CHAPTER FIVE

 

INTRODUCING FAMILY PLANNING TO AKHAS

 

Anthropologists are interested in how innovations are introduced, received, and what changes they bring about in the culture.  Toward the Akhas of Thailand, I was a proponent of certain changes.  How did my introduction of family planning influence their reception?  In looking back, what can be learned from this experience which might help others?

 

Historical Background

 

First Term in Thailand

 

The first term my wife and I served in Thailand was from July 1968 through June 1972.  During that term we served primarily the Lahus in various ways, especially in the fields of leadership training, literature production, and church organization.

 

The Lahu-Akha-Lisu Association of Churches (LAL), with which we worked, had an executive committee made up of one representative from each church, together with the general secretary of the association.

 

In March 1970, the LAL Association of Churches held an annual meeting in a large Lahu village on the Mae Kok River.  Some 1,200 people attended, most of whom were Lahu;  but there were many Akha and Lisu as well.  Dr. Edwin McDaniel and Dr. Boon Chom Areewongse of the McCormick Family Planning Program had been invited by the LAL to come from Chiang Mai to explain about family planning.  During that meeting, three Lahu men were selected by the delegates to keep contraceptive pills in their villages to distribute to all interested couples in their area.

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The rate of interest in family planning soared following that meeting, with many couples with four of more children asking for sterilization.  At that time, postpartum sterilization was about the only means available to them.  It was difficult for tribal people to take advantage of that type of operation, however, since there were problems about being away from home so long, and they did not have anyone with whom to stay in Chiang Mai while waiting for the child to be born.

 

During that first term of service, I did not go to Akha villages very much.  In 1969, however, I had the opportunity of making a trip to fourteen Akha villages over a three-week period with the Nightingale family of the OMF.  It was my first experience of visiting Akha villages in Thailand, and it was a very depressing experience to see: 1) how very much poorer they were than the Akhas in Burma, 2) how much more opium addiction there was, and 3) how little land there was for the relatively large number of people.

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Several headmen talked with me about their problem of finding arable land for fields.  They were forced into making fields on tracts that had lain fallow only three or four years, which is insufficient time to regenerate the soil.

 

At that time I did not understand the situation well enough to talk with them about population problems, but I do remember one headman talking with me about wanting to get a breed of pigs which would give large litters.  I motioned to the children the children running around the village and said, "You don't seem to have much trouble producing children in this village." He replied, "It's great to have children--if we could just feed them sand instead of rice.  I am worried, really worried, about the fact that we have decreasing fields to feed increasing families."

 

Furlough

 

When it was time for furlough, I had discussions with various Lahu and Akha friends concerning the work I should undertake when I returned for the next term.  I also talked with the OMF missionaries about it.  At the last meeting of the LAL Executive Committee, I asked them what they would think of my taking special studies during furlough so that I could help develop a family planning program for the Lahu and Akha groups in Thailand.  They gave their consent, and voted that when we came back I was to work in that capacity, while my wife was to give special help in the marketing of handicraft.

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My furlough was spent in the Department of Anthropology at the University of Oregon, seeking to understand how best I could help the Akhas and Lahus of Thailand solve that need. {footnote 1:  I served both groups, but gave special research attention to the Akha group, since they are less educated, have less contact with the Thai, and have more cultural barriers to surmount in such a program.}

 

Initial Contacts

 

While still in Oregon I wrote to Dr. Edwin B. McDaniel (NOT related to the owner of this website), director of the McCormick Family Planning Program, and told him of my hope to help tribal people in this field.  He was immediately receptive to the prospect, and took steps that eventuated in making the Tribal Family Planning Project an arm of the McCormick Family Planning Program, which is associated in turn with McCormick Hospital in Chiang Mai.

 

Upon my return to Thailand, Dr. McDaniel and I went to government officials responsible for family planning in Thailand.  We were very warmly received, especially when they learned I was anxious to help start a family planning program among some of the hill tribes.  They gave us full backing, and encouraged us to proceed, feeling that with my understanding of the languages and cultures of the people I could be useful in helping to establish this needed service.

