A Good Position for Birth
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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.

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Date de parution 23 novembre 2018
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EAN13 9780826522023
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A GOOD POSITION FOR BIRTH
A Good Position for Birth
PREGNANCY, RISK, AND DEVELOPMENT IN SOUTHERN BELIZE
Amínata Maraesa
Vanderbilt University Press
Nashville
© 2018 by Vanderbilt University Press
Nashville, Tennessee 37235
All rights reserved
First printing 2018
This book is printed on acid-free paper.
Manufactured in the United States of America
Library of Congress Cataloging-in-Publication Data on file
LC control number 2017044710
LC classification number RG963.B42 M37 2018
Dewey classification number 362.19820097282—dc23
LC record available at lccn.loc.gov/2017044710
ISBN 978–0-8265–2200–9 (cloth)
ISBN 978–0-8265–2201–6 (paperback)
ISBN 978–0-8265–2202–3 (ebook)
To Kennon Rodney and Miss Margaret Edwards, whose lives—and deaths—have altered my understanding of and relationship with Toledo. And for Afinatou, Safouane, and Douniya, because I love you infinity times pi times the oven you bake the pie in .
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
Figures and Tables
Figures
All photographs are by the author, except as noted.
1. Punta Gorda market with women in Kekchi-style dress selling vegetables
2. Punta Gorda market with Mennonite men selling watermelons
3. The satellite television company in Punta Gorda
4. Stickers affixed to a village shop vitrine
5. The slogan of a popular Belizean brand of purified bottled water reads, “The Melting Pot of Races”
1.1. A Kekchi woman and her children at a mobile health clinic
1.2. Baby suspended from the rafters in a lepob
1.3. Nurse Ical administering a vaccination on mobile clinic in Branch Mouth. Photo courtesy of Skyler Paccio
2.1. Village buses lined up at midday for their return voyages from Punta Gorda
2.2. Nurse Caal administering prenatal care at the San Juan rural health center
3.1. Miss Margaret’s framed TBA certificate reads, “The Ministry of Health certifies that M. Margaret Edwards has satisfactorily completed a course of training, 1987, in Practical Midwifery to enable her to perform efficient service as a traditional birth attendant in Westmoreland Village, Punta Gorda Road, Toledo District”
3.2. Miss Margaret standing in the doorway to her home. With limited telecommunications in Toledo, unannounced visitors knew that Miss Margaret was home only if they saw her door open
3.3. Miss Margaret’s hands ’nointing a woman who arrived complaining of excessive postpartum bleeding
3.4. Kekchi woman carrying her baby in a lepob
3.5. Bush doctor identifying plants at Itzama Medicinal Garden, Golden Stream, Toledo. Photograph by Patrycia Sulich
4.1. Wooden-slat, thatched house in rural Toledo
4.2. Rosalia bent over Elizabeth, timing the fetal heartbeat
4.3. Full width of a Kekchi woman’s skirt, hanging to dry on the side of a house in Esperanza village
4.4. Local blue crabs in a barrel
7.1. Sign erected at the entrance of Punta Gorda after the death of MaSauce. “Peini” is the name given to the area by the first Garifuna settlers
7.2. View of the sign leaving Punta Gorda erected after the death of MaSauce
7.3. The new hospital under construction in rural Toledo (2008)
7.4. Miss Margaret in her home with the author
Tables
1. Ethnic Composition: Belize and Toledo District (2010)
2. Parity of Women Attending Prenatal Clinic at Punta Gorda Hospital (July 2006)
1.1. Rural Health Center Data for the San Juan Catchment Area, pop. 5,150 (2003–2005)
1.2. Rural Health Center Data for the San Juan Catchment Area (2013–2015)
1.3. Maternal Deaths and Maternal Mortality Rates (1998–2013)
2.1. PG Prenatal Clinic Attendance and Parity
2.2. PG Prenatal Clinic Attendance and Marital Status
Acknowledgments
I thank first and foremost the people in Belize who shared their time with me throughout my fieldwork and beyond. To protect their anonymity, I cannot identify individuals by name, but please know that I am grateful for your kindness and your offering of the sensitive and personal information that has contributed to this work on reproduction. I am forever indebted to Shanon Rodney for taking care of my children, taking care of me, and eventually including us in her household and extended family network. I must acknowledge the invaluable assistance of the Ministry of Health and the many officers and personnel who facilitated my quest for knowledge. I also wish to thank GIFT and its employees for opening their doors to my project and giving me an initial start in the field. Finally, I am deeply appreciative of the many individuals who assisted me over the internet (especially Mr. Marvin Moody and the Statistical Institute of Belize) in acquiring last-minute data from archival sources in Belize and Ruth McDonald for hospital logistics and data. Thank you to Santiago Shol and Eduardo Salam for their assistance with the Kekchi-English translations, Ignasi Clemente for Spanish help, and Tyrone Avila for Garifuna grammatical correctness.
I thank my academic interlocutors Connie Sutton, Aisha Khan, Emily Martin, Don Kulick, Ulla Dalum Berg, Jack Murphy, Lauren Fordyce, Alyshia Gálvez, and Kristina Baines who provided continuous encouragement, advice, and critical reflection throughout. I especially thank Rayna Rapp for her unwavering support and confidence in my work and for looking out for me on countless occasions. And thank you Theodore Kirkland, Mark Payne, and Mohammad Hassan for your initial faith in me.
I am deeply appreciative of my many friends who maintained their belief in my madness—without your support this work would not exist (I love you Lynda, Sadiqa, Latá, and Nara). Brigitte et Daniel, je n’y serais pas arrivée sans vous . Nicole, my rock together young until we die. And Madala who was there literally from day one. But of course, Afinatou, Safouane, and Douniya: you never cease to exhibit incredible patience with a stressed-out mom. Thank you for allowing me to uproot you from the City and replant you in the bush. Life begins anew. I dream of fish. Aum Shanti .
Generous funding for various stages of this research and writing was provided by the Wenner Gren Foundation for Anthropological Research, the International Women’s Anthropology Conference, and internal grants at New York University.
A heartfelt thank you to my editor, Michael Ames.
Portions of Chapters 4 , 5 , and 6 also appear in Maternal Health, Pregnancy-Related Morbidity, and Death among Indigenous Women of Mexico and Central America: An Anthropological, Epidemiological and Biomedical Approach , edited by David Schwartz and published by Springer (2018).
Introduction
“Here we could have as many babies as we want. We no have no laws against that.”
Comment I often heard from pregnant women at the prenatal clinics
“Mr. Price say mek we build the nation!”
Teodora, a thirty-eight-year-old Mopan Maya woman discussing pregnancy 1
It is early Wednesday morning, February 2006, in Punta Gorda, the only town in the southernmost Toledo district of Belize. The sea laps at the rocky coastline, hens shepherd their broods, and schoolchildren join their peers across the country as they stand to start the day with the national anthem. Most wear uniforms, although some do not have shoes, and all learn from a very young age to be proud citizens of this peaceful democratic nation located between Central American and Caribbean political unrest and economic instability. Strolling down the sidewalk and past the open-air classrooms are the many pregnant women who come to shop, visit friends, and attend the prenatal clinic at the town hospital. Some are accompanied by young children, and others must hurry home to cook for those returning from school. For some, this is a first child, while for others who have had four, five, or more children already, this pregnancy confirms their belief that only God knows how many they will have. Although all are eligible for the free prenatal care offered through the Ministry of Health (MOH), most will not take advantage of these services until the second or third trimester, when their bodies have confirmed the existence of the pregnancy, and many will deliver their babies at home without the presence of a trained birth attendant—abiding by the folk-wisdom of the mothers before them who ensured the safe delivery of their babies through a particular kind of prenatal massage believed to set the fetus “in a good position” for birth.
