A Good Position for Birth

Pregnancy, Risk, and Development in Southern Belize

Aminata Maraesa

• Publisher: Vanderbilt University Press
• Year: 2018
• ISBN:
  9780826522023
• Topic: Politics & International Relations
• Subtopic: Global Politics
• Index: Politics & International Relations

In order to understand the local realities of health and development initiatives undertaken to reduce maternal and infant mortality, the author accompanied rural health nurses as they traveled to villages accessible only by foot over waterlogged terrain to set up mobile prenatal and well-child clinics. Through sustained interactions with pregnant women, midwives, traditional birth attendants, and bush doctors, Maraesa encountered reproductive beliefs and practices ranging from obeah pregnancy to 'nointing that compete with global health care workers' directives about risk, prenatal care, and hospital versus home birth.Fear and shame are prominent affective tropes that Maraesa uses to understand women's attitudes toward reproduction that are at times contrary to development discourse but that make sense in the lived experiences of the women of southern Belize.

CHAPTER 1

Local Values in Action

“In Belize City you just throw culture away, and you grow up Belizean. In Toledo, we still have our special ways.”

Comment from a nurse in Toledo

“They say in Belize, time di run slow. But in PG, time di stop.”

Comment by a police officer from Belize City recently reassigned to Punta Gorda

It was a hot, wet morning in July 2006 as I waited for the MOH mobile health team on the steps of the corner Chinese shop. Men had started to chop their yards with machetes and motorized weed-whackers, and children were out running morning errands before school. The days in Toledo begin well before dawn, so Nurse Ical was already running late for our five-hour (one way) trip to Branch Mouth village located in the most southwestern corner of the country, adjacent to the Sarstoon River and a few miles from the Guatemalan border. I recognized the heavy-duty MOH pickup truck as it drove toward me from the hospital, which is located at the very end of Main Street adjacent to the town cemetery. Stopping to pick me up, Nurse Ical extended greetings: “A pleasant good morning!” and asked, “Are you ready for a li’ walk in the bush?” I hopped in the truck’s bed and off we went.

PG is located at the dead end of the San Antonio Road, which runs eastward along the former Toledo Estate sugar plantations. At the intersection locally referred to as the “Junction,” marked by a gasoline station and a bus stop, the San Antonio Road turns abruptly northward. The Junction marks the beginning of the stretch of two-lane roadway that spans vertically across Belize, meandering as the Hummingbird Highway through the mountainous central region of the country before it heads west toward the country’s capital of Belmopan and then to its former capital, Belize City, where it resumes its vertical trajectory as the Northern Highway clear to the Mexican border. The entire artery was paved beginning in the late 1990s; however, a nine-mile stretch of the Southern Highway located a few miles from the Junction had been left rocky since the project was “completed” in 2000. Rumor had it that this last patch was going to be paved during the 2003 general elections. The latest “shush” (purportedly factual gossip) or “rass” (purportedly false gossip or exaggeration)—which one depending on one’s political affiliation—was that it would be completed by the incumbent party before the 2008 elections.¹ Nonetheless, the six-hour overland journey from PG to Belize City was far preferable to the overnight journey by sea that was the only viable means of transportation between the two ports as recently as the late 1980s.²

It was also rumored that plans were in the works to pave the San Antonio Road as it continues eastward from the Junction to the many villages that dot Toledo’s landscape, winding its way some thirty miles to the border of Guatemala where it would connect to the Pan American Highway and link Belize via roadway to the rest of the Americas.³ In 2006, this feat—and the paving of the remaining nine miles of highway—remained speculative, and both potholed dirt roads were often washed out and at times flooded during the torrential seasonal rains that make Toledo the wettest region in the country.⁴ Our mobile medical clinic expedition occurred just a few days after a heavy rainfall that raised river levels above the low-lying wood and concrete bridges, leaving a number of villages inaccessible by vehicle. But on this morning the bridges were dry, and we were able to reach the village of Santa Madre in an hour. There we picked up Sergio, a thirty-six-year-old Kekchi man who had been his village’s community nurse’s aide since 1992 and its TBA since 2001.

Primary Health Care in Belize

The government of Belize was cosignatory to the 1978 World Health Organization (WHO) declaration at Alma-Ata calling for “health for all the people of the world by the year 2000,” which outlined the standards for primary health care for many postcolonial and developing nations (Ministry of Health 1996a; World Health Organization 1978). Formulated as the first level of treatment for illnesses before they reach a level requiring hospitalization, primary health care was a strategy to improve the health of rural and poor populations with limited access to medical resources. Ministers of health from a number of developing countries, including Belize, agreed on the need to restructure their health systems to include outreach and training to community members as liaisons between the rural areas and the urban medical centers. In Belize, these outreach efforts included training rural health workers, constructing and staffing rural health posts, and instituting mobile clinics to bring medical care to the outlying communities.