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Later in Chiang Mai and Chiang Rai I contacted the Provincial Health Officers to talk with them about our hopes of developing family planning programs for Akhas and Lahus in their provinces.  They gave us their full backing.  During the four years of our program, the Provincial Health Officer for Chiang Mai changed several times, but Dr. Kitchai Yingseri remained the Chief Medical Officer in Chiang Rai throughout the entire period.  Upon his recommendation of our program, it was officially approved by the Chiang Rai Provincial Hill Tribe Committee in January 1975.  This committee was chaired by the governor, and had the heads of all the divisions of the province sitting on it.

 

Lahus

 

The executive committee of the Thailand Lahu Baptist Convention (formerly LAL) was the main Advisory Committeee for the Lahu sector of the family planning program for most of the four-year period.  Two attempts to bring in some non-Christian Lahus for such a committee failed.  In July 1977, however, after thorough preparation, we had an expanded Lahu Advisory Committee which included both Christian and non-Christian members.

 

Akha Contacts

 

It was difficult to contact the Akhas living in Thailand, since they had no organization with representatives from various villages.  So I asked the two OMF families to talk with the Akha Christians at their next meeting, in addition to which I visited some twenty Akha villages, many of them several times. {footnote 2:  These villages were on or near roads, which meant that they were not always typical.  There were people passing through from more remote villages I met and talked with, however.}

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The Akha Christians were the group that knew the most about family planning at that time, since many of them had already received help from the missionaries, and I knew they were anxious for a program to start right away.  In the non-Christian villages I visited I talked with the leaders, as well as a cross-section of the members of the villages.  The idea of family planning was a new concept to most of them, although some had heard that the Thai had some means of preventing pregnancy.

 

The Program Develops

 

Field Workers

 

Bringing family planning help to tribal villages, I felt, could best be done by means of someone who was from the same culture and spoke their language.  So I worked to find men to receive the needed training and then go serve the people in the villages.  I felt further that the groups to be sreved should have a voice in selecting them.

 

1) How chosen.  The Executive Committee of the TLBC chose Nai Ci Dusaeng, a Lahu man, to be the field worker to serve Lahu villages.  When it came to choosing an Akha field worker, I asked the OMF missionaries to talk the matter over with the Christian Akhas.  The reason for this was that we needed a man who was literate, and at that time the only Akhas that qualified were Christians.

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The Akha Christians selected Yaju Cehmui to be the field worker for this project.  They did not like to let him go from his place of leadership in Huay San village, but they decided that if he would live in the village of Namlat (across the river from Chiang Rai) and help look after the growing number of Akha children attending the boarding school there, they would be willing to "share" him in this way.

 

Their choice of the worker was good, for though he had had only a few years of formal education, he had a wonderful spirit.  They also proved right in asking that he live in Namlat, since that has turned out to be an excellent place for our Tribal Family Planning Center. {footnote 3: This consists of a small plot of land with Yaju's house and a guest house where people can stay at night when they come for contraceptive or health services in Chiang Rai of Phayao.}

 

2) Initial surveys.  The Akha field worker began visiting Akha villages in December 1973.  His main purpose at the time was to discover the felt needs of the people, especially in the area of family planning.  He filled in forms I had devised for each village, and each household in each village.  In the meantime the Lahu worker was doing the same in the Lahu villages.  At the end of each month the three of us would meet in Chiang Mai where we discussed the work for that month and planned strategy for the coming month.

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3) Information and education.  The field workers had had some training by Dr. McDaniel and staff before they started, and I also presented new information and instruction at our monthly meetings by way of in-service training.  They in turn relayed this teaching on to the tribal people.

 

The men presented five methods of contraception to the people (in this order): 1) pills, 2) injections, 3) IUDs, 4) female sterilizations, and 5) vasectomy. {footnote 4: We did not introduce condoms since the Akha are culturally opposed to them.  The field workers carried a supply with them in case there was ever a request.}  At the time all they could provide on the spot were contraceptive pills.  It was our aim, however, to make the villagers aware of all of the alternatives.

