines more available in urban areas & areas with higher income & educ. Richer people get the more expensive services. Govts need to gather data and use it to look at where inequalities exist. Then target services there. Best if paired with improved water, sanitation, nutrition, hygiene, health behaviors (via increased knowledge)
7. Access and Equity
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Part III of your country papers: Health System
Organization, financing, coverage – previous lecture.
Key Sector Issues: Analyze the ability of your country’s health system to tackle its health issues by researching and describing each of the following issues discussed in class (a few sentences for each issue, or a short paragraph on each, is sufficient):
demographic and epidemiologic changes
health workforce concerns (human resources)
access and equity
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Nomads and Nationalists in the Eritrean Sahel
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The Practice of International Health: A Case-
Based Orientation
Daniel Perlman and Ananya Roy
Print publication date: 2009
Print ISBN-13: 9780195310276
Published to Oxford Scholarship Online: September 2009
DOI: 10.1093/acprof:oso/9780195310276.001.0001
Nomads and Nationalists in the Eritrean Sahel
Assefaw Tekeste Ghebrekidan
DOI:10.1093/acprof:oso/9780195310276.003.01
This chapter presents an account of the plight of the people living in the Sahel,
one of Eritrea’s most inaccessible regions. It describes the devastation wrought
by thirty years of war. It recounts experiences serving as a medical cadre among
the pastoralist communities, particularly describes the impromptu cooperation
between a liberation front and a marginalized population totally unaware of
politics.
Keywords: nomads, pastoralists, Eritrea, medical personnel, health services, health care, public
service, public health practice
Shielded by high mountain ranges that make a dramatic descent into the
western lowlands and Red Sea plains, the Sahel is one of Eritrea’s most
inaccessible regions. It is a land of two winters, with June to September rains in
the highland plateau and November to February rains in the lowlands, which
draw the 27 clans of the Tigre ethnic group like a magnet. They travel along arid
paths from the highlands of the Sahel in groups of three or four families, taking
different routes to ensure that all their livestock have sufficient grazing room.
The women are wrapped in brightly colored dresses with only the sun-darkened
skin around their eyes showing; the men, tall and thin, herd goats across the
dusty ground; children trek alongside their parents, likewise tending to the
herds. In June, they pack up and return to the Sahel for the rainy season there.
The Tigre pastoralists make this trek every year, stopping only a few weeks at a
time in any one place. Because their livestock is their primary asset and serves
for everything from their daily livelihood to dowry payments, they follow the
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rainy season to wherever the grass is green. They have lived this life for
generations. They would not live any other way.
In 1972, a new “clan” came to the Sahel: the Eritrean People’s Liberation Front
(EPLF). The EPLF chose this inaccessible region as a base for guerrilla
operations against Ethiopia, which had illegally annexed Eritrea as a province.
The war went on for over 30 years—the span of an entire generation—during
which Ethiopia was backed by the United States and provided with modern
weaponry from 1961 to 1975 and by the Soviet Union thereafter. In 1993, after a
national referendum supervised by the United Nations produced an almost
unanimous vote for its independence, Eritrea was proclaimed a sovereign state.
(p.20) The guerrillas’ mobility was compatible with the nomadic life of the
pastoralists, but unlike the latter’s, the guerillas’ movements were not dictated
by the need for grass; instead, they were governed by the strategic rules of
warfare. Their lives depended on blending in with the pastoralists. Their
ideology was one of social change, with emphases on literacy, self-reliance, and
women’s rights. They lived the nomadic life for less than one generation. It was
a step toward living in a completely different way.
Thirty years of war were unthinkably ruinous and tragic for Eritrea. I was there,
yet even I can scarcely conceive of the devastation wrought in terms of lives,
suffering, and property damage. Although I will never forget the horrors I
witnessed, serving as a medical cadre among the pastoralist communities is one
of my most cherished memories. The beauty of the impromptu cooperation
between a liberation front and a marginalized population utterly unaware of
politics has forever changed me.
I was born at the northern flanks of the central highlands, where the lands of
farmers merge with the trails of the nomadic pastoralists. At age 19, I went to
Ethiopia to study medicine. The hospital where I was placed after graduating
from medical school, in the port of Massawa, was not far from my home in the
highlands, and I lived comfortably. As one of only 16 doctors in Eritrea at the
time, I had my own home and a car, luxuries that most of the population could
not afford. This ended for me, though, after my arrest by the Ethiopian
government.
I had been a clandestine member of the EPLF since the age of 19. From the time
I began working as a physician in Massawa, through my promotion to hospital
director, until I was uprooted and sent back to Ethiopia, I had been meeting
secretly with Tegadelti (liberation fighters), who would sneak into the city in the
dark of night.
I would meet with Tegadelti in my home to talk about the marvels in the Field,
and I would hand off medicine, microscopes, and other necessary provisions for
the camouflaged hospital in the Filfil, a nearly inaccessible region in north
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central Eritrea, shielded by high mountain ranges and thick forest that
descended dramatically into the coastal plains.
Not long after my arrest, I was contacted by the Front to plan my escape from
Ethiopia. They arranged for me to fly back to Asmara, the capital city of Eritrea,
via a circuitous series of local flights. I then met up with a man who guided me
north, and we began our walk that very day toward the base of the Front. It was
a long walk across rocky terrain, throughout the afternoon and into the evening,
with a 4-hour rain that pelted my skin and soaked my clothes.
