Hey, leave those clits alone!

Warning: This post is graphic. It describes female genital mutilation and other negative practices.

“It should look like a flower,” sighs the speaker Madame Traore, cueing visuals of pastel Georgia O’Keefes, potpourri, and oddly, Kathy Griffin. We are sitting in a classroom at a three-day workshop on excision, women’s reproductive health, and children’s rights. All the local big-wigs are here: mayors, school directors, imams (Muslim priests) and radio DJs; trained midwives and traditional medicine women; town criers and local NGO workers. While I am the only foreigner amidst over 60 Malians, I realize I am also one of the movers in my community, and I am heartened to see how many people are passionate about this issue. I see my friend, who, disturbingly, I found out performs excision on the village girls, sometimes 20 girls with one knife. At least she’s here. And today, together, we are talking about the “should.”

We begin by discussing traditional practices here in Mali that can be detrimental, specifically those common in three ethnicities present at the meeting: Dogon, Peul, and Malinke. In addition to female genital mutilation and male circumcision, many of those present talked about practices such as ear and nose piercing, tattoo of the lips and the gums, scarring (often done on the sides of the face, next to the eyes or down the middle of the forehead), teeth filing, blood-letting, and taboos against certain foods for pregnant women and children. They also cited more traumatic practices of tribal initiation for men, extreme diets or force feeding for to-be brides, levirat and sororat, the tradition of marrying the brother/sister of your deceased spouse, degrading customs for sterile women such as putting hot pepper into the vagina or burning pubic hair, forced early marriage of girls, and forced child labor.

The common and arguably the most damaging practice that affects girls in these cultures is excision. Excision, the softer term used here for various types of female genital mutilation/cutting (FGM/C) or female circumcision, is extremely prevalent in Mali, one of the highest occurrence rates in the world with estimates ranging from 90- 95%. In my region, Kayes, the rate is at a heartbreaking 98%. Mali does not have a law that prohibits excision, despite efforts by the former president Konare to pass a bill in 2002 to criminalize it. Historically, female circumcision has links to Egypt, and is practiced in parts of Africa, particularly in the western and eastern countries, as well as in the Middle East. While excision is not a practice mentioned in the Koran or the Bible and has been discouraged by Islamic religious authorities, many of the participants cited a biblical origin. In the story, Sarah forces Abraham to circumcise Hagar, the Egyptian slave who bore Ishmael. God then commands Abraham and Sarah to circumcise themselves in response to their actions. There is also tribal traditions that are used to explain excision. Stories from the Dogon tribe include the belief that babies are born of both sexes, and just as the “feminine” foreskin must be removed from the penis, the “masculine” clitoris must be removed from the vagina, which also ties into Egyptian origins.

While in the past excision had sometimes been a ritual of the wedding ceremony, it is now normally performed on girls between the ages of birth until five years, and sometimes until puberty. The extent of the mutilation ranges from just the partial or total removal of the clitoris, known as clitorodectomie, to excision, the most common form, which includes the ablation of the clitoris, the labia minora and/or parts of the labia majorta, which is most common form in Mali. Rarer types include infibultation, a narrowing of the vaginal orifice where the clitoris and both inner and outer labia are ablated and sewn to create a small opening. The last type includes a variation of mutilations, including pricking the clitoris with needles, introducing corrosive substances to the vagina, and introcision, where the vagina is expanding through stretching or tearing the perineum (the area between the vagina and rectum).

The possible consequences of FGC are manifold and can be debilitating. The most obvious result of excision is reduced sexual pleasure, but is by no means the only effect the practice can have on the women and their families. The procedure itself can cause hemorrhaging, which could also occur as the vagina ruptures during childbirth, leading to anemia and possibly death. In addition, the scarred tissue creates a narrower birth canal, where the infant’s head sometimes cannot pass through easily, and sometimes even not at all. Often during a women’s first childbirth, the head becomes misshapen as the still soft skull becomes indented trying to pass through the vagina, which can lead to head trauma and possibly long-term brain damage. Mme. Traore explains that often, these infants do not cry right after birth, as their reflex center is affected. This explains all the bewildering silent birth I’ve seen. There can be difficulty during sexual intercourse, which can result in forced penetration, vaginal tearing, and rupture of the perineum. Infibulation can cause an accumulation of menstrual blood and urine, which can lead to uterine infections and sterility. Uncontrollable urination can also occur as the urinal passage can become defective. The procedure is often performed by untrained women and with unsterlilzed tools. These unsanitary conditions increase their risk of infection, including tetanus, HIV, and hepatitis B. Finally, girls who have undergone excision, particularly at a later age, can experience psychological trauma from the ordeal, affecting their sexual and social relationships.