Since the mid-1900s, the training of village-level health workers and “traditional birth attendants” (TBAs) by the Belizean MOH has been part of a World Health Organization (WHO) development model to encourage rural-dwelling women to engage with official medical care providers and close the purported ideological gaps between global public health-care initiatives and local practices, thereby legitimating a specific role for traditional practitioners alongside the nurse-midwives who dominate the domain of public health. In 2000, Giving Ideas for Tomorrow (GIFT), a US-based nongovernmental organization (NGO), began a TBA training program in Toledo that sparked the controversies associated with foreign involvement in local affairs observable during my fieldwork in 2006. 2 On the periphery of mainstream maternity care are “bush doctors,” the traditional healers who influence the health-care decisions made by pregnant women and their perception and management of perinatal risk.
The chapters that follow focus on pregnant women and maternity care providers in the Toledo district. Despite both cultural and geographical variation in the region, the people hold in common the lowest economic and social indicators countrywide: the greatest poverty, the lowest levels of education, the highest fertility, and the greatest difficulty in obtaining emergency medical services. The maternity services provided by the MOH, the practices of TBAs, and the influence of sociocultural and environmental realities on women’s reproductive decision-making processes constitute the main focus of this book, whose argument is that these intimate processes reflect the wider contexts in which they occur (Ginsburg and Rapp 1991).
Geography of a People
Belize is a small country located in Central America; its territory includes a multitude of small islands and mangrove tangles that dot the Belize Barrier Reef off its Caribbean coastline. According to 2010 Census data, the country’s population of 324,528 individuals comprises at least eight distinct ethnic groups and admixtures thereof, almost equally divided between males and females and found in near equal proportion in both urban and rural settings, with an extremely low average population density of thirty-six persons per square mile (Statistical Institute of Belize 2013). English is the official language of Belize, which is a former British colony, although Belize Creole, Spanish, Garifuna, three distinct Maya languages, and Plautdietsch are commonly heard. Since the 1980s, Belize has experienced an influx of Spanish-speaking immigrants. As a result, the ethnic demography has rapidly changed, as has the first language of many Belizeans (Woods et al. 1997; Statistical Institute of Belize 2013).
The territory now known as Belize was originally part of the Spanish claim to the New World. Contact and subsequent conquest dates to 1508, at which time Belize was home to several Mayan civilizations with extensive trade networks from Mexico through Central America and even to the Caribbean islands (Jones 1989; Farriss 1984). Mayan sites, predating Columbus by more than half a century, dot the countryside. These colossal stone structures bear witness to a civilization that inhabited the area fifteen hundred years ago, the decline of which is dated to around 800 CE. Now, these sites are some of Belize’s key tourist attractions and provide the hard evidence cited by contemporary descendants of ancient Mayan peoples in their struggles for indigenous privileges and land rights (Maya People et al. 1997).
The colonial history of the Americas was fashioned from warfare and exploitation. European powers fought for control of human and natural resources through official treaties and declarations. Meanwhile, they also engaged in extralegal activities that played a role in the history of Belize. High demand for the logwood booty of British pirates led to the eventual settlement of Belize in the mid-seventeenth century by British hardwood cutters pursuant to various accords between Britain and Spain. Eventually Spain lost this part of what was ubiquitously called Honduras in 1862, whereupon the territory was renamed British Honduras. To this day, the romanticized entrepreneurial spirit of these settler ancestors is eulogized in the chorus of Belize’s national anthem:
Arise! Ye sons of the Baymen’s clan
Put on your armours, clear the land!
Drive back the tyrants let despots flee—
Land of the free by the Carib Sea!
Early foreign interest in the country’s rainforest ecology meant that the colonial economy of Belize developed very differently from other New World territories under British control that were economically and socially organized around plantation economics and sugar production (Mintz 1985). The British introduced enslaved Africans to the territory, but Belize’s orientation toward lumber exports did not require extraordinary numbers of human laborers. According to Bolland, “The extraction of the timber was executed by small gangs of slaves who did not appear to experience the hierarchy of control which characterized the plantation system. . . . [They] were distributed in small groups, with little supervision but great knowledge of the terrain, throughout hundreds of miles of uncultivated and essentially uninhabited land” (2003, 23–24). Because of these unique conditions, it has been argued that enslaved Africans in British Honduras enjoyed a freedom greater than their plantation counterparts (Caiger 1951; Metzgen 1928). However, relative liberty cannot be conflated with absolute freedom, and Bolland emphasizes that there is no evidence that enslaved Africans “were content to be dominated” (2003, 25). Indeed, the colony’s early history is marked by numerous revolts that shook the foundations of the early settler community, while the country’s vast forested regions provided enslaved laborers with opportunities for escape and refuge from colonial control (Bolland 2003, 25–28).
Creoles (who make up 25.9 percent of the total population) are officially defined as descendants of these enslaved Africans mixed with European ancestry. Yet, as a category of difference, Creole has also come to blur ethnic distinction. Belizeans commonly refer to “Creole” identity as a mixture of any sort—one sometimes referred to as “rice and beans.” Others, who defy an ethnic label all together, protest what they feel is political manipulation and simply call themselves “Belizean” (Merrill 1992). Nonetheless, Belizeans must still choose from the colonial legacy of unitary ethnic demographic categories, so some redefine Creole to include ethnic mixtures of all types, as evidenced by the small number of people who categorize their ethnic identity as “Other” (1.2 percent) and the Census’s disclaimer that “Column percentages [of ethnic identity] will not sum to 100, as some persons claim more than one ethnic group” (Statistical Institute of Belize 2013:20) (see Table 1 ).
The Garifuna people comprise 6.1 percent of the country’s population. According to oral testimony, the Garinagu are descendants of shipwrecked Africans who landed on St. Vincent and resisted enslavement by escaping to the peripheral forestry of colonial settlements and mixing with the Carib and Arawak indigenous populations. 3 As tension between France and England mounted over the colony’s ownership—and the Garinagu began to assist the French—they were exiled by the British from St. Vincent to the island of Roatan, Honduras, in 1796 (Gonzalez 1988). European colonial warfare again displaced the Garinagu along the Central American coastline where November 19, 1802, is celebrated in Belize as Garifuna Settlement Day. The Garinagu were the first to populate Toledo’s coastal areas and the first to settle what they called Peini—now the town of Punta Gorda (PG), Toledo’s peripherally located urban center. They pride themselves on never having been enslaved, on their fierce independence, and for maintaining their distinctive traditions and language in spite of the anti-Garifuna sentiment of early British settlers and Creole elite (Cayetano and Cayetano 1997).

