Gender differences in three African societies: effects on health management
Postgraduate School of General Surgery, La Sapienza University of Rome, and Division of General Surgery, Nuova Itor Private Hospital, Rome, Italy.
Received 12 June 2017; accepted 2 November 2017.
Summary. The activity of an Italian surgeon in Uganda, Mali and Libya and his collaboration with humanitarian missions as “Ridare la Luce” (Giving Back Light) and “4 Stelle per l’Uganda” (4 Stars for Uganda) are described. The experiences are illustrated in the light of the gender differences regarding the health personnel and the relationship with patients, keeping in mind also religious and cultural factors.
Key words: Africa, gender differences, humanitarian aid.
Differenze di genere in tre società africane: riflessi sulla gestione della salute
Riassunto. Vengono descritte l’attività di un chirurgo italiano in Uganda, Mali e Libia e la sua collaborazione con missioni umanitarie come “Ridare la Luce” e “4 Stelle per l’Uganda”. Le esperienze sono raccontate alla luce delle differenze di genere sia per quanto riguarda il personale sanitario, sia nel rapporto con le pazienti e con i pazienti, tenendo in considerazione fattori religiosi e culturali.
Parole chiave: Africa, differenze di genere, aiuti umanitari.
As chance would have it, I was born in a fortunate part of the world: my outlook could have been much worse. There are countries, like those in Sub-Saharan Africa, where the average life expectancy is little more than 40 years, neonatal mortality is staggering, the average income is a few dozen euro a year, and mosquitoes still cause thousands of deaths.
As a result of this, we find it insurmountably difficult to fully understand a reality where, due to a cruel twist of fate (and other causes as well), millions of people struggle to survive.
Even more difficult to understand for someone who, as a surgeon, has spent a lifetime in operating rooms where technology reigns, diagnostic and therapeutic equipment is always state-of-the-art, materials are increasingly disposable, new, strictly sterile and non-reusable. Working in a hospital without computed tomography and ultrasound scanning equipment, without air conditioning when the outside temperature is over 40°C, is simply unthinkable.
Ridare la Luce (Giving Back Light)
The third millennium saw me travelling backwards, as if in a wonderful time machine, to an unexpected and, in a way, magical setting, where I rediscovered my role as a physician: no more paperwork, applications, authorizations, laws and regulations on the economic value of every treatment administered.
This is how, in autumn 2007, I happened to meet a general of the Italian Air Force and military physician, who, together with the Fatebenefratelli “friars”, had been carrying out for several years a humanitarian mission that they called “Ridare la Luce” (Giving Back Light).
Based in Mali, Africa, the mission aimed to perform cataract procedures that would restore vision in 70% of the population affected by this condition due to environmental and genetic factors.
The project required transporting personnel and equipment by aircraft made available by the Italian Air Force and Alenia Aeronautica. I suggested considering the possibility of including a surgical program in the “Ridare la Luce” project: unexpectedly, the proposal was not rejected - in fact, some time later it was approved. I found myself on board an extremely noisy C130, sitting on a seat made of interwoven red strips, with plugs in my ears.
After many, many hours of flight on a “non-soundproof” military airplane, where the only possible form of communication is by gestures and facial expressions, we proceeded to unload tons of humanitarian aid, medical equipment, supplies, bottled water, spaghetti, mosquito spray, and set off for the last stretch of our journey, an interminable dirt road by which we finally reached our destination. The reward that immediately made us forget the hardships we had endured was the incredible, touching and even embarrassing welcome we received from the local people.
All around us, as far as the eye can see, a magical landscape of simple things: few, essential objects, and long, long roads that people walk to come home at night, tired, carrying weights on their heads - roads covered in dust or, during the rain season, in mud and slime.
In clashing contrast with this scenery, the Niger river flows unperturbed, without realizing that without its water, all around it there would not even be the little that there is. Evening after evening, at sunset, it quietly goes to sleep (Figures 1-2).