In 1981, Belize negotiated political independence from its longstanding colonial relationship with England. Postcolonial movements and new nationalisms, articulated around ideals of independence and self-sustenance, are often formulated with a commitment to public and maternal health (cf. Farquhar 1994; Greenhalgh 1995; Pugh 2003). In Belize, the goal of total health coverage also became a platform for Belizean self-governance at the level of the individual with primary health care conceptualized as a partnership between the MOH and the community (see Foley 2010 for identical language in Senegal). Formulated along the same lines as the Alma-Ata convention, the success of Belize’s primary health-care strategy depends on community involvement and the understanding that the health of the population is the “shared responsibility” of the community (Ministry of Health 2014, 8). Belize also formulated primary health care as a means though which to build a cohesive multiethnic nation in the face of long-standing border disputes with neighboring Guatemala. The government could use a discourse of public health to articulate concern for all its citizens, including border-dwelling recent immigrants, to instill a nationalist sentiment within the fledgling nation, and to sway allegiance toward a purportedly benevolent democratic government (Foucault 1978).

The aptly named Unity Brigade (1979–1981) marked the introduction of primary health care to Toledo, the region with the greatest ethnic diversity and a marked connection to Guatemala through the many unregulated and informal economic transactions among rural villagers as well as through marital and other familial relations. The stated purpose of the Unity Brigades, which were comprised of students from the Belizean School of Nursing and the Teacher’s College, was to “assist in a process of empowerment to help people take control over their lives and their health” (Ministry of Health and Pan American Health Organization 2003). Under the direction of the MOH, the Brigadistas lived with villagers in remote and underserved communities for three weeks during the summer to promote intracountry cultural and ethnic exchange and to educate village residents on issues of sanitation and nutrition. To this day, one of these students, Nurse Lee, has remained in service to the Toledo community as the head public health nurse and director of the maternal and child health (MCH) program at the PG hospital.⁵

Other relationships that formed between the Brigadistas and the community were equally long-standing. Starting in 1980, certain villagers were identified to serve as liaisons between the village and MOH personnel, marking the beginning of the community health worker (renamed community nurse’s aide [CNA] in 1998). After being chosen at a village-level community meeting, the proposed CNA is then approved and trained by the MOH in rudimentary health-care services including basic first aid, monitoring blood pressure, and distributing over-the-counter medications such as aspirin, cough syrup, and deworming pills. Once the CNA proves reliable, and if ministry personnel and funding are available, the CNA learns more advanced skills such as suturing minor skin lacerations and administering prescription injections. Furthermore, the CNA assists during mobile clinic rounds to the village. In return, he/she receives a small monthly stipend of 100BZ (50USD), representing a gratuity more than an income, as the CNA is understood to “volunteer” service to the community in the spirit of public health and a commitment to the nation.

In addition to opening the rural health post three days a week and assisting at the mobile clinic to Santa Madre, Sergio routinely assisted Nurse Ical on his scheduled mobile clinics to remote villages that did not have their own CNA. Other than a small food allowance, he did not receive extra compensation for his additional service. Looking to earn a little money wherever he could, Sergio did not purchase food along the way to Branch Mouth. Instead, he saved the extra money allotted to him by bringing his own lunch of boiled plantains and stewed chicken in a plastic container.

After picking up Sergio from Santa Madre we continued our journey over very rough terrain until the road ended abruptly in the village of Viejo del Carmen at a recently burned cornfield, which stretched for at least a mile up the sides of a mountainous hillside. Only a half-dozen scorched cohune palm trees stood amid ashes and fallen vegetation. Despite controversy over possible adverse ecological implications, Maya have been using a slash-and-burn method for centuries. Few see the need to change, and none sees any feasible alternatives. As subsistence farmers, villagers rely on their crops for food and to sell for cash needed to purchase durable goods and supplies (Wilk 1997).

A few weeks before this mobile run, I had come to this same spot to meet Alfredo, the village’s CNA who received TBA training from GIFT in 2001. I went hoping to interview him about his experiences as a TBA. However, bus service to Viejo del Carmen was infrequent and apparently unreliable, as the letter I sent with the bus driver did not reach the intended recipient. After a nearly three-hour journey in a rented pickup truck on the day specified in my undelivered letter, I was told by Alfredo’s wife that he was in the plantation, whereupon I found him in this very cornfield covered in sweat and soot, apologizing for the miscommunication. Alfredo suggested we meet a week later when he would be in town to withdraw his CNA stipend. I later learned that would be Alfredo’s last MOH payment. Villagers had been complaining that Alfredo was lazy. Moreover, they asserted that he was never home when they needed his services. Indeed, there was some truth to these allegations—I did not find him either! But like many farmers living in the rural areas, Alfredo needed to supplement his income.

