Introduction

In November 1986 I went to Nicaragua to attend the Fourth Annual Nicaragua/North America Colloquium on Health. I had been working for Hesperian on a manual on midwifery for use in the Third World, and went to the colloquium to meet people, especially traditional midwives and community health workers, to learn a little more about the Nicaraguan situation, and to give a presentation on childbirth education.

One of the participants in the conference was Sylvia, a doctor from the Philippines. She was a small, round, good-natured, very intelligent person. I liked her. Trying to be friendly and make conversation, I asked, “Oh, you’re a doctor? Do you have a medical specialty?” “Why yes, l do,” she replied, giving me a cheerful smile. “I specialize in the rehabilitation of torture victims.”

Three years later, the first draft of the midwifery manuscript is finished, and I am facing a new task: how to evaluate all the feedback and criticism we have received from around the world and integrate it into the revision.

And, even more important, how to take this raw material and turn it into something that is as useful and as easily accessible as possible to health workers and midwives, and something that is culturally appropriate in a variety of settings. I explain this problem in a letter to Sylvia (who has in the meantime become a friend and one of the reviewers). She writes back with an intriguing suggestion.

 

Two months later I am on a plane to Manila. Gabriela, a 50,000-member progressive women’s organization, has invited me to come teach a course on basic midwifery for midwives and health workers from poor urban and rural areas. I will start by receiving a two-week orientation to the health situation in the Philippines, will then teach for a month (during which time I will also be “field-testing” the manuscript), and will wrap up my stay by spending a couple of weeks in the countryside and conferring with Sylvia on the book. This article is a summary of some of my impressions and experiences during my visit.

Sex Work in Olongopo

Between 11,000 and 17,000 “prostituted women” here service the US Subic Bay Naval Base. I am still under-going my orientation, which includes visits to various health sector and women’s organizations, as well as to several urban poor communities. Today I have made the journey here from Manila with a companion to be exposed to this aspect of the situation in the Philippines. Gabriela has created a “Commission on Violence Against Women.” Here in Olongopo this Commission has set up the Bulkod Center for Prostituted Women, which teaches the women English and other skills, raises consciousness about the rights of prostitutes as workers, provides health education workshops and counseling, and offers a “night care center” for the children. When a prostitute gets pregnant and is kicked out of the bar where she works, she can stay at the center.

 

Two women, one a former prostitute, the other still working as one, come to act as our guides and take us around to visit the bars. I am trying to put myself in a frame of mind that will allow me to feel and understand the experience of these women, and I find myself doing the same towards the American servicemen I see in the street. What is it like for them to be here? I am especially intrigued by the black servicemen. What does it feel like to suddenly be one of the oppressor class? I watch their faces, wondering.

The whites and blacks have separate bars. They are not segregated, but are different. The first two bars we visit are white bars. There is a long counter for serving drinks. On one side are barstools, tables, and chairs. Men sit in groups or with Filipino women, drinking, talking, laughing, or watching the stage. This platform is located on the other side of the counter. On it are 10-15 women in bathing suits or leotards dancing listlessly, making sexy gestures, or just sort of standing there. Mary, one of the guides, tells me that many of the women take valium just to get up the nerve to go on stage. The men watch and shop. Some look like real jerks, but most just look like ordinary guys. Some look young and rather sweet. Watching them, I get the clear sense that they think they are looking at “dolls”—exotic “China” dolls.

If a man wants to talk to a woman, he can buy her a drink (she gets a percentage—perhaps a dollar). At one of the bars a small Filipino woman is sitting on the lap of a large white GI (he looks like a Marine to me). She is maybe 16 years old, maybe 20. She is half his size—by weight probably less than half. He whispers in her ear and she laughs. He puts his arms around her; she is still smiling, but I see her shoulders hunch…

What makes the poverty so grinding is the total lack of backup. There is no welfare, no medicare, no food stamps. If you get sick, it's too bad.

If a man wants to “take a woman out,” he must pay a “barfine” to the bar to do so. Again, she gets a percentage—perhaps four dollars, it depends. After several loud disco songs, the group of women leaves the stage and another batch comes on. If a woman is not chosen, she receives only 40 pesos, or about two dollars, for a night’s work of standing, dancing, and waiting.

