AN ANALYSIS OF PEOPLE AND PROGRAM

 

The previous chapter dealt with the historical aspects of the Akha family planning project.  This chapter focuses upon the program itself.  It analyses the various people and expanding programs involved, and shows how they intersect.

 

Program Director

 

In the initial stages, it seemed necessary for me to be the director of the program.  I sought from the beginning to find ways whereby the various aspects of the work could be turned over to local personnel.

 

As the program director, my major responsibilities were:

 

1) To convene meetings of the Advisory Committee, and implement its actions.

 

2) To draw up budgets, and make requests for grants.

 

3) To make quarterly reports for funding agencies.

 

4) To send out to interested groups and individuals quarterly progress reports on three phases of the program: a) tribal family planning, b) tribal education, and c) tribal economic development.

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5) To prepare forms in Lahu and Akha for the field workers to use in their work.

 

6) To prepare educational cassettes on family planning in both Akha and Lahu to be played by the field workers.

 

7) To serve as the support person for the men in the field (both family planning workers and later inoculators).

 

8) To serve as coordinator with government agencies and programs.

 

9) To prepare radio announcements in Akha and Lahu.

 

                                                Medical Advisor

 

Dr. Edwin McDaniel has served as the medical advisor since the start of the program.  Born in Thailand of missionary parents, Dr. McDaniel has served as a mission doctor since 1949, first in Chiang Rai, and later in Chiang Mai.

 

When he saw the need of Thai families for family planning services, he helped start a family planning program in 1962 at McCormick Hospital, which has become famous throughout Thailand and Southeast Asia.  It has pioneered in many ways, and has produced a perceptible effect upon the demographic picture of the Thai population in Chiang Mai Province.  He has shared time and experience with us in developing a program especially geared to meeting the needs of the populations "on the mountains."  

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                                                  Medical Supervisor

 

Dr. Arunee Fongsri joined the McCormick Family Planning Program in November 1974.  Tribal women living in Chiang Mai Province who wanted tubal ligation were given the service by Dr. Arunee at the Chiang Mai Christian Clinic.  She exhibited infinite patience as often women scheduled for surgery failed to show up, came at the wrong time, or came without having any appointment.

 

Her trips to Phayao for the monthly sterilization clinics were physically and emotionally exhausting.  She has not complained, but has worked faithfully with her excellent staff to give such good care to each patient that now the women asking for sterilization want the "Phayao operation."

 

                                                   Local Workers

 

                                                    Field Workers

 

The main field worker has been Yaju Cehmui, who visited ten or eleven villages each month.  He tried to contact each village twice a year, although there were problems due to: 1) village movement, and 2) travel conditions.  Throughout the life of the program he has made an average of sixty village contacts twice a year.  There was an average of over 8,400 people living in those villages, which means that he visited about 60% of the population twice a year.

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                                             Part-time Field Workers

 

Two other field workers have been working part-time in this project.  One is a Lisu headman who lives a three-day walk from the main road.  He speaks six languages fluently.  He came to me in 1975 asking that we help the Lisu and other tribal women in his area who wanted to limit the number of children they had.  He had purchased contraceptive pills for some twenty women on his previous trip to Chiang Rai.  There were many more who were interested, he said.  We gave him instructions in oral and injectable contraceptives, and he has been giving good service in that remote area.  It is impossible to include data from his service in the report of our total program, however, since I could not get written data on each woman that was helped.

 

The other part-time worker is an Akha named A Tu, who lives on the Burma side of the border.  He travels to many Akha and Lahu villages on a regular basis.  We have supplied him with oral contraceptives (injectables are illegal in Burma) which he takes out to the villages.  He has stimulated interest in contraception, and through his personal contacts has encouraged more than fifty women to come to Phayao for tubal ligation.

 

Another man, a former opium addict, was tentatively hired by the Akha Advisory Committee to serve as a second field worker.  Before he could actually become engaged in the program, however, he became readdicted to opium.  At the time the committee talked with him about the position, they had said very clearly that if he ever became readdicted they would not use him.  Therefore, there has been only one full-time field worker during this period.

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                                                Precautions

 

There are certain precautions which we tried to build into the project as it went along, to obviate problems and insure a smoothly functioning program.

 

                                                 Cultural

 

We sought to remain sensitive in every way to the culture of the people.  For example, when discussing any contraceptive method, we felt that the husband and wife needed to concur before the service could be offered.  Indeed, because the elders have a legitimate concern in such matters in Akha society, we asked a couple contemplating sterilization that they consult the husband's parents as well.

