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Partner to the Poor
A Paul Farmer Reader
By Paul Farmer, Haun Saussy
UNIVERSITY OF CALIFORNIA PRESSCopyright © 2010 The Regents of the University of California
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Bad Blood, Spoiled Milk
Bodily Fluids as Moral Barometers in Rural Haiti (1988)
Current discourse in medical anthropology is marked by an increasing appreciation of the body as physical, social, and political artifact. Concepts such as somatization, which implies the making corporeal of nonbodily experience, are by now common coin, and there is considerable enthusiasm for the increasingly fine-grained analyses that appear in several new specialty journals. But others discern an overweening analytic urge that yields fragmentary knowledge resistant to synthesis. Illness experiences are picked apart under the dissecting gaze not only of biomedicine but of anthropology as well, a discipline long parsed into such officially sanctioned subfields as "psychological" and "biological" anthropologies. Appreciating the full weight of centuries of what has come to be called Cartesian dualism, Nancy Scheper-Hughes and Margaret Lock write forcefully of our "failure to conceptualize a 'mindful' causation of somatic states." How might we gather up our fragmentary knowledge? Several of those seeking to reconcile the three bodies have turned, in the past few years, to emotion.
An illness widespread in rural Haiti speaks to this and several other dilemmas central to contemporary medical anthropology. To use the tropes now common in our field, move san is somatically experienced and caused by emotional distress. Move san—for which a literal English equivalent is "bad blood"—begins, report my informants, as a disorder of the blood. But it may rapidly spread throughout the body, so that the head, limbs, eyes, skin, and uterus may all be affected. It most frequently strikes adult women; some assert that only women are afflicted. Although considered pathological, move san is not an uncommon response to emotional upsets. The disorder is seen as requiring treatment, and this is commonly effected by locally prepared herbal medicines.
The course and outcome of this illness, if it is untreated or unsuccessfully treated, are reported to be dismal: several of my informants speak of friends and relatives who have succumbed to move san. Those most vulnerable are pregnant women or nursing mothers; in such cases, chances are good that the malady will affect the quality of breast milk. Move san is the chief—and some say the only—cause of the lèt gate, or spoiled milk, syndrome: "bad blood" is held to make it impossible for a lactating mother to afford her infant "good milk." It is thus a frequently cited motive for early weaning, which, in rural Haiti, often has disastrous effects on the infant's health. The chief effects of move san, however, are judged to be manifest in the mother.
Although I first encountered the move san/lèt gate complex in 1984 while doing research on childrearing in peasant families, its significance as a perceived threat to health was not clear until research conducted during a 1985 census revealed a 77 percent lifetime prevalence rate of move san (with or without lèt gate) in Do Kay, a small village in central Haiti and the site of most of the research reported here.
Move san has not been systematically studied, nor have thorough case studies been presented in the anthropological literature on Haiti. The disorder is of interest to medical (and psychological) anthropology for several reasons, many of them obvious. Those who suffer from move san/lèt gate cite it as a danger to the health of women already beset with intractable and unrelenting difficulties. Child health specialists from several traditions would maintain that move san, like all other motives for early weaning, constitutes a threat to the health of infants. The disorder joins a long and varied list of conditions in which women question their ability to breastfeed. But move san and lèt gate are more than ethnographic exotica or public health nuisances. The significance of the syndrome lies in the fact that social problems and their psychological sequelae usually are designated as the causes of the somatically experienced disorder. For this reason, the Haitian syndrome poses a challenge to overly simplistic interpretations of "folk illnesses."
Following the suggestion of others who advise that indigenous illness categories first be studied "emically," from within their cultural context, I will consider the move san/lèt gate complex to be an illness caused by malignant emotions— anger born of interpersonal strife, shock, grief, chronic worry, and other affects perceived as potentially harmful. It is thus not possible to relegate move san to such categories as "psychological" or "somatic." This stance, which avoids the strictures of a dogmatically "medicalized" anthropology, is reconsidered in the conclusions offered at the end of the paper.
