case study e

Nomads and Nationalists in the Eritrean Sahel

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The Practice of International Health: A Case- Based Orientation Daniel Perlman and Ananya Roy

Print publication date: 2009 Print ISBN-13: 9780195310276 Published to Oxford Scholarship Online: September 2009 DOI: 10.1093/acprof:oso/9780195310276.001.0001

Nomads and Nationalists in the Eritrean Sahel Assefaw Tekeste Ghebrekidan

DOI:10.1093/acprof:oso/9780195310276.003.01

Abstract and Keywords This chapter presents an account of the plight of the people living in the Sahel, one of Eritrea's most inaccessible regions. It describes the devastation wrought by thirty years of war. It recounts experiences serving as a medical cadre among the pastoralist communities, particularly describes the impromptu cooperation between a liberation front and a marginalized population totally unaware of politics.

Keywords:   nomads, pastoralists, Eritrea, medical personnel, health services, health care, public service, public health practice

Shielded by high mountain ranges that make a dramatic descent into the western lowlands and Red Sea plains, the Sahel is one of Eritrea’s most inaccessible regions. It is a land of two winters, with June to September rains in the highland plateau and November to February rains in the lowlands, which draw the 27 clans of the Tigre ethnic group like a magnet. They travel along arid paths from the highlands of the Sahel in groups of three or four families, taking different routes to ensure that all their livestock have sufficient grazing room. The women are wrapped in brightly colored dresses with only the sun-darkened skin around their eyes showing; the men, tall and thin, herd goats across the dusty ground; children trek alongside their parents, likewise tending to the herds. In June, they pack up and return to the Sahel for the rainy season there. The Tigre pastoralists make this trek every year, stopping only a few weeks at a time in any one place. Because their livestock is their primary asset and serves for everything from their daily livelihood to dowry payments, they follow the

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rainy season to wherever the grass is green. They have lived this life for generations. They would not live any other way.

In 1972, a new “clan” came to the Sahel: the Eritrean People’s Liberation Front (EPLF). The EPLF chose this inaccessible region as a base for guerrilla operations against Ethiopia, which had illegally annexed Eritrea as a province. The war went on for over 30 years—the span of an entire generation—during which Ethiopia was backed by the United States and provided with modern weaponry from 1961 to 1975 and by the Soviet Union thereafter. In 1993, after a national referendum supervised by the United Nations produced an almost unanimous vote for its independence, Eritrea was proclaimed a sovereign state.

(p.20) The guerrillas’ mobility was compatible with the nomadic life of the pastoralists, but unlike the latter’s, the guerillas’ movements were not dictated by the need for grass; instead, they were governed by the strategic rules of warfare. Their lives depended on blending in with the pastoralists. Their ideology was one of social change, with emphases on literacy, self-reliance, and women’s rights. They lived the nomadic life for less than one generation. It was a step toward living in a completely different way.

Thirty years of war were unthinkably ruinous and tragic for Eritrea. I was there, yet even I can scarcely conceive of the devastation wrought in terms of lives, suffering, and property damage. Although I will never forget the horrors I witnessed, serving as a medical cadre among the pastoralist communities is one of my most cherished memories. The beauty of the impromptu cooperation between a liberation front and a marginalized population utterly unaware of politics has forever changed me.

I was born at the northern flanks of the central highlands, where the lands of farmers merge with the trails of the nomadic pastoralists. At age 19, I went to Ethiopia to study medicine. The hospital where I was placed after graduating from medical school, in the port of Massawa, was not far from my home in the highlands, and I lived comfortably. As one of only 16 doctors in Eritrea at the time, I had my own home and a car, luxuries that most of the population could not afford. This ended for me, though, after my arrest by the Ethiopian government.

I had been a clandestine member of the EPLF since the age of 19. From the time I began working as a physician in Massawa, through my promotion to hospital director, until I was uprooted and sent back to Ethiopia, I had been meeting secretly with Tegadelti (liberation fighters), who would sneak into the city in the dark of night.

I would meet with Tegadelti in my home to talk about the marvels in the Field, and I would hand off medicine, microscopes, and other necessary provisions for the camouflaged hospital in the Filfil, a nearly inaccessible region in north

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central Eritrea, shielded by high mountain ranges and thick forest that descended dramatically into the coastal plains.