Then why is it done? Participants cite reasons including hygiene, preservation of virginity, fidelity, increased male sexual pleasure, esthetics, society initiation and cultural/tribal identity. They agree that lowered sexual sensitivity is a major underlying factor, which is intended to reduce the risk of wife infidelity. While women have told me they believe the clitoris is unclean, there is no evidence of any hygienic advantages to excision; on the contrary, the procedure, the healing process and the subsequent possibility of vaginal tearing during intercourse and childbirth increases their risks of contracting infections, including HIV and other STIs. It is also believed that it helps facilitate a healthy childbirth, which also has no medical support; excision can actually create serious difficulties for the mother and the child, sometimes resulting in the need for a Cesarian section or even the possibility of maternal and infant death. As detrimental as it can be, however, excision has a strong traditional foundation and is important to feminine identity and social acceptance. As surprising as it may seem, a great deal of the push for the continuation of excision comes from the mothers and the older generation of women, who, in addition to wanting their daughters to have a normal status in their society, believe that it is necessity for their hygeine, reproductive health, and spiritual well-being.

During our talks on female and male reproductive systems we argue about women’s rights, the appropriate age for first marriage, and even a very humorous, if not awkward, debate on penis size (yes, men are men everywhere). We look at children’s rights, and how excision and forced early marriage of girls– girls are typically married off around age 15 in my village, as early as 12 - violates their vulnerability and their rights to a healthy childhood. Finally, we end the last day planning an activity to fight-excision in our individual communitites. The school director of my village suggests a theater competition, where the girls and boys will put on plays about the dangers of excision and the importance of promoting children’s rights.
At the end of the third day, we all gather together for a picture, and make our way back to our villages. I see my friend, who tells me that she has learned a lot. The Mayor says he wants to work on campaigns with the doctor of my health center, and is excited to see the theater competition. As for me, I will work in the background to support anti-excision campaigns. Though I find myself passionately against excision, frustrated by its recklessness and disturbed by its consequences, I am the foreigner, and I know I can never truly understand its complex role in female identity here. This is not my culture, and I know in the end it is not my fight.

A book, a book...

In between and during my time spent at the health center, fumbling in my language with my villagers, or here working and playing in Kita, I spend a good chunk of my time reading. Luckily, volunteers before me have joined in this art of social withdrawl, leaving libraries of books that supplement the ones I brought. I am halfway through my service and halfway to my goal of 100 books. So here is the list of 50 books I’ve read this past year:

1. On the Road – Jack Kerouac
2. Night Trilogy – Eli Weisel
3. A Moveable Feast – Ernest Hemingway
4. Do Androids Dream of Electric Sheep – Philip K. Dicks
5. Beneath the Wheel – Hermann Hesse
6. Dead Souls – Nikolai Gogol
7. Still Life with Woodpecker – Tom Robbins
8. The Prophet – Khalil Gibran
9. Sailor Song – Ken Kessey
10. Brave New World – Aldous Huxley
11. Grendel – John Gardner
12. The Picture of Dorian Gray – Oscar Wilde
13. Tropic of Cancer – Henry Miller
14. Mountains Beyond Mountains – Tracy Kidder
15. Dubliners – James Joyce
16. Foucault’s Pendulum – Umberto Eco
17. Poisionwood Bible – Barbara Kingsolver
18. The Fall – Albert Camus
19. Slapstick – Kurt Vonnegut
20. The Hamlet – William Faulkner
21. Greatest Russian Short Stories - Various
22. Catch 22 - Joseph Heller
23. A Clockwork Orange- Anthony Burgess
24. The Death of Ivan Illych and Other Stories – Nikolai Tolstoy
25. Things Fall Apart – Chinua Achebe
26. The Enormous Room – ee Cummings
27. Desolation Angels – Jack Kerouac
28. Letters to a Young Poet – Ranier Maria Rilke
29. Air Guitar – David Hickey
30. Sanctuary – William Faulkner
31. The Martian Way – Issac Asimov
32. Blink – Malcom Gladwell
33. Half Asleep in Frog Pajamas – Tom Robbins
34. Sula – Toni Morrison
35. Zen and the Art of Motorcycle Maintenance – Robert Pirsig
36. Heart of the Darkness – Joseph Conrad
37. Peter Camenzind – Hermann Hesse
38. Tropic of Capricorn – Henry Miller
39. The Plague – Albert Camus
40. The Awakening and Other Stories – Kate Chopin
41. Mostly Harmless – Douglass Adams
42. The Air Conditioned Nightmare – Henry Miller
43. Portrait of the Artist as a Young Man – James Joyce
44. The Sirens of Titan – Kurt Vonnegut
45. Kafka on the Shore – Harukami
46. The Stranger – Albert Camus
47. Desert Solitaire – Edward Abbey
48. Pylon – William Faulkner
49. The Alchemist – Paul Coelho
50. Atlas Shrugged – Ayn Rand

Cervical Cancer Screening Campaign

Cervical Cancer Screening Campaign – Bougaribaya Commune
Dina Carlin, Peace Corps Mali Health Education Volunteer
August 23-28, 2010

Six days, six villages, and 299 women later, Founeba and I returned from our cervical cancer campaign. We were exhausted, run down, but proud. Using visual inspection with acetic acid (VIA) and Lugol’s iodine (VILI), we screened an average of almost 50 women in each village, and had found that 48 women had at least the first signs of infections that can lead to cervical cancer.