THE RESEARCH SETTING
The Republic of Haiti occupies the western third of the island of Hispaniola. After the Dominican Republic, which borders it to the east, its nearest neighbors are Jamaica to the southwest and Cuba to the north and west. Haiti, born of a slave revolt that ended in 1804, is the hemisphere's second-oldest independent nation. Its inhabitants are largely the descendants of the African slaves that made western Hispaniola France's most lucrative colony. During the nineteenth century, the nascent peasantry, left to its own devices, developed richly syncretic linguistic, religious, and ethnomedical institutions. In 1982, Haiti's population was conservatively estimated to be 5.1 million, or 345 persons per exploitable square kilometer. Despite the alarming density, 57 percent of the labor force is involved in small-scale agriculture. Some 74 percent of the country's inhabitants are rural; many live in villages similar to the one described in this study. Estimates of per capita income usually put Haiti last among the countries of the Western Hemisphere, and this poverty is reflected in the health status of the nation: a life expectancy of forty-eight years and an infant mortality rate of 124 per 1,000.
Do Kay stretches along an unpaved road that cuts through Haiti's Central Plateau. A small village in great flux, it has been the locus of almost all "development" efforts in the area. Consisting of 123 households in 1985, Do Kay had a total population of 677. Exactly one year later, a census by the same team revealed 11 new households, bringing the number of inhabitants to 772. Some of the increase in population is due, it seems, to the construction, since 1980, of a church, a school, a clinic, and a community bakery and the initiation of a project to make pigs available to the rural poor.
The area has a curious and ironic history. Before 1956, there was no Do Kay; the village of Kay was situated in the fertile valley of the nation's largest river. A great many of the persons now living in Do Kay then lived in an area adjacent to Kay called Petit Fond. When the valley was flooded to build a hydroelectric dam, the majority of villagers were forced to move up into the hills on either side of the valley. Kay became divided into "Do" (those that resettled on the stony backs of the hills) and "Ba" (those that remained down near the new waterline). Most villagers received no compensation for their land, nor were they provided with water or electricity. For many, the years following the inundation of their lands were bitter. As deforestation and erosion whittled away at the hills, it became more and more difficult to wrest sustenance from them. And yet Do Kay is typical of many small Haitian villages in which the great majority make a living by tending small gardens and selling much of their produce. Marketing is largely the province of young to middle-aged women, many of whom are also responsible for growing their merchandise.
The majority of the houses comprise two rooms: a sal with chairs, and a cham with straw mats or, occasionally, a bed. Although average household size in Do Kay is between five and six persons, it is not unusual to find more than ten sharing these two rooms. Typically, dwellings are constructed of stones covered with a cement-like mud, although wattle daubed with mud is not uncommon. There is still no electricity in the area, and none of the houses has running water.
Until recently, for their water supply, residents of Do Kay were forced to scramble down a steep hillside to a large spring 800 vertical feet below the level of the road. Although villagers seemed to know the dangers of drinking impure water, the temptation was to store water in large pots or calabash gourds. Infant deaths due to diarrheal disease were commonplace. A hydraulic pump now moves springwater up to three public fountains placed along the road and also to the school and other buildings run by the church.
There is no village center or "square," although the school-church-clinic complex may be beginning to take on this function. The clinic was inaugurated in 1985 and began offering consultations with a Haitian doctor two days per week. Until March of that year, when the bakery opened, there were no retail shops or businesses, though a few commodities (canned milk, local colas, small quantities of grain) could be obtained from the handful of families known to "resell."
Excluding the doctor, all the informants cited in this research were born and grew up in rural and agrarian Haiti. They are all, by their own criteria, extremely poor. This brief introduction is intended to situate the move san/lèt gate syndrome, primarily an affliction of women, against the background of the daily struggles of the remarkable women of Do Kay.