The women work very hard, they cook, go get water however far it may be, harvest and grind wheat to make bread, and watch the children, however numerous. They walk miles and miles, slowly, carrying incredible weights on their heads: extremely heavy containers, clothes still dripping with water from the river, stacks of firewood. You see them often, in groups, on the bank of the river along which, over time, a small cluster of mud and straw dwellings has developed: it’s a gathering place, perhaps the only one, where they can socialize, take their children to play when the school is too far away and the kindergarten is right there, along those few yards of riverside where the Niger flows more slowly.
The river is life. Here, it is easy to imagine the birth and development of the great civilizations of the past: you can readily understand how essential it is to reach the opposite bank and how valuable is a pirogue made of four hand-sawn and tarred planks. On the other side of the river there is the market. There is the hospital. The price to cross the river is high: it takes the equivalent of one euro to get to the other side, and few people can afford it. And so it happens that diseases are left untreated on the other side and the river becomes death.
Freeing a blind person from the cataract that progressively blurs vision until none is left, also means freeing a great number of children who are used to guide blind elderly people, sacrificing their adolescence and their education. Over the years, through the “Ridare la Luce” program implemented and supported by the Italian Air Force, Alenia Aeronautica and AFMAL, hundreds of surgical procedures have been performed to restore the vision not only of adults but also of many children who, due to environmental reasons and genetic predisposition, never had eyesight or lost it early. The journey to reach the hospital is long and expensive, and sometimes the patients cannot leave their families, or the family refuses to leave their loved one alone. So they all leave together and remain inside the hospital walls: the patient in the ward and the family at the foot of a tree with few things to survive: a little saucepan, a burner, a few sheets to sleep on, the two goats that also could not be left alone. There they wait to go back home all together. People pay for healthcare: in such a poor country, the state cannot afford to provide free care. The medicines required for general anesthesia and for the surgery have to be bought; the same applies to antibiotics and everything else. The surgical procedure also has to be paid: if it is not particularly complicated, it costs the equivalent of the price of a goat sold hastily at the market. It is easy to see, then, why people may choose what they call traditional medicine: witch doctors and healers who promise an unlikely cure in exchange for a chicken if the case is particularly difficult.
In these countries, governments and local administrations need to strike a delicate balance in managing healthcare, dictated by the absence of free public healthcare. Any change can result in an imbalance that alters the trust relationship between the citizen-patient and the hospital. This explains why in Mali, after completing our mission and performing a great number of procedures, I was summoned by the director of the hospital who invited me to pay for the use of the operating rooms.
The news of the arrival of the Italian doctors spreads fast, usually announced a few days in advance by local radio stations and word of mouth. Early in the morning, they were already there waiting for us, with suffering on their faces, in contrast with the wonderful African colours of the clothes on their lean bodies.
4 Stelle per l’Uganda (4 Stars for Uganda)
In Uganda, the requests for support in certain specialized areas of medicine and surgery, received from the Saint Joseph Hospital of Kitgum, where the NGO AVSI has successfully operated for years, found immediate response. During approximately 10 days of activity, the mission “4 Stelle per l’Uganda” (4 Stars for Uganda) carried out by Armed Forces personnel and volunteers of the Nuova Itor clinic of Rome, performed over 100 surgical procedures, 230 digestive endoscopies, hundreds of gynecological and obstetrical examinations, ultrasound scans, colposcopies and orthopedic examinations, as well as over 500 microscopy analyses and laboratory tests. The previous year, in Mali, we reached remote villages on the banks of the Niger river on board an unsteadily floating boat that, judging from the camouflage uniforms, seemed to overflow with marines in full fighting gear, rather than with doctors on a healthcare program.
Deeply convinced that “it is better to teach a man to fish than to give him a fish”, we dedicated most of our daily activities to a prevention and training program: by the time we left, the hospital staff was able to make a basic endoscopic diagnosis, had improved their sonography skills, learned new surgical and clinical-diagnostic techniques, and could provide basic cardiopulmonary first aid.
Here, the children are more alone. They can often be seen wondering with an uncertain look in their eyes, looking for who knows what. Those who manage to summon the courage approach you, asking “cadeaux, cadeaux!”.