Not long after my arrest, I was contacted by the Front to plan my escape from Ethiopia. They arranged for me to fly back to Asmara, the capital city of Eritrea, via a circuitous series of local flights. I then met up with a man who guided me north, and we began our walk that very day toward the base of the Front. It was a long walk across rocky terrain, throughout the afternoon and into the evening, with a 4-hour rain that pelted my skin and soaked my clothes.

We finally stopped walking when we saw light from the house of semisedentary farmers. The woman inside gave me dry clothes and a plate of sorghum porridge, all the while quietly continuing her work. Finally she looked up at me and said simply, “Why are you here?” Her hands were tough, their papery skin dry against the stones she used to grind sorghum for the next day’s meal: sorghum bread, more sorghum porridge. She eyed me from her place on the floor mats, (p.21) where she’d been on her knees, grinding endlessly. “Look at you. Your skin is so soft. Why did you come to this misery?” Her eyes narrowed, her mouth turned down. I tried to explain to her about our position as a colonized people, that life without liberty is worthless. My explanation did not impress her. “Why don’t you just go live somewhere else as a doctor? You can live comfortably,” she said. In the morning I thanked her for her hospitality and continued my journey toward the Sahel and the spartan life of poverty that awaited me.

There were a number of new recruits heading north to join the Front, and we were lucky that our guides knew the route well. We had camels to carry all of our supplies—food, drink, everything. However, we were forced to walk at night, as it was imperative that we avoid the Ethiopian army and the merciless heat of the lowlands. Although our guides were knowledgeable, their task became difficult when winter clouds passed by overhead, rendering navigation by the stars nearly impossible. But the camels knew their direction, and their inner compass led us safely to our destination.

The first night of our journey was intolerable. Many of the recruits whispered to the guides that they needed water. I understood. My own thirst was desperate. Being in the lowlands made it worse, and our dehydration was fierce. We each had a cup that held barely more than three handfuls of water. “You will drink one of these at a time and only when needed most,” the guide explained, holding his own cup up against the moonlit panorama of desert. “But no more.” He kept to his word.

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Assefaw Tekeste in an underground health center in 1985. (Photo: Peter Wolff.)

(p.22) There it was, the guerilla base in the Sahel, and I found that a friend of mine was already there. I sat with him, grateful for a moment’s rest after so many days of walking, and we talked. It surprised me when he very suddenly took off his trousers. I watched him, silent for the moment, as he began to pick tiny lice from the cloth, killing them in the heat of the afternoon.

“You know,” I told him, “Having lice doesn’t make you a revolutionary. There’s no reason for this. Simple cleanliness is all it takes to avoid lice.” My arms were draped across my knees, and my own clothes were free of contamination.

My friend laughed and squashed yet another louse between thumb and forefinger. “Take your time, maybe few months, Assefaw,” he said. “You will do what I am doing and a newcomer will ask the same question to you.”

In less than 3 months my hair, clothes, and everything were covered with lice. With no running water and the opportunity to bathe arising only once every 6 or 7 months, it was impossible to keep the bugs from communing on my body, on my single shirt and only pair of trousers. It was simple to be an idealist back in the city. In practice, it was uncomfortable to say the least. This was the life I had chosen, one of blending in willingly with the poor, surrendering fleeting personal leisure for a permanent, gratifying communal life in a liberated country. And so I shared the poverty, and despite the inconveniences it posed, I felt alive to the fullest.

AN UNLIKELY ALLIANCE Morning in the Sahel bled the bone-aching cold of night into the blistering heat of day. Days rolled into months. The underground hospital served as our base. The nature of our struggle forced us to work from the most difficult and barely accessible locations—the terrain was inhospitable but defensible. It did not take long before that stony land became our home. We lay low during the day, coming back to life at night, between dry valleys and mountains slippery with erosion.

The paths of the nomads were ample, winding throughout Eritrea in the highlands and down the mountain flanks into the lowlands. Some of the clans crossed to the Sudan, oblivious of the borders, while others stayed only within the country. There were spots where the tribes would stay for months, where

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there were ample grasses to sustain their livestock. The pastoralists’ sense of cultural identity is deeply rooted in this way of life, an inextricable mix of age-old tradition and necessary adaptations to the exacting conditions of the environment. Neither the term pastoralist nor nomad fully describes the complexity and diversity of their economic and social adaptations. Inevitably, their paths crossed our own—a meeting that sparked the beginning of change for all of us.