 

                                                 Medical

 

We took certain precautions in the medical sector of our program as well.  For example, the field worker used only disposable syringes and needles when giving DMPA injections.  As far as we know, there was never an infection from these injections.

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To prevent the problem of heavy bleeding following DMPA injection, each woman who received it was given a capsule with 400 micrograms of Estrovis to take immediately, and another three capsules to take later if she had heavy bleeding.  This usually kept down possible complications.

 

                                                Educational

 

We tried to educate the Akhas on the subject as much as possible in every contact.  This meant that all of the alternatives available to them were presented, and their questions answered honestly.  Sometimes being so frank with them may have caused minor problems, since we felt we should tell them the pros and cons of each method.  We would explain the side effects of the pill, for example, explaining that nursing mothers sometimes lose their milk when taking the pills.  This was important, since many of them had nursing children.

 

We would also tell them that a few women would experience nausea from the pills.  Whether it was a psychosomatic reaction or not I am not sure, but it seemed that an inordinate number of women who took the pill suffered from nausea. {footnote 1: Dr. McDaniel felt this could be partly due to diet, and the lack of certain vitamins.  We gave out special vitamin pills made according to his formula, with a high concentration of B-6.  It helped some women, but even so contraceptive pills were very unpopular.}

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                                            Problems Encountered

 

                                              By the Field Worker

 

1) Physical problems, such a sheer fatigue, the necassity of traveling through heat, cold, rain, and caring for many people with various problems in a short time, drained his energies.

 

2) Often people are not home when he gets there.  We can only announce over the radio the month he will come, not the day, for two reasons: a) we can never be sure what day he is going to be able to get to the village, and b) if the exact date were given, there might be robbers who would ambush him.

 

3) There are dangers of travel.  In May 1976 Yaju and his travel companion were held up by robbers, and had everything they had with them stolen.  (Less than a year later Mr. Peter Wyss, OMF missionary, was killed in the same area.)

 

4) People are often suspicious.  Anyone who grows or smokes opium and does not know Yaju may wonder if he is a special agent, using the family planning work as cover.

 

                                         General Problems in the Program

 

1) Migration, especially internal.  Often women who were receiving DMPA on a regular cycle would move to a new area and did not receive their next injection in time.  When that happened there was the possibility they might become pregnant before they could find other means of protection.  However, such migration helped word about contraception to spread more quickly.

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2) Rumors have plagued the program from its inception.  I discovered that in Burma some of these rumors were started by Thai and Chinese medicine sellers living interspersed with the Akhas.  They were evidently afraid of losing some business.

 

3) Lack of education hinders their ability to use contraceptive methods properly.  There was an Akha couple anxious for the wife to take oral contraceptives, so I explained to them how they were to be taken.  Later the woman complained to me about bleeding problems.  Upon questioning her I learned that the husband had insisted she take them a different way than she was doing (she was correct).  If they had had education and could have read printed directions they might not have had the problem.

 

4) Many Akhas are too poor to pay for contraceptive care.  The situation is especially severe in the case of opium addicts.  During the last year of our program most of the population was affected, however, due to a massive influx of rats which devastated the corn and rice crops.

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5) Communication has been a constant problem, as can be illustrated best by what happened in the village of Sa Cu.  Early in 1975 the field worker got to this very remote village, only to learn from the 'village priest' that no one in the village was interested.  Later the Akha radio announcer was in the village, and learned that several couples were interested in contraceptive aid, but they had not learned that Yaju was in the village so had not been able to contact him at that time.  It was decided to send one of the Lahu field workers, since the village was only about a four-hour walk from a Lahu village he was to go to, but the Akhas of Sa Cu village refused to accept his help, and insisted that the Akha man come back.  When the Akha field worker did return six months later, he found a total of eighteen couples interested in contraceptive injections, but most were afraid to have them.  One woman in the village had it, however, and the rest said they would watch her.

 

Six months later the field worker injected six women, and took their names for sterilization as well.  Since their village is closer to the road leading to Chiang Mai, I scheduled them for operations there, and even arranged for the second Lahu field worker to go to their village to bring them down on the right date.  They did not come when they were supposed to, and I later learned that the 'village priest' had declared that time to be their New Year, when no villager could leave, including the six women.