Table 1. Ethnic Composition: Belize and Toledo District (2010)

(Statistical Institute of Belize 2013)
By the mid-1800s Belize’s timber trade had declined, and economic development shifted to export agriculture. Slavery was abolished in 1834, yet coerced labor continued in the form of an “apprenticeship” system and later the indentured servitude of Chinese and East Indians who came to the colony via Jamaica and Guyana to work on the new plantations (Ranguy 1999). The territory officially became a British colony in 1862. This coincided with political upheaval in the United States whereupon colonial administrators in British Honduras successfully enticed Southerners to operate plantations in Belize (Simmons 2001). A Louisiana-based company, Young Toledo and Co., and upward of fourteen white families set up large tracts of sugar plantations in what became the Toledo Settlement along the roadway connecting PG to the rest of the district (Hill 1936; Wilk 1997). The company went bankrupt in 1880, and most of the white families moved back to the United States. However, the village settlements along what is now the San Antonio Road continue to be predominantly populated by East Indian descendants of these indentured peoples (Shoman 2000). 4
Political instability and warfare in neighboring countries as well as economic opportunity led three linguistically distinct Maya groups as well as Mestizos—defined as the descendants of the miscegenation of early Spanish colonists and the indigenous populations and usually referred to as “Spanish”—to immigrate into present-day Belize. When combined, the Mopan, Kekchi, and Yucatec Maya make up 11.3 percent of the Belizean population; however, they comprise a 66.5 percent majority of the population in Toledo (Statistical Institute of Belize 2013). 5 Although the Maya are lumped together for Census purposes, each group has a distinct history of immigration and settlement. The Yucatec Maya, found in the northern areas of Belize, are descendants of refugees from the 1847 Caste War, which also displaced large numbers of Mestizos from the Yucatan Peninsula into neighboring Belize. The Mopan and Kekchi are found primarily in the southern Toledo district to whence both migrated in the late 1880s (Rambo 1962). The immigration of Kekchi Maya is ongoing, and many immigrants have a fluid border relationship with family and economic markets in neighboring Guatemala.


Figure 1. Punta Gorda market with women in Kekchi-style dress selling vegetables.
Due to violence and economic hardship, Mestizos also continue to immigrate into Belize from Guatemala, El Salvador, and Honduras at a growing rate, such that they are now the majority (52.9 percent) of the national population (Palacio 1993). In Toledo, the Spanish-speaking Mestizo population constitutes a relatively large segment (19.9 percent) of the district’s inhabitants. However, they are concentrated in a few villages located at the border of the Toledo and Stann Creek districts. There they form a peripheral presence that is economically and socially oriented away from PG toward the plantations and urban centers in the country’s central region.


Figure 2. Punta Gorda market with Mennonite men selling watermelons.
Mennonite groups immigrated to Belize to maintain religious freedom and a way of life based on agricultural production (Sawatsky 1969). They comprise 3.6 percent of the national population and 0.8 percent of the population in Toledo, where they fall into two categories. Recently arrived, proselytizing missionary groups from the United States live in close proximity to PG, while a closed community of Russian Mennonites, who began migrating in the 1940s from Canada, live in a private farm community located at some distance from the town center. Despite their small numbers, the Mennonites are the main producers of all agricultural products for the entire country. In Toledo, the Low German-speaking Mennonites are likewise farmers; however, their lifestyle forbids the use of electrical equipment and machinery. They live a separatist lifestyle and partake little in the social world of the Toledo district except on Wednesdays, when pregnant women attend the prenatal clinic at the PG hospital, or Saturdays, when a few men drive their horse-drawn wagons loaded with watermelons—their primary cash crop—to the town market. 6
Chinese immigrants also fall into two groups: those whose ancestors were indentured migrants and who have blended into the country’s social fabric, and a recent wave of Chinese immigrants that began arriving in 2000. This latter group dominates ownership of small grocery stores and fast-food restaurants, which stay open through lunchtime and well into the evening hours after most Belizean establishments have closed for the day.
Those categorized in the Census as “Caucasian/White” or “Other” may include Lebanese, Syrians, and increasing numbers of expatriate North Americans who are taking advantage of early retirement incentives to encourage English-speaking settlement (no doubt to counter the recent influx of Spanish speakers as well as to capture US pensions). While US retirees are not allowed to seek employment, they are permitted to engage in their own small business ventures and generate employment for native Belizeans. Many in the Toledo district have done just that.
In 1961, at the height of worldwide decolonization struggles, Belize was granted “full internal self government” (Shoman 2000, 197). British aid and protection remained crucial because of the ravages of Hurricane Hattie in that same year and ongoing border disputes with Guatemala that have yet to be resolved. The Belize Defence Force (BDF) continues to patrol the Guatemalan borders in the Toledo district, where land claims to certain areas remain unsettled.
Full independence was not achieved until 1981 with the establishment of a parliamentary democracy dominated by two political parties: the People’s United Party (PUP) and the United Democratic Party (UDP). No overtly expressed political differences exist between the two parties, and the outcome of elections tends to flip from one party to the next with each successive term or two. Indeed, whenever I tried to elicit an understanding of the differences between the two parties, I was almost always told, “One red and the next one blue,” referring to the colors used to symbolically represent each party.
Belize, however, remains beholden to US interests. The United States has been the primary source of imported materials since the late 1800s, and by 1920 it dominated Belize’s export economy to become “the dominant metropolitan power in Belize” (Shoman 2000, 109). Historically tied to the US dollar, the current fixed rate of exchange, two Belize dollars to one US dollar, has been in effect since 1976. In addition to its economic influence and control, the United States exercises much influence over quotidian life via televised images of North American life and culture. During my initial fieldwork period (2006–2008), a videotape of the national evening news arrived by plane for broadcasting in Toledo one day after the information was disseminated to the other districts. Although the delayed Belizean news was still eagerly awaited, real-time satellite images from stations based in Texas and New York had come to dominate the living rooms of most Belizeans with access to a television, as well as the bars and restaurants of public establishments (Wilk 2002). Likewise, country music and hip-hop are liberally interspersed with local punta rock and Jamaican dancehall in the discos and karaoke clubs that dominate nightlife from PG all the way to the generator-powered zinc-roofed bars of the Maya Mountains in the district’s highlands.


Figure 3. The satellite television company in Punta Gorda.
Historically, the social and economic life of Belizeans and the natural environment of this subtropical country have been inextricably connected (Steward 1968). Up to the present, the Belizean economy continues to be influenced by environmental conditions because of its concentration in tropical (bananas, citrus, sugar) and Mesoamerican (corn, beans) agricultural products, wet rice farming, and saltwater seafood. More recently, the natural environment has been marketed to ecotourists and nongovernmental research and conservation organizations alike to make agriculture and foreign money invested in natural attractions the “twin pillars” of the Belizean economy (Government of Belize 2001, 2004a).
Similarly, the environment profoundly impacts quotidian life. Belize has a hot and humid climate, prone to heavy rains and hurricanes. Imported supplies tend to degrade under these adverse conditions, rivers flood onto roads and bridges causing difficulties in both basic and emergency transportation, and infectious and parasitical diseases are easily spread. Far from taming the forces of nature, local ingenuity has developed a mode of existence accepting of life’s precarious condition. Adversity, misfortune, and death are understood as factual and unavoidable circumstances, and Belizeans of all ethnic groups hold strong religious beliefs in God and the spirit world to which their fates are beholden. Throughout the book, I will refer to the ubiquitous presence of this untamed environment and its influence on women’s reproductive behavior. In the Toledo district—the most rural and underdeveloped region of the country—coexistence with the awesome, yet precarious, natural environment is mirrored in the individual behavior and interpersonal relationships of its residents, which can be characterized by the importance they place on free will, independence, and a heightened sense of personal responsibility to the social collective (Gonzalez 1988, 156; McClusky 2001, 250–51).
Notes on Language
Belize Creole is an English-based language that contains words derived from Amerindian and African languages, as well as words and phrases from Spanish and US English (Young 1995). Among Toledo’s multiethnic and multilingual populations, Belize Creole is also the lingua franca of social life. With the exception of the East Indians who entered Belize already removed from their linguistic ancestry, the languages of the principal ethnic groups in Toledo (Garifuna, Mopan, and Kekchi) continue to be used to communicate within families and among same-language speakers. Garifuna is ubiquitously spoken by older Garinagu. However, the language is reportedly dying as younger generations are favoring Belize Creole as their first language (Bonner 2001; Cayetano and Cayetano 1997; Izard 2005). Some Garifuna household heads try to keep the language alive by insisting that their children speak it at home. In contrast, most of the Garifuna phrases uttered in the household in which I came to live were deployed to intensify inflammatory gossip and not for deep communicative purposes.