We finally stopped walking when we saw light from the house of semisedentary
farmers. The woman inside gave me dry clothes and a plate of sorghum
porridge, all the while quietly continuing her work. Finally she looked up at me
and said simply, “Why are you here?” Her hands were tough, their papery skin
dry against the stones she used to grind sorghum for the next day’s meal:
sorghum bread, more sorghum porridge. She eyed me from her place on the
floor mats, (p.21) where she’d been on her knees, grinding endlessly. “Look at
you. Your skin is so soft. Why did you come to this misery?” Her eyes narrowed,
her mouth turned down. I tried to explain to her about our position as a
colonized people, that life without liberty is worthless. My explanation did not
impress her. “Why don’t you just go live somewhere else as a doctor? You can
live comfortably,” she said. In the morning I thanked her for her hospitality and
continued my journey toward the Sahel and the spartan life of poverty that
awaited me.
There were a number of new recruits heading north to join the Front, and we
were lucky that our guides knew the route well. We had camels to carry all of
our supplies—food, drink, everything. However, we were forced to walk at night,
as it was imperative that we avoid the Ethiopian army and the merciless heat of
the lowlands. Although our guides were knowledgeable, their task became
difficult when winter clouds passed by overhead, rendering navigation by the
stars nearly impossible. But the camels knew their direction, and their inner
compass led us safely to our destination.
The first night of our journey was intolerable. Many of the recruits whispered to
the guides that they needed water. I understood. My own thirst was desperate.
Being in the lowlands made it worse, and our dehydration was fierce. We each
had a cup that held barely more than three handfuls of water. “You will drink one
of these at a time and only when needed most,” the guide explained, holding his
own cup up against the moonlit panorama of desert. “But no more.” He kept to
his word.
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Assefaw Tekeste in an underground
health center in 1985. (Photo: Peter
Wolff.)
(p.22) There it was, the
guerilla base in the Sahel, and I
found that a friend of mine was
already there. I sat with him,
grateful for a moment’s rest
after so many days of walking,
and we talked. It surprised me
when he very suddenly took off
his trousers. I watched him,
silent for the moment, as he
began to pick tiny lice from the
cloth, killing them in the heat of
the afternoon.
“You know,” I told him, “Having
lice doesn’t make you a
revolutionary. There’s no reason for this. Simple cleanliness is all it takes to
avoid lice.” My arms were draped across my knees, and my own clothes were
free of contamination.
My friend laughed and squashed yet another louse between thumb and
forefinger. “Take your time, maybe few months, Assefaw,” he said. “You will do
what I am doing and a newcomer will ask the same question to you.”
In less than 3 months my hair, clothes, and everything were covered with lice.
With no running water and the opportunity to bathe arising only once every 6 or
7 months, it was impossible to keep the bugs from communing on my body, on
my single shirt and only pair of trousers. It was simple to be an idealist back in
the city. In practice, it was uncomfortable to say the least. This was the life I had
chosen, one of blending in willingly with the poor, surrendering fleeting personal
leisure for a permanent, gratifying communal life in a liberated country. And so I
shared the poverty, and despite the inconveniences it posed, I felt alive to the
fullest.
Morning in the Sahel bled the bone-aching cold of night into the blistering heat
of day. Days rolled into months. The underground hospital served as our base.
The nature of our struggle forced us to work from the most difficult and barely
accessible locations—the terrain was inhospitable but defensible. It did not take
long before that stony land became our home. We lay low during the day, coming
back to life at night, between dry valleys and mountains slippery with erosion.
The paths of the nomads were ample, winding throughout Eritrea in the
highlands and down the mountain flanks into the lowlands. Some of the clans
crossed to the Sudan, oblivious of the borders, while others stayed only within
the country. There were spots where the tribes would stay for months, where
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there were ample grasses to sustain their livestock. The pastoralists’ sense of
cultural identity is deeply rooted in this way of life, an inextricable mix of age-old
tradition and necessary adaptations to the exacting conditions of the
environment. Neither the term pastoralist nor nomad fully describes the
complexity and diversity of their economic and social adaptations. Inevitably,
their paths crossed our own—a meeting that sparked the beginning of change
for all of us.
Historically, the pastoralists have had little if any access to modern health
services. When the Front arrived in the region, it provided primary health care,
then secondary and finally tertiary care. Those pastoralists who crossed into the
empty lowlands of Sudan, had no health-care options. In the beginning, few but
(p.23) major ailments were treated by the barefoot doctors of the Front.
Despite the pastoralists’ skepticism, their recovery was convincing. Eventually a
mutual bond was established.
One afternoon, some men came to the hospital from a pastoralist village where a
woman had been in labor for 3 days. It took me hours to walk there under the
sun of the Sahel, and when I arrived the husband looked at me and said, “I was
expecting a woman. You cannot go inside the tent.” I tried to explain that I could
help her, that there was a strong possibility that she could die. An elder came
and apologized for my having walked so far, and I was sent back to the hospital.
But that night they came back, and again I made the trek, this time cold beneath
the moon. Inside the tent, the woman held onto a rope that dangled from the
ceiling, her legs bent into a squat. Her eyes were focused on the rope and her
teeth clenched against screams; women in Sahel never utter a sound while
giving birth. I could tell immediately that she was anemic. Her skin, her hands,
her tongue, everything was so pale. There were five women gathered around,
including a traditional birth attendant who was rubbing some butter onto the
woman’s belly.
I needed more space to do a vacuum extraction, so I told them, “She needs to be
in the supine position. That’s the only way this will work.” The women refused. It
was not the way they did things in the Sahel. Her husband told them to let me do
my job, so we stretched her out into the supine position and I could see then that
her hips were too small—the baby’s head was stuck. I put on my gloves, washed
her, and placed the cup over the fetus’ tiny skull. The mother was very strong
despite being anemic and in so much pain; she listened carefully, pushing when
told. Her courage and tolerance to pain were remarkable. That facilitated the
vacuum extraction, and the baby was born blue, not breathing, and nearly
lifeless.