They don’t ask for money. Their eyes light up if you give them a pen, a notebook or a sweet, which sometimes you have to unwrap for them. Then they turn around and walk away with a saucepan on their back, a half empty bag, a plastic bowl and your notebook, every page of which will remain blank.
They make their own toys: bundled up plastic bags to play football, a few pieces of wood to make a truck, a bicycle tire becomes a colored crystal circle that can be rolled along for hours. Sometimes you see them happily running towards you, they smile at once and wave their hands in joy, without waiting for you to smile first. Sometimes they surprise you with their simplicity: they suddenly realize we are there, and are instantly out of the water, naked, laughing as they run towards us. Other times the roles are inverted: they stand in front of you, staring at you, face intentionally blank, arms down their sides, and in their eyes - nothing. If you are not quick in showing them the smile they are asking for, a second later they turn around and run away, leaving you a little sad.
The children of Kitgum, the children of Gao, like all the children in the world, play in the same way, use the same language, the same gestures. They have an innate desire to socialize, form groups, share adventures, victories and defeats. They imitate the grownups, they play at war. They don’t know yet that, when the time will come for the real battle, the only weapons they can rely on are those provided by education and training programs. However, the adults are finally becoming aware that a better future will be the result of knowledge: it is no longer as unusual as it used to be to find parents who are willing to make enormous financial sacrifices (school is also very expensive here) for their education.
Along with school, an equally important role is played by religious education, which has a significant part in instilling the principles of unity and equality which, in essence, are common to all faiths. In these countries, the participation of the faithful in religious rites is particularly heartfelt and arouses admiration. In the church of Kitgum during Sunday Mass, deeply moving moments of silent prayer alternate with the sound of many voices singing to the rhythm of tribal instruments. In Djenne, Mali, the world’s largest Mosque, a World Heritage Site, built with mud and straw, melts during the rain season, and every year thousands of pilgrims rebuild it the way it was before.
And then it’s time to go home. You look at the mosquito net over the bed, you put a few things back in your bag, many more you leave behind as a last action intended to prolong our presence for a few more days.
And as you fly back, sitting on a seat made of interwoven red strips, with plugs in your ears, you think. You ask yourself questions, you seek an answer. “What could they be doing now? Will they be able to perform on their own that procedure I taught them? We will never be able to carry out that telemedicine program. This was just a drop in the ocean, but... when are we going back?”
Gender differences in Central Africa, Uganda
The Kitgum hospital is about two hours of unpaved road away from the capital Kampala. It was created among mug huts thanks to the obstinacy of a group of Comboni missionaries who succeeded, by winning the trust and participation of these extremely poor people, in building from nothing an efficient hospital, two schools and a large church. Boko Haram and its bloodthirsty followers would enter the country from South Sudan, rape women and girls, and take away the boys from their families and force them to become child warriors. On these sad occasions, the Kitgum hospital with the unrelenting support of the Comboni missionaries, some of whom were killed, kept in hiding and saved from death hundreds of people. In this context, the Catholic religion found a favorable ground to expand, disseminating principles of mutual respect and equality (Figures 3-4).
This is how they were able to bring about the birth of a micro society, removed from the local context, where men and women are equally respected. In the hospital, non-medical healthcare personnel is employed without discrimination between the sexes; in fact, female nurses are assigned roles of responsibility in day-to-day care: examples of this are the non-medical manager of the anesthesia service and the Catholic nuns who manage the healthcare departments. The medical staff, consisting of the sons of the wealthiest families, provides care to the 250 patients hospitalized in the facility.
The two school buildings are attended by children up to an apparent average age of 10-12 years; boys and girls wear a similar blue smock of which they are very proud. As with healthcare, however, the price of sending children to school is high, not only in financial terms. Considering that the daily activities of a local family require, in order to survive, the constant presence of each one of its components, it is easy to understand that giving up a member of the workforce in favor of education can be unsustainable. Poverty is even more evident outside this microcosm, throughout dozens of miles in the surrounding area, where the lack of free healthcare and the absence of mandatory schooling imposes the need for families to make choices in favor of one child instead of another. It is not coincidental that, in this type society, parents who gave three of their children the opportunity to graduate in medicine chose in favor of their sons, while heavier work like fetching water or carrying firewood on their back has always been assigned to women.