In the rural areas predominantly inhabited by Maya populations, Mopan and Kekchi are spoken as first languages of communication. Although most villagers have at least rudimentary primary school English, some older people cannot speak English or Belize Creole at all. Likewise, more recently immigrated Kekchi have the least interaction with ethnic groups outside of their own and have the greatest difficulty conversing in both English and Belize Creole, although they often can communicate in Spanish as a second language. Interestingly, the Kekchi language as spoken in Belize by native-born Kekchi is often referred to as Kekchi-Creole, blending what Belizean Kekchi speakers call “pure” Guatemalan Kekchi with Belize Creole. Nonetheless, Kekchi-Creole was very dissimilar from Belize Creole, and I remained beholden to translation to understand the rural world around me. Throughout my fieldwork, I gained competency in Belize Creole. However, because of my own inhibitions about my accent, I had difficulty speaking it to those who could understand my US English. I learned to say a few polite phrases in Kekchi and Mopan and a few curses in Garifuna, and my ability to speak Spanish came in handy with recent Kekchi and Mestizo immigrants from Guatemala.
I have transcribed the words of individuals speaking Belize Creole, including those speaking Belize Creole as a second language, as they were uttered to include grammatical structures that do not conform to the rules of Standard English. However, I have minimized phonetic transcription to facilitate the readability of direct quotations. Although the full effect of the Belizean “voice” (accent) may not be readily perceived, I believe that the transcripts are easier to comprehend and require less translation this way. The copular variants “di,” a present-tense form pronounced “dee,” and “mi,” a past-tense form pronounced “mee,” which are used in place of the Standard English verb “to be” (Escure 1992), occur throughout the speech reported in this book. “I mi see it” means “I did see it” or “I saw it.” “I di see it” means “I am seeing it” or “I see it.” When this grammatical element of Belize Creole was used, I did not translate transcripts unless other speech elements are difficult to comprehend by a Standard English speaker.
The Way of Life in Toledo
Residents of the Toledo district explain that life there is different from the rest of Belize. It is a place where people still say good morning, good afternoon, good evening, or good night when they pass on the streets. It is a place of familiarity and relative safety, with a pace slower than most. “Right now” means “As soon as I can get to it.” And “soon” means anywhere from a few minutes to a few hours. Waiting is common and seldom complained about. Many Belizeans north of Toledo have never even visited the remote southern region. It is an out-of-the-way place with its own way of doing things. Childbirth is no exception.
The Toledo district has the largest rural population with the lowest population density in the country (Statistical Institute of Belize 2012). Pregnant women in town live within walking distance of PG hospital, but pregnant women in the villages are often far from medical facilities—both in terms of actual distance and when considering lack of access to transportation. However, pregnancy and childbirth in Toledo cannot be simply mapped onto a town/village dichotomy. Lifestyles in urban areas differ from those in the periphery; however, the villages themselves differ in their ethnic constituencies, access to town, and level of development. This includes their use of so-called modern conveniences—such as electricity, piped water, sanitation systems, telephone, and so on—or “household amenities” (Central Statistical Office 2001a). The villages also differ in whether they are oriented economically toward the Belizean market or toward Guatemalan commercial centers. All of these factors make it impossible to give a uniform account of Toledo women’s reproductive activities.


Figure 4. Stickers affixed to a village shop vitrine.
Nonetheless, my research does suggest a continuum of attitudes and practices that cross ethnic and geographical distinctions. For example, belief in the power of supernatural causes of sickness (obeah) and the preventative measures to combat malevolent powers (like wearing red beads and amulets or burning copal incense) is ubiquitous across Toledo. The hot/cold humoral concept of health and healing is also a regional universal, and as I worked closely with the public and rural health nurses, who were themselves an ethnically diverse population that hailed predominantly from Toledo, I observed how they interpreted and modified, with a large degree of continuity, the uniform international standards of reproductive health for the varied cultural and practical realities of their constituents. In addition, many attitudes and practices surrounding issues of shame and force remained consistent with varying degrees of intensity throughout the district. Moreover, Toledo as a whole has undeniably limited economic and human resources—further limited by the forces of nature, which often impede access and dictate human action. It is no wonder that many residents of Toledo, both town and village, answered questions of agency with a smile and a resigned utterance: “Only God knows.”
Local MOH personnel proudly claim a near 100 percent compliance with antenatal protocols in Toledo. However, the district has the highest rate of out-of-hospital births (Smith and Klima 2004; Woolfrey 2002). The home birth “nannies” (the local term for the older generation of home birth attendants) who provided midwifery services to residents of PG have all died, so, with few exceptions, town residents give birth at the local hospital. Throughout the 2000s, however, many villagers gave birth in their homes. These home births occurred (and continue to occur as recently as my latest visit to the region in August 2016) for a variety of reasons—some cultural and some unavoidably pragmatic. The majority of these births are unassisted or under the care of a husband, mother, or mother-in-law; a TBA attends others.
Race and Ethnicity
Although Belizeans have been mixing for centuries (Crawford 1984, 95; Merrill 1992), the postcolonial creation of the Belizean nation as an ethnic “melting pot” is, nonetheless, influenced by the colonial legacy of racial and ethnic hierarchy and Belize’s current relationship with the United States and its two-tiered racial system. Ethnic tension maps subtly—and sometimes explicitly—onto a colonial legacy of racial hierarchy that privileges lighter skin over dark. During my research, I was privy to much discussion among African descendants who wanted a lighter-skinned baby with “good hair,” and among Maya and East Indian girls who said that their parents would never allow them to date a “black boy.” A Garifuna woman expressed it this way: “I like to see races mix-up. But I mi want got pickney [child] with a light skinned man so they would have a better chance in life.” 7 Another dark-skinned man of mixed ethnic descent similarly expressed, “We see people that look different every day, but we di mix-up so much, I no even notice.” Indeed, most people were undisturbed by interethnic relationships. However, many women and men expressed a strong desire to lighten the complexion of their offspring by forming a relationship with a person of a lighter skin tone. For many (like the man above who claimed not to pay attention to race but had three children with three different women who were all light-skinned “Spanish”), actual ethnic identity was often secondary to skin color when choosing a sexual partner. Nonetheless, high school students in Toledo of all ethnic backgrounds, who “mix up” with their peers on a regular basis, told me that they had friends across ethnic lines, and no one spoke of any overt ethnic tension nor of the types of racial animosity they saw on US news broadcasts.
While the geographical constraints of the rural areas coupled with regular but infrequent transportation between town and village may impede interethnic social relationships, these social patterns are changing as the younger generations find more opportunities to explore beyond their immediate environment. For many years, the only high school in the district was a Catholic extension of the primary school located in town. Rural families who could afford secondary education for their children had to relocate to town temporarily, creating an area “to the back” of PG now known as Indianville. Many of these families stayed in town, and more continue to come. In 2000, a school bus system was implemented to shuttle high school children from the rural areas to the town high school, and three rural-based high schools opened within the following ten years. These newer schools accept students with lower scores on their high school entrance examination. Hence, high school–aged children from PG who do not score well enough to attend the Catholic institution can reverse commute to the outlying areas. Many young people attending high school in 2006 explained that they have friends across ethnic lines and that these divisions were not important when determining their social circles. However, they indicated that it is difficult to maintain these relationships with limited transportation and means of communication outside the school setting.


Figure 5. The slogan of a popular Belizean brand of purified bottled water reads, “The Melting Pot of Races.”