I placed my mouth over his tiny face coated in birthing fluid and breathed. I
pressed on his tiny chest, his 7-pound body so slight under my hands, and after 3
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or 4 minutes he was resuscitated. He lived, they never forgot about it, and that
was how the trust between us was built.
Before the war, several of my colleagues had not known the Eritrean nomad
community. Growing up in the cities, they assumed that all people were settled.
Although I had known of the pastoralists before the war, I didn’t know much
about them. Like my colleagues, I thought that they simply didn’t know a better
way of life. With disdain, we sought to change them. We thought that settlement
(the only way of life we knew) would be for their own good—they would have
access to health care, education, and all the things we felt would solve their
problems, make their lives better.
They intensely challenged our attempt to impose change. “We love our way of
life. Don’t interfere,” the elders told us. “We didn’t come to you. You came to us.”
And it was true. We had moved into their lands, we had been fed and protected,
our wounded had been helped by them, and above all they had taught us how to
live in that desolate terrain. We knew our position was that of learners.
(p.24) Slowly, their world became intertwined with ours. Their camels carried
most of our food and artillery. They were a natural target for the Ethiopian
bombs that rained down on their livestock and their tents. Often, our fighters
were carried into medical facilities by the nomads, open wounds dripping blood
onto their clothing. Survival in the face of a common enemy linked us together.
The nomads paid for liberation as much as we did, if not more.
One such case involved a child who had wandered with a baby goat a short
distance from his family. He stepped on a land mine, and his delicate rib cage
became a cave of bone fragments and muscle tissue. Blood spread slowly up his
shoulder and across his abdomen. Miraculously, he survived.
The boy’s parents carried him to the hospital. His younger sister was slung
across the mother’s chest and, as the boy lay unconscious, her screams were
more deafening than anyone’s. It was a delicate procedure—we had to treat this
wound very carefully, tweezing the smallest bits of dead tissue and shrapnel
from his flesh, which were placed into a shallow metal pan at the side of the
operating table. It was then that I wondered about this war. How many Ethiopian
children have starved in their poverty-stricken country to pay for the bomb that
had injured this innocent child? The war of liberation was the only means of
bringing an end to such atrocities. Fortunately, the shrapnel did not penetrate
deeply enough to be fatal, and although it was a painful recovery, eventually the
boy grew strong once again, with a thick scar braided over his chest and the loss
one leg.
The Front, although initially few in number, had a medical service almost from
the very beginning. We started by training medics who traveled with the military
units and eventually developed a mobile service tailored to their needs. By 1982,
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we had over 20 mobile health teams, each consisting of a nurse, about five
health workers, and—when available—an assistant midwife and several armed
guards.
Although pastoralists in Eritrea make up one-third of the total population of 4
million, they are historically a forgotten people living on the margins of a colony.
The center of power forgets them, and they forget the center. The presence of
the EPLF in the Sahel represented, in many ways, a reversal of the status quo:
for the first time there was a political center—that of the independence
movement—located in the pastoralist region. Political power was concentrated
at the margins. For both the pastoralists and for us, this shift was revolutionary.
It meant that after liberation, the national government had to recognize the
pastoralists for the first time. It meant that our ethnic groups—the Tigre
pastoralists and the EPLF—had truly joined forces.
In the beginning, there were no liberated areas. There were only guerillas
moving across Eritrea’s tough terrain, constantly changing location to avoid
being targeted by the Ethiopian army. However, small areas were soon liberated
and we were free (p.25) to set up bases—hospitals and stationary health clinics
—to which fighters and civilians alike could come for free health care. Although
those fighting for independence no longer needed mobile health teams, we kept
them intact and sent them out among the nomads to provide care for them
during their long treks in search of greens for their livestock.
Having worked with the pastoralists for some time, we had become increasingly
familiar with the health problems they faced. Endemic falciparum and vivax
malaria sapped their strength by depleting their blood and overtaxing the supply
of iron to their bodies. We also noticed that many of the nomads suffered from
undernourishment. Their basic diet consisted of sorghum porridge with milk.
Fruits were unknown to them, and the meager vegetables available were given
to the livestock. Despite this, micronutrient deficiencies such as scurvy, goiter,
and beriberi were rare; however, during periods of drought, when livestock died
and the milk supply decreased, undernourishment among the children rose
quickly. Community health was intimately linked to the health of the livestock—if
the animals suffered, the people suffered.
They became afflicted by a variety of illnesses that could have easily been
prevented if even the simplest of measures had been implemented appropriately.
The extremes of temperature in this desert land coupled with undernutrition
increased the people’s vulnerability to respiratory tract infections, particularly
pulmonary tuberculosis and pneumonia, the primary causes of death among
children. Schistosomiasis, which had previously not been prevalent, was
spreading quickly with the altered movement of the people during the war, and
cases were arising in areas that had not been previously affected. Other vector-
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borne diseases, such as leishmaniasis, were common, and epidemics of
meningococcal meningitis and cholera occasionally affected the western
Eritrean lowlands.
The nomadic way of life also has many healthy aspects to it. Communicable
diseases due to overcrowding—such as dysentery, typhoid, typhus, trachoma,
and intestinal parasites—were rare. The people lived spread thin, denying the
bugs passage from one person to the other.
Despite these complex issues surrounding health provision for the pastoralists,
they led a very simple life. It took some time for me to understand the appeal of
this wandering from place to place, although a friend I made was very influential
in helping to make this knowledge sink in. Each year, this friend from Biet-
Abrehe passed by in search of the rainy season, his family in tow. One day he
arrived on his way back from Sudan, a bottle of milk for me in hand. I thanked
him for the gift, and we sat in a patch of shade with the underground hospital
beneath us.
