A review of The Gift of Cure: Childbirth Injuries, Clinical Structures, and Religious Subjects in Ethiopia, by Anita Hannig.
Over the last years, obstetric fistula has received increasing worldwide attention. Popular media, NGOs, and influential personalities have contributed to a portrayal of (African) fistula patients as young, rural, poor, physically wounded, and socially abandoned — relegated to obscure sheds beyond the community borders. In The Gift of Cure, Anita Hannig takes issue with this narrative. On the basis of ethnographic research in two foreign-run, Protestant-based fistula centers in Ethiopia, she provides an in-depth account of the actual experiences of Amhara fistula patients and of the motivations driving biomedical staff to provide “the gift of cure.” The aim of the dissertation is to expose and denounce several assumptions underlying the international “fistula myth” that guides current humanitarian and medical interventions, and to critically rethink notions of “disease” and “cure.” Anita Hannig’s argument evolves from a thorough analysis of her rich empirical data, as well as from a constant dialogue with diverse bodies of anthropological literature pertaining to medical missions in Africa, kinship, embodiment, cure-sickness dualism, and disease as crisis and exclusion. The result is an amazingly comprehensive, well-embedded, and well-written thesis, offering a unique account and multi-level understanding of obstetric fistula in Ethiopia.
The dissertation is divided in two parts. The first part (Chapters 1-3) situates fistula within the social configurations, kinship relations, and religious obligations that characterize Amhara daily life; the second part (Chapters 4-6) unravels the institutional and structural intricacies of fistula treatment within the hospital setting and beyond. As personal and clinical trajectories often overlap, Hannig argues, the two parts should be seen as dialectically related to each other.
Chapter 1 sketches those facets of Amhara daily life that inform women’s sense of being and that are jeopardized by obstetric fistula: marriage, childbirth, and religiosity. Outlining the normative frameworks, cultural logics, and practical realities regarding marriage and childbirth in this society, Hannig argues that what is most at stake for Amhara men and women is the creation and maintenance of social relationships. For this reason, marriages may occur early and people may express a desire for large offspring (yet, contrary to common portrayals in the “fistula myth,” Amhara women rarely start bearing children “prematurely”). Childbirth also brings into relief another set of social relations: women’s connections with the Christian Orthodox community. An intricate description of the post-partum separation of Amhara mothers and their newborn babies — driven by notions of religious impurity — sheds light not only on emic notions of reproductive risk and danger, but also on the essential role of religious subjectivity in Amhara social life.
The next chapter illuminates another component of women’s identity: kinship relations. Here, Hannig contests the assumption that fistula necessarily brings about a severe disruption of existing kin connections and other social entanglements. Drawing on the life history of one of her informants as well as recent contributions in the anthropological study of kinship, she shows that Amhara “kinship” attachments are constantly created, maintained, and actualized through material and social acts of caring. Misfortunes such as obstetric fistulae, and the bodily care they necessitate, therefore form a rich terrain for the assertion and negotiation of kin relations. By illuminating the presence of supportive relations and the ways in which Amhara women mobilize and reciprocate them, Hannig does a great job destabilizing common narratives of female victimhood and exclusion, while highlighting the productive, instead of destructive, potential of illness episodes.
Chapter 3 delves into Amhara understandings of purity, defilement, and religious morality. Hannig demonstrates that, in the Christian Orthodox dogma, bodily wholeness and containment — achieved through a strict surveillance of bodily orifices — are essential conditions for entering into contact with the sacred. As the uncontrollable flow of bodily fluids makes such self-mastery impossible, most fistula patients are reluctant to approach the church — for fear of defiling the sacred place and of being exposed to others. Yet, Hannig argues, Amhara women should not be seen as religious outcasts; instead, they employ alternative, accessible, and controllable ways of enacting their religiosity (e.g., by staying outside of the church walls, by obtaining holy water from others, or by fasting and controlling bodily intake). Just like in the social realms outlined in the previous two chapters, fistula patients appear to maintain a degree of agency and control in the religious domain; the image of passiveness, exclusion, and suffering as portrayed in the prototypical fistula narrative seems completely at odds with the Amhara daily life realities as described by Hannig.