Despite this increased opportunity to dissolve historical ethnic divisions and create relationships across geographical barriers, the distinction between urban and rural residence often maps onto ethnicity. Garinagu are concentrated in the coastal areas of their initial settlements, Kekchi and Mopan Maya are concentrated in the rural areas that border Guatemala, and East Indians primarily reside along the stretch of road that connects the two. I found that both ethnicity and environment influence the type of care available to pregnant women in Toledo and the choices they make about their reproductive lives. At the same time, the unique and distinct economic and geographical constraints in Toledo often flatten intradistrict ethnic distinction (see Grant 1976) while still emphasizing the stratification of women’s reproductive practices (Colen 1995). 8 In other words, the social categories of ethnicity and race at play in the Toledo district are linked to structural factors (like accessibility) and cultural practices (like husband-assisted birth) that tangibly affect women’s reproductive lives. However, Toledo as a whole occupies an inferior social position relative to the rest of the country’s five districts—linked no doubt to its unique environmental circumstances—such that poverty is equally shared across ethnic groups both urban and rural. As such, I do not take race or ethnicity prima facie; rather, I use ethnically based statistical social indicators to frame my data, and I address these categories as they enter my research.
Social Indicators and Reproductive Trends
Thus it may be that interethnic conflict in Toledo is minimized because, across ethnic lines, the population has limited economic resources. For instance, 79 percent of the Toledo population is classified as poor, which is defined as unable to meet basic food and nonfood costs (this is more than two and a half times the national poverty rate of 33.5 percent), and 56.1 percent is classified as indigent, defined as unable to meet basic food costs (more than five times greater than the national average of 10.8 percent) (UNICEF 2005). Poor living conditions may also influence women’s reproductive lives. Although poverty is not the sole determinant of rapid population growth, many characteristics of poverty contribute to high fertility (Aassve et al. 2005; Government of Belize 1997). Correspondingly, birth rates in the Toledo district are the highest in the country with a total fertility rate (TFR) among women aged fifteen to forty-four of 5.6, while the average of the other five districts is significantly less at 3.65 (Central Statistical Office 2001a).
Assessment of the prenatal records of the 263 women between the ages of fifteen and forty-seven attending the prenatal clinic at the local hospital in Toledo in July 2006 showed that seventy women (27 percent) were attending prenatal clinic for their first pregnancy, eighty women (30 percent) were on their fifth or greater pregnancy, and two women were having their twelfth and thirteenth child. The average number of pregnancies for which a woman was currently attending prenatal clinic was 3.6 (see Table 2 ). Although many women from the rural areas attended the prenatal clinic at the town hospital, a number of women from the more remote areas did not. As such, my data represents only a slice of the pregnant population in Toledo, yet it does suggest that fertility rates have declined. Data for 2014 indicate a TFR of 2.6 countrywide; updated statistics specific to Toledo were not obtainable (World Bank 2016).
The influence of Christianity cannot be overlooked in discussions of women’s reproductive lives, as religion occupies a dominant position in social life. The Anglican Church is the author of the Belizean National Prayer recited before all government-sponsored events. However, Catholicism is the sole religious majority (40.1 percent) and is the dominant religion in Toledo (Statistical Institute of Belize 2013). The Catholic Church is influential in the country’s church-state education system, providing financial support as well as curriculum content for the majority of the country’s public schools. Government legislation also reflects the influence of the church: abortion is illegal for other than life-threatening conditions, though illicit abortions are a common practice. Christian attitudes toward female sexuality, marriage, and corporeal punishment are all reflected in Belizean law, affecting the decisions women make concerning their reproductive lives. 9

Table 2. Parity of Women Attending Prenatal Clinic at Punta Gorda Hospital (July 2006)

(Data obtained from an analysis of local hospital records in July 2006)
Overview
In the summer of 2004, I spent two months in Belize forming relationships with the nurses at PG hospital and with MOH officials. During this initial period of contact, I concentrated on gaining a better understanding of the Belizean medical system and maternity care. In 2005, I traveled to GIFT’s US headquarters to meet with the midwife who conducted the first round of TBA trainings in Toledo. I also spent a significant amount of time exchanging emails with the midwife who conducted the second and final round of TBA training in 2001.
In January 2006, I embarked on eight months of intensive research in Toledo with the working hypothesis that the TBAs trained by GIFT would be better equipped to service their communities than the TBAs previously trained by the Belizean MOH. I based my thesis on prior anthropological analyses of TBA training programs conducted by the various ministries of health in different parts of the developing world; this research suggested that these training programs had not helped reduce mortality rates, in part because of culturally ineffective teaching methods and the rejection of traditional practices (Brink 1982; Cosminsky 1986; Hunte 1981; Jordan 1993a; Pigg 1995, 1997; Sesia 1996). I reasoned that a TBA training program conducted by midwives who allied themselves with nonmedicalized midwifery practices, self-identified with village life in the rural United States, acknowledged a mutual exchange of information during the training experience, and were instrumental in the North American alternative birth movement (Gaskin 1990, 2003; Lay 2000; Meenan et al. 1991) would have a high success rate training TBAs who could implement their midwifery skills and contribute to the ministry’s goal of lowered maternal and infant mortality rates. At the time of my fieldwork, nurse-midwives had begun to report on these types of midwife-to-midwife training programs (Houston 2000; Lang and Elkin 1997), but an in-depth anthropological analysis of this type of training program had yet to be done, despite a call for such research made two decades prior by scholars prominent in the field of the anthropology of reproduction (Cosminsky 1986; Jordan 1993a).
Since GIFT’s project was no longer active, I entered the world of “traditional” midwives and pregnant women through official channels. I associated closely with the public health officials and staff at PG hospital and a rural village health post where I conducted participant-observation twice a week at the prenatal clinics and accompanied weekly mobile clinics to various remote villages. I also familiarized myself with the labor and delivery nurses in the hospital’s maternity ward.
Until I gained a better understanding of the public bus routes and the informal transportation system (catching rides on the school buses, riding with schoolteachers, and hitchhiking), I made weekly trips with GIFT’s staff to the villages where they were working on primary school gardening projects. While GIFT’s workers tended children and vegetables, I sought out the village TBA. However, not all the villages in which the TBAs resided were accessible in this manner, so I also traveled independently on weekend trips to interview all of the twenty-one TBAs GIFT trained in 2000–2001 (GIFT actually trained twenty-two TBAs, but one died a year before my arrival). I also interviewed six of the still-living TBAs trained by the MOH. Based on my initial interviews, I became close with four TBAs and subsequently traveled for longer periods of time to their villages to observe their practices and interview pregnant women who utilized their services.
Previous anthropological studies of midwifery training programs in developing countries focused on classroom dynamics and the hierarchical teacher-student relationship to argue that programs conducted by ministries of health did little to alter traditional practices that may adversely affect mortality rates. Prior to conducting my field research in southern Belize, I correspondingly believed that TBAs trained by an NGO with a self-proclaimed understanding of village life and orientation toward a small-scale existence would comprehend and use their training more effectively. Interestingly, I found that, in Belize, the MOH conducts one-on-one training and employs a long-term apprenticeship model that corresponds to so-called traditional models of skill acquisition (Sibley 1993) and is more conducive to the small scale of Belizean society more generally. Three of the younger TBAs from Toledo had been trained exclusively by apprenticing with a rural health nurse who was on permanent residency in the village, and I was able to observe the training of one woman during my fieldwork period. As such, I found the disparity in the quantity of TBAs trained (a handful by the MOH since the late 1950s versus twenty-two by a foreign NGO over a period of only two years) to be one of the biggest hindrances to the success of GIFT’s program because the ministry’s limited economic—and human—resources prevented adequate follow-up to ensure that the large number of TBAs dispersed throughout the district’s environmentally challenging topography were practicing according to medical standards, or even practicing at all (Maraesa 2012).