“You know,” I said to him, “each year you pass by from highland to lowland. Your
family is always walking along with you. Why don’t you at least leave your wife
and children here? We have the school, the hospital. They could get an
education, medical treatment if they get sick. …”
He smiled at me and remained quiet for a moment. When he spoke, his voice
was rough, like his callused hands. “You know, every time I go to the lowland
end, (p.26) you are here. I come back, and you are still here. What a boring
life,” he laughed, pointing to the underground bunker where I lived.
“Here’s the thing. …” He lifted his left hand, gestured at the goats grazing on
the hillside. “The goats are also a family. That goat, well, she has kids. I can take
care of the adults, but the small goats, my wife has to take care of, and my
children. So, we cannot split up. It’s a family of goats as we are a family of
people.” It was wisdom gained by life experience.
What he told me made sense: they hadn’t chosen the nomadic life for
themselves, it had been dictated to them by nature. They could not be farmers in
that arid land because there was not enough rain to support agriculture. While
sedentary people often viewed them with contempt, no one can deny the
productivity of the pastoralists: livestock became the main or only export
commodity after Eritrean independence. And how can anyone scorn the
pastoralists’ lifestyle?
However, while I learned to respect the pastoralist way of life, I still could not
come to terms with certain social and cultural practices that have a bearing on
their health, particularly the health of women. Nomadic society, rooted in a
patriarchal order that greatly circumscribes women’s rights and power in the
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community, dictates that lineage and inheritance, thereby the transfer of rights
and resources, travel along the male line. I would see the women in their
seasonal villages grinding cereals between two stones to mill the seeds for
porridge or bread, a task that often kept them busy until 3 or 4 o’clock in the
morning. The nomadic women were also expected to bear children, take care of
home and offspring, and prepare the food, including the laborious task of milling
sorghum, tending and milking animals, fetching water and firewood,
constructing and dismantling makeshift huts, and more.
As with many ethnic groups, the women were served food last. This uneven
distribution of food within the family, combined with poverty, has damaging
effects on the nutritional status of women in general and of pregnant and
lactating mothers in particular. These conditions, coupled with strenuous work,
make nomadic women disproportionately vulnerable to illness. Maternal and
infant mortality rates in the region are extremely high (an estimated maternal
mortality rate of 1,000 per 100,000 live births), which is aggravated by the
severely limited accessibility of maternal and child health care, immunization,
family planning, and general health education.
The patriarchal social structure and the low average education level of women
further complicate their access to what few health services may be available.
However, the revolution did make some differences in the emancipation of
women. The female nomads who came to join the Front carried guns and donned
clothes like ours. It was only a short time until a law was passed that at least
30% of each village council must be made up of women.
One of these councilwomen was Fatima, but everybody called her Mussolini.
This Mussolini was only in her early thirties and not much taller than a medium-
sized young girl, but she struck fear in many of the people she encountered. She
was a (p.27) divorcee—owing to her nonconformist will of steel—and so her
lack of husband to complain about her status as a councilwoman, coupled with
fair judgment, made her an excellent candidate for village office.
It was late at night when a dark shape scurried toward us under a desert moon. I
could see that he was a pastoralist from the clothes he wore. He carried nothing
but concern in the deep lines of a weathered face. He was from Brij, Fatima’s
village, and begged us to come quickly to treat his wife. I went.
We arrived at the man’s tent an hour later. The woman had pneumonia and was
critically ill with other complications. Her daughter mopped sweat from her
mother’s forehead with a bright yellow cloth. The woman shivered despite a thin
blanket tucked around her bony shoulders and the perspiration that poured from
her skin. I squatted on the floor of the hut and examined her. She was febrile
and severely dehydrated. She was very ill, so I took the woman’s husband
outside with me.
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“We must take your wife to the clinic,” I told him. “She’s dehydrated. She needs
an intravenous infusion and maybe blood.”
“I can’t take her to the clinic,” he said. He shook his head and shrugged. “I don’t
have anybody to help me and I can’t take her alone.”
“What do you mean you can’t take her? She’s your wife,” I said. “If she doesn’t
go to the hospital, she’ll die.” He was a young man, in his late twenties at most,
and he simply refused. I left the hut and walked over to Fatima and explained
the situation to her.
“You go back to the clinic,” she told me. “Don’t worry. He’ll meet you there.”
I left, sure that I would never see the man or his wife again.
A short time later, to my surprise, the man did arrive, carrying his wife on his
back. The effective outcome of sharing power with women struck me.
I watched one of the pastoralists’ healers late one night. Fire blazed while he
chanted and cast herbs into the flames—a practice that seemed irrational and
bizarre. I asked him about it later, with the pale moon illuminating his black
freckles.
“I cannot tell you the secrets of my ways,” he told me. He shook his head in
refusal, crossed his arms.
“But if this truly works for healing sickness, isn’t it better to tell others about it
so more people can benefit from the practice?”
“No,” he said. He continued to shake his head as he spoke. “Revealing secrets
affects the potency of the therapy, and for this reason, I cannot tell you or
anyone else.”
Traditional healers were the prime health-care providers to the pastoralist
communities. The fact that they charged excessive prices for their services,
contrary to the practices of the Front, was in no way compensated by the
occasional destitute family they helped for free or the fact that they did not
charge for patients (p.28) they failed to cure. Our stand against the healers
was aggressive—we believed in doing away with some of the old habits and
paving the way for improved modern health services. Typical of the arrogance of
modern medicine, we prohibited their activities, sending fighters to arrest them
in the most extreme cases. Consequently most of the healers fled their
communities or went into hiding.