Historically, the pastoralists have had little if any access to modern health services. When the Front arrived in the region, it provided primary health care, then secondary and finally tertiary care. Those pastoralists who crossed into the empty lowlands of Sudan, had no health-care options. In the beginning, few but (p.23) major ailments were treated by the barefoot doctors of the Front. Despite the pastoralists’ skepticism, their recovery was convincing. Eventually a mutual bond was established.

One afternoon, some men came to the hospital from a pastoralist village where a woman had been in labor for 3 days. It took me hours to walk there under the sun of the Sahel, and when I arrived the husband looked at me and said, “I was expecting a woman. You cannot go inside the tent.” I tried to explain that I could help her, that there was a strong possibility that she could die. An elder came and apologized for my having walked so far, and I was sent back to the hospital. But that night they came back, and again I made the trek, this time cold beneath the moon. Inside the tent, the woman held onto a rope that dangled from the ceiling, her legs bent into a squat. Her eyes were focused on the rope and her teeth clenched against screams; women in Sahel never utter a sound while giving birth. I could tell immediately that she was anemic. Her skin, her hands, her tongue, everything was so pale. There were five women gathered around, including a traditional birth attendant who was rubbing some butter onto the woman’s belly.

I needed more space to do a vacuum extraction, so I told them, “She needs to be in the supine position. That’s the only way this will work.” The women refused. It was not the way they did things in the Sahel. Her husband told them to let me do my job, so we stretched her out into the supine position and I could see then that her hips were too small—the baby’s head was stuck. I put on my gloves, washed her, and placed the cup over the fetus’ tiny skull. The mother was very strong despite being anemic and in so much pain; she listened carefully, pushing when told. Her courage and tolerance to pain were remarkable. That facilitated the vacuum extraction, and the baby was born blue, not breathing, and nearly lifeless.

I placed my mouth over his tiny face coated in birthing fluid and breathed. I pressed on his tiny chest, his 7-pound body so slight under my hands, and after 3

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or 4 minutes he was resuscitated. He lived, they never forgot about it, and that was how the trust between us was built.

Before the war, several of my colleagues had not known the Eritrean nomad community. Growing up in the cities, they assumed that all people were settled. Although I had known of the pastoralists before the war, I didn’t know much about them. Like my colleagues, I thought that they simply didn’t know a better way of life. With disdain, we sought to change them. We thought that settlement (the only way of life we knew) would be for their own good—they would have access to health care, education, and all the things we felt would solve their problems, make their lives better.

They intensely challenged our attempt to impose change. “We love our way of life. Don’t interfere,” the elders told us. “We didn’t come to you. You came to us.” And it was true. We had moved into their lands, we had been fed and protected, our wounded had been helped by them, and above all they had taught us how to live in that desolate terrain. We knew our position was that of learners.

(p.24) Slowly, their world became intertwined with ours. Their camels carried most of our food and artillery. They were a natural target for the Ethiopian bombs that rained down on their livestock and their tents. Often, our fighters were carried into medical facilities by the nomads, open wounds dripping blood onto their clothing. Survival in the face of a common enemy linked us together. The nomads paid for liberation as much as we did, if not more.

One such case involved a child who had wandered with a baby goat a short distance from his family. He stepped on a land mine, and his delicate rib cage became a cave of bone fragments and muscle tissue. Blood spread slowly up his shoulder and across his abdomen. Miraculously, he survived.

The boy’s parents carried him to the hospital. His younger sister was slung across the mother’s chest and, as the boy lay unconscious, her screams were more deafening than anyone’s. It was a delicate procedure—we had to treat this wound very carefully, tweezing the smallest bits of dead tissue and shrapnel from his flesh, which were placed into a shallow metal pan at the side of the operating table. It was then that I wondered about this war. How many Ethiopian children have starved in their poverty-stricken country to pay for the bomb that had injured this innocent child? The war of liberation was the only means of bringing an end to such atrocities. Fortunately, the shrapnel did not penetrate deeply enough to be fatal, and although it was a painful recovery, eventually the boy grew strong once again, with a thick scar braided over his chest and the loss one leg.

The Front, although initially few in number, had a medical service almost from the very beginning. We started by training medics who traveled with the military units and eventually developed a mobile service tailored to their needs. By 1982,

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we had over 20 mobile health teams, each consisting of a nurse, about five health workers, and—when available—an assistant midwife and several armed guards.