This campaign was designed as a follow up to a workshop in May, where doctors and matrones from each of the 35 health centers (CSCOMs) in the the Kita Cercle were trained in visual inspection, a preventative screening method for cervical cancer. VIA and VILI is carried out by applying an acetic acid solution (for VIA) or Lugol’s iodine (for VILI) directly to the cervix. Pre-cancerous cells, known as cervical intraepithelial neoplasia (CIN), are cervical cells that have been exposed to persistent infections from one or more high-risk strains of the Human Papilloma Virus (HPV), which often lead to high-grade lesions. In almost 50% of cases, these lesions develop into cervical cancer. In VIA, precancerous cells form white areas (acetowhite) while in VILI pre-cancerous cells turn yellow (iodine non-uptake) when exposed to the solution. These results occur within a minute, and are easily seen using a strong light source. Along with Dr. Oussman Sangare, Chef de Poste at the Bougaribaya CSCOM, Mme. Founeba Dansira, the CSCOM’s head matron, the health center’s governing board (Bougaribaya ASACO), and community health workers (Relais), and myself, the campaign focused on expanding the accessibility of VIA and VILI to communities without health centers, as well as promoting the importance of women’s reproductive health care and the CSCOM’s activities.

After informing all the villages of our campaign schedule the previous week, the doctor went to Kita to attain some final materials needed for the screenings. The morning of the campaign, the matrone and I found ourselves alone, as the doctor had had to stay in Kita indefinitely due to domestic difficulties. While this left only Founeba to perform the screenings, we decided to go ahead as the villages were awaiting our arrival. Armed with my backpack full of supplies – speculums, placental probes, cotton, gloves, acetic acid and Lugol’s iodine - we set off for Karo, our first village. We arrived late in the morning, and set up in the hut of the Relais. Founeba did the screening in the dark hut, using a flashlight as the women laid on a bamboo bench. I sat outside the door, taking down the information of the women who crowded around me. Founeba explained the procedure, and performed the screening. At the end of each screening, I would run in to confer with her results and record them. From time to time Founeba paused to breastfeed Omou, her 8 month old baby, while I tried my best to trudge through the questions, helping them gauge their age despite their lack of birthdates, and talking to them about family planning and STI prevention. When we finally finished after 5pm, we had seen 43 women, had found 9 of them were infected or had high-grade lesions, and had seen two cases of suspected cancer. With the women’s approval, we gave the list of the positive women to the Relais and spoke individually to her and her husband, if available, trying to convey the importance of a follow-up appointment at the health center. We urged the Relais to follow up on these women to ensure treatment was sought.

The second day we gathered the women at the school of the next village, Bagnakafata, where we designated one of the classrooms as the screening/consultation room. By midday the sky had darkened and the rainstorm raged as we performed the screening. Many of the determined women waited, soaking under the hangar as we called each name, while the rest of the women went home. We ended the day with headaches, colds and 10 new positive cases or infections. The next few screenings went much more smoothly as we became used to the system and had additional help. Some we did in classrooms, others in dimly lit huts. After the six days, we had seen 299 women, and found 48 of them had infections or pre-cancerous cells. We urged many of the positive screenings come into our health center, where the test would be repeated by Dr. Sangare. However, several screenings showed high grade lesions or invasive cancer, which we referred directly to the health center in Kita. The Relais were encouraged to talk to the women in their individual village about the importance of following up with their screenings, and to organize transportation and fundraising.

There are still missing links, however. It is difficult for rural women to find funds to travel to Kita, but, due to lack of equipment, the health center is unable to provide adequate treatment. In an ideal case, immediate treatment would be available, like cryotherapy and loop electrosurgical excision procedure (LEEP). Linking screening to treatment is critical in providing comprehensive prevention in rural areas, as the probability of follow-up treatment decreases with multiple visits. Both are simple and minimally invasive treatment options, but are currently unavailable at the village level. A follow up to this screening campaign would include investigation into the accessibility of such treatment methods at the village level. For now, however, there is infrastructure in place to support these women, at the cercle, regional and national levels. With the support of their communities and annual preventative screenings, and with further investigation on increasing the availability of appropriate treatment techonologies, we can start to makes moves towards reducing cervical cancer here in Kita, and in Mali at large.