However, there were also traditional birth attendants, women who assisted in
labor. They very rarely asked for payment up front and did not necessarily
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charge patients who could not afford to pay, and we began to wonder if the ban
on traditional healing had not been a mistake. We were obliged to revisit the
policy and reverse it. There was an attempt to reconcile our differences and
integrate the beneficial aspects of traditional health practice with modern health
services.
I went to one of the villages and began asking around about the traditional
healers, where they had gone and how I might find them, saying that we had
been wrong. Most of the nomads said, “No, we don’t know where they are.”
Finally one man leaned close to me and said, “Well, there are three of them. But
they don’t operate openly because they are scared of you. Before, we had seven.
But now there are just the three.”
“Where did the other four go?” I asked. I was skeptical.
“Well, two of them fled to Sudan, and the other two you arrested. And the three
that are still here, well, nobody’s supposed to know that.”
That night, I went in search of the traditional healers, entering each of their huts
with the best of intentions. They all denied that they were practicing, though,
and it was then that I knew: in our haste to ban traditional healing practices, we
had lost their trust forever. We were never able to close the gap we had created.
I did know one traditional healer, though. His name was Sheik Abdul, a very rich
man who was intelligent and cultured. He came to the hospital for his diabetes,
a disease he knew he needed our help to control. He had been coming for some
time, but when I saw him one morning I asked him to follow me. I began to
examine him outside the outpatient department, where other pastoralists would
see him.
He laughed and said, “You want to do this here? So everyone can see that I come
to you?”
I smiled back at him and nodded.
“Okay, then,” he answered, and allowed me to finish the exam.
When I was finished, I sat down next to him and said, “You know, I’ve been to
your home; I’ve seen you giving treatments. And you have over 100 patients a
day because they trust you. Here, we only see 30 or so people a day. And that’s
okay. But you know that there are some diseases you cannot treat, right?”
“Yes, sure. Tuberculosis, fever. … You can treat these things better than I can.”
“So, when you have patients with these illnesses, do me a favor. Refer them to
us.”
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He agreed, but only if I would refer psychiatric patients to him. In the end, many
of the patients he referred received treatment from both of us, inevitably
believing in the end that it was the traditional healing that cured them.
(p.29) This daily interaction brought us together, resulting in a mutual respect
and trust that enabled us to accomplish a great deal, especially in making it
easier for them to understand modern health treatments, such as the one for
tuberculosis (TB).
TB, a bacterial disease that is often spread through coughing or sneezing, was
very common among the pastoralists and their livestock. Generally TB infects
the lungs, although it can also affect the peritoneum, bones, kidneys, or any
other organ. Most of our patients would come to see us after 2 or 3 months or
more of a productive, grating cough, sometimes producing mucus tinged with
blood. At that time, the treatment for tuberculosis took 18 months to complete.
Patients were advised to come every 3 months for a checkup and to refill their
prescriptions. After 5 years, we carried out an evaluation of the program, and to
everyone’s surprise, 97% of the pastoralists had completed their TB treatment—
a remarkable demonstration of adherence in a nomadic community.
Sometimes, though, we seemed to have elicited too much faith. In one particular
community, we had assured the people that if they attended the prenatal health
clinic at the health stations and made use of the trained traditional birth
attendants (TBAs), no more women would die in labor. But once a woman did
die.
The family went to the clinic nearest their encampment and demanded to know
what had happened. “We did everything we were supposed to do,” they said.
“She took her tablets, she attended your clinics, we had a trained birth
attendant by her side. You told us she wouldn’t die. Tell us what happened.”
The birth attendant who assisted her, a very young girl, probably less than 20
years old, was asked about the night of the birth.
“We did everything we should have,” she said, but she looked down at the floor,
her voice hushed and unsure, fingers fidgeting.
Eventually, she took a deep breath, and looked back at me. The woman, she said,
was her aunt. Her labor was delayed, and although she had been advised to
deliver at the health center, she wanted to give birth at home. The traditional
birth attendant did her a favor. In the middle of the birth, her aunt had collapsed
and her breath had suddenly halted. The birth attendant began to cry, repeating
that she had only wanted to do what her aunt wanted her to do—she thought she
was respecting her request. Thus we had an answer for the young woman’s
tragic death.
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The village, however, was not satisfied. They decided that the birth attendant
should no longer serve there. The woman’s husband was still angry: “This is only
partially her fault,” he said of the birth attendant. “If the medics stated that my
wife should deliver in the clinic, they should have been paying closer attention.
They should have been following her pregnancy to make sure she went in when
it was time. We’ve done our part. It’s time for you to do yours.”
This attack, while humbling for our medical staff, was the point at which I
realized the people knew their rights—and they considered it a right to
understand that which they did not. It was a nascence of awareness, a healthy
sign of social change, not to mention the sobering effect on the souls of us
clinicians.
The woman on the delivery table looked at me very seriously and without
blinking said, “If you don’t do it here, they’ll do it back in the village.”
I sighed and looked at the traditional birth attendant who had accompanied the
young woman. Mere minutes after the birth of a healthy baby boy, the woman
asked us to stitch closed her old infibulation wound. Infibulation was the
practice of suturing the labia majora together—a traditional surgical procedure
that allowed for an opening only small enough for urine and menstrual blood to
pass through. Once married, the opening was enlarged just enough for the penis
to fit through. However, this scar tissue would once again need to be cut in order
to deliver babies; otherwise the possibility was very high that the inflexible scar
tissue would simply rip apart and cause a large vulval tear, requiring surgical
repair.
We campaigned vigorously against infibulating females, since it was one of our
most critical reproductive health goals.
“It’s clean here,” the TBA said. “If I take her back to the village, they’ll use
thorns to suture it; your hands are blessed.”