Although pastoralists in Eritrea make up one-third of the total population of 4 million, they are historically a forgotten people living on the margins of a colony. The center of power forgets them, and they forget the center. The presence of the EPLF in the Sahel represented, in many ways, a reversal of the status quo: for the first time there was a political center—that of the independence movement—located in the pastoralist region. Political power was concentrated at the margins. For both the pastoralists and for us, this shift was revolutionary. It meant that after liberation, the national government had to recognize the pastoralists for the first time. It meant that our ethnic groups—the Tigre pastoralists and the EPLF—had truly joined forces.

MEDICINE ON THE MOVE In the beginning, there were no liberated areas. There were only guerillas moving across Eritrea’s tough terrain, constantly changing location to avoid being targeted by the Ethiopian army. However, small areas were soon liberated and we were free (p.25) to set up bases—hospitals and stationary health clinics —to which fighters and civilians alike could come for free health care. Although those fighting for independence no longer needed mobile health teams, we kept them intact and sent them out among the nomads to provide care for them during their long treks in search of greens for their livestock.

Having worked with the pastoralists for some time, we had become increasingly familiar with the health problems they faced. Endemic falciparum and vivax malaria sapped their strength by depleting their blood and overtaxing the supply of iron to their bodies. We also noticed that many of the nomads suffered from undernourishment. Their basic diet consisted of sorghum porridge with milk. Fruits were unknown to them, and the meager vegetables available were given to the livestock. Despite this, micronutrient deficiencies such as scurvy, goiter, and beriberi were rare; however, during periods of drought, when livestock died and the milk supply decreased, undernourishment among the children rose quickly. Community health was intimately linked to the health of the livestock—if the animals suffered, the people suffered.

They became afflicted by a variety of illnesses that could have easily been prevented if even the simplest of measures had been implemented appropriately. The extremes of temperature in this desert land coupled with undernutrition increased the people’s vulnerability to respiratory tract infections, particularly pulmonary tuberculosis and pneumonia, the primary causes of death among children. Schistosomiasis, which had previously not been prevalent, was spreading quickly with the altered movement of the people during the war, and cases were arising in areas that had not been previously affected. Other vector-

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borne diseases, such as leishmaniasis, were common, and epidemics of meningococcal meningitis and cholera occasionally affected the western Eritrean lowlands.

The nomadic way of life also has many healthy aspects to it. Communicable diseases due to overcrowding—such as dysentery, typhoid, typhus, trachoma, and intestinal parasites—were rare. The people lived spread thin, denying the bugs passage from one person to the other.

Despite these complex issues surrounding health provision for the pastoralists, they led a very simple life. It took some time for me to understand the appeal of this wandering from place to place, although a friend I made was very influential in helping to make this knowledge sink in. Each year, this friend from Biet- Abrehe passed by in search of the rainy season, his family in tow. One day he arrived on his way back from Sudan, a bottle of milk for me in hand. I thanked him for the gift, and we sat in a patch of shade with the underground hospital beneath us.

“You know,” I said to him, “each year you pass by from highland to lowland. Your family is always walking along with you. Why don’t you at least leave your wife and children here? We have the school, the hospital. They could get an education, medical treatment if they get sick. …”

He smiled at me and remained quiet for a moment. When he spoke, his voice was rough, like his callused hands. “You know, every time I go to the lowland end, (p.26) you are here. I come back, and you are still here. What a boring life,” he laughed, pointing to the underground bunker where I lived.

“Here’s the thing. …” He lifted his left hand, gestured at the goats grazing on the hillside. “The goats are also a family. That goat, well, she has kids. I can take care of the adults, but the small goats, my wife has to take care of, and my children. So, we cannot split up. It’s a family of goats as we are a family of people.” It was wisdom gained by life experience.

What he told me made sense: they hadn’t chosen the nomadic life for themselves, it had been dictated to them by nature. They could not be farmers in that arid land because there was not enough rain to support agriculture. While sedentary people often viewed them with contempt, no one can deny the productivity of the pastoralists: livestock became the main or only export commodity after Eritrean independence. And how can anyone scorn the pastoralists’ lifestyle?