This is a tame week. Over and over I’m told that right now there is “no ship,” and therefore the bars are patronized only by the men permanently stationed at the base. A ship may bring in 9,000 men at a time. Then things get pretty wild, with live sex shows on stage, and things like that. In one popular act, a woman sucks coins out of a bottle with her vagina. Mary says that when there is no ship, there is no money, and things can get pretty hard for the women. There may not be much to eat.

At one point a lone black man comes into the white bar. He sits at a table in the back and watches with a grim expression. He drinks one beer. He does not smile. After about 15 minutes, he leaves.

Visiting a Black Bar

Later we visit a black bar. The women here are also working, of course, but the atmosphere and the physical environment are different. There is no “China doll” feeling here. The stage has been replaced by a dance floor, and the music is more rap and less disco. Men pick partners by dancing and socializing freely among the women. It is a tribute to racism that it took me a full 24 hours to figure out why the setup in the black bar is so different. The music is obvious, a matter of cultural preference, but why no stage? Then it hit me: the image of brown women standing on a platform being looked over and bought by white men must be profoundly disturbing to the blacks stationed at Olongopo.

Back at the center, I ask about AIDS prevention and birth control. There are over 52 known cases of HIV infection, virtually all among women who service the US bases. The Philippine government wants the US to pay for the medical care of these women, but the US refuses. Most of the infected women probably won’t get care, at least not much. Some have disappeared—gone home, perhaps, or left Olongopo to continue their work in some area where no one knows of their condition.

Condoms are available, but some men won’t wear them, and some women don’t like them because the say they hurt. Lubricants such as spermicide or Kare too expensive. Natural lubrication is, I assume, absent due to the woman’s lack of enthusiasm for paid sex. [Editor’s note: Condoms absorb natural lubrication, and generally require added lubricant.]

Like so many developing nations, the Philippines is very much under the thumb of the International Monetary Fund and other creditors . . . To pay its debts, it must place social services and political reforms on the back burner.

Abortion is illegal here. A woman who needs an abortion must go to a traditional midwife for services. The midwife squeezes the womb until she dislodges the pregnancy, or else puts a catheter up through the cervix into the uterus and leaves it there for several days to cause a miscarriage. The first person I ask, “Do you know anyone who ever had a problem with one of these abortions?” answers, “Yes, I have a friend who died of one last year.” (In fact, during the midwifery training, almost every time we studied a complication of pregnancy or birth, someone would say, “Yes, I know someone who died of that.")

It’s mostly poverty that drives women into prostitution. The poverty I see in the urban squatter communities is appalling. It’s not just the little handmade houses patched together from this and that, sometimes huddled between factory and railroad tracks, or perched on slender poles over the polluted rivers. Actually, the houses have a certain charm. They are creatively built and surprisingly solid inside (though I worry about how well they would hold up in a typhoon).

No Support for the Poor

What makes the poverty so grinding is the total lack of backup. There is no welfare, no medicare, no food stamps. If you get sick, it’s too bad. If you have no food, it’s too bad. If your kid gets hit by a bus, or grows up disabled or blind from lack of vitamins, it’s too bad. I would say that about a third of the children I saw in the poor urban communities I visited were visibly malnourished and/or ill. Many communities have no plumbing. Clean water must often be hauled in from a faucet several blocks away. And it’s not always so clean. For those who are better off, the toilet may consist of a porcelain bowl that is flushed with a bucket by hand. For others, it is a rickety box with a hole in the bottom suspended over the river. You pee through the hole into the river. Squatters may live in such a community for years, yet they can be kicked out by the landowner at a moment’s notice.

 

The countryside is very beautiful, but I’m told that the poverty there is often even worse than it is in the cities. Large landholders own the best land, and the poor must sharecrop or grow rice on little paddies up m the mountains. Also, there is a war going on. The Philippines is embroiled in a protracted struggle similar to those in El Salvador and Guatemala. Recently, the Aquino government has been forcibly relocating peasants in many areas from their villages to camps where little food or medical care is available. The purpose of this policy is to allow the military to go into the countryside and hunt Communists.

There was much hope, I think, when Aquino first came to power. But many people I talked with had become disillusioned, saying that her Administration has not instituted much in the way of meaningful programs or reforms, and that regression continues. For instance, early in her administration a group of farmers marched to the National Palace to demand agrarian reform, only to be gunned down by the military.

