Gone with the Wind

I had a pleasant weekend. On Saturday I made pancakes, did yoga, cleaned up a little, and read Gone with the Wind.

This was on the cover of the copy that I read.

(Spoiler alert in case I wasn't the last person ever who didn't know anything about Gone with the Wind.)

I've never seen the movie, but I'd absorbed enough information from crossword puzzle clues and just living in America to know that it’s an epic romance about a pretty lady on a plantation during the Civil War. I knew there was a part about Atlanta burning, something about curtains, a house called Tara, and Clark Gable not giving a damn. I figured that there would be a lot of picturesque landscapes and racism and accounts of historic battles and people falling in love under difficult circumstances.

As it turned out, there were indeed long and captivatingly yonic descriptions of the countryside, and the tumult and history of the war and the deterioration of the social order all made for good reading. I was distracted but not surprised by the racism, both depicted and inherent, and kept being reminded of a part of this David Sedaris short story called Six to Eight Black Men that goes "history has proved that something usually comes between slavery and friendship, a period of time marked not by cookies and quiet hours beside the fire but by bloodshed and mutual hostility." 

The thing that caught me off guard was the ending. I just wasn't expecting “the greatest love story of our time” to finish with a fatal miscarriage and the post-mortem of a broken marriage. Tomorrow may be another day, but I still closed the book feeling slightly gut-punched. 

In any case, I found myself reading so much of the novel from the perspective of a Public Health Volunteer - I liked how often dysentery was mentioned, interested that diarrhea was given a place of prominence among the many undignified ravages of war and poverty. I liked that the notion that women invariably possess a “maternal instinct” was thoroughly dragged through the mud. I liked that reproductive health issues kept coming up – the unmet need for reliable contraception, the burden of unwanted pregnancies, the many forms of prostitution, the grim dangers of childbirth and back-alley abortions. (I feel compelled to point out that these are still very real problems for women and girls around the world.) I couldn't help but think that modern contraception and obstetric care could have saved Scarlett from resenting motherhood and Melanie from suffering horribly and dying. I feel like Scarlett would have been all about birth control. 

But I suppose that if Scarlett had been on the pill and Rhett had just talked about his feelings then maybe they would have figured things out and built a happy life together, but it wouldn't have made for such a dramatic saga. 

Also, I now really want to read/watch 12 Years as a Slave. I've been hearing wonderful things about how harrowingly good it is, and I feel like it would be a good counter-balance to Gone with the Wind's rosy portrayal of slavery and the whole master-slave relationship. 

Pilot Project: Community-Level Contraception

There is a huge unmet need for contraception in Guinea. Pretty much everyone here loves babies, but women often aren't able to space out their pregnancies or to stop getting pregnant once they have the number of children that they want. Especially in rural areas, too many girls and women are injured or killed by complications from pregnancies that are too close, unwanted, or high-risk. Using contraceptives for birth-spacing and avoiding unwanted pregnancies means healthier babies and healthier mothers, and in a culture that really values having children that message is appealing to a lot of people. Unfortunately, actually getting contraceptives can be difficult, especially for women living in rural villages without health structures. There are efforts to increase access, including launching programs to recruit and train people who are literate, responsible, and respected in their communities to be Community Health Workers (CHWs). These CHWs are able to serve as a accessible resource for information, advice, condoms, contraceptive pills, and referrals to local health structures. 

Photo courtesy of Save the Children/Guinea.

Save the Children launched a pilot program to improve and expand access to contraceptives by working with the Ministry of Health to recruit successful CHWs and train them to administer DMPA, a contraceptive injection better known as Depo-Provera. (DMPA is safe, reversible, extremely effective and lasts for three months at a time - not having to take (or hide) packets of pills is really appealing for many women.) Aside from safely giving an injection it is really important to make sure that a women is eligible (not pregnant, no relevant health problems) and understands the risks and benefits of DMPA. The CHWs were trained about reproductive health issues, effective communication methods, reporting and evaluation, when to make referrals to medical professionals, and how to minimize the risk of infection. A lot of work also went into communicating with local authorities, community members, religious leaders, village chiefs, husbands, and health professionals, so that people understood what the project was all about and to raise awareness about maternal morbidity and mortality in Guinea.

By all accounts, the pilot project was successful: when it was added to the other contraceptive options available in their villages, many women opted to switch to DMPA, and other women who hadn't used contraceptives before opted to try it. Women who tried DMPA reported that they had been advised about common side effects and nearly all reported a high level of satisfaction, even when they had experienced minor side effects. The biggest problem was that supply chains are really unreliable in Guinea "and ruptures of stock" are really, really common. (Stock-outs are really disruptive, not just for contraceptives, but of all sorts of medications and supplies.) There were no reports of serious side effects or infections, and all the women surveyed at the end of the pilot phase reported that they were planning on going back for their next injection, which says a lot. 

Photo courtesy of
Save the Children/Guinea.

Photo courtesy of
Save the Children/Guinea.

The Save the Children team presented all of this (and much more!) in Conakry last week, and it was really interesting to watch the response to presentations and to listen to all the questions and feedback. Despite the mountain of evidence demonstrating the many benefits of reversible long-acting contraceptives like Depo-Provera and Intrauterine Devices (IUDs), it can still be a touchy subject – even in the U.S. we can’t seem to figure out a way to make them affordable and widely accessible.

There seemed to be a lot of interest in the project, and a lot of support for better access to reproductive health services in general, which was encouraging, and I'm hopeful that I'll be able to work on the project as it continues on the next phase.