This must be the place

Feet on the ground, head in the sky…

I came back to village after almost two months of America, the steel and bottled water still swimming in my stomach. My hut, of course, was a mess – bits of my new straw roof was strewn across my bed and floor; the termites had eaten out my bookshelf and some of the books with it. But how good it is to be home! I came back, not as a guest, a burden, a novelty, but as just another villager, missed but not paraded.

The first night I got back, I walked to see Soliba and caught her on the path. She said she was going to the health center, where her friend was giving birth. I joined, and as we came we found little Tene’ba, the tiny older midwife, happy to see me as she sat outside. Soliba went inside; Tene’ba told me about her friend’s baby, how it had died during the birth. The young mother lay curled under a piece of fabric; Soliba and her sisters sat quietly. I went in to see the baby, a plump thing, but gray and of course silent. Tene’ba spit on the baby and folded it into a clay pot. It fit so neatly into the little pot, all the sudden out of its tiny existence. We walked to the treed area next to the health center where they are buried. Two of the mother’s friends joined us with a daba, a type of shovel. Tene’ba broke the soil, as she did she let out a cry, intensely violent and controlled, a sad anger. I thought, at least someone is angry. After the pot was in the mound she spit on the ground, three times, the animist warning off of evil spirits. We walked back to the health center and washed the dirt off our feet.

A few days later my host mother Hagi invited me to join the women from the Women’s Association, who were farming at the peanut fields to raise money for our garden project. We went out early, the first ones there beside the little drummer man we met on the way, who told us he was drumming to call in the women to work. They came in with dabas and their littlest babies, maybe twenty in all. The man beat his drum the whole day, keeping a persistent beat that the women worked to. The Griot, a sort of town songstress, came and sang with the women in her faded yellow lace outfit, and the women would sing in response as they bent over their rows of peanuts. They worked in groups of 5 or 10, all of them in a line, progressing in time with the other women as they cleared the weeds from the new peanut plants. They insisted I sit in the shade and watch the babies, but every once in awhile I would come and relieve some of the women who looked tired. We would stop sometimes to dance; someone would throw a scarf to the next women, whose turn it was to dance to our claps and the drums. We worked until late afternoon, the women working bent throughout the day. Making food for their children, working together, what more could we have to celebrate? And I thought, this anger I've seen, this joy I feel is as human as technology is not. Without the computers, the gadgets and cell phones and nothing but our hands in the ground, we find that all we have is each other. I like that.

Africa is Sexy

Sitting in my hut, the new straw roof is even worse than the last one; it’s not sealed, and I feel each irate wind. And my kitchen is a mess and it won’t be dry enough to fix tomorrow morning. And here I sat rehearsing my anger speech to the village, how I would tell them I couldn’t live another day in a busted hut. But the music in my ear, Devendra Banhardt plucking along, is just too damn beautiful and sexy and bright and now I’m grinning and excited for my upcoming trips around this place, and to come back and chat with Soliba and see other volunteers and paint more health murals. So I just can’t stay mad or sad in this electric storm and I’ve never been able to, I just feel the energy glittering and I’m on the world’s greatest adventure, I am the fearless pioneer of treacherous truck rides and jumping to the drum beats and filling empty bellies and sucking enveloping sculpting all of this.

Yea, Africa is sexy me and Eric agreed the other day, sitting on the floor of the Chief’s lodge in the gold mining village. What is sexy about Africa? We pondered this and sweat dried foreheads, snacking on peanuts on the scratchy plastic mat. And the more we talked we felt how sweltering these hot days are, sultry and invading, as if the air is pressing its heavy body against you, with intoxicated passivity you ache under its weight. There is no promise of a release except for these electric rain storms, and when it rains it begins with the violent winds where the dust makes you squeeze your eyes shut tight; then the rain swells and unleashes its tiniest drops first and then bigger, faster, your pores cry for relief. Soon the rain is too strong, you can escape under the shelter of leaky straw but maybe you are better off getting wet, sopping, streaming, but finally cool.

So we sat smelling the roasted goat meat and we saw this taunting "modesty" of the African Muslim culture, the innocence easily seen through as the endless children parade by; let’s not pretend they all sprung from the drowsy gardens. Everyone is together, sweltering skins touch as we squeeze in Bush taxis or sit and talk on the one mat or bench around. And if you are not touching, right next to everyone, well then you are alone in the bush and you are really nothing if you don’t reverberate with everyone in the overflowing drum circles and call out to one another in song. Yes, Africa is sweltering and naked and orgiastic with human energy, so concretely human.