INTERVIEWING METHODS, CASE-FINDING, AND SURVEY RESULTS
The research on which this paper is based was conducted as part of a larger study of childrearing and nutrition in rural Haiti. When the study was initiated in 1985, I restricted in-depth interviewing to Do Kay. I had already lived in the village for over a year and knew many of its inhabitants. Other researchers working in Haiti have found familiarity with informants to be crucial to obtaining reliable data. Initial interviews indicated the modal weaning age to be eighteen months, and so I decided to interview the mothers or primary caretakers of all children eighteen months and younger. By September 1985, there were forty-seven such infants in Do Kay. Interviews with mothers were preceded by three lengthy "pretest" interviews with tried-and-true informants (such as Mme. Kado, introduced later) who had helped me in the past. Most mothers (or primary caretakers) were interviewed, in their homes, more than once in 1985.
Although the interviews were open-ended and followed no rigid format, several issues were always addressed. Among these were move san and its relation to breastfeeding. As the significance of the disorder became manifest, I devoted more interview time to its characterization. Among my informants were three women who claimed to be experiencing move san at the time of the initial interview. These were considered "active cases." Two of the three were attempting to breastfeed infants; these women were interviewed several times over twenty months.
For purposes of this preliminary discussion, it is necessary to indicate that a startlingly high percentage (thirty-six mothers, or 77 percent) of those interviewed had experienced at least one identifiable episode of move san. Thirty-two of the thirty-six, or 89 percent, sought treatment in the professional or popular health sectors: three went to a biomedical practitioner; thirteen consulted only a dokte fey or other herbalist; sixteen sought treatment from more than one source (although recourse to an herbalist was almost always included in the quest for therapy). In the majority of cases, professional care was preceded and then supplemented by home health care.
The central problematic of this paper is not, however, move san as an isolated disorder, but rather the move san/lèt gate complex. Of the thirty-six women who had experienced at least one episode of move san, seventeen, or 47 percent, stated that they had been breastfeeding an infant during an episode. (Of the three women who remarked that they felt that their lives had been in danger, two were among this group.) Of the seventeen, fifteen sought treatment outside the home for (or, in two cases, to prevent) lèt gate. One woman who had not sought treatment outside the home was one of the three respondents who had move san/ lèt gate at the time of the 1985 survey; she was gathering the funds necessary to defray her treatment expenses. The other respondent was treated effectively at home, by her mother's sister. Ten of the treatment regimens for move san/lèt gate met with success; these women declared that they had been "cured" by the remedies. The remaining six all weaned their children, citing lèt gate as the motive; only two of these six children were normal weight for age by the Gomez scale, a widely used measure of childhood malnutrition.
In all cases, the etiology of the lèt gate was held to be move san; in other words, their association, which was guaranteed by the methodology, was never labeled as chance by an informant. The etiology of move san itself was invariably seen to be a malignant emotion, most commonly caused by interpersonal strife. Of the thirty-six informants with a history of move san, twenty-four cited such strife as the cause of the disorder. Seventeen of these conflicts involved a spouse, partner, or family member (in descending order of importance: husband or mate, brothers and sisters, parents and children); five involved vwasinay, or neighbors; and two involved near or total strangers. Of the remaining twelve informants with a history of move san, there were five related cases of shock (sezisman), and the other seven adduced a mixed bag of stressors, most related to chronic financial problems (for example, shame at being unable to feed children), all of which had led to "too much bad emotion." Distinctions between personal and social stressors seem significant, but I have not yet discerned any clear pattern of course or outcome that might be related to such differentiation. No clear symptomatology for move san emerged from the preliminary readings of the interviews.
Given that move san is a common problem among the mothers of children under eighteen months of age in Do Kay, what is the natural history of the illness? What are the psychological concomitants of "bad blood"? Who is at risk? How long does it last? What are its symptoms? How is it treated? Why do some women find successful therapy, while others do not? These were among the questions that led me to elicit more psychologically detailed case histories from the three women afflicted with move san at the time this study was initiated. Because I knew little about the perceived course of the illness, it seemed imperative to follow the cases over long periods of time. Two of these histories are presented here, the first in detail because it is a good example of the common scenario in which the label move san is invoked. It is also prototypical in that it illustrates what appears to be the classical course of the disorder. The second case is one in which the move san/lèt gate syndrome was caused by "shock" (sezisman) or fright; though far less frequently invoked as precipitating the disorder, it was the second most common etiology given by my informants.