 

As the Akha field worker travelled to Akha villages, he found they were interested in contraception, but they lost much of that interest when shown the oral contraceptives.  "We cannot possibly remember to take a pill every night," the women said.  Many Akha couples asked Yaju for the contraceptive injections he told them about, but at the time he could not give these injections.  Chiang Mai was probably the closest place they could receive them, but this was out of the question due to the time and expense involved in such a trip.

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IUDs could be fitted in Chiang Rai, which was nearer, but there were certain possible complications with IUDs.  We felt we had to tell the couples the main pros and cons for each method, so that they could make their own decision based on that knowledge.  When the couple learned that some women with an IUD still become pregnant, they said, "We don't want that then.  We have enough children."

 

A few asked Yaju about female sterilization, but at the time our program had no way to help such women directly, and most of them could not get the operation on their own.

 

Mobile Trips

 

When the field workers and I saw that the villagers were anxious for 1) contraceptive injections, and 2) general medical care, we talked with Dr. McDaniel (Not related to the owner of this website), and he helped us to set up quarterly mobile clinics in the northern section of Chiang Rai Province.  The clinic was held in a large Lahu village named Goshen, which served all the Akhas and Lahus in the area.

 

We had very good reception in those clinics, where inoculations were given, the sick examined, and family planning services offered.  Many women came for contraceptive injections (the three-month variety), and several couples asked about sterilization.  One of the major problems we confronted was that the doctors and nurses spoke Thai, and most of the patients spoke only Akha or Lahu, we had to provide translators for every medical worker.  Sometimes there were not enough translators available.

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The political headman from an Akha village near Goshen came asking about sterilization for his wife, who was then ill.  We suggested that he could have a vasectomy right there, and although the idea of having a vasectomy has not taken with most Akhas, he was willing to undergo the operation, which was performed on the spot.  He was the only Akha man to have the sterilization in our program.

 

At the time of the thrid mobile trip we took to Goshen for the clinic, it was raining hard.  The road leading up to Goshen was impassable, so we held the clinic instead in a Shan village at the foot of the mountain.  Many Akha and Lahu patients walked down to the clinic, but those who were the sickest could not make it.  In addition, many of the women who were due for a contraceptive injection were not able to come down, which meant that they would soon have no protection from pregnancy.

 

After several of us discussed the situation, we decided to dipense with the mobile clinic trips.  Instead we trained the field workers to give contraceptive injections, as well as to take certain frequently needed medicines with them out to the villages.  We had learned two valuable lessons from the experience: 1) we should take the service out to the people, and 2) we should provide it through one who speaks their language, rather than trying to provide translators.  It was decided to have the field workers give six-month injections instead of the three-month variety, because it would be impossible for them to reach every village on a three-month cycle.

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Akha Advisory Committee

 

From the start of the program, I had conceived of having an Akha committee which would give direction and oversight to the family planning program as it developed among their people.  There were three basic reasons I wished to have such a group: 

 

1) The program would go much better with the full cooperation of those involved (Goodenough 1963:387).

 

2) There must be continuing evaluation, and I believed that the group which is most affected by the program should be the one to make that evaluation.

 

3) From the start I wanted it to be their program, so that even as it was developing they could handle it with the minimum of outside aid.  To do this, we had to have representatives from the Akha community.

 

As I travelled to Akha villages, I talked over the possibility of having such a committee made up of Akha leaders from many villages.  There was a good response, especially from those in the 25-45 age-group.

 

We had the first meeting in December 1974, with a total of forty-six Akha men from twenty-three villages attending.  This meant that about 25% of the Akha villages in Thailand were represented.  Three of the representatives were from two Christian villages.  The rest were all non-Christian, for from the start the matter of religious affiliation has played no part in the proceedings.

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The reason there was more than one man from a village in many instances was that they did not feel safe travelling alone.  Besides, Akhas much prefer doing things with friends.  Eleven of the representatives that first meeting were village priests.  Political headmen and other elders were also present.  One of the most enthusiastic, and perhaps the youngest, was the Akha radio announcer.  He and several of the village leaders of the larger villages tended to become the natural leaders in the discussions.

