Prompt: Choose a health crisis faced by developing countries and offer one solution.
Author: Alankrit Shatadal, Age 22, Wisconsin
A developing country is defined as one with low industrialization and hence, low per capita income; on the flip side of this definition, we can understand that developing countries face more conditions of poverty. Poverty intersects a plethora of medical needs. Yet the need for better reproductive health care remains one of the most pressing and unwieldy. In addition to being a problem across multiple continents, there are a range of issues within reproductive health which should be termed as crises. In this overview, we will discuss issues which plague women both of and not of reproductive age.
Impoverished areas in developing countries often rely on agriculture as a source of income. This makes jobs in the field a prized position, and can be the singular livelihood for people in a household. For the landowners, having reliable workers becomes paramount. In a village of Beed, Maharashtra, this pressure to have consistency has made many male landowners skeptical of hiring female workers. The fear of women potentially missing work due to their periods or pregnancy can lead to a landowner’s refusal to hire women. But as the main source of income in the area, the women must find a way around the issue, and with no birth control options available, the most common option is a complete removal of their uterus. In 2018, a state-commissioned study found that 36% of female sugarcane laborers in Maharashtra had undergone a hysterectomy (Maharashtra State Commission for Women, 2018). When interviewed, the participants cited the lack of sanitation facilities as a primary reason behind their decision. Without the proper facilities, disinfecting their menstrual cloths would increase their risk for other diseases. Furthermore, they found it close to impossible to spend money every month for disposable menstrual pads. With both potential options for safe menstruation eliminated, they feel hysterectomy is a valid option. They are not made aware that the procedure is typically only performed if absolutely necessary, and furthermore, are not told of the potential health complications which may accompany it. Women in Beed interviewed about their hysterectomies explained that new issues with chronic pain in their abdomens made work just as much a struggle as before surgery.
This state of technically having a choice, yet having that choice dictated by your situation, falls under an umbrella term called ‘structural violence.’ The full definition explains that a person unable to achieve their capabilities due to the constraints enacted upon them through everyday practices of bureaucracy is a subject of violence by the nation-state (Farmer, 2003). But bureaucracy does not always mean the government; the first political order in any society is the one developed between men and women, according to a recent theoretical framework (Hudson, 2020). Then, in the context of reproductive health, it is important to note that verbal consent is not consent if one’s autonomy is bound by conditions of poverty. The following quote explains, and comes directly from a 14-year-old girl in rural Uganda
(Ninsiimi et al., 2011):
“Sometimes girls lack basic items in their homes, so it makes the girl accept money from the boy/men. For example, books, pads, or those that do not pack food for lunch, they accept money from boys/men and the boys want sex in return. You cannot refuse to have sex with a man when you have received material things from him. You fear that he may speak out and your parents would get to know. He may even kill you.”
Sexual coercion, in turn, increases a girl’s risk for HIV, early pregnancy, premature marriage, and sexual violence later in life (Madise, Zulu, and Ciera, 2007; Meyer et al., 2014). Due to the diminished capacity to seek justice in such cases, the practice often goes unpunished. In a study by Amnesty International, it was found that in several developing countries, prosecution for sexual violence is rare, even in nations where appropriate laws exist (Amnesty International, 2010).
Maternal age, safety/support, and preexisting conditions are all key factors in determining the safety of a pregnancy. It is sobering, yet unsurprising, that 99% of pregnancy-related deaths occur in developing nations. Of these deaths, the World Health Organization estimates the incidence of preeclampsia to be seven times higher in developing countries (2.8% of live births) than in developed countries (0.4%) (WHO, 2005). Additionally, while C-section deliveries in developing countries are less common, maternal death due to infection from surgery remains the primary cause of pregnancy-related death (Eskenazi, 1991). In both cases, the blame lies squarely on the impoverished state of these countries. Access to medical centers, and moreover, the capacity for mothers to use them, could dramatically improve the rates of pregnancy-related deaths in developing areas of the world; but this seems like a lofty goal, nothing short of saying “Solve poverty!” We know that specific problems have their own clinical particulars which are tempting to view as solutions. For example, if pre-eclampsia is properly diagnosed, magnesium sulfate can be administered to lower the risk of eclampsia developing. However, the context of a developing nation means understanding that resources, even if they could be made available, may not be a valid choice. Consider how difficult it would be for a woman making very little money to obtain such supplements: the cost of transportation to a doctor, payment for the medicine, and the docked pay from missing work would force her to evaluate her need secondary to her obligations.
Furthermore, some ‘quick fix’ solutions coming from industrialized parts of the world overlook the differences between countries when designing their ideas. For example, menstrual cups like the Divacup have become increasingly popular as a sustainable option beyond pads and tampons. For women without access to running water, however, it would not be realistic. Beyond practical concerns, there are also cultural factors to consider. What norms and taboos exist? How will they impact the way any particular solution is received? One thing we do know is that societies which are highly subordinative of women end up with worse health outcomes (Hudson, 2020). Perhaps the solution to these reproductive health issues begins there. If menstruation were seen as less taboo, if children were educated about their bodies and keeping them safe from an early age, perhaps there would be more social support for ensuing reproductive care and facilities. However, the cyclical nature of poverty demands that this be paralleled by an investment to economically empower communities (Ninsiima et al., 2011). This approach would not only give young people the educational resources they require, but also the potential to overcome the structural violence to which they may be subject. One program which already exists as a model is called the Ganokendra. A school-hostel-workshop hybrid, this literacy and entrepreneurship program enacts the dual-pronged approach to alleviating the pressures of poverty (Alam, 2006). The flagship program in Bangladesh provides a framework from which both government and non-government organizations can begin to provide communities with ways for women to overcome the structural violence which pervades their reproductive health.
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