The first chapter of Part II moves its focus from Amhara society to the hospital setting. Situating the protestant-based Hamlin Fistula Hospital (and the regional outreach hospitals that it has opened over time) within a broader history of protestant mission and evangelical humanitarianism in Ethiopia, Hannig shows that what happens in this hospital is more than biomedical fistula treatment alone: its moral and religious underpinnings make the clinic also a place of reform. As such, the medical itinerary is pervaded by notions of salvation and rebirth, and by attempts to “civilize” patients originating from “backward” and “pathological” rural settings. The attainment of reproductive health, then, becomes reframed as a matter of moral development. Hannig argues that the propagated vision — pervading numerous socialization processes in the hospital — has only a moderate impact on the short-term patients. Yet it does contribute to, and reinforce, the international “fistula myth” — portraying fistula patients as sufferers of inhumane cultural traditions — that guides current development projects and the international donations necessary to sustain them.
The last two chapters of the dissertation describe the situations of two groups of women who have entered into a long-term relationship with the fistula hospitals: so-called nurse aides who still have fistula-related problems and occupy nursing jobs in the clinic (Chapter 5) and chronic, incurable fistula patients inhabiting a fistula-settlement called Desta Mender (“Joy Village”) (Chapter 6). Despite the unique differences between these groups of women, Hannig shows that both of them, as chronic fistula patients, represent a challenge to the ideal of a definitive cure. They try to conceal their conditions from outsiders, occupy an intermediary position between the hospital and their local cultures, and have ambiguous feelings about returning to the latter (since they appropriate the image of the defective, harmful rural Ethiopia as promoted by fistula hospitals and NGOs). As a result, these women create novel forms of sociality and sociability. The argument running through these rich descriptions is that the experience of disease can be socially productive and should not only be understood in terms of social crisis, rupture, and disconnection. Further, Hannig critically rethinks the notion of “cure.” Not only does chronicity upset a strict dichotomy between sickness and cure, but, as Chapter 6 shows, in the context of the current development agendas it can also bring about drastic reinterpretations of what it means to be “cured” (in Desta Mender, for instance, the unattainable criterion of “bodily wholeness” has been replaced by more pragmatic measurements of women’s “attitudinal change” and “economic self-reliance”). Hannig’s reflection on how the current logics of Western charity and interventionism contribute to these trends, and how fistula treatment is pervaded by complexities and internal contradictions as a result, constitutes an impressive and convincing end of the thesis.
Offering a comprehensive analysis of obstetric fistula and its treatment, this dissertation offers many valuable insights for scholars working in different areas. It is obviously of interest to those interested in Amhara culture, fistula experiences, and fistula treatment, but it also forms a rich source of information for scholars in the fields of kinship studies, religious studies, and development studies. In fact, one of the most impressive aspects of the thesis is the manner in which Anita Hannig manages to interweave and meaningfully connect these different domains in her fine-grained analysis. The resulting comprehensive and convincing contestation of some of the most pervasive common assumptions about fistula further endows this dissertation with the potential of impacting lay thinking about fistula in particular, and about “rural, African women” more generally.
Erica van der Sijpt
Amsterdam Institute for Social Science Research
University of Amsterdam
Interviews with fistula patients and staff at the Addis Ababa and Bahir Dar Fistula Hospitals, as well as with the inhabitants of Desta Mender.
Literature on: medical mission in Africa; disease and cure; reproductive health and female bodies; sociality and kinship.
University of Chicago. 2012. 327 pp. Primary Advisor: Jean Comaroff.
Image: Fistula hospital in Bahir Dar. Photograph by Anita Hannig.