Gender differences in Mali, Sub-Saharan Africa. Gao and Mopti hospitals
Mali is one of the poorest countries in the world, and its hospital, located in one of the few larger cities, is actually even poorer. It is essential to know that, here again, healthcare is fully private, and therefore it is reserved for those who can afford to pay for hospitalization or surgery, and even the medications required for a surgical procedure have to be purchased before admission to have them available before, during and after the operation (Figure 5).
Numerous specialists participated in the humanitarian mission, including a gastroenterologist, whose main task was to teach two hospital physicians the basics of endoscopic diagnostics. One of the many gastroscopies performed by our gastroenterologist showed the presence of a gastric neoformation of suspected neoplastic nature: for histological confirmation, a biopsy was performed which, placed in an appropriate container, was ready to be sent to the capital Bamako, where the University is located. Intending to repeat the same humanitarian mission, eight months later some of us visited the same hospital and were greatly surprised to find that the container and the biopsy were still were they had been left the previous year. Unfortunately, the histological test to be sent to Bamako had a cost that the patient evidently could not afford. The question is: if the test had been performed and had confirmed the presence of a neoplasm, would the woman have the financial means to undergo surgery? And if the patient had been a man instead of a woman, as in this case, would the situation have been different? Would there have been greater support from the family to incur the cost of the necessary treatment? Probably not: albeit with different roles, apparently both sexes enjoy equal dignity, and although Islam is the dominant religion in this country, here women rarely wear anything more than a simple veil on their head. The face is left uncovered in order not to hide the beauty of Mali women. In this area, the entire territory around the towns of Gao and Mopti, where the hospitals in which we conducted our activities are located, there is a strong presence of members of the Tuareg tribe, who have significantly influenced the local habits and culture.
Although the Tuareg are Muslim, unlike other societies of the Islamic world their culture is advanced with regard to the role and emancipation of women. For example, it is the men, not the women, who cover their faces. However, Tuareg societies cannot be described as matriarchal: the most important political decisions are made by men.
In this context, archaic superstitions are left behind, like the traditional discrimination against albino children, previously isolated and abandoned by everyone: one of them, a little girl, was affectionately accompanied by her parents to the ophthalmological examination.
Another project, instead, failed since the beginning: the presence of a mammograph at the hospital would have allowed us to promote a breast cancer awareness and prevention campaign.
A radio announcement would broadcast the news; the women of the nearby villages would undergo a free breast examination and, if appropriate, a mammogram, the cost of which we would incur ourselves. The project was never carried out, because offering a free healthcare service would constitute a dangerous precedent, which after our departure could have given rise to demands for free care.
Experience at the hospital of Benghazi, Libya
As is well known, the presence of the Muslim religion is very strong in this country. Many women wear the Burqa or a black tunic that covers the entire body, including the eyes. Gender discrimination is predominant, and women (nurses or, rarely, physicians) do not have responsibility roles in the hospital. I performed many outpatient examinations, and I often had to examine patients who were completely covered, with only the eyes barely visible, hidden by a thick fabric mesh. Many times, male physicians are not allowed to visit patients of the opposite sex other than in the presence of a female nurse and with the husband’s permission. Another time, in front of me in the surgery was a young married couple: she was wearing a burqa and never said a single word, he sat stiffly and answered for both of them. As my eyes shifted from one to the other, I noticed that my interpreter looked increasingly nervous. I learned only later that the man had felt offended by my behavior, since I had dared look his bride repeatedly in the eye. I performed many surgical examinations and procedures in this country, but my limited and highly specialized field of action did not allow me to conduct definite evaluations on gender differences in the conditions I treated. Quite evident, and equally well-known is what can be easily observed in everyday life, where the woman - whether wife, sister or daughter - submits to the decisions of the man and accepts this submission without showing any uneasiness or dissatisfaction.
Conflict of interest statement: the Author declares no potential conflits of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.
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