The Toledo district is saturated by NGOs (in 2006 approximately fifty-five small-scale organizations existed in a town of four thousand with a rural population of nineteen thousand) and missionary religious organizations that conduct regular medical missions (about six per year that the public health office knew about and many of which operated independently and without the approval of the Belizean MOH). 10 This familiarity with foreign medical providers and students facilitated my access to the field. The hospital staff treated me like an intern or midwife apprentice, and pregnant women initially mistook me for a doctor or midwife. No matter how carefully I clarified my position as a researcher, many pregnant women—especially when they found out that I had my own experiences with childbirth—still turned to me for advice while telling me about their pregnancies or births.
Two months into my research the hospital asked me to attend and speak at the first-ever childbirth education classes held weekly at the town hospital for first-time mothers. 11 In general, childbirth education is not something offered in Belize except at the private hospital in Belize City, which caters to a socioeconomic group that can afford services similar to those in the United States at a cost astronomically higher than childbirth in a public medical facility or at home. 12 The six-week “primip classes” were organized by the psychiatric nurse, who was concerned about how the psychological state of young and unmarried pregnant women could affect the health of the newborn. Covering prenatal nutrition, labor and delivery preparation, newborn care, and family planning, the classes offered insight into the main concerns of the individuals working for the MOH, who voiced the concerns of international public health initiatives as well as distinctly Belizean beliefs and sensibilities.
I assisted three women during childbirth: two births that were planned to take place at PG hospital and one birth that arrived unexpectedly at a village health post. The wife of the NGO worker with whom I primarily traveled was pregnant. Both Alton and Samiya wanted a home birth, but they were afraid of the backlash that would result from this decision. There are no laws in Belize against having a home birth, but since the couple lived only a few miles from town, the nurses were expecting Samiya to deliver there. Alton and I had many long discussions in the car about both my professional and my personal experiences with childbirth. 13 Feeling like they wanted the “natural” birthing experience they read about in the books published in the United States, Alton asked if I would attend his wife’s birth in the hospital. I also befriended a young women attending the childbirth education classes who was nervous about the pain she would experience during labor and requested my assistance. Because I was a familiar face at PG hospital, I was allowed to accompany both of these women. These experiences permitted me to obtain a firsthand account of hospital protocols for managing labor and delivery.
Finally, I attended a weekly women’s group facilitated by the Ministry of Human Development. The ten-week program focused on learning to cook quick and nutritious “Belizean” recipes for family consumption and profit. Attendance averaged ten per session; four of the women were pregnant. While we waited for the food to cook, the group’s facilitator encouraged group discussion about reproductive health, sexual and familial relationships (including domestic violence and rape), and strategies for the empowerment of young women in a society socially and economically dominated by men (Government of Belize 1997, 63–65). Through these informal sessions I gained unsolicited insight into women’s attitudes about reproduction and gender relations in southern Belize more generally.
During my fieldwork, I became quite close to a number of nurse-midwives, TBAs, and pregnant women who allowed me to film them for what I still envision to be a documentary about the unique conditions under which “public health” is conceptualized and actualized in Toledo. This documentary is a work in progress; however, I used the raw footage to further my understanding of the decision-making processes surrounding pregnancy and childbirth. Three of these filmic texts are transcribed in the following chapters, forming a basis for analyses of the interactions between pregnant women and their care providers.
I am thankful to have made the decision to study so-called traditional practices by first acknowledging the efforts of the MOH. It would be naive to think that public health initiatives and medical protocols are embraced and followed by everyone all of the time. In fact, this book closely examines the disjuncture between enunciated policy and actual practices. But, in a small place like Toledo with a relatively recent, yet profound, public health movement, the few dedicated individuals who have worked hard to bring health care to the people are involved on an intimate level with their constituencies and serve as gatekeepers to even the most remote populations. As a head nurse at the local hospital exclaimed to me: “Here in Toledo you can’t do anything hidden, ’cause we-ah know!” Indeed, someone is always listening, and news travels faster than the many buses that zigzag the countryside.
Aside from a two-day bout with food poisoning (from eating unrefrigerated beans), a three-week ordeal with Hepatitis A (from eating food contaminated with infected fecal matter), and nearly cutting off my middle toe when I stepped on barbed wire while making my way in the dark and barefoot through Esperanza village, I encountered minimal difficulties and was generally provided unlimited access to various fieldwork sites, MOH records, and the reproductive lives of women in town and in the rural areas. I am a single mother of two children who accompanied me to the field where my then eight-year-old daughter attended the Catholic public school and my then two-year-old son attended a secular preschool. I believe the difficulties of parenting while in the field are obvious: needing formalized childcare arrangements that precluded spontaneous interaction with respondents, juggling my fieldwork assignments with parental obligations, and being unable to conduct lengthy travel to the villages once my children were established at schools in town. However, the benefits far exceeded the hardships. Through my experiences as a mother in the field, I was accepted into the various social networks that were the focus of my research, and I was respected as an experienced woman with personal knowledge about reproduction and childbirth. Moreover, my son inspired an invitation to live with his teacher/babysitter after which childcare ceased to be a problem, and I was privy to the closest “informant” relationship that an anthropologist could imagine. Two months into my fieldwork, I was set squarely in the middle of Belizean family life where I quickly learned “the Belizean way”!
In fact, it was while lounging in Shanon’s living room that I learned a crucial piece of cultural practice. While I dazedly thought about the week’s events, my morning shopping, and my new life in Belize, the entire household had readied itself to embark on an afternoon event. Yet there I had sat, amid it all, having no idea anyone was preparing to go anywhere! I often found myself confused by Belizean protocols, but on this occasion I decided to ask, “How come I’m always the last one to know what’s going on?” Shanon’s response: “ ’Cause you no pay attention when people di talk, gal. You no listen !” By this she did not mean that someone had explicitly told me we were going to leave soon and I had not heard; rather, others around me had discussed plans for the afternoon, and I was to have inferred through indirect conversation—also known in my cultural experience as eavesdropping—what was about to happen. Indeed, Belizeans in Toledo learn much through surreptitious listening—something I soon learned to do well. Fears of jealousy-incited obeah and the loosely faith-based belief in spiritual determinism (often cited as “only God knows”) prevent people from making—or talking openly about—plans for the future. Since they do not like to talk about themselves, the best way to obtain information is by listening to others. Gossip—or “shush” in Belize Creole—is the best way to learn what is happening in the community. And much time is devoted to talking about the activities of others.
Anthropology, as an interpretive science, is based on what people say and do. Questions concerning levels of mediation—what is truth and what are the methods appropriate to constructing knowledge—have preoccupied anthropological theory (Moore and Sanders 2006). However, Belizean understandings of truth are quite simple: “If dah no so, dah nearly so!” (If it’s not true, it’s nearly true!). As such, multiple levels of mediation openly influence my purportedly objective construction of women’s reproductive realities. What others said about each other—as well as what I heard —became a crucial part of my data and integral to my subjective interpretation of sexual and reproductive culture in Toledo. Hence, I admit to my use of gossip in constructing anthropological knowledge, as well as my own subjectivity as researcher, childbirth activist, and single mother (Martin 1994).
At times I elicited gossip through constructed and informal interviews with twenty-eight pregnant women of various self-identified ethnic groups, five nurse-midwives, five public health workers, and twenty-seven TBAs. I also ceaselessly discussed issues related to pregnancy and childbirth in social situations with anyone interested in voicing their opinions and personal experiences. Before long, I was “known” to be a midwife, a medical student, an NGO worker, or a teacher—categories of familiarity in a small town frequented by such foreigners on a regular basis—which positioned me differently depending on context, resulting in very different sets of interactions, levels of intimacy, and degrees of complicity (Haraway 1991; Marcus 1995).