 

All agreed from the outset that the meetings would be conducted in the Akha language.  If some Thai official were present and spoke in Thai, then it all must be translated into Akha.  By using Akha as the "official" language, we had good participation, and could deal in depth with their problems without having to worry about understanding or being understood.

 

At the end of the first meeting they insisted that we meet again, so we tried to meet three or four times each year.  The typical Akha Advisory Committee meeting went something like this:  I would first of all give some information concerning population problems, contraceptive methods, and guides to better village health (including preventive medicine).  Following questions on these matters, we would talk about the family planning program as it was developing in their midst.  Problems from the field worker and villagers would be brought up and discussed.

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The committee made decisions regarding the program, such as:  how much to charge for each service provided, determining which people should be eligible for what services, deciding what area the field worker should serve, determining how much time the field worker should give to help with opium detoxification programs in the villages, and devising various development programs.

 

The question came up one time as to whether we would accept Akha women for tubal ligation who had only two living children.  The Akha elders felt that "since Akhas live far away from hospitals," so that accident or disease might well carry off one or both children, we should as a general rule only accept women who had at least three living children for sterilization.  It was, however, left to the doctor and me to decide upon exceptional cases.

 

The meetings were very informal, with everyone having an opporunity to express his opinion on all subjects.  There was no show of hands or actual votes.  Each subject was discussed until there was no more dissent.  The consensus of the group was then acted upon.  If there was no unanimity, the decision was delayed until the next meeting.

 

The Akha Advisory Committee has become a body that legitimizes decisions which those Akha leaders in attendance feel will be beneficial.  These decisions were reached in part upon the basis of technical information provided by an outside agent, and on the basis of resources made available through him.  So for the first time they were able to share their common Akhahood in developing action programs.

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Village Outreach

 

From the start, the focal point of our family planning education and service has been the Akha village.  Upon his arrival in the village, the field worker goes to the home of the 'village priest' or the political headman.  In an Akha village one must not try to introduce a program such as this without going through the village leadership.  The field worker explains why he has come and requests permission to to talk with the families in the village who might be interested in contraceptive help.

 

The Akha field worker has never been turned away from any village.  Sometimes the villagers did not accept contraceptive aid, but at least they welcomed him and listened to what he had to say.  Admittedly, his reception may have been in part due to the fact that he carried medical supplies with him, and the villagers were anxious to buy good drugs at cost price.

 

The very first time the field worker visited a village, the couples would be a bit puzzled and sceptical about the possibility of accepting contraceptive aid.  Six months later at his next visit, after he had repeated his explanations and patiently answered questions, one or two families might try some form of contraceptive help.  By the third and fourth visits often more accepted.  One reason that the Akhas are hesitant to get involved in a program like this is that in the past they have seen outside agencies start up programs which had high promises, only to see them collapse and their hopes vanish with them.  We had to work all the time to let them know we would keep our word.

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If the village leaders were willing to let the field worker introduce family planning, he either asked that the interested couples meet him at the leader's house or he went to their homes to talk with them.  In the initial stages of the program, we felt it was best that the village head be present to see that there was nothing subversive or threatening about the program.

 

The field worker first of all told of the five available contraceptive methods and then asked the family which one they felt met their needs the best.  The discussions were very open, often with men, women, and children all crowded into the house.  Each family was considered in light of its own particular needs.  For example, in one family the husband was an opium addict, and the family was very poor.  In another there were only a few children, but the wife almost died each time she delivered a child, and the complications were getting worse with each pregnancy.

 

If the wife asked to start on contraceptive pills, the field worker examined her blood pressure and asked her a set of ten questions in order to weed out any who might have problems with the pills.  If her blood pressure was too high or there were other potential complications, the field worker instructed her to consult a doctor to find the best contraceptive for her.

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Sterilization Requests

 

As our program developed, we got more and more requests from Akha women for steriliztion.  This surprised me, as I had not anticipated this surge of interest.  There were many couples who had "enough" children (or at least all they felt they could care for), and they simply did not want to think of having a "method failure" with some reversible contraceptive.  There were even some families with only one or two children who were thinking of sterilization as a possibility for the future.