However, while I learned to respect the pastoralist way of life, I still could not come to terms with certain social and cultural practices that have a bearing on their health, particularly the health of women. Nomadic society, rooted in a patriarchal order that greatly circumscribes women’s rights and power in the

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community, dictates that lineage and inheritance, thereby the transfer of rights and resources, travel along the male line. I would see the women in their seasonal villages grinding cereals between two stones to mill the seeds for porridge or bread, a task that often kept them busy until 3 or 4 o’clock in the morning. The nomadic women were also expected to bear children, take care of home and offspring, and prepare the food, including the laborious task of milling sorghum, tending and milking animals, fetching water and firewood, constructing and dismantling makeshift huts, and more.

As with many ethnic groups, the women were served food last. This uneven distribution of food within the family, combined with poverty, has damaging effects on the nutritional status of women in general and of pregnant and lactating mothers in particular. These conditions, coupled with strenuous work, make nomadic women disproportionately vulnerable to illness. Maternal and infant mortality rates in the region are extremely high (an estimated maternal mortality rate of 1,000 per 100,000 live births), which is aggravated by the severely limited accessibility of maternal and child health care, immunization, family planning, and general health education.

The patriarchal social structure and the low average education level of women further complicate their access to what few health services may be available. However, the revolution did make some differences in the emancipation of women. The female nomads who came to join the Front carried guns and donned clothes like ours. It was only a short time until a law was passed that at least 30% of each village council must be made up of women.

One of these councilwomen was Fatima, but everybody called her Mussolini. This Mussolini was only in her early thirties and not much taller than a medium- sized young girl, but she struck fear in many of the people she encountered. She was a (p.27) divorcee—owing to her nonconformist will of steel—and so her lack of husband to complain about her status as a councilwoman, coupled with fair judgment, made her an excellent candidate for village office.

It was late at night when a dark shape scurried toward us under a desert moon. I could see that he was a pastoralist from the clothes he wore. He carried nothing but concern in the deep lines of a weathered face. He was from Brij, Fatima’s village, and begged us to come quickly to treat his wife. I went.

We arrived at the man’s tent an hour later. The woman had pneumonia and was critically ill with other complications. Her daughter mopped sweat from her mother’s forehead with a bright yellow cloth. The woman shivered despite a thin blanket tucked around her bony shoulders and the perspiration that poured from her skin. I squatted on the floor of the hut and examined her. She was febrile and severely dehydrated. She was very ill, so I took the woman’s husband outside with me.

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“We must take your wife to the clinic,” I told him. “She’s dehydrated. She needs an intravenous infusion and maybe blood.”

“I can’t take her to the clinic,” he said. He shook his head and shrugged. “I don’t have anybody to help me and I can’t take her alone.”

“What do you mean you can’t take her? She’s your wife,” I said. “If she doesn’t go to the hospital, she’ll die.” He was a young man, in his late twenties at most, and he simply refused. I left the hut and walked over to Fatima and explained the situation to her.

“You go back to the clinic,” she told me. “Don’t worry. He’ll meet you there.”

I left, sure that I would never see the man or his wife again.

A short time later, to my surprise, the man did arrive, carrying his wife on his back. The effective outcome of sharing power with women struck me.

LEARNING TO LISTEN I watched one of the pastoralists’ healers late one night. Fire blazed while he chanted and cast herbs into the flames—a practice that seemed irrational and bizarre. I asked him about it later, with the pale moon illuminating his black freckles.

“I cannot tell you the secrets of my ways,” he told me. He shook his head in refusal, crossed his arms.

“But if this truly works for healing sickness, isn’t it better to tell others about it so more people can benefit from the practice?”

“No,” he said. He continued to shake his head as he spoke. “Revealing secrets affects the potency of the therapy, and for this reason, I cannot tell you or anyone else.”

Traditional healers were the prime health-care providers to the pastoralist communities. The fact that they charged excessive prices for their services, contrary to the practices of the Front, was in no way compensated by the occasional destitute family they helped for free or the fact that they did not charge for patients (p.28) they failed to cure. Our stand against the healers was aggressive—we believed in doing away with some of the old habits and paving the way for improved modern health services. Typical of the arrogance of modern medicine, we prohibited their activities, sending fighters to arrest them in the most extreme cases. Consequently most of the healers fled their communities or went into hiding.