Both my professional and personal experiences with women’s reproductive health made it difficult for me to remain detached when I was solicited for advice and assistance. The most salient example of my complicitous behavior is detailed in Chapter 6 where, undeniably, my presence altered what would have been—if not what should have been (Strathern 1987). Yet, I too was changed during the course of my fieldwork experiences, as I was often forced to reexamine my own culturally mediated truths under the scrutiny of those who were just as curious about me as I was about them (Bakhtin 1984). These queries also lent themselves to my understanding cultural imperatives, as well as the ethical contract within which I was engaged as a researcher and fellow human being. As such, this book represents the polyphony of voices upon which I have based my situated interpretation of the cultural matrix of women’s reproductive health.
One theoretical model that is useful to help make sense of why the individuals described therein “do what they do” (Foucault, quoted in Dreyfus, Rabinow, and Foucault 1983, 187) comes from Geertz’s grappling with the “native’s point of view,” as he came to the conclusion that there are “experience-near” and “experience-distant” ways of understanding the world (Geertz 1983, 57). According to Geertz, experience-near perceptions are the definitions, thoughts, or feelings that are subjectively experienced at the level of the individual or the collective cultural body, while experience-distant concepts are scientifically formulated and objectively employed by an outsider. In my ethnographic interpretation of the culture of reproduction in southern Belize, I have applied Geertz’s categories to help make sense of women’s reproductive behaviors and those of the birth attendants and MOH employees involved in women’s reproductive lives to argue that people in Toledo come to understand reproductive situations and act according to a belief system that privileges experience over speculation. Whether choosing between hot peppers and iron supplements, drinking coffee or lime juice, delivering a baby at home or in the hospital, or concealing or revealing a pregnancy, women in southern Belize prioritize their experience-near perceptions, and those of their epidemiological community (Rapp 1999, 176), when making life-and-death decisions. On the other hand, MOH workers, who must employ the experience-distant discourse of the international health world, try to bridge the gap between perceptions of risk and reality.
Geertz emphasizes that “the matter is one of degree, not polar opposition”: an ethnographer must strike a balance when making the cultural analyses so important to the anthropological project (1983, 57). Given this understanding, I probe this chasm to find competing ways of knowing that employ the language of the other to assert a dominant awareness. Beginning with an overview of how abstract global health paradigms are actualized in local practice, the book moves from the workings of nurse-midwives to traditional healers, and finally to an in-between and invented category of “tradition” that is somehow “supposed to” straddle the two. The book culminates with two case studies of pregnancy and birth that further blur the spatial categories of experiential distinction and clearly show how the lives of pregnant women and birth attendants are tightly woven together in the reproductive social fabric of the Toledo district. By acknowledging the lived realities of population targets, the global shrinks to the local levels of importance that influence women’s reproductive behavior and—ultimately—their lives.
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 the Belizean government or nongovernmental development agencies state their intention as “Building a Better Belize.” 7 The certificates presented at the end of a training program act as a kind of cultural capital—a locally recognized measurement of an individual’s commitment to the community and, hence, to the nation.
Yet, many of the self-sacrificing public health workers and “volunteers” felt that their local commitments were not fully appreciated by the MOH officials located in the urban areas of Belize City and Belmopan who did not understand the arduous environmental conditions unique to the Toledo district. None was complaining about lack of payment per se, but rather about the lack of appreciation for their efforts. They were looking for respect. And some of the rural health nurses and public health employees at the hospital began to ask me to take digital photos of public health efforts as well as to film the difficult conditions in the rural areas of Toledo to show to the head offices. On this particular mobile clinic, I came with video camera in hand to document our journey to Branch Mouth.
Vehicle access to the outlying villages began in the late 1990s. Two villages, however—including Branch Mouth—remain accessible only by foot. 8 As the ministry vehicle reached its limit on this particular morning, the driver parked at the edge of the burned field and made himself comfortable; we would return in seven hours. Nurse Ical, Sergio, and I unloaded the backpacks full of medical supplies, vaccines protected by a small insulated cooler, and well-child growth and immunization charts for the fourteen young children living in Branch Mouth. Accustomed to walking long distances over rough terrain, Nurse Ical and Sergio came well prepared for the jungle walk. As a New Yorker, I was, as usual, ill-equipped for the many weather-related situations I encountered in southern Belize. Prior to the trip Nurse Ical had offered me a pair of his daughter’s rubber boots. Of course, I did not check to see if they would fit, and, as my ill-fated luck would have it, he had misread size 6 as size 9. The boots were actually four sizes too small for me. Thus, I brazenly opted to walk shoeless—trying to imitate the way I had seen countless Maya women trek through thick brush and deep mud seemingly unperturbed—tacitly asserting my engagement as a “barefoot anthropologist” (Scheper-Hughes 1995) alongside the MOH’s commitment to universal health care.
The relatively wide road that had been recently plowed for logging vehicles stopped less than a mile into the dense vegetation, at which point a narrow muddy footpath led to Branch Mouth. Six-inch-deep horse and human footprints were filled with water and served as swimming pools for tadpoles and small water insects. About an hour into our journey we were covered in blood from slapping the mosquitoes that descended on our skin like flies on fresh meat—and then it started to rain. We trudged onward through mud up to our ankles until we met a river about twenty feet wide. The narrow concrete bridge was visible a few feet under the water, but a dory was conveniently left on our side of the overflowing river, so we opted to stay as dry as possible and paddle across. The dugout canoe was overburdened with our heavy bags and the three of us, such that any slight movement pitched it to the side. The river lapped at the boat’s edges; water seeped through the fissures along its bottom. While Nurse Ical paddled, Sergio and I scooped water with our cupped hands to keep our backpacks from acting like sponges.
After another hour of walking, we met the second body of water: a marshy swamp about fifty feet in length that, with the heavy rains, had turned into a still pool of mosquito larvae. It was quite deep with no way of crossing except to carefully follow a slab of lumber invisible under the murky water but graspable with my bare feet. As it was, the water was waist high, and we held our backpacks (and my video camera wrapped in a plastic garbage bag) high above our heads. Before us was another thirty minutes of travel and, I mused, the return trip!
Suddenly, like an oasis in a desert, a humble wood house with a perfectly manicured lawn and a family of ducks stood in majestic splendor around a tangle of tropical greenery. Small children lingered in the doorway, hiding their smiles behind their hands as we approached and announced the arrival of the mobile clinic. After two-and-a-half hours of walking through the jungle, two sweaty Belizeans with overstuffed backpacks, still dripping from the swampy travels, and one barefoot gringa with a camera emerged. No wonder the children looked amused!
At a few minutes to eleven in the morning, we opened the door to the community center (a wooden, one-room structure with a thatched roof and hard mud floor) that served as an ad hoc clinic. Inside we found a dusty plywood table and two benches. Nurse Ical and I opened our backpacks and prepared the room for the villagers while Sergio went to ring the primary school bell to signal our arrival. “They soon come,” said Nurse Ical, pointing in the direction of the palms that obscured the village dwellings from our central vantage point. And we waited.
It took about twenty minutes for women, children, and babies to arrive. Dressed in the ubiquitous woven Kekchi skirt and brightly colored polyester-and-lace blouse, their thick, dark hair oiled and pulled back tightly in a bun and secured with a vibrant colored plastic flower and ribbon, with long strands of multicolored seed bead necklaces adorning their necks, each woman had two or three small children clutching at their long woven skirts or wrapped in a white cloth lepob (baby carrier) suspended from their foreheads. A few had coughs, colds, or fungal infections, but most of the children were coming to receive their vaccination booster shots.