Ethnographies of the Caribbean have examined the varied ways individuals make a living by piecing together odd jobs and sideline employment (Browne 2004; Freeman 2000). Belizeans in the Toledo district, including the rural village dwellers, are no different. They supplement their seasonal farm-based income with short-term employment opportunities in other districts and small-scale tourism ventures, including the informal market sales of the many crafts surrounding tourists at every archeological site and eco-lodge. A few are able to obtain relatively unskilled government employment with site-based construction work or nongovernmental development projects. Some find a steady salary as a village council officer or with the MOH as the CNA or health post caretaker. Others, like Alfredo, also embark on religious study provided by the many missionary groups who frequent the area. Since Alfredo began studying to become a preacher, he was also spending more time at the Baptist church and traveling with missionaries away from his village.

However, Alfredo’s unavailability was understood to be an active unwillingness to perform his duties as a health worker. The village made a formal complaint to the MOH. The rural health nurse, who similarly found Alfredo unavailable to assist during mobile clinics, corroborated the story, so Alfredo was dismissed from his position. However, no one stepped forward to replace him, nor were the funds available to train anyone new. Although Alfredo told me that he was unhappy about losing his position, he said that he was glad to be rid of a very difficult and time-consuming job—a job that had little monetary recompense.

Local Values: Money, Morality, and Volunteer Service

A review of the literature written by Belizeans shows . . . a clear pride in the nation’s ethnic variety and in things Belizean.

(Excerpt from a publication by Belize Family Life Association [Jagdeo 1993, 17]).

Remuneration was always a topic of discussion for most salaried employees and “volunteers” at the MOH who felt they went above and beyond the call of duty. Those who provided service without complaint were well liked by the community and received their payment with the high moral standing accorded selfless volunteer service. Those who grumbled too much were branded lazy or greedy and were likely to lose respect.

To understand the importance Belizeans place on moral deeds and actions, it is useful to look at Wilson’s (1969, 1973) categories of reputation and respectability, which he developed to analyze postcolonial social relations in the Caribbean. According to Wilson, respectability is rooted in the colonial social order, and high social status is equated with “whiteness.” Reputation places an emphasis on intrinsic moral worth, personal attributes, and social ties based on friendship and kinship, and it is equated with “blackness.” Reputation is an indigenous value system that arose in response to the colonial situation, providing marginalized individuals alternative criteria for assessing personal worth and according respect. In a multiracial and multiethnic society such as Belize, nothing is as clear-cut as “white” or “black.” However, in a postcolonial and developing country that is struggling to create and maintain a national identity, Belizean understandings of the global (“white”) and local (“black” or indigenous) can easily map onto Wilson’s racialized categories.

Wilk’s (2006) historical analysis of the relationship between Belizean nationalism and Belizean gastronomy is also helpful for understanding the moral value accorded things local and actions locally directed. According to Wilk, locally produced Belizean commodities have difficulty competing with imports for a number of reasons ranging from the relatively high cost of production to the lack of variety for the consumer. Yet consumption of locally produced foods such as “local chicken”—recently popularized by the brand “Dis da fi wi chikin” (This is our chicken)—has been a political rallying cry since the early days of colonialism. Wilk further discusses how Belizeans “localize” global ingredients to make an authentic Belizean product—a product that may not be sought after by Belizean consumers in part because of the factors mentioned above, but a product that is accorded a moral value because of the nationalist sentiment it invokes.

I similarly saw how nonfood items Belizeans made by hand with meager resources were given moral worth superior to imported material goods by using the prefix “local.” A “local lamp” made from a kerosene-filled glass jar and a piece of cotton wick and “local electricity” generated from a car battery were spoken about with humble pride that raised the status of these “local” items over imported or store-bought goods. Indeed, many Belizeans, especially those in Toledo, do not have the money for the things they can, and do, make for themselves. In 2006, the median household monthly income countrywide was 1,170BZ (585USD) (Statistical Institute of Belize 2007). In Toledo it was 660BZ (330USD).⁶ Making do with little money is something to which people in Toledo have become accustomed. It is also a source of pride. During my research, a college-educated Mopan Maya man in his early twenties named his first-born son Utzil, which in the Mopan language means “poor.” By no means am I suggesting that residents of Toledo are content with being poor or that they do not have a need for money. But what is interpreted as greed, the accumulation of wealth, and the desire for foreign things upset the delicate social balance of relational poverty, inciting jealousy and even inviting obeah directed at those who have more than others. Being poor is respectable—especially when one remains in service to the people of Belize and to the nation.

Documenting Service

Belizeans likewise have localized the colonial practice of documentation to imbue nationalist sentiment. Belizeans are very proud of the course completion certificates they receive, usually framing them for display in the common household areas. Nation building is contingent on community support and relies on the selfless service of its citizens who act on behalf of the nation without thought of monetary compensation. Thus, most training courses sponsored by t...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Contents
• Figures and Tables
• Acknowledgments
• Introduction
• 1. Local Values in Action
• 2. Risk and Blame
• 3. In a Good Position
• 4. Fearless Encounters
• 5. “Obeah Pregnancy” and the Power of Shame
• 6. Adoption and Anthropological Complicity
• 7. Of Birth . . . and Death
• Notes
• References
• Index