 

Two months later three of the six women from this village got to Namlat, and were able to get the operation, but unfortunately there was no room for them with the Phayao group, so they had the operationin the government hospital in Chiang Rai.  With no translator and no one to help them they had a very difficult experience, however, which may account for the fact that no other woman has since come from that village for sterilization.

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                                          Problems Involved with Sterilization

 

1) The term used.  When Akhas first heard of the operation from the Thai, they visualized it as major "abdominal surgery," so that is what they called it (m ma peh-eu).  This was frightening to many, especially since there were various persons in Akha villages who had had abdominal surgery, and they saw the disability which often accompanied it.  I introduced a term which means to 'cut the cords' (a ca yeh tseh-eu) which more clearly explained the operation, and reduced the amount of fear.

 

2) Having enough sons.  Cultural pressure is strong to have at least two living sons, but by the time a couple has had three or four girls before getting to two sons, they and all society are the losers.  This is a problem the Akha themselves must solve.

 

3) Remoteness.  Many Akha women live too far away from the car road to receive the service easily.  Those in the Mae Kham area have to walk three days, for example.  They could walk in, but would not feel like walking back after the operation.

 

4) Finding the right time.  For those groups which make swidden, much of the year is occupied with clearing, planting, weeding and harvesting their rice crop.  There are various ceremonial times in between as well.  It is very difficult to find times when: a) they are free, b) their families are not sick, and c) the roads are in reasonably good shape.

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5) Too much time lag.  There is often a lag of two to four months from the time they request the operation to the time we can actually do it.  If they have no other protection many of them become pregnant during the period they are waiting.

 

6) Failure to appear.  Many women who have asked for the surgery do not show up after they have been called.  This has happened in over eighty cases of Akha women from Thailand.  Some of the reasons for this are: a) the woman has no radio (or does not hear the announcement), b) she or some other member of the family is sick at the time she is to go, c) there may be two or three women from the same village scheduled to have the operation at the same time, but when one of them for some reason cannot go, she will beg her friends to wait for her, d) the woman may be pregnant by the time she is called, e) the couple may have been frightened out of having the operation by rumors, f) the couple may have lost a child through death between the time they gave the wife's name and the time she is called, g) the woman may have moved to another village and is not able to get to the place where she is to report for the operation, or h) the woman may have died.

 

7) Complications.  From one to six months after sterilization, some women return with what they consider to be complications.  There have only been four or five women out of the total of 1,351 we have had in the total program who have had complications serious enough to necessitate surgical or medical attention.  Yet I paid the expenses for over seventy women from all groups to come either to Chiang Mai or Phayao in order to be checked.  In most cases their complications could not have been related to tubal ligation, but were most often due to hookworm or malaria.

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8) Financial.  We promised the women to pay their travel expenses, as well as all expenses related to the operation.  Early in the program the question was raised concerning women with nursing infants.  They said they needed to bring someone to care for the infant while they were being operated on.  In a four-month period we had 131 women out of a total of 168 (78%) who had nursing infants with them, which meant that we had to pay for an extra 131 people to accompany them.

 

9) Undue pressure.  There are many Akhas who are too poor to buy contraceptive pills or to pay for the injections.  Since they can have sterilization free, this tends to become their only option.  This may put undue pressure on those who would rather just have better spacing for their children but cannot pay for reversible contraception.  (I have not met any couple that stated this, but it is a possible problem.)

 

10) Polygynous marriages.  Many men have two wives, and want one or both or them sterilized.  If the wives are relatively young and are later widowed (as many of the minor wives are), whatever children the women have revert to the family of the husband, so they are left with no children and slim chances for a new marriage because of sterility.  I suggested to the Advisory Committee that a vasectomy for the man was far better, but the men tend not to think of the problems women confront in this situation, and simply turned down the idea.

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                                          Advisory Committee Expands Program

 

When the Akha Family Planning Advisory Committee meets, there is no fixed agenda.  They bring up whatever issues they want.  The group will then discuss what has been raised and seek to take some action if it is felt to be beneficial and practical to do so.  Following are some of the main projects they have developed so far:

 

1) Education.  Many of the Advisory Committee members were anxious to find ways whereby their children could be educated.  Various possibilities were discussed, following which it was decided to help start primary schools in a few Akha villages which had no school as yet.  The villages which were chosen by the group promised to build the school building and a house for the teacher, as well as provide his rice.  I sought outside funds to help toward the teacher's salary.  In 1977-78 there were six Thai teachers in five villages teaching in this program, which is completely run by the Akhas.