Nurse Ical, a Mopan Maya who can also speak Kekchi, explained to the mothers that it would be normal for their children to get a fever after the vaccine and to have pain at the site of injection, and he put me to work breaking aspirin tablets with my fingers into halves and quarters for the proper reduced dosage indicated for young children. Meanwhile, Sergio weighed the babies by suspending them from a hanging scale using the same lepob in which the children are carried until the age of two. Sergio and Nurse Ical updated the children’s growth chart and vaccine record; any children missing were summoned to ensure that each child due for a booster shot received one. Belize has a near 100 percent vaccination rate for children under one, with no occurrence since the 1990s of any of the major life-threatening childhood diseases for which vaccinations are available (poliomyelitis, measles, tetanus, and rubella) (UNICEF 2005). The health teams in Toledo worked tirelessly to close the existential gap between the statistical figures and reality. As such, the rural health nurses in Toledo, and the Ministry of Health more generally, are justifiably proud of these statistics.


Figure 1.1. A Kekchi woman and her children at a mobile health clinic.


Figure 1.2. Baby suspended from the rafters in a lepob .
However, there are other treatable illnesses that remain deadly. On this day Nurse Ical learned that a fifteen-month-old baby had died from an acute respiratory infection since the last mobile visit six weeks earlier. Respiratory illnesses are the second-leading killer of children in Belize under the age of five (Ministry of Health 2014). While such diseases can be reliably controlled through basic hygiene practices and improvements to sanitation, information that public health teams disseminate, respiratory complications may originate from poor maternal health and gestational environment. Poor health conditions in general are exacerbated by poverty, which can turn treatable conditions into lethal illnesses (Black 1984). As the poorest region in the country, Toledo has the worst nutrition-related maternal and child health statistics. Gestational anemia, which can lead to preterm labor and premature birth that can affect infant pulmonary development, is higher in Toledo than in other regions (Ministry of Health and Pan American Health Organization 2003), and the growth of children in Toledo is substantially stunted in comparison to children from other parts of the country (Government of Belize 1996). 9
Mobile clinics attempt to address nutritional deficiencies through counseling, but aside from the iron supplements available to pregnant women, there was little Nurse Ical could offer. 10 As a few adults came forward with aches and pains of all sorts, Tylenol was the uniformly prescribed treatment. Cough syrup, poured from a brown gallon jug into the empty plastic soda bottles villagers knew to bring with them, came in a close second. Oral rehydration salts, deworming pills, and antibacterial ointments were also among our supplies. There was one bottle of pain reliever containing codeine that Nurse Ical gave to a woman suffering from severe muscle aches. The bottle was sealed, but it was only half full because it was a sample sent from a drug company. Indeed, most of the medications were donated from various medical missions, and some had labels indicating they were not for use outside the United States.
The population of Branch Mouth was extremely small. Only about sixty people (twelve families) lived there. All were born in Belize, yet the villagers had an economic relationship with neighboring Guatemala, selling their corn to Guatemalan distributors for 60 quetzales (about 10USD) per one-hundred-pound sack. Since there are no other ways for villagers to make money locally, many men leave the village for seasonal employment in the agricultural sector and on the shrimp farms in the neighboring Cayo and Stann Creek districts. Some men also leave to pursue religious education with missionary groups. For women there is little opportunity for movement.
While I was in between filming the mobile clinic activities and making myself useful to Nurse Ical, one young woman caught my attention. Julia smiled and ushered me to her. Unlike most Kekchi women, who, in my experience, hesitated to initiate conversations with strangers, Julia immediately asked my name and wanted to know what I was doing in her village. She spoke perfect English and asked me just about as many questions as I then asked of her. We talked about our children, our husbands (or my lack thereof), my life in New York City, and her life in Branch Mouth. Julia, who was nineteen years old with two children, ages two and three, had finished the village primary school and passed the high school entrance examination. Her family, however, did not have enough money for tuition or books. Soon after, Julia became pregnant at age sixteen and was dependent on her husband for support. I later learned that Julia “shared” her husband with her sister, who also had a small child by him. Julia’s situation was not unique, as multiple partners were commonplace in southern Belize. However, sharing a man also meant sharing his already meager resources, and it was Julia’s fifteen-month-old baby who had died of the treatable respiratory infection. Julia was now worried about her three-year-old daughter, who was refusing to eat. Nurse Ical wanted to give her vitamin B complex, but the MOH did not supply vitamin supplements except the iron and folic acid reserved for pregnant women, and Julia had no means to purchase the supplement on her own. 11
Julia explained that she saw Nurse Ical for prenatal care at the mobile clinics. Because there was no bed in the makeshift medical center, Nurse Ical took her to the church to lie on a pew while he palpated her abdomen and listened for the fetal heartbeat. Julia emphasized the importance she attributed to checking for the position of the baby. As her due date approached, she would also travel “ ’cross” to Guatemala to see a doctor who would similarly ascertain the fetal position. Indeed, many villagers found it easier to cross the porous border to find medical care than to wait for the mobile clinic or to make the arduous journey to PG hospital. Pregnant women, however, preferred to deliver at home or in the local hospital on Belizean soil in order to facilitate registration of the baby as a Belizean citizen. The only pregnant women I spoke to who chose to deliver their babies in Guatemala were not Belizean citizens, and a number of these women confided that they were afraid to go to the local hospital undocumented out of fear they would be turned away during labor and then deported. Although Julia is Belizean, she told me that she chose to deliver all three of her children at home because she did not feel “ ’fraid for birth” and getting to town was too difficult. Julia’s mother attended the birth of her first child “for mek she show me husband how for cut the cord.” He was then “on he own” for the next two births, which went without complication.
Maternal and Child Health Initiatives
In 1984, Belize joined internationally recognized public health initiatives by establishing its own MCH program. Mobile health clinics such as the one I accompanied to Branch Mouth arose out of this program, which targeted pregnant women and children under age five for perinatal care and vaccinations (Government of Belize 1997). Many nurses remember with nostalgia and a genuine smile the days they trekked by foot and on horse, through water and swamps, to reach the then remote villages now accessible via four-wheeled transport. Because of the time needed to make the voyage, the nurses would sleep the night at a villager’s house, the owner of which was, by making the house available, contributing to bring health services to the communities. Now, only Nurse Ical continues to walk upward of three hours each way, across a river, and, in the rainy season, through a chest-high swamp to reach the last two villages in Toledo that remain without road access.
In the mid-1980s, the MOH also began constructing rural health posts. Full-time nurses staff some posts, others have only a CNA or caretaker, and a few open only for the mobile team every six weeks to maintain the vaccination booster schedule. Ironically, before vehicular access was possible, mobile clinics visited the villages every four weeks. Although adverse weather conditions sometimes negatively affected the ability to adhere to this timeline, the intention was to provide the rural areas with medical attention about once a month. The reduced six-week schedule remains influenced by natural forces; however, it is also dictated by the international vaccination guidelines to which the MOH is beholden. The actual—or expressed—community needs figure far less in the standardization equation that results in less frequent availability of primary health care for satellite villages.
According to Nurse Ical, the primary agenda of the mobile clinics is “the babies.” Prenatal care and outpatient treatment is also provided, but the order of operations privileges well-child services to the extent that children who do not come to the clinic are sought out and brought to the nurse for vaccination. There were numerous instances when I accompanied Nurse Ical into the homes of the children who did not show up for their booster, where he vaccinated them on-site.

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