However, there were also traditional birth attendants, women who assisted in labor. They very rarely asked for payment up front and did not necessarily

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charge patients who could not afford to pay, and we began to wonder if the ban on traditional healing had not been a mistake. We were obliged to revisit the policy and reverse it. There was an attempt to reconcile our differences and integrate the beneficial aspects of traditional health practice with modern health services.

I went to one of the villages and began asking around about the traditional healers, where they had gone and how I might find them, saying that we had been wrong. Most of the nomads said, “No, we don’t know where they are.” Finally one man leaned close to me and said, “Well, there are three of them. But they don’t operate openly because they are scared of you. Before, we had seven. But now there are just the three.”

“Where did the other four go?” I asked. I was skeptical.

“Well, two of them fled to Sudan, and the other two you arrested. And the three that are still here, well, nobody’s supposed to know that.”

That night, I went in search of the traditional healers, entering each of their huts with the best of intentions. They all denied that they were practicing, though, and it was then that I knew: in our haste to ban traditional healing practices, we had lost their trust forever. We were never able to close the gap we had created.

I did know one traditional healer, though. His name was Sheik Abdul, a very rich man who was intelligent and cultured. He came to the hospital for his diabetes, a disease he knew he needed our help to control. He had been coming for some time, but when I saw him one morning I asked him to follow me. I began to examine him outside the outpatient department, where other pastoralists would see him.

He laughed and said, “You want to do this here? So everyone can see that I come to you?”

I smiled back at him and nodded.

“Okay, then,” he answered, and allowed me to finish the exam.

When I was finished, I sat down next to him and said, “You know, I’ve been to your home; I’ve seen you giving treatments. And you have over 100 patients a day because they trust you. Here, we only see 30 or so people a day. And that’s okay. But you know that there are some diseases you cannot treat, right?”

“Yes, sure. Tuberculosis, fever. … You can treat these things better than I can.”

“So, when you have patients with these illnesses, do me a favor. Refer them to us.”

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He agreed, but only if I would refer psychiatric patients to him. In the end, many of the patients he referred received treatment from both of us, inevitably believing in the end that it was the traditional healing that cured them.

(p.29) This daily interaction brought us together, resulting in a mutual respect and trust that enabled us to accomplish a great deal, especially in making it easier for them to understand modern health treatments, such as the one for tuberculosis (TB).

TB, a bacterial disease that is often spread through coughing or sneezing, was very common among the pastoralists and their livestock. Generally TB infects the lungs, although it can also affect the peritoneum, bones, kidneys, or any other organ. Most of our patients would come to see us after 2 or 3 months or more of a productive, grating cough, sometimes producing mucus tinged with blood. At that time, the treatment for tuberculosis took 18 months to complete. Patients were advised to come every 3 months for a checkup and to refill their prescriptions. After 5 years, we carried out an evaluation of the program, and to everyone’s surprise, 97% of the pastoralists had completed their TB treatment— a remarkable demonstration of adherence in a nomadic community.

Sometimes, though, we seemed to have elicited too much faith. In one particular community, we had assured the people that if they attended the prenatal health clinic at the health stations and made use of the trained traditional birth attendants (TBAs), no more women would die in labor. But once a woman did die.

The family went to the clinic nearest their encampment and demanded to know what had happened. “We did everything we were supposed to do,” they said. “She took her tablets, she attended your clinics, we had a trained birth attendant by her side. You told us she wouldn’t die. Tell us what happened.”

The birth attendant who assisted her, a very young girl, probably less than 20 years old, was asked about the night of the birth.

“We did everything we should have,” she said, but she looked down at the floor, her voice hushed and unsure, fingers fidgeting.

Eventually, she took a deep breath, and looked back at me. The woman, she said, was her aunt. Her labor was delayed, and although she had been advised to deliver at the health center, she wanted to give birth at home. The traditional birth attendant did her a favor. In the middle of the birth, her aunt had collapsed and her breath had suddenly halted. The birth attendant began to cry, repeating that she had only wanted to do what her aunt wanted her to do—she thought she was respecting her request. Thus we had an answer for the young woman’s tragic death.

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The village, however, was not satisfied. They decided that the birth attendant should no longer serve there. The woman’s husband was still angry: “This is only partially her fault,” he said of the birth attendant. “If the medics stated that my wife should deliver in the clinic, they should have been paying closer attention. They should have been following her pregnancy to make sure she went in when it was time. We’ve done our part. It’s time for you to do yours.”