Philippines Under the Thumb of International Capital

One obstacle to progress is the fact that, like so many developing nations, the Philippines is very much under the thumb of the International Monetary Fund and other creditors. To obtain international aid, the country must pay its debts. To pay its debts, it must place social services and political reforms on the back burner. Too much dissent can lead to detention, assassination, or worse. The price of rice keeps going up. And even when wages rise, they remain abysmally low. At present, though I twice saw gold Mercedes driving through these same streets, at east 30 million people in the Philippines—over half the population—live in abject poverty.

In response to this situation, there are a great many NGOs (nongovernmental organizations) doing impressive work. I visited MAG (Medical Action Group), which provides rehabilitation services to survivors of torture and offers medical care to families displaced by the war, as well as to the families of the disappeared and politically detained. HEAD, another NGO, provides medical services at rallies, marches, and demonstrations. HAIN is a large primary health care library which also produces publications dealing with the health care situation in the Philippines. I also visited a union office for hospital health workers, as well as a center for herbal and traditional medicine located in a squatter community. Then there was BUNSO (see below) and the Commission on Violence Against Women, and on and on.

I remember at one point complaining to a friend of mine there: “I’m very interested in all the political groups, of course, but what I really want to do is get my hands into primary care. I like visiting communities and working with the people.” She replied, “But there can be no real change without the political work.” Then she dropped her eyes and said softly, “We all started out doing primary care.” Some time later I learned that one of her close childhood friends had been murdered by the military at age 16 for doing primary health work among the poor. (This was during the Marcos days, but such things continue to happen under the Aquino government.)

Efforts to deal with problems directly are still often thwarted by the government or the military—especially if these efforts have a political flavor. In one community I met the pregnant wife of a young health worker/community organizer who was in jail because he had attended the funeral of another health worker who had been assassinated. The woman was trying to raise the money for the bail, which was an enormous sum for such poor people. Her husband had helped organize the construction of a latrine and sewage system in the community.

Visiting BUNSO—Promoting Breastfeeding

BUNSO (it means “youngest child”) is a large organization that promotes breast feeding. It goes into poor communities and trains mothers to teach others about breas feeding and baby care. In one community I saw, it has set up a food supplement co-op. It does organizing work on issues affecting mothers, babies, and children. Recently, I am told, several breast feeding teachers were arrested, charged with being subversives, and thrown in jail. After spending some time there, they were finally released.

I was appalled by the number of infant formula ads on television. * Next to electric fans, there seemed to be more commercials for this than for any other product. At least, thanks to BUNSO’s efforts, the ads no longer target newborns, but are limited to babies over six months. Nestle, which ran ads for its coffee products as well as for its infant’s/children’s milk, appeared to be the single biggest overall advertiser.

At the same time that they suffer difficulties and harassment, some of these organizations do receive some support and respect from the government. Many receive funding from international agencies such as UNICEF. I was also very impressed by the strength and level of organization of these groups, and by the degree of cooperation among them. In these respects they put us here in the US to shame.

 

Finally the orientation was over and it was time for the training to begin. We had about 16 students (two dropped out and two joined late). One woman was a “Hilot,” or traditional midwife. We also had three government-trained midwives who had each completed a two-year hospital course. Most of the others were community health workers who were getting their introduction to midwifery in this training. All could read. Formal schooling ranged from the third grade (our Hilot) to a couple of years of college. But the average seemed to be about six years of school. The participants came from all over the Philippines.

What good does it do to give dietary advice when there is no money for food? Or to teach cleanliness when there is neither soap nor clean water available?

We spent the first two weeks on prenatal care. We used lectures, slides, sewn teaching aids (like a cloth placenta and even a cloth pelvic bone), demonstrations, illustrations, and role-playing. To role-play a prenatal exam, a participant would be given a slip of paper describing a situation. For example: “You are 26 years old. This is your third baby. Your last period was December 4. You are having some pain m your lower belly and a little bleeding.” Then we would take a doll of the appropriate size and put it under her shirt, and pin a paper belly button at the appropriate level on the outside of her shirt. (The relationship of a woman’s belly button to the top of the uterus is one way to tell how pregnant she is.) Another participant would play the role of the midwife: take blood pressure, work out the due date, feel the belly, do an interview, and decide whether there was a problem and what to do about it. Sometimes we put the doll in “breech,” or set the doll size and belly button position for a date that conflicted with the calculated due date, and the students would have to figure out why. It was a lot of fun.