I looked between the two women, weighing the issue—under anesthesia, the
procedure wouldn’t be so painful, and in the clinic the wound had less chance of
becoming infected. At the same time, though, I did not want to send the message
to the other members of the community that circumcision and infibulation were
right, or circumcision alone, the procedure in which they remove the clitoris of
young girls. Either way, it would be wrong, and unfortunately this was the
dilemma we faced.
Outside the delivery room, the argument persisted. Every 2 months, medical
cadres met to discuss the progress of the campaign against infibulation and
female genital surgery in various regions. The effectiveness of the campaign
against circumcision and infibulation was assessed in the meetings of village
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councils. Although our results were unimpressive, there were some signs of
change.
In Hager, it seemed that a health worker was not doing enough to dissuade the
nomads from the practice of infibulation. Some of the Front members at the
meeting pointed out that incidents of female circumcision were declining in most
of the villages, but in the area which this man oversaw, it remained steady.
Upon the man’s arrival back in his village, he announced to the pastoralists that
there would be no more female circumcision. “It is against the law,” he told them
forcefully, “and anyone who is caught performing or condoning this ritual will be
arrested.” Clearly, this man wanted to be able to bring results at the next
meeting, to show that he had made positive changes in the community.
However, his forcefulness was met with defiance, most surprisingly from the
women. “It’s none of your business,” they stated, shaking their heads at the
man. He persisted, though, and kept pressing the issue on the people, until one
afternoon the women came out of their huts, raising not only their voices in
defiance but also their skirts—hems lifted to their knees in an act of rebellion as
they cried, “You can’t tell us what to do with our bodies!”
(p.31) Higher authorities eventually had to intervene, and it was decided that
the women could do whatever they wanted with their bodies; it was our place to
give advice, but we could not impose our will. This traditional practice was
something I strongly disagreed with, but the women’s resistance was a healthy
sign of the power of the community.
Although 33% of the EPLF cadres and 52% of the medical cadres were women,
we made limited progress on the topic of circumcision and infibulation. The
pastoralist women claimed that the surgeries, which were mandatory for all
girls, had no negative effects on their health, even though we knew that the
procedure often caused complications such as excessive bleeding, urinary
retention, infection, cyst formation, keloids, fistula, and deformation of the
pelvis.
The women, for the most part, argued adamantly that it was simply not possible
to choose to not be circumcised—it was tradition, cleanliness, religion, morality,
health, and beauty for them. One woman once told me that it is done because
they love their daughters and want to protect them from ostracism in the
community. Besides she said, “If you had to keep your mouth open, bugs and
spiders would get in there. The same is true of our genitalia.” Although some
local religious leaders have indicated that there is no verse in the Koran
supporting the practice and a few even regard infibulation as anti-Islamic, the
practice continues.
Nomads and Nationalists in the Eritrean Sahel
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In private, we occasionally found women who complained about the practice.
The relatively rare women who had been circumcised in later life were far less in
favor of the practice. A few even admitted that they did not want their daughters
circumcised. The anti-FGS (female genital surgery) trend was fairly restricted to
younger women, including TBAs, who generally avoided performing FGS, but
older TBA and non-TBA women in the clan remained true to the custom,
performing the surgery without hesitation. Even after so many years of living
and working with the pastoralists, our stand against subjecting girls to genital
surgery never made much of an impact.
The high demand for health professionals grew with the nomadic communities’
awareness of their own rights. Over the years, we trained over 200 TBAs and
350 village health workers to serve the different nomadic communities with
whom they lived. Because of our proximity, we were able to offer training as well
as monitor their activities over extended periods of time. When it came to
childbirth, the TBAs performed wonders and saved countless lives. They referred
those in need of surgical intervention to the nearest hospital, although it was
often inaccessible.
Training the women was very difficult owing to their high illiteracy rate. Hot
afternoons dragged on, and the sweat dripped from the overworked body of the
TBA trainer as she tried to explain to overworked brains concepts that would
make so much more sense if only they could be written down. We used a system
(p.32) of symbols based on those used by the World Health Organization
(WHO) and labored day after day with these symbols until a girl asked, “Instead
of teaching us all these symbols, signs, and designs, why not just teach us how to
read? After all, the alphabet is made up of symbols, isn’t it?” So we did.
The TBAs played important roles in these communities, especially because they
were often the only accessible and affordable source of health care for women in
that society. They would often impart information on the prevailing side effects
of female circumcision. Given the high birthrate among pastoralists, TBAs were
encouraged to provide family planning education, although it was not always
met with support.
Overall, the medical services offered by the Front were an enormous success.
The mobile health teams and TBAs were received very positively. In time, the
Front grew larger and stronger. As the forces of the EPLF gained the upper hand
and commanded control of a wider territory, we were able to build stationary
hospitals and clinics all over the Sahel. The nomadic population of Eritrea finally
had health services and the fighters had a home and a family in the Sahel.
In 1991, when we won the war, everything changed.
Nomads and Nationalists in the Eritrean Sahel
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Many Front members left the rural landscape that had been our home for so
many years, a flood of people going back to the cities. Several committees
representing the population in the Sahel made their way to Asmara to appeal to
the leaders of the Front, who were now the government of Eritrea. Their
questions were simple: “Why are the schools closed? Why aren’t the health
clinics helping us anymore? Where are the doctors?” They missed the spirited
camaraderie they had had with the health workers and teachers. But the
dynamics of relationship had changed. Now they were subjects living at the
periphery, again forgotten by the center. One pastoralist, reminiscing about the
level of commitment to the community evinced by the health cadres during the
war and the current lack thereof, recounted a recent incident:
One night in our village, a pregnant woman was bitten by a snake and we
wanted to take her to Wade health station. However, because the health
unit was far away and the patient was restless, we resolved not to take her.
We sent a messenger to the health worker but he was unwilling to come.