This attack, while humbling for our medical staff, was the point at which I realized the people knew their rights—and they considered it a right to understand that which they did not. It was a nascence of awareness, a healthy sign of social change, not to mention the sobering effect on the souls of us clinicians.

(p.30) IRRECONCILABLE DIFFERENCES The woman on the delivery table looked at me very seriously and without blinking said, “If you don’t do it here, they’ll do it back in the village.”

I sighed and looked at the traditional birth attendant who had accompanied the young woman. Mere minutes after the birth of a healthy baby boy, the woman asked us to stitch closed her old infibulation wound. Infibulation was the practice of suturing the labia majora together—a traditional surgical procedure that allowed for an opening only small enough for urine and menstrual blood to pass through. Once married, the opening was enlarged just enough for the penis to fit through. However, this scar tissue would once again need to be cut in order to deliver babies; otherwise the possibility was very high that the inflexible scar tissue would simply rip apart and cause a large vulval tear, requiring surgical repair.

We campaigned vigorously against infibulating females, since it was one of our most critical reproductive health goals.

“It’s clean here,” the TBA said. “If I take her back to the village, they’ll use thorns to suture it; your hands are blessed.”

I looked between the two women, weighing the issue—under anesthesia, the procedure wouldn’t be so painful, and in the clinic the wound had less chance of becoming infected. At the same time, though, I did not want to send the message to the other members of the community that circumcision and infibulation were right, or circumcision alone, the procedure in which they remove the clitoris of young girls. Either way, it would be wrong, and unfortunately this was the dilemma we faced.

Outside the delivery room, the argument persisted. Every 2 months, medical cadres met to discuss the progress of the campaign against infibulation and female genital surgery in various regions. The effectiveness of the campaign against circumcision and infibulation was assessed in the meetings of village

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councils. Although our results were unimpressive, there were some signs of change.

In Hager, it seemed that a health worker was not doing enough to dissuade the nomads from the practice of infibulation. Some of the Front members at the meeting pointed out that incidents of female circumcision were declining in most of the villages, but in the area which this man oversaw, it remained steady.

Upon the man’s arrival back in his village, he announced to the pastoralists that there would be no more female circumcision. “It is against the law,” he told them forcefully, “and anyone who is caught performing or condoning this ritual will be arrested.” Clearly, this man wanted to be able to bring results at the next meeting, to show that he had made positive changes in the community.

However, his forcefulness was met with defiance, most surprisingly from the women. “It’s none of your business,” they stated, shaking their heads at the man. He persisted, though, and kept pressing the issue on the people, until one afternoon the women came out of their huts, raising not only their voices in defiance but also their skirts—hems lifted to their knees in an act of rebellion as they cried, “You can’t tell us what to do with our bodies!”

(p.31) Higher authorities eventually had to intervene, and it was decided that the women could do whatever they wanted with their bodies; it was our place to give advice, but we could not impose our will. This traditional practice was something I strongly disagreed with, but the women’s resistance was a healthy sign of the power of the community.

Although 33% of the EPLF cadres and 52% of the medical cadres were women, we made limited progress on the topic of circumcision and infibulation. The pastoralist women claimed that the surgeries, which were mandatory for all girls, had no negative effects on their health, even though we knew that the procedure often caused complications such as excessive bleeding, urinary retention, infection, cyst formation, keloids, fistula, and deformation of the pelvis.

The women, for the most part, argued adamantly that it was simply not possible to choose to not be circumcised—it was tradition, cleanliness, religion, morality, health, and beauty for them. One woman once told me that it is done because they love their daughters and want to protect them from ostracism in the community. Besides she said, “If you had to keep your mouth open, bugs and spiders would get in there. The same is true of our genitalia.” Although some local religious leaders have indicated that there is no verse in the Koran supporting the practice and a few even regard infibulation as anti-Islamic, the practice continues.

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In private, we occasionally found women who complained about the practice. The relatively rare women who had been circumcised in later life were far less in favor of the practice. A few even admitted that they did not want their daughters circumcised. The anti-FGS (female genital surgery) trend was fairly restricted to younger women, including TBAs, who generally avoided performing FGS, but older TBA and non-TBA women in the clan remained true to the custom, performing the surgery without hesitation. Even after so many years of living and working with the pastoralists, our stand against subjecting girls to genital surgery never made much of an impact.