We also had two pregnant women in the training, who let us practice feeling their babies' position and doing real prenatal checkups before we went to work on women in the community. One of these was the nurse, Besing. The other was a Belgian obstetrician, Rita, who was working as a volunteer in the Philippines and assisted with the class. We also practiced other skills (such as taking blood pressure) on each other.

Community Prenatal Day

About two weeks into the training, we held a “Community Prenatal Day” in a squatter community named Apelo Cruz. About 15 women came, and the students took blood pressures, felt bellies, and did interviews. In a healthy population one might expect to find one or two women out of 15 with some kind of problem requiring special attention. In this group we found only four women who did not have a problem needing special attention (and they were all young women having their first babies). About five women were suffering from moderate to severe problems related to hypertension (high blood pressure/pre-eclampsia). One woman had a blood pressure of 170/110, which is extremely high for an 18-year-old pregnant woman. This woman also had a urinary tract infection. She had been experiencing symptoms for several months, during which period she had been going in for regular prenatals at a public clinic -apparently nobody had noticed. We found her problem during our routine interview.

 

Another four or five women had urinary tract infections. One woman had strange sores all over her body. One had lost her last baby after the birth, but did not know why. One, a tiny woman with a small pelvis, had undergone a previous C-section. This time the baby’s head was not in the pelvis at all (not head down), but up and off to the side—a sign of a baby too big (or pelvic bones too small) to fit. Small bones can be simple heredity, or the result of malnutrition in childhood. I do not know which was responsible in her case.

But what struck me the most that day, beyond the fact that statistically this was all wrong, was the realization that no amount of medical training or knowledge of the sort I was trying to share with these people is going to get to the root of the problem. What good does it do to tell a woman with high blood pressure to get bed rest if a day’s missed work means that she and her family won’t eat that night? What good does it do to give dietary advice when there is no money for food? Or to teach cleanliness when there is neither soap nor clean water available? Or to send people to a public clinic (assuming there is one) if, again, a day’s missed work means no food, and medicines are too expensive to buy? The women told me that sometimes they go to the public prenatal clinic and wait all day, but neither the doctor nor the nurse shows up. Clearly, something very fundamental has to change, and while the health work we do does save lives and improve people’s physical and even emotional well-being, it is the unfair distribution of wealth and power that is really making these people ill.

After the prenatal section of the workshop, we tackled labor, birth, and complications. We used local resources for teaching. For instance, to demonstrate what the uterus should feel like after childbirth, we had a woman lie down, placed a coconut on her stomach, and laid a sheet of foam over it: this simulated a well-contracted uterus felt through the flesh of the belly. To demonstrate an uncontracted uterus and to teach how to massage the belly to prevent hemorrhage, I lay down next to her and had people feel my soft belly and showed them how to rub it up. Then they felt the coconut to see the difference.

 

Looking back, it is clear that we did not leave enough time for this part of the training. It was too much to squeeze into such a short time, and we should have arranged some way to take participants to real births, especially those without prior experience. This could have been done if we had allotted a little more time, and held prenatals regularly in a particular community from the first day (thus getting to know the women and finding some who wanted us present at their births). Still, we covered a lot of ground, and people were pleased. The experienced midwives felt that they had added considerably to their knowledge and skills, and the novices felt that they now had a good foundation to build on. I learned much that will be helpful in revising the book—and also in life.

After the training the participants went back to their respective communities to begin or continue working m women’s health. The local organizations will be providing follow-up, while the participants will be sharing what they learned with others m the community.

 

With this phase done, I spent a week editing the book with Sylvia, and then went off to Mountain Province to meet with midwives there. Some of them had between 10 and 14 children of their own! One, Romana, told us that she had given birth to most of her babies alone without any help at all. “In the morning my husband would wake up and say, “Well, did you have the baby last night?,” and I’d say ,”Yup."' She was quite incredible—very strong. What must it be like to live “close to the earth” in a place where your ancestors have been for thousands of years?