After some time, the woman passed away in front of our eyes. If the health
worker had been one of us, he would have been available at any time and
in any place.
There were few listening to the legitimate requests of the pastoralists. The
government decided to settle all the nomadic communities permanently. We
tried to persuade state officials that movement was the crux of the pastoralist
lifestyle and that the settlement of nomadic communities in other countries,
such as Libya (p.33) and Somalia, had failed. But the political game had
changed. The desires of the pastoralists were overruled by state proclamation.
Having a say in their lives was considered an offense the new nation could not
tolerate.
Many of Eritrea’s pastoralists admit that nomadic life has become increasingly
difficult and risk-prone. The impact of 30 years of war, responsible for many
deaths and injuries and a landscape littered by land mines, has taken its toll. The
nomads’ ability to protect themselves against the risks of drought and advancing
desertification has greatly diminished. Political instability in the Horn of Africa
has forced many to flee their homes and traditional routes and to settle in
neighboring countries. The Afar, relatively poor compared with the Tigre and the
worst affected by drought, are resorting to salt mining, wage labor, and trade,
which offer a meager living.
The precariousness of their position within modern states and their vulnerability
in times of political instability feature predominantly in the life of all the
pastoralist groups. Over the years, the pastoralists have taken charge of their
own survival and moved around the region irrespective of imposed constraints
and boundaries—not, however, without cost. As conflicts arouse border
sensitivity, local and regional authorities on all sides create obstacles and are
Nomads and Nationalists in the Eritrean Sahel
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Access brought to you by:
hostile toward or suspicious of peoples insensitive to what are, in geographical
terms, artificial boundaries.
To the Eritrean pastoralist community, freedom means the right to live the life of
their choice without interference. To the totalitarian regime that has taken
control of the country, it means forcibly settling those who wish to remain
unsettled. As an elderly pastoralist said in disdain, “I was part of the struggle for
freedom, so that my goats could move back and forth freely, without any fear, in
peace. Now my mobility is limited and my security is threatened. Where is my
liberty?”
- Nomads and Nationalists in the Eritrean Sahel
Daniel Perlman and Ananya Roy
Nomads and Nationalists in the Eritrean Sahel
Assefaw Tekeste Ghebrekidan
Abstract and Keywords
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
AN UNLIKELY ALLIANCE
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
MEDICINE ON THE MOVE
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
LEARNING TO LISTEN
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
(p.30) IRRECONCILABLE DIFFERENCES
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
BIRTH ATTENDANTS AND BAREFOOT DOCTORS
NOMADS AND NATION BUILDING
Nomads and Nationalists in the Eritrean Sahel
Nomads and Nationalists in the Eritrean Sahel
6.2: Medical Humanitarianism and the “Four Cultures” of Global Health
1
Exam study topics
Describe the 4 “cultural roots” of the current global health system, including the main health and economic orientations of each root.
Given a case study about a global health issue, identify the particular culture/s at play in the situation
Understand the origins and differences between the ICRC and MSF
Describe the moral and ethical dilemmas involved in the medical humanitarian response to the Rwandan refugee crisis
What is “temoignage” (bearing witness) and why is it an important element of MSF’s mandate?
List the kinds of things that go into a humanitarian kit for a refugee camp
2
19th-century roots:
“The four cultures” of global health
Adapted from Brown, P. J. (2019), in Foundations of Global Health, eds. Brown and Closser.
3
International Health Regulation
Disaster and War Victim Relief
Military Medical Research & Hygiene
Medical Missionaries
Recap of Lecture 5.3:
Eras of International Health Activity
“Bureaucratization and Professionalization,” 1946–1970
Permanent health organizations founded
Large scale training of personnel
Global disease campaigns in the context of the Cold War
“Contested Success,” 1970–1985
Vertical campaigns (e.g., smallpox) versus horizontal health and social infrastructure efforts (e.g., primary health care)
“Evidence and Evaluation,” 1985–present
Demand for measurable successes and “evidence-based” interventions
Reinforcement of technical and cost-effective global health initiatives
Renewal of countering paradigm stressing social justice, infrastructure, human rights
Birn, et al2017, p. 52
Here’s what we looked at in lecture 5.3 at the end. The main message was that there are multiple approaches and ideologies influencing global health right now. Sometimes these priorities are compatible but others times, they are not… [go back to previous slide]
4
Adapted from Brown, P. J. (2019), in Foundations of Global Health, eds. Brown and Closser.
“Miasmists” vs. germ theorists origins of modern biomedicine
Collection of vital statistics revolutionary
Cholera interrupting trade and commerce
International Sanitary Conferences (11 held between 1851-1903)
Origins of the WHO
1. Regulation: goes back to the debate between “miasmists” and “germ theoriests” – the latter is the foundation of modern biomedicine. Based on microbiological discoveries and hospital-based experiments, and the new practice of collecting vital statistics. Remember John Snow? He was the vanguard of the germ theorists. Cholera was a scourge at the time, especially because it was interrupting international trade. Ships often had to sit in bays of foreign ports undergoing lengthy and costly quarantine. Many foreign ports has strict laws on quarantine. Germ theorists thought those laws were too onerous.
There were annual international “Sanitary Conferences” held to deal with these things, to generate international cooperation and to maintain epidemiological boundaries (quarantine, vaccination, and inspection of foreign travelers and immigrants). These international conferences were the basis for the founding of the WHO in 1948!
5
International Health Regulation
Adapted from Brown, P. J. (2019), in Foundations of Global Health, eds. Brown and Closser.
Humanitarian aid began in the mid-19th c. in response to war, famine
New weapons technology changed warfare (swords machine guns)
Red Cross/Red Crescent societies and Geneva conventions established
Professionalization of nursing, based on biomedicine and duty to alleviate suffering
Often work in tandem with military establishment
Key to humanitarian aid: principle of neutrality
6
Disaster and War Victim Relief
Adapted from Brown, P. J. (2019), in Foundations of Global Health, eds. Brown and Closser.