 

1) Chiang Rai, Overbrook Hospital.  In March 1974, at their request, I helped two Akha women go from the Nikhom area to get tubal ligations in Overbrook Hospital in Chiang Rai.  At that time sterilization was not given as an outpatient procedure, so the women had to stay in the hospital several nights.  They experienced quite a bit of pain following the operation, which made me wonder if their experience would discourage other women.  After they returned to their village, however, other women began to ask me for help.

 

2) Chiang Rai, Government Hospital.  About that time I learned that the Government Hospital in Chiang Rai had a laparoscope and performed laparoscopic ligations on an out-patient basis.  I contacted Dr. Renu Srisamitr, the very capable woman doctor who performed the operations, and made arrangements for tribal women to receive sterilization there.  This was a great improvement, for this technique involved far less pain, and was performed on an outpatient basis.

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There were still some major problems which kept this from being the ideal situation for tribal women.  We could never be sure whether the women would be accepted for the operation, even when we had made appointments well in advance.  This was not the fault of the doctors or the hospital--their operating space was limited, and was sometimes pre-empted for emergency operations.

 

3) Phayao Government Hospital.  In November 1974, the McCormick Family Planning Program hired Dr. Arunee Fongsri to work full-time in their program and to specialize in giving sterilizations.  Dr. Arunee had grown up in Phayao, a town about one hour's drive south of Chiang Rai town.  She had been working in the government hospital there, serving under her brother who is director, at the time she was called to work full-time in family planning.  We got permission from Dr. Arunee to visit Phayao the last Friday of each month to perform sterilizations on tribal women.  The hospital graciously made available a large ward and one operating theater for this program.

 

Dr. Arunee gave laparoscopic ligation (or the minilap operation if the woman had complications) on an outpatient basis.  This meant that most of the women needed to stay in the hospital only one, or at the most two, nights.  After resting a few hours following the operation, many of the women returned to spend the night at the Tribal Family Planning Center in Namlat the returned home the next day.

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After several months, one day each month was not enough to accomodate all of the tribal women in the Chiang Rai area who wanted tubal ligation.  We therefore worked out a schedule whereby we started operating Thursday afternoon and went through Friday.  After a few months we had too many women to accomodate on that schedule, so again we asked for permission to extend the time.  Therefore, for about the last year of the program, we began the operations on Wednesday afternoon, and continued all day Thursday and Friday.

 

One reason for the mounting influx of sterilization candidates in Phayao was that word was reaching tribal people living across the border in Burma, who began coming across for the operation and returning home thereafter. {footnote 5: Tribal people are permitted to cross the border in order to buy things on the other side, and to receive medical services.}  By the end of the project as many as 80% of the women coming in for steriliazation came from across the border.

 

The main reasons for the success of the Phayao operation were that it was relatively close to their home, thus reducing travel, and there was a minimum of layover time.  The hospital care was good, the services efficient, and the cost inexpensive.  Above all, the fact that the doctor was a Thai woman, a translator was present, and other Akha women were undergoing the operation at the same time, gave them reassurance.

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4) Chiang Mai.  Many of the tribal women we were trying to reach, especially from the Lahu and Lisu tribes, lived in Chiang Mai Province.  It was much easier for them to come to Chiang Mai than to Chiang Rai or Phayao.  At first we brought them to McCormick Hospital for the operation, but beginning December 1974 we began using the newly built Chiang Mai Christian Clinic, with Dr. Arunee doing almost all of the surgery.

 

Only a few Akha women have come to Chiang Mai for tubal ligation.  One reason is that it is not the proper geographical center for most of them.  Even those who could come to Chiang Mai more easily often preferred going to Phayao.  "We want to go where our sister Akhas are having their operation," they would say.

 

Diffusion of Family Planning Information

 

How widely has family planning information diffused into the scattered Akha villages in Thailand?  Has it presented the Akhas with viable options?