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2) Opium detoxification.  The matter of opium detoxification comes up at every meeting since it is such an overwhelming problem.  So far the tentative "solutions" reached have not proven practical, but it is still helpful for them to discuss this common problem.

 

3) Tribal Inoculation Project.  It is impossible for the government to get out to the tribal villages.  This committee therefore worked out a means whereby they could send Akha inoculators out to give DPT, BCG, and smallpox immunnizations, furnished with training and serum by the provincial health office.  It was funded from the Canadian University Services Overseas, and worked well for the year in which it was carried out.

 

4) Relief.  At the time when rats destroyed much of the corn and rice crops, I was able to get approximately $1,700 (34,000 baht) in relief aid to turn over to the committee for disbursement to those who had no seed rice to plant.  Thirty-five families whose homes had burned down were also given special aid.

 

5) Scholarship aid.  Aid has been given to two Akha boys in teacher's college, impressing upon them that the committee expects them to return and serve their people upon the completion of their training.

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6) Swidden regeneration project.  At one meeting I brought up the dearth of new land for expansion, and mentioned that the Lahus were experimenting with what is called a "swidden regeneration project."  This has resulted in a similar project being started in one of the Akha villages, although it is not really a project of the Advisory Committee. {footnote 2: This is a project which takes a swidden field, and building up the soil by rotating crops and planting various legumes, makes it possible to plant that field year after year.}

 

Expanding the program from family planning to other community development programs has helped the Akhas to have a greater awareness both of their common problems and of how these problems can be attacked in a cooperative way to their advantage.

 

                                          Cooperation with Other Groups

 

One of our aims was to cooperate with other groups that are interested in serving the same population.  There is so much work to do that no one group or single program can hope to establish it all.

 

                                             Dr. Thatsanai's Program

 

In the early phase of our program, we sought to serve all Akha villages, including those in the Nikhom area.  When Dr. Thatsanai and his team (see page 82) became interested in performing a total health survey and combined health-family planning program in the Nikhom area, we told the Akhas there that Dr. Thatsanai's program would see to their needs.

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One problem resulted from this.  An Akha woman from the Nikhom area had asked us for a sterilization, but was told by the Nikhom not to go, since they would have a team of doctors coming who would perform the surgery there.  As it turned out the doctor scheduled to come could not do so, so eventually the woman and her husband came to Phayao, where Dr. Arunee gave a tubal ligation.

 

                                               Border Patrol Police

 

We have received excellent help from the BPP men in the field.  They encouraged the field workers whenever they came across them, and also tried to convince the villagers to accept contraceptive aid from the field workers.

 

There was one case where potential conflict developed in several large Lahu villages when the BPP promised to give free contraceptive injections to the women who wanted them.  As a result of this, over thirty Lahu women did not take injections from our Lahu field worker when he visited.  Since the BPP could never come through with the promise, many of the women became pregnant.  Later, when they learned that the BPP could not give the service, they began to accept it from our program.

 

                                          Opposition to the Program

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The only opposition that caused concern to the program was not from Thailand, but came in 1976-77 from a man in the United States who at one time had had some contact with the Akhas.  After hearing and reading various things concerning the Tribal Family Planning Project, he came to the conclusion that it was endangering the Akha tribal group.  His major objections were:

 

1) The Akhas evidently did not understand that sterilization is irreversible.

 

2) Surely the Akhas (who are illiterate) could not be giving informed consent for the operation.

 

3) The data being used were inaccurate.

 

4) No corresponding program to cut down on the death rate was being undertaken.  (Family planning was being carried on in a "vacuum.")

 

5) At the rate that sterilizations were being performed, within eighteen to twenty-seven years there would be no work force among the Akhas of Thailand.

 

Since much of the program's funding came indirectly from AID, the critic contacted AID in Washington, as well as a congressman with whom he had worked as a consultant in another capacity.  Various accusations were made, which were later retracted after the Congressman and the critic had been able to investigate the program as it was being carried out.  At one time, however, it looked as if our program, as well as AID funds for family planning for all of Thailand, might be cut off.

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The Royal Thai Government was naturally concerned when it learned of this possibility, so they evaluated our program.  Their conclusion is summed up in a telegram that Dr. Somboon sent to the Secretary of State in Washington, D.C. (see the Appendix).

 

Family Planning International Assistance (FPIA), the actual funders, also investigated carefully to see if there was any substance to the accusations.  The director himself came to observe the program, and was more than satisfied that the charges were baseless.