New killing technologies better treatments for wounded soldiers
Colonial armies in tropical areas had high morbidity and mortality rates
Advances in the smallpox vaccine technology allow it to be used in tropical areas
In the colonial home front: cost-effectiveness was the rationale for sanitary laws
CDC originated from the “Malaria Control in War Areas” agency
Chloroquine and DDT developed during WWII by military medical-scientific research program
7
Military Medical Research & Hygiene
Adapted from Brown, P. J. (2019), in Foundations of Global Health, eds. Brown and Closser.
Heyday of Protestant missionaries in South Asia and sub-Saharan Africa: 19th and 20th c.
Long-term view, permanent outposts to “serve the natives” mind, body and soul
Demonstration of Christian kindness and mercy and…
…the superiority of Western Christian society, culture and science
~60% of health services in Kenya today through Faith-Based Organizations
8
Medical missionaries
Health Orientations
Public health
Research
Prevention
Disease Specific
Clinical care
Action
Cure
Comprehensive Health
Adapted from Brown, P. J. (2019), in Foundations of Global Health, eds. Brown and Closser.
International Health Regulation
Disaster and War Victim Relief
Military Medical Research & Hygiene
Medical Missionaries
Economic Orientations
Public funding
Economic rationality
Measurement/statistics
Research grant funding
Private funding
Human rights over cost/benefit
“Not everything that counts can be counted, not everything that can be counted counts”
Charity fundraising
Adapted from Brown, P. J. (2019), in Foundations of Global Health, eds. Brown and Closser.
10
International Health Regulation
Disaster and War Victim Relief
Military Medical Research & Hygiene
Medical Missionaries
Founded 1849, in response to Crimean War and Battle of Solferino (Italy)
Founder (Henry Dunant) received the first Nobel Peace Prize, 1901
Dunant heavily influenced by witnessing events during WWI
Crimea, Solferino battles – horrible wounds to soldiers
ICRC became institutionalized as the civilian auxiliary to national armies
Strict doctrine of neutrality and discretion
Necessary to operate on the battlefield
Problematic during Holocaust – moral authority of ICRC challenged
Not much to say about colonialism or conflict outside Europe at founding
Medical Humanitarianism:
11
Founded 1971 in response to Biafran crisis (Nigeria) and flood/independence struggle in Bangladesh
Heavily influenced by the age of genocide and decolonization/independence movements of the 1960s and 70s
Combined a “realist rejection of utopian politics and a romantic rejection of authority”
Today: an international movement of 19 loosely inter-connected groups
A “more engaged and daring version of the Red Cross”
Nobel Peace Prize, 1999
Balance operational neutrality with a willingness to speak out
Medical Humanitarianism:
12
What do they have in common?
Both emerged in response to conditions created by conflict
Both later expanded their scope of work to address the “expanding horizon of disaster”
How do we define a “disaster”?
What is the difference between development and humanitarianism?
Both respond to suffering through the health framework (rather than poverty or hunger)
13
14
Moral and ethical questions of medical humanitarian aid to Rwandan refugees
Is it acceptable for MSF to assist people who had committed genocide?
Should MSF accept that its aid is instrumentalised by leaders who use violence against the refugees and proclaim their intention to continue the war in order to complete the genocide they had started?
For all that, could MSF renounce assisting a population in distress and on what basis should its arguments be founded?
From: Binet, Laurence. 2013. “Rwandan Refugee Camps in Zaire and Tanzania, 1995-1995.” Médecins Sans Frontière.
15
MSF and témoignage (bearing witness)
Témoignage = Not just to witness, but also to speak out
“MSF never asks the permission of a given population to speak out on its behalf.”
Best understood as a secondary effect of medical humanitarian action – but one that is essential and unavoidable
16
“Temoignage Toolbox”
quiet diplomacy
transfer of information
denunciation
accusation
withdrawal of a mission
17
Transformation of MSF, 1970-2001
In 1970, an original “community of friends” offered “love to Third World populations” along with residual Maoist principles and hallucinogenic substances. By 1980, “mercenaries” of a private organization offered food aid to “Ethiopians, Afghans, and other victims of the Moscow Olympics boycott.” In 1990, a “profitable multinational company quoted on the unlisted securities market” offered assistance to populations victimized by disasters and was so overwhelmed as to “no longer know where help is needed most.” By 2000, the e-charter of MSF.com championed both the 35-hour work week and the right to “full and free on-line access for anti-retroviral drugs.”
– From Redfield (2005: 332), “Doctors, Borders and Life in Crisis”
18
In the news:
March 2017 – WHO delivers cholera kits to Yemen
July 2020 – Oxfam delivers cholera kits to Yemen
19
The “humanitarian kit”
Basic building block: 1 unit = 625 treatments; Weighs 6,000 kg
Drugs: 6,500 oral rehydration salt packets, 10,000 tablets of a broad-spectrum antibiotic
Materials to take patient samples (dissecting forceps, permanent black markers)
Materials for performing basic medical procedures (surgical gloves, tunics, trousers, boots of several sizes, ten 500g rolls of cotton wool, 25 arm splints, catheters and bandages)
100 buckets, 100 disposable razors, notebooks, pens, wire ties, 2 staplers
Land Cruisers (cold or warm-weather) + stickers & flags
Guidelines and “how-to” information booklets, in several languages:
Set up a simple water sanitation system
Conduct minor surgery in a war zone
Build a pit latrine
Blood transfusion in a nutshell
Look after a refrigerator
“Human rights in a nutshell”
20