BIRTH ATTENDANTS AND BAREFOOT DOCTORS The high demand for health professionals grew with the nomadic communities’ awareness of their own rights. Over the years, we trained over 200 TBAs and 350 village health workers to serve the different nomadic communities with whom they lived. Because of our proximity, we were able to offer training as well as monitor their activities over extended periods of time. When it came to childbirth, the TBAs performed wonders and saved countless lives. They referred those in need of surgical intervention to the nearest hospital, although it was often inaccessible.

Training the women was very difficult owing to their high illiteracy rate. Hot afternoons dragged on, and the sweat dripped from the overworked body of the TBA trainer as she tried to explain to overworked brains concepts that would make so much more sense if only they could be written down. We used a system (p.32) of symbols based on those used by the World Health Organization (WHO) and labored day after day with these symbols until a girl asked, “Instead of teaching us all these symbols, signs, and designs, why not just teach us how to read? After all, the alphabet is made up of symbols, isn’t it?” So we did.

The TBAs played important roles in these communities, especially because they were often the only accessible and affordable source of health care for women in that society. They would often impart information on the prevailing side effects of female circumcision. Given the high birthrate among pastoralists, TBAs were encouraged to provide family planning education, although it was not always met with support.

Overall, the medical services offered by the Front were an enormous success. The mobile health teams and TBAs were received very positively. In time, the Front grew larger and stronger. As the forces of the EPLF gained the upper hand and commanded control of a wider territory, we were able to build stationary hospitals and clinics all over the Sahel. The nomadic population of Eritrea finally had health services and the fighters had a home and a family in the Sahel.

NOMADS AND NATION BUILDING In 1991, when we won the war, everything changed.

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Many Front members left the rural landscape that had been our home for so many years, a flood of people going back to the cities. Several committees representing the population in the Sahel made their way to Asmara to appeal to the leaders of the Front, who were now the government of Eritrea. Their questions were simple: “Why are the schools closed? Why aren’t the health clinics helping us anymore? Where are the doctors?” They missed the spirited camaraderie they had had with the health workers and teachers. But the dynamics of relationship had changed. Now they were subjects living at the periphery, again forgotten by the center. One pastoralist, reminiscing about the level of commitment to the community evinced by the health cadres during the war and the current lack thereof, recounted a recent incident:

One night in our village, a pregnant woman was bitten by a snake and we wanted to take her to Wade health station. However, because the health unit was far away and the patient was restless, we resolved not to take her. We sent a messenger to the health worker but he was unwilling to come. After some time, the woman passed away in front of our eyes. If the health worker had been one of us, he would have been available at any time and in any place.

There were few listening to the legitimate requests of the pastoralists. The government decided to settle all the nomadic communities permanently. We tried to persuade state officials that movement was the crux of the pastoralist lifestyle and that the settlement of nomadic communities in other countries, such as Libya (p.33) and Somalia, had failed. But the political game had changed. The desires of the pastoralists were overruled by state proclamation. Having a say in their lives was considered an offense the new nation could not tolerate.

Many of Eritrea’s pastoralists admit that nomadic life has become increasingly difficult and risk-prone. The impact of 30 years of war, responsible for many deaths and injuries and a landscape littered by land mines, has taken its toll. The nomads’ ability to protect themselves against the risks of drought and advancing desertification has greatly diminished. Political instability in the Horn of Africa has forced many to flee their homes and traditional routes and to settle in neighboring countries. The Afar, relatively poor compared with the Tigre and the worst affected by drought, are resorting to salt mining, wage labor, and trade, which offer a meager living.

The precariousness of their position within modern states and their vulnerability in times of political instability feature predominantly in the life of all the pastoralist groups. Over the years, the pastoralists have taken charge of their own survival and moved around the region irrespective of imposed constraints and boundaries—not, however, without cost. As conflicts arouse border sensitivity, local and regional authorities on all sides create obstacles and are

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Access brought to you by:

hostile toward or suspicious of peoples insensitive to what are, in geographical terms, artificial boundaries.

To the Eritrean pastoralist community, freedom means the right to live the life of their choice without interference. To the totalitarian regime that has taken control of the country, it means forcibly settling those who wish to remain unsettled. As an elderly pastoralist said in disdain, “I was part of the struggle for freedom, so that my goats could move back and forth freely, without any fear, in peace. Now my mobility is limited and my security is threatened. Where is my liberty?”