 

It is not to be expected that the majority of the people who learn about the program will immediately accept it.  For example, Hogan (1977) discovered in his survey of tribal women in the provinces of Chiang Mai and Chiang Rai that 78.4% of them were"aware of family planning," whereas only 24.7% were currently using contraception (including sterilization).

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The main means of diffusion of information is through word of mouth, when the field worker and I went to the villages to inform the people of available services.  The reception of information concerning family planning is not typical of the manner in which other types of information are received.  For example, information regarding the availability of iodized salt and the value of this salt to help prevent goiter diffuses in a ragged manner, with few people interested since they do not recognize any urgency in this matter.  On the other hand, information relating to family planning is basic to life itself, and relates to the perpetuation of Akha ancestral lineages.  The subject elicits lively and emotional discussion.

 

There are three efficient communication networks within Akha society by which information regarding family planning is diffused:  the network within the village, the network between villages, and the network within peer groups.

 

Within an Akha village the main group that disseminates family planning information is the female segment, to which the issue is of particular interest.  As the women often go in groups to gather firewood, carry water, go to the fields and work in the fields, they have plenty of opportunities to discuss matters of special interest to themselves as women.  Family planning information is frequently passed one to the other at such times.

 

However, it is not only the women who discuss family planning.  Men are also concerned about such matters, and discuss them within their peer group.  Young people and children are often present when family planning is being dicussed, so that they also become aware of it.

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The network of diffusion of family planning information between villages is also often through the women.  For example, on one occasion four Akha women from a village where no family planning worker had ever been came in for sterilization.  When asked how they had learned about the service they said, "Our fields are adjacent to the fields of Pa Mi village.  At noon we rested together with the Pa Mi women, and they told us about it."  Thus, although Akha women do not generally travel to distant places, they do communicate with their sisters in nearby villages.

 

Since it is the men who generally travel they are often the ones to pass information from one village to another.  They may be traders going to buy pigs or to purchase opium.  Perhaps they are visiting a sick relative, or are young men seeking a bride.  The word is spread within and between villages as these travellers relax around the fire at night with their hosts.

 

In our program we have found that family planning information diffuses more rapidly and evenly when it is closely tied in with meeting other needs the people have.  For instance, a mother may hasten to take her child to the Akha field worker when he visits her village to get medicine for an infection in her child's foot.  That is her primary objective at the moment.  While she is there she may hear him talking to others about contraceptive injections of sterilization.

 

The most effective dissemination is reinforced through many different networks.  Suppose the following sequence takes place:

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1) The field worker visits the village of Ba Jaw and tells them about contraceptive methods.  At the time they do not understand too well.

 

2) Later I visit the village, and some of the more interested couples ask me about the things Yaju told them, so I have a chance to explain further and in more depth.

 

3) A man from another village stays overnight in Ba Jaw, and mentions to the host family that his wife is now getting contraceptive injections.

 

4) The radio announcer says that over forty tribal women received tubal ligation in Phayao last month, and mentions the nems of many Akha women who will be going this month.

 

5) Two Akha inoculators come to the village to immunize the children, and one of them mentions that his wife used to have an IUD, but she has had a tubal ligation now.

 

6) Three new families move into the village.  One of the women says she had received contraceptive injections twice while living at the old site; now she is thinking of having a sterilization.

 

7) Border Patrol Policemen spend a night in the village, and one of them mentions he has had a vasectomy.

 

Whether the villagers of Ba Jaw accept contraceptive aid or not, at least information about family planning has diffused throughout their village, reinforced by repetition from many different sources.

                                                                                                                              p.108

Conclusion

 

The innovation of family planning has been introduced to a preliterate tribal group.  It was introduced in part by a missionary using applied anthropological techniques.  The message of contraception spread from village to village through the Akha field worker, the missionary, gossip, rumor, radio broadcasts, and the testimony of those who had received help.  Many Akha families accepted short-range contraceptive aid (pills, injections) or long-range aid (sterilization).  Those who have accepted this change have been able to fit into their community with no visible trauma, and in turn have often become advocates of family planning to their friends.