Ti Malou Joseph, thirty years old, has had recurrent episodes of move san; each has been precipitated, she readily avers, by discord with the father of her children. She and her living children brought to a total of thirteen the number of persons sharing her parents' two-room house. Although I have only indirect indicators of socioeconomic status, the Joseph family is considered one of the poorest in the village. The house is roofed with tin, but the floor is tamped dirt. Both of her parents are frequently ill, and Ti Malou and a younger sister are usually the major breadwinners for the family. To generate income, they engage in small-scale gardening and the buying and reselling of produce and staples such as raw sugar. Often, Ti Malou lacks the (very small amount of) capital necessary to participate in the rural marketing network. Currently estranged from the father of her children, she is emblematic of the uncounted Haitian women who labor against increasingly dismal odds.
Excerpted from Partner to the Poor by Paul Farmer, Haun Saussy. Copyright © 2010 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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Table of ContentsContents
Foreword: He Stole My Necktie for the Poor
Introduction: The Right to Claim Rights 1
Part 1. Ethnography, History, Political Economy
Introduction to Part 1
1. Bad Blood, Spoiled Milk: Bodily Fluids as Moral Barometers in Rural Haiti (1988)
2. Sending Sickness: Sorcery, Politics, and Changing Concepts of AIDS in Rural Haiti (1990)
3. The Exotic and the Mundane: Human Immunodeficiency Virus in Haiti (1990)
4. Ethnography, Social Analysis, and the Prevention of Sexually Transmitted HIV Infection among Poor Women in Haiti (1997)
5. From Haiti to Rwanda: AIDS and Accusations (2006)
Part 2. Anthropology amid Epidemics
Introduction to Part 2
6. Rethinking "Emerging Infectious Diseases" (1996, 1999)
7. Social Scientists and the New Tuberculosis (1997)
8. Optimism and Pessimism in Tuberculosis Control: Lessons from Rural Haiti (1999)
9. Cruel and Unusual: Drug-Resistant Tuberculosis as Punishment (1999)
10. The Consumption of the Poor: Tuberculosis in the Twenty-First Century (2)
11. Social Medicine and the Challenge of Biosocial Research (2)
12. The Major Infectious Diseases in the World—To Treat or Not to Treat? (2001)
13. Integrated HIV Prevention and Care Strengthens Primary Health Care (2004)
David A. Walton, Paul Farmer, Wesler Lambert, Fernet Léandre, Serena P. Koenig, and Joia Mukherjee
14. AIDS in 2006—Moving toward One World, One Hope? (2006)
Jim Yong Kim and Paul Farmer
Part 3. Structural Violence
Introduction to Part 3
15. Women, Poverty, and AIDS (1996)
16. On Suffering and Structural Violence: Social and Economic Rights in the Global Era (1996, 2003)
17. An Anthropology of Structural Violence (2001, 2004)
18. Structural Violence and Clinical Medicine (2006)
Paul Farmer, Bruce Nizeye, Sara Stulac, and Salmaan Keshavjee
19. Mother Courage and the Costs of War (2008)
20. "Landmine Boy" and Stupid Deaths (2008)
Part 4. Human Rights and a Critique of Medical Ethics
Introduction to Part 4
21. Rethinking Health and Human Rights: Time for a Paradigm Shift (1999, 2003)
22. Rethinking Medical Ethics: A View from Below (2004)
Paul Farmer and Nicole Gastineau Campos
23. Never Again? Reflections on Human Values and Human Rights (2005)
24. Rich World, Poor World: Medical Ethics and Global Inequality (2006)
25. Making Human Rights Substantial (2008)
Conclusion: An Interview (2009)
Paul Farmer and Haun Saussy
Editorial Note and Credits
What People are Saying About This
"A crucially important book for physicians."Jama
"[Farmer] brings an energized yet pragmatic passion to an enduring problem in global health."Practical Matters
"Highly engaging and intellectually satisfying."Perspectives
In Science And Christian Faith